Skype Away: Online Therapy is Still Exciting!

By John M. Grohol, PsyD

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.

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.

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