Over-Simulated

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Be warned: 'Online therapy' is not therapy, not really

Buyer beware: 'Online therapy' is not really psychotherapy

I want to share some thoughts after a few days reviewing several dozen web-sites that offer what they call "online therapy." Don't worry, I'm not about to launch such a site nor was I having an especially masochistic weekend; it was research for a workshop I'll be doing on "techno-ethics" for psychotherapists.

Let me start by noting that many different activities can yield healing, support, and growth: time with friends, family, and lovers; exercise; mindfulness practice such as yoga or meditation; religious practice; service to others; gratitude work; making art; journaling. I could go on and on (and on) but I'll stop there with my point hopefully made: life is replete with options that can help solve problems in living.

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And as different as these experiences are, and they are fundamentally different in many ways, they can all be therapeutic, meaningful, and valuable; in addition, they share the common feature of not being psychotherapy. What I want to say after reading through all those sites is that "online therapy" is also not psychotherapy.

I know everyone has to make a living—finding a niche in the crowded, squeezed mental health marketplace is not easy—but practitioners of "online therapy" have gone too far in the direction of preying on vulnerable people in need of help. While I may get my nose bloodied for saying so (although I hope not), practitioners of online therapy just assume that the service they offer is a new flavor of psychotherapy, albeit with some tremendously helpful new features and easily avoided downsides.

I know, I know, people have been helped; I have no doubt about that. But having satisfied customers does not automatically license calling new technologically-mediated practices "psychotherapy" and thereby connecting the new practice to generations of research, clinical experience, and study. Doing so both diminishes psychotherapy and increases the stigma of reaching out to another human being for help when needed. Imagine the absurdity of yoga instructors marketing the value of the classes they offer by referencing research documenting safety and efficacy for a variety of psychotherapies, from CBT to psychoanalytic psychotherapy. All they would have to do is call it "yoga therapy" and then say "yoga therapy" is not exactly like traditional psychotherapy, although it can be used for the same purposes and may in fact be better.

I found "not the same as face-to-face psychotherapy" disclaimers in almost all the sites I visited. These disclaimers are just part of how the sites implicitly claim that the email, IM, and even SKYPE exchanges being sold are just another kind of psychotherapy. No need for that pesky travel to someone's office. Shy about disclosing personal material in person, no problem, try the new and improved therapy! Therapy when it is convenient for you, when and where you want! Just click here, give us your credit card, and start the healing.

But "online therapy" is not a new kind of psychotherapy; it is a technologically-mediated simulation of psychotherapy. And like any simulation it has different limitations and is built from different processes than the traditional actuality being simulated.

That's right, it is a simulation, like Disney's Jungle World cruise is a simulation of an actual journey through the jungle. Or consider a flight simulator. Pilots log time in flight simulators to develop skills and learn emergency procedures. They are hugely important tools. But they have different limits than actually flying; no matter how much pilots learn in simulators, they can't be used for an actual journey. And psychotherapy is an actual journey. Simulations always have limits, so much so that the burden of proof must be on the purveyors of the simulation that the simulation is, in fact, good enough. No one has yet offered that proof.

But there's more at issue than clashing metaphors of travel. I have no problem with someone deciding to pay for an email exchange with someone else. I have a big problem painting that exchange to make it look like psychotherapy. Here are a couple of specific ways that the simulations provided by "online therapy" are fundamentally different than actual psychotherapy.

Safety and risk: A frequently noted feature of effective psychotherapy across many different techniques and schools is a positive "therapeutic alliance." In the alliance built by the participants, the patients/clients have to feel safe enough to do the often difficult work; there must be what Winnicott, the British psychoanalyst, called a "holding environment." But in the absence of physical co-presence (the fancy term for being in a room with someone) there is an artificial limit on how safe one can feel. Email or SKYPE is just not risky enough on its face for it to provide the same context for the development of safety. When there is no possibility of being dropped, i.e., all the fleshy consequences of two bodies being together that therapists restrain, then there is no possibility of feeling held. Instead of comfort and safety most of what is possible online is an absence of consequence, and the absence of consequence is not the same as the presence of safety.

Empathy: Knowing the mind—and heart—of another is not magic, nor is it purely linguistic. Since the late 1990s neuroscientists have been studying "mirror neurons," brain systems that allow for a kind of direct access to the mind of an other. For example, when you watch someone grimace, neurons you would use to perform the same action are activated thereby generating a direct experience of what is going on in the mind of the other because the same thing is going in yours. Even video-conference based online therapies can't overcome the loss of physical co-presence, at least not now, because it is impossible to look someone in the eye and be looking at the camera at the same time. And the experience of empathy depends in part on such properly timed mutual gaze behavior. While online interactions can generate the feeling of being understood, that is fundamentally different than the fleshy, messy process of actually being understood.

So, if you are a consumer/client/patient thinking of getting help with problems in living by reaching out to that seemingly wise kind person behind that interesting web-site, maybe you should take a deep breath and ask whether a simulation is what you want? What you need? While it may be a first towards an actual journey, is the simulation enough right now? If not and if you can access an actual therapist, someone with whom you can sit and talk, I hope you'll reconsider the seductions of technology.

And for my colleagues out there pushing this new frontier, maybe you want to dial-back on the evangelical fervor, maybe even consider clearly stating that what you are offering is a simulation, not the actual journey that has been subject to decades of research and study.

Todd Essig, Ph.D., is a training and supervising psychoanalyst at the William Alanson White Institute with a clinical practice treating individuals and couples.

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