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

http://trueslant.com/toddessig/2010/03/15/warning-online-therapy-is-not-therapy-not-really/

I thought the original post and subsequent discussion would be of interest to all,

Best,

Kate

DeeAnna Merz Nagel
Just thought I would share some resources to balance the discussion.
Online Therapy Institute- http://www.onlinetherapyinstitute.com and the International Society for Mental Health Online http://www.ismho.org have established ethical guidelines for delivering counseling and psychotherapy via technology. Azy Barak,PhD has compiled an awesome bibliography that spans over 10 years- http://construct.haifa.ac.il/~azy/refthrp.htm

I contract with an EAP in Canada that has been providing asynchronous counseling for a decade- 10s of thousands of cases each year…

Online counselors do not prey on people- I am sure there are unethical practitioners online- just as there are face-to-face.

I am offering a glimpse into the world of professionals who do it, have been doing it for quite awhile, and wrote the book on how to do it ethically…

DeeAnna Merz Nagel, LPC

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5:18 pm on 03/15/10

Kate Anthony
Also to redress the balance:

I’m not sure anyone is claiming that online therapy is a new kind of therapy rather than a different way of delivering therapeutic services. My model (Anthony, 2000) was certainly based on f2f theories and models of the last 100 years and my own psychotherapeutic MSc training.

As leading ethicist on the topic (co-author of the British Association for Counselling and Psychotherapy Guidelines for Online Counselling and Psychotherapy 2001, 2005 and 2009), and also co-author of the Online Therapy Institute Ethical Framework for the Use of Technology in Mental Health plus assorted articles, chapters and 3 text books, I’m wondering if the Online Therapy Institute could help in preparation of your workshop? We are happy to disseminate information and education on the topic.
We have trained and consulted (face-to-face and online) for over a decade. More than happy to help!

“Not the same as face-to-face therapy” is not the same as “not as valuable as face-to-face therapy”, and therefore not really a disclaimer. A small point but an important one I think!

My final point – as DeeAnna mentioned, we have over a decade of empirical peer-reviewed evidence. I disagree that there is no “basis” for these services (and would argue that with -holding them from clients in need is unethical in itself, but maybe that’s a different thread).

With respect and look forward to more comments,

Kate

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5:54 pm on 03/15/10

Stephen Goss
Psychotherapy, counselling and psychiatry have been carried out via (electronic) technologies of one kind or another since the late 1960s. Research into tele-psychiatry (particularly video) took off in the 1970s and continued through the 1980s and onwards. And yes, the findings were, on balance, favourable. (Therapy by text based means has an even longer heritage too, if we include older means – Freud carried out analyses by letter, the technology of his time.)

More recent innovations like therapy by email, chat or other technologies are no longer new either – having been around since the mid-1990s. There are clear, strong ethical guidelines for those that offer such services produced by the leading professional associations around the world (BACP in the UK, NBCC in the US and so on) and the value of technological interfaces is now very widely recognised. BACP recently ammended their code of ethics to include explicit recognition of its value. It has an increasingly strong evidence base too and a burgeoning literature to support it. In the UK, the leading medical body whose remit is to approve interventions for the NHS, known as NICE – the National Institute for Clinical Excellence) has even made a ‘class statement’ that software providing computerised CBT (CCBT) is not only effective but sufficiently cost effective to be rolled out across the country at governmental expense. This is based on thorough, independent and systematic reviewing of the evidence.

Can a therapeutic relationship be created online, by email for example? Most definately – and there is good research to base that statement on (see Prof Azy Barak’s site for an introduction to just some of it). Is it a simulation? Why would it be? What is simulated about what I am expressing now? People certainly perceive feelings and personality via text based communication and can establish powerful relationships – therapeutic and otherwise. The fleshy messiness of live co-presence *is* sometimes essential – but that is a very long way from it always being the case.

Many professionals react to the idea of technological interfaces negatively, but I am yet to meet one who persisted in that view (whether they chose to incorporate it into their practice or not) once they were sufficiently informed about what can be achieved. Furthermore, it should be noted that these services began not as a result of professionals feeling squeezed by a competetive mental health market (most services I know in the UK, at least, have long waiting lists so there is no shortage of work) but as a result of demand from that proportion of people who preferred not to have to sit in a therapist’s office. As a specialist in service evaluation, I have long been struck by the repeated finding that clients value therapy but find the therapist less important than the therapist reports they were. Art Bohart’s work on the ways clients make therapy work highlights how people often wrangle help out of what their therapist says in ways the therapist never imagined – so if you want a physically present therapist, use one. If you don’t, and your problems are suitable for online therapy, you don’t have to do it in one specific way and may not have to look them in the eye just because some therapists want you to or claim that that is vital for your experience to count as ‘real’ – email, chat, teleconferencing, virtual realities are all options, as is CCBT and the other possibilities – look around: the world is bigger than you think.

I came to the topic of online therapy with a sceptical mind, very aware of the need for evidence based progress (my main specialty is evidence based practice). I have since been convinced – after more than 15 years investigating the subject – that not only can much be achieved by online therapy (including that it really is therapy, complete with empathy, interpersonal processes, congruence and activation of mirror neurons) it has the capacity to be accessible for people who would otherwise never receive help. That is in no small part due to the *reduction* in stigma people accessing online therapy frequently report. It is not for everyone, but for those it suits, calling it a simulation is misleading, baseless and risks putting people off recieving help they would otherwise feel able to reach out to.

The Internet does have its faults – a major one being the level of disinformation that people can post – it is always wise to find out the facts first.

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6:11 pm on 03/15/10

John Wilson
Wow! This is controversial!

Why not pay a visit to OCTIA 2010 conference http://www.octia.org.uk all about online counselling! I challenge anyone to spend more than 10 minutes in the chatroom without feeling connected to the audience, the experience and impacted by the connection that can happen both online and offline!

John Wilson
http://www.onlinevents.co.uk
http://www.wilsoncounselling.co.uk

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7:14 pm on 03/15/10
TODD ESSIG
Simu-Nation
Four very welcome responses, however much we may disagree. And thanks DeeAnna for the “call to arms” you put out on FB and Twitter, actually more like a “call to conversation”! Hopefully, more will participate, or at least read the exchange. As much as you feel this is an opportunity to teach and spread the word, I view it as an opportunity to encourage practitioners to tone down the evangelical fervor with which the potential value of new technologies is getting explored.

And there’s lots to say, but let me reassure you that I’m familiar with the resources you cite. First lets make sure we distinguish between various well-researched telepsychiatry programs (the Barak biblio is a wonderful resource I consult often) and private practitioners hanging out an e-shingle to offer “online therapy.”

Also, John Wilson mentions “feeling connected.” Of course in a simulation like “online therapy” there can be the feeling of connection, but the limits of the experience and the processes that go into its creation are different than the limits and processes in the connection one feels in actual psychotherapy. Recruiting research, even implicitly, from the latter in support of the former is very troubling.

In terms of Kate’s comment about “Not the same as face-to-face therapy” and “not as valuable as face-to-face therapy” I’m a bit confused. Asking whether a marriage or a religious practice is more or less “valuable” than f-2-f therapy does not make much sense to me. Same thing with “online therapy” and f-2-f therapy. The important issue is that they are not the same, so much so that we need to do a much better job educating people not to seek one when what is needed is the other.

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6:06 am on 03/16/10

Leon Tan
Dear Todd,

I find your article rather disingenuous, particularly the claim

But “online therapy” is not a new kind of psychotherapy; it is a technologically-mediated simulation of psychotherapy.

The disingenuity lies in the implicit assumptions regarding the ontological status of virtuals (simulation) vs actuals. One could just as easily say psychotherapy itself is a simulation of social life, watered down and reduced to a dyadic format that lacks the vitality and dynamisms of actual social living.

Yours is just the latest in the kind of cheap naive realism that permeates policy circles and professional associations alike, and perhaps such naive realism needs to be dialed back a little.

I mean, what are you really claiming when you oppose ’simulation’ to actual life, and when you suggest that simulation is thus not quite as valid or real?

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7:32 am on 03/16/10
TODD ESSIG
Simu-Nation
Who said ANYTHING about not as valid or real? These defensive responses that distort and misunderstand the basics of what has been written all confirm the excess of evangelical fervor and paucity of critical thinking among practitioners of “online therapy.” So, thanks for making my point!

So to repeat, a simulation is just as real as the actuality being simulated, a flight simulator is just as real as an airplane. But it is different, fundamentally. The experience it offers has different limitations and comes from different processes — and it is used for different purposes. If you want to go on an actual journey get on an actual plane.

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6:36 am on 03/16/10

John Wilson
I like your “call to conversation”, its what i am passionate about!

and I really agree that there is a difference between F2F and online.

I feel that our consciousness is always mediated through a physical technology whether that is my vocal chords or my fingers as I type …

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7:57 am on 03/16/10

DeeAnna Merz Nagel
Yes Todd, my call to conversation was about encouraging a dialogue here instead of in our offices or on private listservs. You have made your statement on the Internet and by having a blog that allows for comments- I assume you are open to discussion. My intention is certainly not to create a long-winded rant from therapists, but to use this platform for intelligent conversation.

Your title to the post was a “WARNING” and while I agree too that many practitioners are uninformed about work they are doing- whether it is delivering therapy via technology or conducting EMDR without the proper training, there are those of us that are informed about the work we do.

There are many of us who have been conducting online therapy for years- not in an effort to increase our income but because we are passionate about the work and have seen the benefit. To that end, we have spent many years teaching other practitioners how to use technology effectively and ethically.

Cyberspace is a culture that many therapists choose to ignore. If we are to be truly multicultural in our response to people reaching out, we must understand the nuances and the differences about real world and cyber-world experiences and that includes relationships, therapeutic or otherwise, that are technology-enhanced or are completely void of “physicality.”

This is the beauty of Web 2.0- it allows for collective intelligence that perhaps should not be interpreted as defensiveness.

DeeAnna

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8:33 am on 03/16/10
TODD ESSIG
Simu-Nation
Conversation? Good!!

A word about the warning in the title. I do think consumers need to be warned about online therapy sites. To be blunt, I think it is a dangerous practice in it’s current form, in part because the current practice undermines rather than encourages the appropriate clinical use of emerging information technologies (and if you’ve read other things I’ve written you would know I am a long time technophile).

A little context about ethics and “online therapy” that went into the title. First, there are huge problems with self-appointed ethical guardians setting up new organizations that promulgate new guidelines. I believe the guidelines need to come from within the messy. complex procedures of existing professional organizations.

So, with that said and out of the way, a 2003 study looked at compliance with ISMHO guidelines. They found less than 1/2 of online therapy provider sites were incompliance with 13 of the 20 guidelines. Only 1/4 said anything about potential risks, only 14% identified local back-up. Emergency procedures? Less than half. Confidentiality and informed consent? Less than half. These numbers were consistent with my unscientific visits to sites over the last few day. Plus, there was a disturbingly high number of sites that seemed to encourage practice in states in which the person was not licensed and would therefore lack malpractice insurance.

What about compliance with professional organization guidelines? A 2009 study looked at 66 online therapy sites put up by social workers to see if they were in compliance with NASW ethical guidelines. Only 1/3 of the sites had information about local backups and only 2/3 had information about emergency procedures, about the same as 6 years earlier.

So, as I said in the piece, I know people have to make a living, but I also want to warn potential consumers/clients/patients about current online practice. And, at the very least, I want people to know that “online therapy” has at best a weak connection to psychotherapy as it has been practiced and studies for generations.

Finally, a process comment about Web 2.0. It allows for both collective intelligence AND collective stupidity, the hive mind magnifies both ends of the spectrum. If you’re interested, you might want to take a look at Jaron Lanier’s excellent new book You Are Not a Gadget

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9:05 am on 03/16/10

Leon Tan
I think a word of warning is in order about psychotherapy in its ‘actual’ image also… as a case in point, the recent involvement of psychologists in the APA in the US state’s torture programs.

I would pick that you also like Andrew Keen’s The Cult of the Amateur if you liked Lanier’s ‘You are not a gadget’.

Finally, a comment about professionalization, this can work well as a concentrator of stupidity also.

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10:08 am on 03/16/10
TODD ESSIG
Simu-Nation
This is off-topic but take a look at the following if you are interested in the APA torture story:

http://trueslant.com/toddessig/2009/08/12/organized-psychology-also-to-blame-for-well-intentioned-torture-a-personal-story/

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11:52 am on 03/16/10

Martyn Clark
I’ve been mulling this today. Interesting stuff. I’m interested in the notion of online therapy as simulation. That makes sense to me. A lot of sense. My experience of in-person psychotherapy (as a client) is that in a real sense it is also a sort of simulation. I think it’s a different kind, more full, more embodied, maybe. I’ll never forget the session where I said to my therapist “I’m not sure if this relationship is real… you know… I pay you to have a relationship with me: how real can it be? It’s a bit like being a prostitute”. Turns out it can be very real, but it’s still a model, a reference, a simulation of “real” relationships.

In my practise (exclusively face to face, creative, existential executive coaching), I tell people that I like to help them jump off the cliff in their heads before it actually happens to them in their life. In that sense, all the work I do is a simulation. I personally prefer doing it while sharing a coffee, scribbling together on a piece of paper, playing a piano, rather than online, because I feel it gives more opportunities for embodied experiencing, and gives me more ways to work (i.e. not just rational, but also directly working with movement, facial subtlety, body language, gesture, non-verbals, creative media, etc). I do most of my work in public places, so the simulation is as real as it can be. Having said that, some of the most rewarding conversations I’ve had this year have been on Skype.

Really thought-provoking stuff. Just to be clear, though… to the French, Cheddar isn’t cheese. American Swiss definitely isn’t. In fact the cheeses that are sold as french cheese abroad are mainly called “fromages pauvres”, poor cheeses. They’re not real cheese because they’re not aged enough, not proven. If you’re Italian, Parmesan isn’t cheese until it’s been aged 12 years. CheeseWhiz isn’t cheese, no matter where you’re from. My relatives in Nashville swear it’s food, though, and get really excited pouring it on broccoli bake. It’s not my gig.

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2:39 pm on 03/16/10
TODD ESSIG
Simu-Nation
Hiya Martyn, welcome. Glad you’re finding interesting stuff here. And I must say, I love (LOVE!) your cheese comment; it might be the best thing I have ever read on True/Slant!

Whenever I talk about simulations people always think I’m contrasting it to “real,” that I’m making some sort of ontological distinction. I think Leon sees me doing that. But I’m not. Real is real. Our interaction via the T/S web-site is just as real as if we talked while sharing some Hudson Valley goat cheese from Acorn Hill Farm. The difference is not in the reality of the exchange but in the nature of the experience shared, especially the limits of that experience and the processes that generate it.

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1:09 pm on 03/16/10
DAVID DISALVO
Brainspin
Todd, great piece, very thought-provoking. I’m especially interested in the simulation and reality discussion. I’ve spent more time than I like to admit studying Jean Baudrillard’s simulacra and simulation theory and it’s helped calibrate the way I view simulation, and not necessarily in support of his thesis.

Example: Baudrillard used Epcot as an especially salient example of simulation (visiting “countries” without traveling to them, etc.) and with that example he had a point, since the simulation is so overt—the manufactured countries are nothing but a proxy for the actual experience, and quite obviously so. But the more I’ve studied neurobiology, the more I think his position on simulation was extremely limited. For example, I don’t think he knew, as we do now, that the brain has difficulty distinguishing between reality and fiction. When we come to “know” someone on a reality TV show, our brain does not intrinsically separate that “knowing” from knowing someone in person. We (if we choose to) make that division in conscious processing, and plenty of people do not (or choose not to).

I mention all of this because I wonder to what extent we’re compelled to consciously distinguish “simulated therapy” by your definition, with real therapy? Is it possible that the way in which our brains react neurochemically to, let’s say, a really good space shuttle simulation is similar to how our brains react in a virtual therapy environment (real therapy = real space shuttle)? And if the answer to that is yes (and I’m not presupposing one way or the other) then is it also possible that we can simply choose to abide our brain’s native tendency to not distinguish between “realities” and sort of just go with it and derive worthwhile benefits?

(off point, you’ve given me a great idea for a post topic…hope you don’t mind me “launching” from your good work.)

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8:06 pm on 03/16/10
TODD ESSIG
Simu-Nation
Your point about the neuorbiology of simulations is well taken: when simulations work, they work. And when they work there is likely to be significant overlap between the simulation and the traditional actuality being simulated. But even there, there are qualities to the experience, and therefore in the underlying neurobiology, that would be different. In the actual space shuttle, there would be no way to escape layers upon layers of the experience. There is no way not to know you are on the shuttle. But in the simulation, an awareness that it is just a simulation is always at hand, you have to do some psychological work, some suspension of disbelief, to stay in the simulation. Albert Borgmann has described this as a quality of repleteness, although I think he is more critical than he needs to be.

What fascinates me about simulations is not when they work, which is already pretty fascinating, but when they don’t work and the limits of the experience are reached. That is what I was getting at in talking about safety and risk in therapy vs. “online therapy”

Consider the following situation: someone on the actual space shuttle and on the simulated shuttle having nearly identical experiences each begin to feel discomfort in the center of their chest, a kind of squeezing pain that does not go away. They notice a shortness of breath, cold sweat, even some lightheadedness. In short, they each think they are having a heart attack. What do they do? In the simulation they can scream, “turn this off, I’m having a heart attack” while in the actual shuttle they would have to initiate emergency medical procedures.

Kind of garish example I know. But the point is that the experience of risk is different. And as such, the experience of landing will also be different. No mater how good the simulation there will always be differences one could point to. As a psychotherapist who is also a bit of gear-head and who thinks about this stuff, I think we need to look at where the experience of technologically-mediated simulations of psychotherapy break down as well as when the simulations work well. Current “online therapy” practice does not pay sufficient attention to the limits of the experience it provides (and I am not saying this about researched telepsychiatry projects nor even other innovative approaches like the NYU chat room work I wrote about — http://trueslant.com/toddessig/2009/10/03/queer-confused-and-in-college-a-chat-room-provides-help/ )

(looking forward to reading the piece our conversation helped launch!)

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4:18 am on 03/17/10

Leon Tan
Whilst Internet technologies may blur the spatial boundaries of conversation partners, they do not by any means deprive conversations of their reality. We are thus not forced to the strange conclusion of this article’s logic, that conversations cease to be conversations and become simulations when they take place online.

http://bit.ly/dqnu8N

I’m intrigued you choose not to publish my response to your response Todd.

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7:45 am on 03/17/10
TODD ESSIG
Simu-Nation
To keep conversations manageable (especially technologically mediated simulations of conversation like this one [grin]) I don’t “call-out” to use the T/S phrase those comments that repeat distortions and mis-statements. They have to add something.

The big distortion you keep asserting (is it an intentional misunderstanding on your part?) concerns what is or is not “real.” I am saying (again) that “online therapy” is not really psychotherapy, it is a tech-mediated simulation of psychotherapy. I am not saying it is not real. Of course, it is a real. It is a real experience of, for example, paying for an email exchange or a phone call with someone. Yoga is real, religious practice is real, and yes “online therapy” is real. But none of them are psychotherapy, should not be called as such, and people should not be led to believe that the experiences they offer are the same as those that have been researched and studied for generations. And yes, people do, I think, need to be warned.

Here’s something I said to you earlier in the conversation (again!):

“So to repeat, a simulation is just as real as the actuality being simulated, a flight simulator is just as real as an airplane. But it is different, fundamentally. The experience it offers has different limitations and comes from different processes — and it is used for different purposes. If you want to go on an actual journey get on an actual plane.”

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6:18 am on 03/17/10
helenglatt
So given that your title, ‘WARNING: Online therapy is not therapy, not really’ turns out to mean, ‘Only face to face psychotherapy should be called psychotherapy’, may I suggest you correct it to more accurately reflect your views, otherwise it’s somewhat hysterical and misleading, don’t you think?

And you’ve discovered, as have we all, that there are many unscrupulous people in the world making all sorts of false claims in order to prey on the vulnerable, but there are Professional bodies to whom you can complain you know. So why don’t you do so instead of making a technologically-mediated simulation of a complaint?

Helen Glatt http://www.offload-onlinecounselling.co.uk

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10:16 am on 03/17/10
TODD ESSIG
Simu-Nation
Of course I don’t think it is either misleading or hysterical. Misleading and hysterical would be a title saying “Research shows 2/3 of ‘online therapists’ put clients at serious risk by NOT posting information about local back-ups.” Oh wait, that’s true. Or how about “History of depression or anxiety? Even ‘online therapists’ say avoid ‘online therapy.’” Darn, that’s another true one, which I know because your web-site states, “If you have a history of mental illness, it is advisable to see a specialist face to face.”

I actually commend you for stating that. I just wish you and your colleagues were similarly sober about claims about how “If you’re feeling depressed, insecure or generally stuck or you’re having problems in your relationships, online counselling can help you explore your feelings and thoughts from the comfort and privacy of your own space.” (again from your site).

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7:20 pm on 03/17/10
miek
I totally agree with your post! As a client of a psychotherapist, I’m realizing that a PC could never substitute my therapist the days I was suicidal or the days that I was in totally despair. Or all those other days that were so difficult because of my depression. And yes, now, seldom we mail to each other between 2 real (!) sessions when I’m really having a bad time. And then the mails are helping me, most of the times, but that’s because of the relation that is already established.

Also, online therapy is ignoring the fact that 30% of the effects of psychotherapy are because of the relation between the client and the therapist (Lambert). Okay, there is a substitute relation when mailing with somebody you don’t know, but it’s a substitute. When I mailed frequently to somebody (and I did this frequently in the past by special sites), the relation became never so deep as when I had real and frequent contact to people. I think nobody can deny that being connected by e-mail isn’t the same as being connected by face to face contact. Otherwise, why aren’t (young) people happy if they only have virtual friends? Why do they want to have real contacts with persons? Why do we want other people by our side and not just a computer on a lonely island?

I think these substitute and weak form of ‘therapy’ is well designed if someone has a living problem… Problems that aren’t real psychiatric disorders and only need a good talk by a friend (but don’t need therapy).

By the way: is there also a publication bias of that form of ’substitute therapy’ like there is a publication bias on many CBT psychotherapies?
See: http://bjp.rcpsych.org/cgi/content/abstract/196/3/173

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8:16 pm on 03/17/10

John Grohol
It seems strange to define a problem as suggesting something isn’t “therapy” because certain surveys have shown varying compliance with voluntary guidelines. There’s a decade’s worth of research into online therapeutic interventions and multiple international conferences on the topic. Conducting an informal survey of online therapists — as you have — and then making an arbitrary declaration seems to be more oriented toward making sensational headlines than forwarding an intelligent and well-informed discussion on the issue.

Of course, what’s missing here is the actual clinical research evidence that has demonstrated the effectiveness of online therapeutic interventions. For over a decade. A nice literature review or even mini-review of that would’ve been nice. But hey, a quick “survey” of what you, personally, have seen is easier. Not empirical. Not research. Not a data point, but a personal op-ed.

So please, join the ongoing conversation about these issues in a professional organization — like ISMHO — that’s been discussing them for over 12 years. But don’t put out an arbitrary blog entry that pretends to have done anything other than a shallow analysis and come up with “Oh, it’s just a ’simulation’ of psychotherapy.” Please.

One definition of psychotherapy is:

“The treatment of a behavior disorder, mental illness, or any other condition by psychological means. Psychotherapy may utilize insight, persuasion, suggestion, reassurance, and instruction so that patients may see themselves and their problems more realistically and have the desire to cope effectively with them.”

Are you suggesting these things can’t or aren’t being done online today by the thousands (yes, sorry, thousands, not just a few dozen here or there) of mental health professionals? Can you tell all of that just by visiting a therapist’s website??! Are you suggesting that research that has shown CBT techniques translated to online practice can be just as effective is somehow bogus or shoddy?

Be specific. This talk about “not real” and “simulation” simply muddies the water in ways that data can easily clear things up.

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10:48 am on 03/18/10
TODD ESSIG
Simu-Nation
Thanks for contribution John, I’ve been finding your work interesting and useful since the early 90s — however much and profoundly we disagree, glad you’re here.

While your comment about voluntary ethics (which I will comment on in a moment) is part of the emphasis in the discussion on ethics, the piece itslef was that actual psychotherapy and online simulations of it differ fundamentally in terms of the limits of the experiences they provide and the psychological processes that construct the experience. Not much has been said about that … interesting, I guess muddy waters can be in the eye of the viewer.

Now, about what you call “voluntary guidelines.” At least in New York State where I practice, “The practice of psychotherapy is restricted to individuals licensed in the professions of psychology, social work, medicine and as a registered professional nurse or a nurse practitioner or individuals in exempt settings.” (correction: left out source, the quote is from the NYS Education Dept. Office of the Professions). What that means is that adherence to ethical standards is NOT voluntary.

This was not my argument in this piece (again, it was about limits and process), but “varying compliance with voluntary guidelines” is indeed something that is not psychotherapy. Consumers/clients/patients have a right to know that the person they are going to for help with problems in living adhere to the highest ethical standards, both because they want to AND because they have to. If compliance is voluntary, then people need to know it is not actual psychotherapy (and, again, it might be helpful, interesting, etc. like a yoga class, but it should not be put under the same umbrella with actual psychotherapy).

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11:35 am on 03/18/10
donaldcbliss
briefly, i’d like to say that i find this post quite alarmist. in fact, everything you say could have been said – and undoubtedly has been said – about every single development in psychotherapy since freud, up to and including freud’s work and theories themselves. for some, “new” and “different” always equates to “bad” or “worse/lesser than”.

the truth is that if we wanted to we could call psychotherapy itself “simulated relationship”, and one could certainly make a strong argument for that perspective. at least those of us who have profoundly deep and intimate personal relationships could, in particular if we are non-westerners living in cohesive communities where psychotherapy is simply not part of the cultural schema.

i also think it’s sad that you pretty much dismiss outright one of the only means of accessing psychotherapeutic intervention for people with physical mobility issues and those who are otherwise unable to access psychotherapy services face-to-face: people living in remote areas; english speakers living in foreign countries; etc, etc, etc. your message to them is that they are only capable of accessing what are essentially fake psychotherapy services, and that in itself is a grave disservice to them.

there are charlatans and practitioners who fall short of ethical and legal standards in every profession, and there are potential shortcomings to face-to-face therapy and therapists just as there are potential shortcomings to online psychotherapy and online psychotherapists.

don

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12:32 pm on 03/18/10
TODD ESSIG
Simu-Nation
Thanks Don, I’m in profound, deep agreement with you about the value of online interventions when exigent circumstances exist, such as medical or physical problems, geographical dislocations, or even the help provided some people with agoraphobia. Also, as miek said above, in the context of an actual relationship all kinds of online contacts can be very helpful.

We also agree that actual psychotherapy and “online therapy” have potential shortcomings, I just hope we can agree that they are different shortcomings and we owe consumers unambiguous statements about those differences.

But “essentially fake” is NOT the same as a technologically-mediated simulation. The difference is in terms of the limits and processes, not whether one is more or less real than the other.

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2:47 pm on 03/18/10
TODD ESSIG
Simu-Nation
I’m glad you’re starting to hear me, makes me think this long comment thread has been worth the time. A coupe of final thoughts before I bow out:

Please don’t confuse limited practitioners—of whatever variety—with my topic of the limitations of a practice. While I’m glad you find my comments measured, most of them either re-state points made in the post or clarify that something I’m being told I said I did not say. Is it possible that for some an attachment to the practice makes it hard to hear criticism? Maybe. I guess.

In terms of my presentation, I think I may disappoint you. My reaction to the comments received here and back channel have actually solidified my belief that consumers/clients/patients need to be warned about private practitioners tossing up web-sites to sell access to what’s being called “online therapy.” As for my hopes, I hope that after participating in this discussion you will urge your colleagues to dial back on the evangelical fervor found in so much online practice building.

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Email therapy or IM therapy is pretty bogus.

There's some impeccable quantitative data that telephone therapy works as well for people with depression than face to face:

http://www.sciencedaily.com/releases/2010/05/100510141729.htm
http://www.psychologytoday.com/blog/the-shrink-tank/200811/dial-t-therapy-treating-depression-over-the-telephone

Skype? it's a brilliant innovation. Is it as good as being in the room? No. But is it far better than taking three hours out of a day for therapy -- counting traffic, parking, etc? Is it far better than terminating therapy with a strong alliance because of a relocation? It is good for the chronically ill, the housebound, and those who care for them? Yes, yes, yes, yes.

That pesky telephone will never replace the telegraph. An email will never replace a hand-written letter. Books could never be sold online. Surgery could never be done remotely. The internet is nothing more than a "fad." Online therapy can never substitute for actually smelling your therapist in person.

In all seriousness, the internet is nothing more than a delivery method. The content still matters. Regardless of if the therapy is given through http://iCouch.me or in deck chairs on someone's yacht -- it's the content of the sessions that's the key issue, and always will be. Saying that iTherapy isn't "really" therapy is about like saying a telephone call isn't "really" a conversation. While I respect the experience and perspective of the author, we must all be careful not to judge iTherapy on the basis of the websites currently on the market. Just because the current crop might be of varied quality doesn't mean that iTherapy is not real therapy.

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Brian D.
CEO, iCouch, Inc.

What a frankly good piece!

what if I´m moving out of town and I still need therapy. Can online therapy help (with my current therapist) or do I have to find another one?

On or off line are both viable therapy when they are in alignment with the patient. For example HSPs (highly sensitive people) need a therapist who is trained in highly sensitive people. Such training is available, and it puts the light on to about 20 percent of all people.
Of course there are all kinds of thinking that go against any thing new. Some people just enjoy being stubborn, and being stubborn promotes stigmas. American mental health care already has far too many stigmas.

A 2008 meta-analysis of 92 studies found that the difference between Internet-based therapy and face-to-face therapy were not statistically significant (Journal of Technology in Human Services, Vol. 26, No.2).

It is important to keep in mind that while it may be "different" studies suggest that video therapy is "as effective" as therapy which take place in the same room, as commented above.
Providing remote mental health care services increases access to care in an international environment where mental health services are extremely insufficient in relation to need. The World Health Organization considers this a part of the "Human Resources for Health Crisis". Many studies have found that, particularly, mental health care services are grossly inadequate in Low and Middle Income Countries (Rajkumar, 1991; World Health Assembly, 2001; Wiley-Exley, 2006; WHO, 2009; Kakuma et al., 2011; DeSilva, Samele, Saxena, Patel, and Darzi, 2014).

Increasing access to mental health care helps fulfill basic human rights, specifically article 25 of the Universal Declaration of Human Rights "Everyone has the right to a standard of living adequate for health and well-being.... including medical care". Video therapy can be particularly helpful for those who struggle to leave their home such as those experiencing social anxiety or perinetal depression. Video therapy can also be helpful for those who have confidentiality concerns including those struggling with addiction.

It is normal to be risk averse, however, there is significant evidence to support the effectiveness of video therapy provided the individual accessing the service can secure a confidential and safe space to meet.

The Online Psychology Clinic TOPCLINIC.ie provides psychological services for individuals across Ireland including video therapy.

I would like to, specifically, attend to each of your valid concerns;

Saftey and risk:
With encryption technology, ie using a telemedicine platform instead of a chat platform, safety and risk are increased, significantly. Yes, there is the possibility of a call being dropped, and this is annoying. But, I would challenge your assumption that this eliminates the possibility of providing a holding environment. Oxford dictionary also defines co-presence as “The engagement of individuals in synchronous interpersonal communication, not necessarily in the same physical location” The reality of a call dropping, also increases one’s ability to regulate emotions. Individuals who experience a call dropping develop their skill in being able to move into and out of emotional depth with ease. Video therapy may be different, but not in effective.

Empahty:
According to Rogers, the therapeutic alliance is built on empathy, unconditional positive regard (acceptance) and congruence (remaining genuine). This is the ability to enter another person's world without judgement. I do believe that the next big step in technology for video therapy is resolving the issue of not being able to look someone in the eye and into the camera simultaneously. However, mirror Neurons function even if individuals are not making eye contact. If someone was in our peripheral vision and got hurt, our mirror neurons would still fire.
That said, it is VERY important that both the client and the therapist not have notifications or distractions on their device so that mutual gaze behavior can be facilitated. However, this mutual gaze behavior is not necessary for empathy to be experienced. Have you talked to someone on the telephone and felt they understand your experience without judgement?

Thanks for sharing this blog. Life is very busy these days and due to work pressure people are suffering from anxiety, so therapy is very relaxing to release your tensions. With the help of online/individual therapy you can easily release your tensions and anxiety.