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Teletherapy: Breakthrough or Breakdown?

An article on teletherapy made waves this weekend. Poolside waves.

Sandy Huffaker for The New York Times

September 26, 2011

© Ravi Chandra, M.D. All rights reserved.

Did you catch the article on teletherapy that appeared in the "Fashion and Style" section of the New York Times recently? It was bizarre enough to see this article in such a fluffy section, as opposed to "Health and Wellness," but its opening lines were even more bizarre:

"She mixed herself a mojito, added a sprig of mint, put on her sunglasses and headed outside to her friend's pool. Settling into a lounge chair, she tapped the Skype app on her phone. Hundreds of miles away, her face popped up on her therapist's computer monitor; he smiled back on her phone's screen.

She took a sip of her cocktail. The session began."

The groans of thousands of therapists could instantly be heard across the land. Sipping alcohol during a "therapy" session? Poolside? SKYPE? A succession of alarming incompatibilities with professional therapy, it seemed. Certainly, nearly all of us would agree that the first two don't mix with therapy. But the article purported to be about the third attribute, video-therapy. What to say - is videotherapy the wave of the future, a breakthrough in communication and connection - or exactly the opposite, a harbinger of the breakdown of professionalism and therapy grounded in real relationships?

Certainly, there has been no successful effort to keep in check any method of communication. Teletherapy will undoubtedly be a service offered in at least some situations. But defining what the best situations are will require a lot of careful work. Medical, licensing and professional boards will set standards. Ultimately, each therapist is going to have to decide for him/herself if and how to make use of novel forms of technology even within defined parameters. The article makes much of the "wild web west" of this new frontier. I have the sense that this is going to change as we gain more experience.

There has been some evidence for enhanced CBT efficacy using text messaging to deliver messages to those with Major Depression, and also for smoking cessation. So we shouldn't shut ourselves off to the possibilities that technology offers. But there seem to be particular features and benefits of so called FTF (face to face) therapy that may not be present in video-therapy via Skype and similar mechanisms. First, the commitment that is made to personal care (scheduling appointments, taking time away from other activity, going to a private, special place for therapy) does not happen as readily online. The therapy session may be the only meaningful emotionally-connected time of a person's week. Can this really happen on a computer monitor? Different perspectives abound. I know some therapists have claimed very deep emotional bonds over Skype. Personally, I feel the connection is several orders of magnitude higher in person - not to say that it can't happen over the phone or videolink. I can read my client's body language much better in person, and vice-versa. I don't think anything can beat truly being "with" another human being, no matter how fast your bitrate is. Misinterpretations are also a serious hazard in online communication.

Furthermore, distractions can detract from the computerized experience - your patient may check email during a session, or text. There may be interruptions by others. Others may eavesdrop on your conversations. Conversations can be more easily recorded and later made public.

On a procedural level, there is debate about whether Skype is HIPAA-compliant (services such as offer an alternative). From what I gather, it is not legal to conduct ongoing, long-term therapy in a state where you are not licensed. So if you are only licensed in New York, you shouldn't be conducting therapy with a patient in Montana, etc, over the phone or internet.

The article raised another alarming possibility: a client who gets an instant session with her therapist because she has first-date jitters. Is this the kind of accessibility that is good for our patients, or is it simply a financial boondoggle for those who can afford helicopter therapists? It does indeed sound potentially too "attached at the hip", yet the lucrative allure may prove too much to resist for some therapists, who may actually believe they are doing good for their patients.

Perhaps there are some select situations we can generally agree are areas of potential benefit to explore with teletherapy. Disabled clients who can't leave their homes. Remote, rural patients without access to health care. Cases of severe anxiety or OCD (although challenging those anxious states by venturing outside one's confines is paramount to treatment). Situations in which commuting to therapy proves an insurmountable barrier. The New Yorker recently profiled attempts to bring psychoanalysis to China via Skype, perhaps the ultimate example of an impossible commute. At its best, technology collapses barriers and provides the possibility of intimate connection. In the wrong hands or in the wrong situations, it could prove dangerous. For example, if your online patient becomes suicidal or psychotic, how do you intervene?

Technology more generally may prove useful in other situations. Second Life or the equivalent for socially anxious patients. iPad apps to help the autistic communicate. Virtual exposure therapy for PTSD and simple phobias. (See this blog article.) And there are organizations that have been around for years that have constructed guidelines for effective practice (see this comment by one of the proponents and entrepreneurs in teletherapy) However, even this doesn't allay my fears about high-risk patients.

Web Therapy on Showtime satirizes the whole genre. Lisa Kudrow stars as a vain businessperson who sets out to make a quick buck by pioneering "three minute therapy". Sadly, the New York Times article seems to make her more of a prophet than a parody. High-tech therapy may in fact turn out to be lo-fi therapy after all, for many people and situations.

Interested in technology and psychology? See my article on The Emotional Dilemmas of a Technological Age. For fun, here's a poem about the iPad. This is included in my poetry book, "a fox peeks out: poems" due out next week - check here next week for the launch details. If you liked this blog post, please "like", share and tweet it, and consider subscribing to this blog's RSS feed by clicking on the button on the right-hand side. Thanks!

© Ravi Chandra, M.D. All rights reserved.

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