It must be a slow news week, as The New York Times ran another article extolling the virtues of online therapy, with a focus on videoconferencing and Skype. In a well-crafted article, Jan Hoffman gets quotes from a half dozen or so professionals to demonstrate how online therapy (or e-therapy) is on a roll.
But like most articles on this topic, the reporter does the easy legwork — talking to experts in the field — but seemingly doesn’t ask any serious questions. It’s a puff piece wrapped in beautifully baked fantasy-land pastry.
So what’s new? Let’s find out.
Apparently what’s new this go-around is the anecdotal surge of videoconferencing and Skype. There’s zero data in the article to suggest this is actually the case, but that was the focus of this article.
But it’s so cool! You can lounge at your friend’s pool while drinking an alcoholic beverage and have a “therapy” session:
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. […]
“I can have a Skype therapy session with my morning coffee or before a night on the town with the girls. I can take a break from shopping for a session.”
While I have no idea the kinds of problems Ms. Weinblatt is seeing a therapist for, I don’t think they are the same kinds of problems that many people seek therapy for. How many people would be comfortable delving into their childhood abuse or deep, dark depression while lounging at your friend’s pool?
But while the example given is a bit over the top, the reason Ms. Weinblatt sought out online therapy is a very real and legitimate one:
Ms. Weinblatt came to the approach through geographical necessity. When her therapist moved, she was apprehensive about transferring to the other psychologist in her small town, who would certainly know her prominent ex-boyfriend. So her therapist referred her to another doctor, whose practice was a day’s drive away. But he was willing to use Skype with long-distance patients. She was game.
So there’s the catch… Videoconferencing is cool and all, but it utilizes only one of the benefits of remote counseling — taking geography out of the equation. Everything else about the therapy session is the same — the need to jointly schedule a convenient time for both parties, the amount the session will cost (sometimes even more!), lack of anonymity (if one so chooses), and the awkwardness of talking to someone face-to-face about deeply personal, emotional concerns.
Instead, the reporter focuses on some of the little technical details of doing videoconferencing well. Oh, the picture can be pixelated on bad connections. You have to know something about white contrast, and know to look at the camera when speaking. These aren’t the real problems with videoconferencing for psychotherapy.
Video- conferencing therapy provides a handicapped view of nonverbal behavior.
The real problem is simply one of whether the way most people use videoconferencing today for therapy in any way approaches the professional emotional intimacy or therapeutic rapport of a face-to-face session. I would argue it does not, and that most professionals are substituting the idea of intimacy — because both face-to-face and videoconferencing show you a person’s face — with actual therapeutic rapport.
I’m not alone in this observation:
Johanna Herwitz, a Manhattan psychologist, tried Skype to augment face-to-face therapy. “It creates this perverse lower version of intimacy,” she said. “Skype doesn’t therapeutically disinhibit patients so that they let down their guard and take emotional risks. I’ve decided not to do it anymore.”
Indeed, perversely, online therapy done through videoconferencing actually removes one of the benefits of online therapy — increased disinhibition — and replaces it with a handicapped view of nonverbal behavior (someone’s disconnected head). Is viewing a 4 inch video of your therapist’s face on your mobile phone the same as sitting in a room with that person? Does it even come close?
What the article fails to talk about are some pretty important things. Like the fact that nobody has certified Skype for HIPAA compliance — meaning that it doesn’t currently qualify as a technology that one should be using for private and confidential mental health exchanges. To me, that’s a pretty big oversight, since if most patients knew that, they might be wary using it to talk to their therapist.
The other is the lack of any information about whether people are turning to online therapy more or less than they did, say, 5 years ago. Instead, we have this gushing anecdotal proclamation from a psychologist/lawyer:
“In three years, this will take off like a rocket,” said Eric A. Harris, a lawyer and psychologist who consults with the American Psychological Association Insurance Trust. “Everyone will have real-time audiovisual availability.”
Really? That’s an astounding statement to make, considering online therapy has been around for 16+ years now, and videoconferencing for online therapy has been around for over a decade. So during the next 3 years, everything’s going to change. I can’t wait!
The only data point offered is one I’ve seen time and time again — the number of therapists who sign up to offer this kind of service. In 2001, the online therapy clinic I ran had something like 1,000 therapists signed up at its peak. A clinic today touts its 900 professionals number. To me, that suggests little has changed — professionals are always willing to sign-up to potentially use a service (since it costs nothing to do so). But will consumers follow?
While we’re seeing increased interest in some online services from consumers over the past few years, it’s still a drop in the bucket of psychotherapy services. Most consumers who turn to videoconferencing online therapy do so because they have a specific need — one which is usually constrained by geography.
That’s a big market.
But the even bigger market is for people who value all of the benefits of online therapy that videoconferencing can’t offer. These include: not having to schedule an appointment time every week, feeling more able and relaxed to talk about difficult issues because of the disinhibitory effects of online communication, decreased cost (because you’re not taking up 50 minutes of the therapist’s time), and portability to take your therapist on the go without having to worry about sketchy videoconferencing connections.
After all, writers for thousands of years have transformed the written word to communicate immense emotion. While not all of us are Shakespeare, we’ve seemed to do just fine expressing ourselves through this written word online through our social media sites like Facebook and Twitter.
Surely videoconferencing has a place in online therapy, just as it has had for the past decade. But it creates as many problems as it solves (conducting psychotherapy in public places like a friend’s pool or the shopping mall?), and is unable to deliver on some of online therapy’s most important benefits.
Read the full article: Therapists Are ‘Seeing’ Patients Online
31 comments
Skype is not for everyone. Therapy is not for everyone. But for those with busy lifestyles, who don’t want the hassle of a commute and traffic, who want the ease of going from work to a session (in the privacy of their home office, for instance), psychotherapy via Skype can be very effective. Iinitial uneasiness such as “this is different than your office” and “that’s weird seeing myself”, quickly dissipated. I found clients to be much more focused on the issues they wanted to explore or problems they wanted to solve, that the mode of therapy didn’t matter. I found the sessions to be very productive, as did my clients. As for the client who had a mojito (as quoted in the New York Times article), that wouldn’t fly here. It’s unethical to counsel a client who is intoxicated. Further, we cannot ethically counsel a client who has been drinking in the past 24 hours, and, I outline this in my informed consent form.
As an introvert by nature, and a non-techy, I was surprised by how simple Skype therapy has been for myself and my clients. There’s a definite connection between therapist and client, and, interestingly, we’ve had some interesting therapeutic breakthroughs.
I now see therapy via Skype as an important tool to help the client stay focused on their needs and presenting problem, and less on “well, let’s see…what are we going to talk about today”, which often occurs during therapy in a standard office setting.
I highly recommend Skype therapy.
Brenda, what do you do about licensure issues? A recently article in Psychotherapy Networker made the point that a California therapist “Skype seeing” an out-of-state client could be fined by both states.
I can’t wait for the first patient to do a save-to-hard-drive of the entire therapy Skype file and then start posting all his/her therapy sessions for the world to see. I can just see it:
watchmytherapy! dot com.
The psychotherapist-patient privilege rests with the patient, after all.
That could effectively end this form of therapy, no? What therapist would open himself/herself to that kind of scrutiny?
Sure, the therapist could require that the patient sign some kind of I-won’t-do-that form, but it wouldn’t be worth the paper it’s printed on.
This past week I had a video session with a psychiatrist who is an hour’s drive from home- good ones are sorely lacking in our city. It was interesting, nerve racking, and good – I think, but there was something missing – I couldn’t just reach across the table and give him the sheets outlining my history – they were faxed to him earlier, but weren’t in front of him – I had a copy with me, but couldn’t give them to him – won’t go through glass. I also felt an emptiness, or rather a flatness to the experience because I didn’t have the one on one, or in this case – there were 3 people interviewing me (2 students).
So was the experience good? It was okay, the next session should provide me with a better feel to this type of thing.
Well Dr. John, on this I think all I can say is: Well-written (I mean you, but the article too)!) That was similar to my reaction, imm neither too “shock”-oriented nor devoid of actual counseling-relationship issues. In Rorschach terms, it was ok with “d [little detail]” bits, like the importance of eye-contact, and some larger picture points also, like the “convenience” factor and the actual value of having the modality available as an option, where appropriate.
The rest of my visceral and global and researcher-hat responses are all very much in line with your reaction and report, John. ahhhh… Happy Autumn!
Thanks John for a frank overview of the article. I guess I am glad that at least the story is still out there, albiet cloaked in lifestyle and mohitos…
TOG- I believe in this age of technology it would be as easy (except for the commute) to record a therapy session and post the audio or transript on the internet. The therapist would be none the wiser…
DeeAnna
True, to an extent. Except inn the case of transcript or audio, the client would have done the recording secretly (on one of those reccording pens they advertise in the “Skymall” publications you see on airplanes, for example.) The therapist wouldn’t know.
Here? The therapist colludes and enables.
Plus, there’s nothing as powerful as visuals. Just ask Anthony Weiner.
As a psychologist, I would like to see more research. I just did a search on PsychInfo, and while there is good lit about “Telepsychiatry” it is always in well controlled settings, with some sort of pre-assessment of client, usually in geographically remote areas, and for very specific diagnoses, problem areas or targets. Usually using CBT, and likely with pre/post-test measures.
But on general websites, the therapist are trained at lower levels, often from marginal online or other universities, with limited backgrounds in a broad range of mental health issues, and in private practice (ie – no controlled setting). There is no such thing as “chat” as is listed on certain webistes. The research (as I read it ) does not lend itself to generalization in most settings as primatry treatment (I am not including long-term pts, those who travel for a few weeks, etc. I mean a “full” therapy done entirely on line with no F2F.
It’s like saying “there’s research that apsirin works!!!!”. But for what? when? etc.
Can you enlighten me? Thank you.
Thank you, Jon, for writing this retort to the New York Times article. You very eloquently echoed my gut reaction to the article that I had anxiously awaited reading. I had expected more from them, especially given the time that the reporter spent interviewing people in the field.
It is amazing that they haven’t put in restrictions for the Skype therapy yet. You would think that it would have been the first thing done with all the sue-happy people there are these days.
Once HIPAA decides what to do with it, it will be interesting to see what happens. I see the benefits of it. But I can see how it can make therapy more challenging but yet more convenient (as in the location and scheduling).
I guess we’ll see… :-\
I’ve never used video tele-conferencing for therapy, but I’ve used it many times for business meetings. I agree with the ‘pseudo-intimacy’ observation. The video stream raises my expectations that there will be a subtle human connection, but that expectation is never met. It’s as if the video somehow filters the humanity out of it. It feels vaguely Max Headroomish. I can feel more ‘connected’ on a simple phone call.
Sure, the therapist could be trained to look at the camera, not the client’s eyes on the screen. That might look slightly more normal to the client. But if the therapist is staring at the camera, they’re not seeing subtle cues in the client’s eyes.
Conversely, imagine a female therapist and a male client. He could be looking at her eyes on the screen, but the camera angle might give her the disconcerting feeling that he’s talking to her chest. How can she tell the difference? I suppose she could bring it up, but it seems like a waste of the client’s billable time. And would her bringing it up feel like a false accusation to him? How would that effect the therapeutic relationship?
Humans are acutely sensitive to eye contact, sight lines, and even sensing the distance at which a person’s eyes are focused. With video, all of that is filtered out. To my mind, that makes video conferencing nothing more than a gimmick. It’s ok for corporate sales meetings I suppose, but inappropriate for therapy.
(Full disclosure: I’m a client, not a therapist. So my comments are just some dude’s opinion.)
With all due respect, all you have to do is state to the person receiving your “counseling” services that you are simply advising them, coaching them, being a consultant to them to help them improve their personal life in terms of quality and performance. No law can prohibit that.
Samuel Lopez De Victoria, Ph.D.
http://www.DrSam.tv
Actually it is more likely that mental heatlh professionals will be held to the standard of their license regardless of what they choose to call the service. We recently wrote about this very topic:
http://issuu.com/onlinetherapyinstitute/docs/tiltiss7/24
Since there’s been zero tried cases that I’m aware of (happy to be corrected if wrong!), it’s still simply a matter of opinion. While it’s long been argued that it’s what you do that matters, you generally don’t see psychology boards (in the U.S. anyways) prosecuting coaches, much less the multitude of professions who also engage in what are arguably “psychological interventions.”
For example, if one argues that listening and sharing things about one’s life and relationships are components of a therapeutic relationship (or a “psychological intervention”), then hair stylists and clergy are practicing psychology too without a license.
The language most psychology laws are written in tends to be so broad as to capture a wide range of professions and professionals. Coaching is, in this way, no different, and is unlikely to be prosecuted by anything except the most zealous board.
While it’s unlikely that a licensing board would go after a non-psych professional for practicing without a license, it feels more likely that a board would be keenly interested in a licensed therapist who is end-running the law by calling their out-of-state therapeutic work “coaching,” “life-coaching,” or any of the other distinctions without a difference that Dr. de Victoria posits.
@TPG–Sorry for the late reply. Good question! I provide Skype therapy only for clients who reside in California. My CA license limits me to CA, which I view as a good thing. I still need to keep abreast on CA law and reporting issues, as well as knowing where to send a client (in their area) if a life-threatening or safety situation arises.
@TOG–I agree with Ms Nagel. There is certainly the possibility that a client could record a session without my knowledge and permission. The same would apply to an in-office session. Surprisingly, I heard of a client who recorded another therapist’s sessions. So, I agreed to meet after the client proved that they weren’t recording me. Is there still a risk? Sure.
Keeping current on therapy via Skype, taking continuing education classes (I use Ofer Zur’s classes) shows that the clinician is using diligence with regard to confidentiality, as well as legal and ethical issues that may arise in the course of therapy.
Is Skype therapy for everyone? No. Neither is traditional therapy. It’s important that our clients have safe options. Skype therapy with a trained clinician is one of them.
@Dr Sam–We are obligated to present the services we are offering to our clients. It’s unethical to present psychotherapy or marriage counseling (for example) as coaching. Coaching is educational, not therapy. Psychotherapy may or may not include educational components. In CA, we cannot represent one as the other.
I wouldn’t let a doctor examine me over the phone, and half the battle of therapy is learning to talk, so by making it easy to talk in video I’m not helping myself in the real world with comunication because I would have lost the safe place to practice it. . . good for some but not for all!
As I think it through, I can see Skype therapy helpful in a whole bunch of situations:
a. with housebound or ill or hospitalized clients
b. in rural areas where travel is a daily issue
b1. in congested urban areas where travel is a daily issue.
c. where the best person to deal with your particular problem is 300 miles away
d. where a client has previous been “burned” by a therapist crossing physical boundaries
e. with a longstanding therapeutic alliance where the client must move or is transferred, or the therapist must move or be transferred
f. emergency therapeutic interventions
g. with patients who couldn’t easily get to a therapist during “regular” hours.
***
Obviously, the tech here is going to continue to improve. Only a generation ago we were playing “pong” on our computers. Twenty years from now, the webcam tech of 2011 will seem like a joke, compared to the wall-sized screens and holographic or 3-D imaging that will be commonplace. At that point, it’s going to be harder to make a purely the-tech-is-a-barrier or the-tech-limits-the-experience argument.
That day will be here before we know it. We might as well start thinking about it.
Agreed, but many of the things you listed again have to do primarily with geography.
Telepsychiatry and related services have been around for I hazard to guess about 3 decades now — videoconferencing which is used mainly in rural areas to help people connect to a specialist or professional they otherwise couldn’t see.
As for the other reasons you cite…
(D) is an interesting use-case scenario and one I hadn’t thought of. It is indeed a possible reason a person might seek out e-therapy, but would be fairly rare (and I wonder if most people who’ve been so “burned” would really trust any therapist again, no matter how they were seen).
(E) is one of the common things I’ve heard over the years, but is certainly nothing new.
(F) is often cited, but is over-used I think as a reason, because it’s also very rare. Therapists aren’t trained to be “on call” usually, and for many therapists, such an intervention would violate the boundaries of the therapeutic relationship. For others, it would be an option, but what may be an emergency for the client may not be seen as such by the therapist. Do most therapists want to change their practice from a 9-5 job, to one where they could be woken up at 2 am in the morning every night?
(G) Only if the therapist is so willing as well. While that may be the case sometimes, it’s hardly the norm. Most therapists want to work regular hours, just like most people.
As for the technology, I just don’t see it. People are always claiming these wall-sized screens are just around the corner (I heard this same argument made a decade ago). Sure, I suppose holograms and such wall-sized screens might become commonplace someday. But 3-D TV was a bust, and camera phones will always be limited to their physical display size (until those holograms become available). Even then, it all needs to be good enough for both parties to feel immersed in the environment (like a video game). You just can’t get that immersion feeling today without specialty equipment, and without both parties knowing what they’re doing.
As a technologist who regularly works with psychotherapists’ technology and HIPAA issues, I’d like to refute the myth that HIPAA actually provides any protection to clients. HIPAA rules are pejoratively bureaucratic, create legal safe harbors for practitioners and insurance companies, provide almost no actual security that couldn’t be overcome by a high school hacker, and is trivially “broken” by clients who then lose essentially all protection.
For example, if a client responds to a practitioner via common email, this is considered permission by the client to permit non-encrypted communications in the future. Most HIPAA forms signed by patients on first visit are written to protect the practitioner (and technically make them HIPAA compliant) and have absolutely nothing to do with actual privacy.
Skype and Google Chat both provide standard 256-bit AES encryption and as a practical manner are just as secure as the nominally HIPAA-compliant telemedicine networks. Frankly, I am sure the engineering team at Google is a lot more competent to prevent hackers and malefactors than the itsy-bitsy teletherapy startups.
Yeah, reading this thread only reinforces why this kind of treatment intervention is going to further dumb down mental health care should it become a mainstream form of treatment. Anyone think how health care insurance will mutate this into something perverse and poorly reimbursed, plus, anyone think how malpractice coverage will be impacted with these simplistic interactions that in fact have real liability to them?
Nah, it is all about pomp and pagentry first, because technology is made solely to help and improve life. No profit or insidious agendas here.
Hey, maybe we’ll let Facebook manage it!!!
h) it can help therapists who are hungry for clients. they can advertise over the internet so google searches will point to their website
i) it will likely attract those with intimacy issues and worsen their pathology
TOG,
Anytime i come to one of these articles, it’s the same old story. Luckily, I found your comment to be very interesting, thanks for pointing this out.
“I can’t wait for the first patient to do a save-to-hard-drive of the entire therapy Skype file and then start posting all his/her therapy sessions for the world to see. I can just see it:
watchmytherapy! dot com.”
I live in a little town in the Southern Hemisphere and I needed a consult from a doctor licensed to practice in a in the Northern Hemisphere. Online, I found a doctor halfway around the world who had the necessary credentials and was willing to review my medical records by mail, consult with me by Skype video, and provide a professional opinion.
Just the issue of distance and specialty mean that sometimes a Skype chat will be the ONLY way that people on one continent will consult with doctors on another continent, with the right specialties and credentials.
Skype also allows the doctor and patient to exchange data files while holding a discussion, which can save days, weeks and months.
Skype keeps a record of the time and length of the call, which I imagine might be handy for billing purposes.
There is a significant risk that insurance companies would limit patients to Skype calls, if the could financially benefit from doing so.
I am very happy with my ability to speak with a doctor who is an expert in my illness even though the doctor lives on the other side of the Earth.
Well offering psychological therapy via video conferencing is quite new to me. I would say, idea is unique but the implementation needs a bit improvement. I would say video quality with skype is not very good. If you can’t see your physician in a video call, what will you pay for. To get better video calls, you have to get better video quality of rely on the audio conferencing calls only that are providing by many providers like Axvoice, vonage etc.
I think that online psychotherapy would be of great help to people who really need some serious counselling but don’t have the luxury of time to do so. I for one have experienced the services of a particular online therapist from an online therapy site called Talkwelisten. You guys have to check out their services because they helped me a lot to look at the brighter side of each story of my life.
E-Therapy also leaves patients opened to being scammed by fraudulent companies. I found this out the hard way. I signed up for online-therapy.com. Too bad online-therapy.com is a scam. They promised online chat support from a therapist, which I never had access too. When I asked for my money back the owner of the company called me “rude” and proceeded to degrade me for half an hour before he finally agreed to the refund. If you choose online therapy, stay away from online-therapy.com. I’ll never try E-Therapy again.
As with all counseling services, online or in-person, you, the client must take responsibility for selecting a therapist that is right for you and that you feel comfortable with.
For many, the convenience of talking to an online therapist is a great opportunity to get help simply because the online format is less “clinical” and less intimidating. If you are seeking help for anxiety or depression this can be a major factor. Therapy should empower you and help you take charge of your own healing process.
Also, many are not able to leave home – those with agoraphobia and social anxiety or driving anxiety, the elderly or new moms with children to take care of.
There are many, many people who are seeking practical help in learning how to work through difficult emotions, and Online Therapy simply makes this more accessible.
There is a much better solution than Skype to deliver therapy and consultancy online. Fellow therapists are increasingly irritated with Skype, since it is becoming unstable, complicated and with terrible user experience…
An excellent alternative is accessible through “Talkini billable video-conferencing” and it allows you to connect with clients and to charge the fees for your sessions in the same, very simple and user-friendly process.
All patients (even some elderly people) accessed the session and paid with ease through “Talkini billable videoconferencing” (talkini.com)
What I found very useful is that you don’t go through ID exchange and connecting. And you don’t need to download and install anything. Timezones and currencies are supported. Video connection is 100% encrypted (no HIPAA label because they are a Europe-based service).
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