Clinician's Digest Jan/Feb 2011

Virtual Visitation for Parents and Children

When his ex-wife got permission from the court to move out of state with their 4-year-old daughter, computer expert Michael Gough feared that he'd lose his close connection with his child. Aware of the difficulties of maintaining a relationship with a youngster exclusively through phone calls, Gough requested that the judge order regular virtual visitation (VV), so he could use a webcam and the Internet to stay in touch visually as well as verbally. The judge refused initially, saying, "If there isn't case law, state law, or a statute, don't ask for it because I won't order it." Undeterred, Gough brought his laptop to court and demonstrated to the judge how powerful and immediate virtual visitation could be. Impressed with what he saw, the judge granted the order. Since then, at least five states have passed statutes approving VV for noncustodial parents, with several more considering doing the same.

VV is undeniably a potential tool for salvaging and expanding a parent-child relationship that an angry, divorced parent might wish to disrupt. With young children, in particular, who are less verbal and rely more on visual stimuli for processing new experiences, there's a world of difference between VV and the telephone.

Through VV, Gough read bedtime stories to his daughter and sang hand-clapping songs with her. For her part, she took him on a tour of her new home, and, as she grew older, was able to play checkers with her father. They even opened Christmas presents together.

For Gough, an especially important advantage of VV was that his ex-wife couldn't stand beside their daughter, influencing her reactions and responses, during the virtual visits. Even if a parent is standing out of range of the webcam, says Gough, you can still see where your child is looking and perceive whether coaching or sabotage is going on. VV even helped ease their reunion: when Gough and his daughter finally visited face to face, he says, it felt more like they were continuing, rather than restarting, their relationship.

Some parents fear that bitter, alienating ex-spouses might actually suggest VV in an attempt to justify moving to another state with their child. To prevent VV from becoming a tool to abet such behavior, states like Wisconsin and Florida that endorse VV as a legally valid visitation component have specified that it can't be used to help justify an out-of-state move or to determine custody. This means that the only basis for approving parent-child relocations is a compelling need on the part of the custodial parent.

Even when a full-blown case of parental alienation isn't the issue, VV can alleviate some of the loneliness of separation and mitigate the emotional and developmental damage to children caught in the crosscurrents of parental conflicts. While VV may not take all of the pain out of the situation, it certainly helps. "Virtual visitation," Gough says, "is a tool, not a remedy."

Wise Therapists or Technicians?

In a report for the American Psychological Society in November, 2009, psychologists Timothy Baker, Richard McFall, and Varda Shoham decried the "prescientific" emphasis on subjective variables like intuition and empathy in the education and training of therapists. They proposed, instead, strict science, research-based curricula and empirically-supported treatments (see Clinician's Digest, May/June 2010). Their report, which was picked up by such major media outlets as Newsweek, made the profession look foolishly New Agey and insubstantial. Critics of the Baker report contend that it proposed too narrow a knowledge base for therapeutic practice, ignoring the mounting evidence that relationship factors count more heavily in positive outcome than specific clinical methods, however "empirically supported" they may appear.

Rather than moving in the direction of quantitative science, some believe that today's therapists should look for greater understanding of their fundamental task to the age-old concept of wisdom. Among these is Heidi Levitt, a prominent researcher of the therapeutic process from the University of Massachusetts Boston, who insists that therapeutic wisdom encompasses more than knowing the research and becoming adept at delivering manualized treatment. In one of her current studies, she and her collaborator Elizabeth Piazza-Bonin interviewed an elite group of therapists who'd been chosen as individuals who exemplify therapeutic wisdom by a sample of 800 therapists. What did this group of wise therapists consider the therapeutic task to be, and what did they have in common? Instead of seeing themselves as problem-solvers, they emphasized listening empathically to their clients, and knowing how and when to draw from their own life experiences to increase their attunement to their clients' experiences. In addition, rather than moving quickly to resolve their clients' doubts, questions, and confusion, they were at home with tolerating and exploring life's messy ambiguities.

Another psychologist trying to look more systematically at the nature of therapeutic wisdom is Ronald Siegel, an assistant clinical professor of psychology at Harvard Medical School, who, as part of a book project, asked 20 prominent therapists to describe therapeutic wisdom. While several of the authors in Siegel's book give the task of clinical problem-solving its due, most focus on the ability to help clients tolerate ambiguity and emotional pain.

Both Levitt and Siegel believe that training programs shouldn't focus exclusively either on working with empirical data or developing the capacity for wisdom. Nevertheless, they emphasize that wisdom is founded on an appreciation for questions. "Rather than reward students who come up with answers," Levitt says, "we should teach students to spend more time on learning to develop questions—with clients, with themselves, and with their research. Maybe we should admit students by looking at their interpersonal skills, their capacity for empathy, and their ability to tolerate ambiguity. As faculty, we need to model these values, and not just teach interventions."

Siegel feels that the movement to turn therapists into the equivalent of researchers focused on empirical evidence is unwise: "Virtually all models of wisdom, across time and across cultures, point to the limitations of intellect alone, and the importance of other faculties that we might call social intelligence, affective relatedness, intuition, and, in particular, appreciation of the complex interrelatedness of all things—faculties that a narrow focus on experimentally testable mechanisms is unlikely to develop." He has an intriguing suggestion for determining the best method to prepare therapists for the challenges of practice, because we lack clear data about effective training. "Let's have therapists devote two weeks of their lives to reading research studies and then spend a week in a silent meditation retreat," he says. "Then have them do some therapy and report which seemed to improve their treatment more."

Resurrecting Therapy

Even before the recession, when adjusted for inflation, therapists' incomes haven't increased since the 1980s. According to Nicholas Cummings, former president of the American Psychological Association (APA) and founder of the first professional psychology school for therapists, psychotherapists are the lowest-paid doctoral level professionals in the healthcare field. Now he's mounting an ambitious campaign to challenge the professional pecking order within healthcare and boost the economic prospects for mental health practitioners.

For more than five decades, Cummings has been something of a Cassandra for the therapy field—accurately foreseeing the largely negative developments that have shaped therapy's role in healthcare. Well before it showed up on the radar of most other leaders in the profession, he warned that managed care and the medicalization of mental health were going to divert hundreds of thousands of potential clients from therapists' offices to physicians' waiting rooms. Today, he says that more than 60 percent of primary care physicians' caseloads consist of people seeking treatment for somatic complaints and disorders for which physicians find no cause or cure—chronic pain, irritable bowel syndrome, mood disorders—that can be treated more effectively by psychotherapy. A report in the December Archives of General Psychiatry by Mark Olfson found that only 43 percent of people who sought treatment for depression went to see a therapist. In the last decade alone, Cummings says, the percentage of people who've been referred to therapists from physicians dropped nearly 50 percent.

Now Cummings and neuropsychologist John Caccavale are beginning a campaign to reverse this decline and educate the public about the distinctive benefits of psychotherapy. Early in 2011, their organization, The National Alliance of Professional Psychology Providers (NAPPP), is launching a campaign to make the case for psychotherapy through advertisements and public service announcements. They've already produced a print advertisement and several videos, and are seeking an alliance with physicians and the American Medical Association. Rather than seeing therapists as being in conflict with physicians, they believe that they're natural allies, who recognize that in too many cases, the pharmaceutical industry has adversely affected the practice of good medicine and good research. So NAPPP wants to educate the public about the many conditions for which psychotherapy is more effective than meds, and encourage non-psychiatrist physicians to make referrals to therapists before writing prescriptions.

The campaign is an ambitious, costly undertaking. Seeking alliances and money—they hope to raise, at least initially, $200 thousand—NAPPP has already been rebuffed by the American Psychological Association (APA) and National Association of Social Workers (NASW), whose vast membership bases contain so many non-practitioners that they're unwilling to commit their resources to expensive campaigns advocating for therapy. "It's not within the genotypes of APA and NASW to fight for psychotherapy," Cummings scoffs.

Cummings and Caccavale hope to raise funds by generating a grassroots movement among psychotherapists who recognize that, finally, there's a concerted effort to address their struggle for recognition and economic viability. The purpose of this new organization is to promote psychotherapy, and their founders are counting on therapists to join their efforts. Whether NAPPP will succeed remains to be seen—but clearly, someone has to try.

What Works for Addictions Treatment?

The term mindfulness—cultivating the ability to notice and calmly, nonjudgmentally observe your emotions—is ubiquitous in the therapy field today. It filters into approaches across the theoretical spectrum, from Cognitive-Behavioral Therapy to humanistic, client-centered treatments. So far, positive results of using mindfulness in treatment have been reported with conditions as varied as anxiety, depression, and even personality disorders. But what about addictions?  With compulsive behavior, how effective is nonjudgmental witnessing and acceptance?

G. Alan Marlatt, director of the Addictive Behaviors Research Center at the University of Washington, came to embrace a mindfulness approach to addiction treatment by accident. Originally a strict behavioral psychologist, in the days when meditation was associated mostly with Eastern wannabes and acolytes of the Maharishi Mahesh Yogi, Marlatt first tried meditation after he was encouraged to do so to reduce his high blood pressure. Skeptically, but curiously, he tried it, and got positive results. From there, he began to apply it to psychological issues. Eventually, he developed a treatment for addiction that combines Motivational Interviewing (MI) and mindfulness.

MI encourages clients to set their own goals around substance use, and then to examine how their behavior fits their goals. The mindfulness component teaches clients not to deny or try to stamp out their urges to use, but rather, to pay attention to compulsive urges and breathe into them while remaining calm and nonreactive. After years of working with this treatment approach, Marlatt came to appreciate the value of helping clients "surf their urge"—experiencing it as a wave that will rise and fall, and using their breath as a "surfboard."

For Marlatt, the core problem with many abstinence-based approaches to addiction treatment is that once you define occasional use as relapse and failure, you trigger the same feelings of shame and hopelessness that originally led people down the path to addiction. He prefers the term "prolapsed," a more positive term that allows clients to view their renewed use as an opportunity for further practice in living in alignment with their goals.

Marlatt believes that the main goal in addictions treatment is helping clients find what works for them, citing the massive Project Match research study of several years ago, which found that no addictions treatment approach is superior to all others. "No two individuals are identical, so it makes sense that no two recoveries or treatments are identical," he says.


Virtual Visitation:

For more information on VV, see

Resurrecting Therapy:

other information on psychotropic meds at

Archives of General Psychiatry 67, no. 12 (December 2010): 1208-1327.

Garry Cooper

Garry Cooper, LCSW, is a therapist in Oak Park, Illinois.


Issues & Developments Addiction Anxiety & Depression Families Professional Development

Earn CE Credits

Just for reading the Networker!