{"id":761,"date":"2013-07-31T18:43:08","date_gmt":"2013-08-01T01:43:08","guid":{"rendered":"http:\/\/blog.stevenreidbordmd.com\/?p=761"},"modified":"2013-07-31T18:43:08","modified_gmt":"2013-08-01T01:43:08","slug":"online-psychotherapy","status":"publish","type":"post","link":"http:\/\/blog.stevenreidbordmd.com\/?p=761","title":{"rendered":"Online psychotherapy"},"content":{"rendered":"

\"helpkey\"<\/a>Telepsychiatry is clinical evaluation and psychiatric treatment at a distance. \u00a0It brings a specialist’s expertise to otherwise inaccessible populations in prisons, military settings, and distant rural communities. \u00a0Introduced decades ago, it\u00a0is perhaps the most successful example of the more general field of\u00a0telemedicine<\/a>. \u00a0Telepsychiatry traditionally treats patients at supervised sites and makes use of secure, special-purpose video conferencing equipment. \u00a0A number of companies<\/a> offer technologies and services to facilitate telepsychiatry. \u00a0The patients served by telepsychiatry often suffer significant mental illness, such that diagnosis tends to be based on overt signs and symptoms. \u00a0Treatment is usually pharmacologic.<\/p>\n

More recently,\u00a0mental<\/a> health<\/a> blogs<\/a> and<\/a>\u00a0articles<\/a>\u00a0have trumpeted the growth of online psychotherapy conducted by private-practice clinicians. \u00a0While this falls under the rubric of telepsychiatry, it differs in important respects from traditional applications of this technology. \u00a0Online psychotherapy is usually conducted as part of a private practice, without institutional oversight or standardization. \u00a0The patient is typically at home or work, not in a supervised setting. \u00a0Off-the-shelf consumer technologies such as Skype and FaceTime are often employed, potentially running afoul of HIPAA privacy regulations. \u00a0And perhaps most crucially, the patients are higher functioning, with more subtle problems that demand nuanced discussion and finessed interventions.<\/p>\n

The idea of conducting psychotherapy at a distance is not new. \u00a0Sigmund Freud often corresponded with his patients in ways he hoped would be clinically helpful. \u00a0Telephone sessions were pioneered in the 1960s with the advent of suicide hotlines, and have expanded to cover many area of mental health counseling. \u00a0(See this 1993\u00a0discussion<\/a> of telephone counseling by an attorney representing the California Association of Marriage and Family Therapists.) \u00a0Psychotherapy by telephone remains extremely popular, often serving as a temporary substitute for in-person sessions, for crisis intervention between regular sessions, and to maintain a therapeutic relationship when one party moves out of the area. \u00a0Despite the lack of visual cues, studies suggest that telephone psychotherapy and counseling are\u00a0effective<\/a> and<\/a> liked<\/a> by clients.<\/p>\n

Early efforts to use the internet as a medium for psychotherapy seemed to take a step backward with text-only channels such as email or chat. \u00a0In contrast to a phone conversation, text chatting hides vocal prosody\u00a0and other paralinguistic features, obscuring irony, double-meanings, and similar subtleties. \u00a0Email shares these shortcomings and is also asynchronous, i.e., the conversation does not occur in real time. \u00a0Despite the severe limitations of a text-only exchange, early computer<\/a> programs<\/a> sparked the public’s imagination that someday the computer itself would conduct psychotherapy, and not simply facilitate communication between two humans. \u00a0With the exception of highly structured cognitive<\/a> and psychoeducational<\/a> interventions, this has not yet been achieved.<\/p>\n

Computer-mediated psychotherapy most commonly takes place online, over video conferencing apps such as Skype and FaceTime. \u00a0These tools are readily available for free, and are easy to set up and use. \u00a0Controversy exists over whether Skype<\/a> and FaceTime<\/a>\u00a0are “HIPAA compliant,” although there is a strong argument that cellphone conversations with patients, not to mention unsecured email, are far more vulnerable to privacy breaches (Skype and FaceTime feeds are encrypted by default, whereas cellphone calls and email are not).<\/p>\n

When the alternative is no psychotherapy at all, the utility of conducting it online seems obvious. \u00a0Example scenarios include patients who are bedridden or otherwise immobile, those in inaccessible locations such as Antarctic explorers, and those who are immunocompromised or\u00a0highly contagious with an infectious disease. \u00a0Additionally, online therapy reasonably substitutes for telephone therapy in typical situations such as crisis intervention or when an existing therapy dyad is geographically separated, perhaps temporarily.<\/p>\n

It is more potentially problematic to choose online therapy over in-person treatment when both are practical options. \u00a0Certain patients, e.g., depressed or agoraphobic, may opt not to venture out of the house when it would be beneficial for them to do so. \u00a0In-person treatment is inherently a social interaction, which may be therapeutic in itself \u2014 or at least good practice. \u00a0Psychotherapy at a distance precludes smelling alcohol on the patient’s breath, as well as noticing auditory and visual subtleties such as a quiet sigh or dilated pupils. \u00a0Micro-momentary facial<\/a> expressions<\/a>, implicated in unconscious interpersonal communication, may be overlooked. \u00a0And to underscore the obvious, the therapeutic frame<\/a> may be harder to maintain when the patient is in swimwear by the pool, and drinking an alcoholic beverage<\/a>\u00a0during the session. \u00a0The potential for patient acting-out, including with suicidal threats or gestures, can render an online therapist especially helpless, and possibly more easily manipulated, than his or her counterpart in an office setting.<\/p>\n

Online psychotherapy has practical advantages in some situations, and as a treatment modality it does not appear bogus or inherently harmful. \u00a0It would be interesting to compare telephone and video therapy in a research context, to see whether the visual channel confers additional useful information, and whether it enhances or detracts from the therapeutic alliance. \u00a0As with most technological innovations, online therapy also introduces new pitfalls and deepens old ones, so it is best not to choose it merely for its novelty or expedience. \u00a0Face to face treatment is still the gold standard.<\/p>\n

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Telepsychiatry is clinical evaluation and psychiatric treatment at a distance. It brings a specialist’s expertise to otherwise inaccessible populations in prisons, military settings, and distant rural communities. Introduced decades ago, it is perhaps the most successful example of the more general field of telemedicine. Telepsychiatry traditionally treats patients at supervised sites and makes use of […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[8],"tags":[12,59],"class_list":["post-761","post","type-post","status-publish","format-standard","hentry","category-psychotherapy","tag-computers","tag-telepsychiatry","odd"],"aioseo_notices":[],"_links":{"self":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/761","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=761"}],"version-history":[{"count":4,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/761\/revisions"}],"predecessor-version":[{"id":766,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/761\/revisions\/766"}],"wp:attachment":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=761"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=761"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=761"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}