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Therapy

Retronyms, Online Therapy, and Implicit Bias

When we say "psychotherapy," do we mean in-person by default?

Key points

  • A retronym is an adjective that provides previously unneeded specification, e.g., "acoustic guitar" or "snail mail."
  • Using a retronym reveals biases in comparing the established with the new.
  • An important example is our use of retronyms and other descriptors to reflect our attitudes toward therapy conducted in person versus online.
  • Such value judgments are nearly inevitable in natural language.

Retronyms are adjectival qualifiers, like “acoustic” guitar and “snail” mail, that were previously unneeded — because all guitars were acoustic and all mail was slow. We only added qualifiers when alternatives arose. As these two examples illustrate, retronyms can be nearly neutral — the status and popularity of acoustic and electric guitars are roughly equal — or plainly judgmental. Snail mail is explicitly inferior to faster email. “Snail” is not a neutral term.

Psychotherapy conventionally occurred between two people in one physical room. Although teletherapy — psychotherapy conducted over telephone or video — is not new, it was previously a special case. As such, it required specification while regular therapy did not. Consider an analogy with “skateboard”: without a qualifier, the word clearly refers to the kind operated by foot power. An electric skateboard is an innovation that must be specified.

However, as alternatives become more established, we often employ retronyms. In contrast to “skateboard,” it is less clear what we mean by “scooter.” There are kick scooters, electric and gas scooters, even “stand up” scooters in contrast to those with seats. Now we routinely disambiguate the word “scooter” by specifying which kind. Likewise, the growing popularity of teletherapy, which was greatly accelerated by the pandemic, now compels many of us to disambiguate “psychotherapy” with a retronym.

Which words should we use to describe these alternatives? And what do our word choices imply about how we judge each alternative’s quality, desirability, and legitimacy?

How do we feel about teletherapy?

When it comes to psychotherapy, many argue for value-neutral contrasts such as “onsite” versus “online,” terms carefully chosen not to telegraph a preference. In particular, “online” therapy avoids the implicit negative bias in alternatives like “remote” or “distance” therapy.

But using “onsite” as a retronym levels the playing field awkwardly and artificially. “Onsite” obscures real differences between talking face-to-face with another live person in the same room, instead of through screens and microphones. (And technically speaking, therapy could be onsite and online at the same time, say in adjoining rooms connected electronically.) Even an alternative such as “unmediated,” which more accurately contrasts the two options, tiptoes around the essential differences between them. We’d be more honest simply sticking with “in-person” despite its positive emotional bias. Or we could use no qualifier at all, and rely on the assumption that psychotherapy is in person unless otherwise specified.

Expressing honest values is not a hard sell

It’s nearly impossible to scrub value judgments from natural language. If a term doesn’t already come with an explicit value judgment, it often develops one over time. “Juvenile delinquent” and “mentally retarded” were both introduced to replace prior stigmatizing terms — and then became stigmatizing themselves. In similar fashion, the fortunes of “online therapy” as a term will rise or fall depending on how the public comes to feel about the practice. Meanwhile, “in person” or “face to face” therapy sounds superior because intimacy is inherently good, especially in a healing context. No linguistic contortion can change that.

Of course, there are competing goods. “New, improved” teletherapy also sounds attractive, as does teletherapy that is “economical,” “accessible,” or “hassle free.” Descriptions of therapy from any angle can sound like an advertising pitch. As healing professionals, we walk an ethical tightrope between presenting alternatives realistically, even though this reveals our values and biases, versus crudely touting our own approach and denigrating others’.

Face to face therapy is different

In walking this ethical tightrope, some try too hard to be carefully neutral. The result is dry and unrealistic. The essential difference between the two types of therapy is not that one is onsite or even unmediated. It’s the difference between talking to a person and talking online to a person.

Subjectively, we all know these are quite different experiences. Moreover, barring practical considerations, the former is usually preferred. When family members meet on Zoom or FaceTime, they typically look forward with anticipation to their next meeting in person (or reminisce about past such meetings). The reverse is not true. When family members meet in person, they do not typically look forward with anticipation to their next virtual encounter. This asymmetry holds in other relationships as well, e.g., in business and romance.

Note that humans have been talking to one another for decades using telephones, and more recently computers. Yet we often don’t employ a retronym to disambiguate “talking” when we mean in person, face to face — the original kind of talking. “I talked to Mary” is usually clarified by context, e.g., where Mary is located, not by an adjective. By extension, “I had a therapy session with Mary” naturally connotes doing so in person, unless the context suggests otherwise. The choice to use (or not use) a retronym is essentially a political act: a way to grant or deny status to the new, as compared to what came before.

This isn’t going away

Looking to the future, we may someday feel pressure to specify “human” therapy in order to distinguish it from computer-generated “AI” therapy. This pressure will come from those who aim to grant AI therapy a legitimacy comparable to the human default. Advocates may even complain that “human” is unfairly positive, and suggest something more neutral.

Does “human” carry positive connotations, an implicit bias? Of course it does. This is inevitable — and it stands in clear contrast to putting our thumb on the scale with terms like “meatware therapy” (to denigrate the traditional type, see “snail mail”) or “inhuman therapy” (to denigrate the new type, see “junk food”). Sometimes accurate descriptors such as “human” or “in person” sound more attractive because they really are — if we choose to use them at all.

©2021 Steven Reidbord MD. All rights reserved.

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