Over-Simulated

Staying human in a post-human world

Telephone Therapy Study Oversold, Polarization Illustrated

Feeding the "smackdown" beast, over-selling a telephone therapy study

If you need a reminder that psychotherapists are more human than anything else—and you really shouldn't—consider the polarized way people write (and talk) about things like telephone and SKYPE mediated psychotherapy. What you'll find is a tendency to "spilt" into an all-good/all-bad dichotomy, splitting that gets even more pronounced when discussing those email and web-chat based efforts called "online therapy" or "e-counseling."

Now, you may think this is just a guild issue, a turf battle. But it is not. When your business is caring for other people when they are feeling especially vulnerable there's more at stake than a slice of the market: that's why the tenor of discussions about technologically-mediated treatments bothers me so much. You'd think the world as we know it was ending in either a rapturous second coming of infinite wonder or an anti-human nuclear winter. Looking for the critical sober-minded middle? Unfortunately, it is too often suffocated by dichotomized agendas.

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Here's an example: In response to a piece I posted about the effectiveness of traditional therapy and the power of "placebo effects" grounded in f-2-f rituals, rituals not present in newly-emerging technologically-mediated attempts at providing care, someone tweeted "this is an opinion piece that ignores research." Since I read the research pretty carefully—at least I think I do—I suspected this was posturing, someone closing down that middle space in support of his own agenda. But maybe not. Maybe I have been missing some important research. And if not, well, I was pretty sure talking with this person would still be interesting.

So I looked for and found the tweeter. He's a social worker who supplements his other work by selling online expertise for $4.99 a minute ($299.40 an hour) or $85 for an "email session" at a web-site claiming to provide access to "a world of experts." I sent him a collegial note asking him to please let me know what research he had in mind. I told him I would happily write about what he told me so I could correct the record. I asked several times, and I always said please.

Didn't work. He told me "It sounds like you have a chip on your shoulder and haven't done your homework" and "I feel that if you are going to make sweeping generalizations to the public about online counseling, that they should be backed by research." I kept asking him to please point me to the research I was missing, to please tell me what research he had in mind. Zippo, and then he just stopped responding.

Of course he did. There was no research being ignored. He was just posturing. Now, I'm sure he's a perfectly decent fellow but something is really, really wrong here. But its not him. I actually want you to notice I haven't named him. Why bother? It would just embarrass him and make this personal when it is not. He's really not the problem. Processes of thought-suffocating polarization are the problem. When technology and therapy are discussed conversation too often becomes a nuance killing smack-down: You ignore research! Do not! Do too!! And this what some call scholarship.

How did this happen? What feeds the polarization (splitting)? Part of the answer is in an overly enthusiastic technophilic bias: you're either on the digital bus or you're off it. Look at all the grief Jaron Lanier has received for daring to call current web-verities into question while pleading for a "digital humanism."

I came across a really interesting example of this therapeutic techno-lust last week in the coverage provided a small, prelimary study about telephone-based cognitive-behavioral treatment for depression. Published in the journal Behavior Therapy, the study concluded "phone counseling in a real-world clinic setting to depressed adults was feasible" and that "that telephone counseling may be an effective treatment alternative" (page 234, Evaluating the Effectiveness of Cognitive-Behavioral Teletherapy in Depressed Adults).

A small, limited study, the grind of science. One step towards really knowing something. But the coverage suggested the second coming. One headline blared, "Study shows phone therapy as effective as face to face method" even though the study did not and could not say that. Another promised "Telephone therapy ‘as good as face-to-face consultations’ to beat the blues." The American Psychiatric Association was a little more sober-minded in their daily news briefing report, "Small Study Indicates Phone Therapy For Depression May Be Nearly As Effective As Face-To-Face Sessions." At least they included the qualifiers "small" and "nearly" which is small consolation and not nearly enough; the study itself says "the lack of a true control group limits the generalization of the outcomes detected" (page 234, Evaluating the Effectiveness of Cognitive-Behavioral Teletherapy in Depressed Adults).

I don't want to turn what should be an interesting blog post into a "Journal Club" meeting where research gets dismantled en masse prior to anyone basing clinical decisions on the findings. But—you knew there was going to be a but didn't you?—some of the study details are fascinating examples of our humanity-denying techno-lust.

First, the study claims that 42% of the 30 people in the study were "considered recovered" by the end (since that would be 12.6 people I'm not sure where they got the number, so lets be generous and say 13 people). What was not emphasized was that 23 people refused to participate in a trial of telephone therapy, despite, as the authors point out, telephone therapy being so much more convenient and easy. That means that out of 53 people who could have been helped by telephone therapy, 13 were helped. Given that spontaneous recovery in mild to moderate depression is often thought to be about a third what we really can say is that telephone therapy in this instance probably didn't hurt anyone, i.e., doing it is "feasible."

Second, all of the therapies were conducted by a single therapist who was also the study's lead author. That's right, one person. One thing we know from psychotherapy outcome research is that the person of the therapist is a powerful variable. Moreso than the specific kind of therapy, the personal qualities of the therapist are often what matters. So, the best conclusion from this study is that we have a very bright, talented young therapist who is going to help lots of people. There is very little or nothing we can say about the relative efficacy of telephone-based psychotherapy other than it probably does not do harm. 

But no one really wants to read about people being important; we love our tools too much and want to read about how they're giving us a better world. And if you don't agree with me, given the current climate, all I can really do is threaten to punch you right in the snoot! After all, truth has become the advantage of the stronger (or at least the better funded).

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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