Online Psychotherapy

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 secure, special-purpose video conferencing equipment. A number of companies offer technologies and services to facilitate telepsychiatry.

The patients served by telepsychiatry often suffer significant mental illness, such that diagnosis tends to be based on overt signs and symptoms. Treatment is usually pharmacologic.

More recently, mental health blogs and articles have trumpeted the growth of online psychotherapy conducted by private-practice clinicians. While this falls under the rubric of telepsychiatry, it differs in important respects from traditional applications of this technology.

Online psychotherapy is usually conducted as part of private practice, without institutional oversight or standardization. The patient is typically at home or work, not in a supervised setting. Off-the-shelf consumer technologies such as Skype and FaceTime are often employed, potentially running afoul of HIPAA privacy regulations. And perhaps most crucially, the patients are higher functioning, with more subtle problems that demand nuanced discussion and finessed interventions.

The idea of conducting psychotherapy at a distance is not new. Sigmund Freud often corresponded with his patients in ways he hoped would be clinically helpful. Telephone sessions were pioneered in the 1960s with the advent of suicide hotlines, and have expanded to cover many areas of mental health counseling. (See this 1993 discussion of telephone counseling by an attorney representing the California Association of Marriage and Family Therapists.)

Psychotherapy 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. Despite the lack of visual cues, studies suggest that telephone psychotherapy and counseling are effective and liked by clients.

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. In contrast to a phone conversation, text chatting hides vocal prosody and other paralinguistic features, obscuring irony, double-meanings, and similar subtleties. Email shares these shortcomings and is also asynchronous (i.e., the conversation does not occur in real-time).

Despite the severe limitations of a text-only exchange, early computer programs sparked the public’s imagination that someday the computer itself would conduct psychotherapy, and not simply facilitate communication between two humans. With the exception of highly structured cognitive and psychoeducational interventions, this has not yet been achieved.

Computer-mediated psychotherapy most commonly takes place online, over video conferencing apps such as Skype and FaceTime. These tools are readily available for free and are easy to set up and use. Controversy exists over whether Skype and FaceTime are “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).

When the alternative is no psychotherapy at all, the utility of conducting it online seems obvious. Example scenarios include patients who are bedridden or otherwise immobile, those in inaccessible locations such as Antarctic explorers, and those who are immunocompromised or highly contagious with an infectious disease. Additionally, 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.

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It is more potentially problematic to choose online therapy over in-person treatment when both are practical options. Certain 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. In-person treatment is inherently a social interaction, which may be therapeutic in itself — or at least good practice. Psychotherapy 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. Micro-momentary facial expressions, implicated in unconscious interpersonal communication, may be overlooked. And to underscore the obvious, the therapeutic frame may be harder to maintain when the patient is in swimwear by the pool and drinking an alcoholic beverage during the session. The 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.

Online psychotherapy has practical advantages in some situations, and as a treatment modality, it does not appear bogus or inherently harmful. It 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.

As 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. Face-to-face treatment is still the gold standard.

©2013 Steven Reidbord MD. All rights reserved.