One of my college professors liked to say that to interview someone effectively, you have to be able to “see the whites of their eyes.” To really get to the heart of another person, she insisted, you have to take in all of their nonverbal cues and quirks—do they have permanent laugh lines, or frown lines? Do they gesture dramatically, or keep their hands in their lap? Similarly, many believe that to treat clients effectively, therapists should be able to gaze into their eyes and engage them through every one of their senses. But more and more these days, technology is challenging the idea that therapy must revolve around the traditional, face-to-face clinical encounter.
The movement to apply new communication technologies to therapy seems to have started over the last 10 years with online therapy. Many of its proponents believe that not only is online therapy a convenient way to deliver services, but that some clients feel freer when using their keyboards in their own homes than they do in person. New York therapist Elizabeth Zelvin, who’s been practicing therapy online for the past decade, says that her largest group of “e-clients” is composed of individuals who have “shaming” issues, such as eating disorders and sexual abuse. Working online helps them feel safe, making it easier to reveal issues at their own pace and giving them more time to express themselves. “The Internet is an egalitarian environment,” says Zelvin. “There’s no intimidating office with a big leather chair.”
To build an effective therapeutic relationship online, therapists need to be sensitive to “reading between the lines” of text to detect emotional nuances. Working with clients in this way means intuiting a lot through how clients use humor and irony. Therapists need to be able to “express warmth through your fingertips,” as Zelvin puts it, by incorporating common Internet shortcuts—emoticons, smiley faces, and acronyms. At times when it may seem like she’s being critical, Zelvin adds a “winkie” face to soften her tone and convey that she’s giving “tough love” because she cares, not because she’s trying to attack her client. While miscommunications happen, she says, they happen no more frequently than when working face-to-face. “There’s more opportunity, not less, to straighten out a miscommunication,” she insists, explaining that if either the client or therapist feels uncomfortable after the session, a brief e-mail might be appropriate, or, the therapist could wait to see whether the client brings it up during the next session. Zelvin says that even after 10 years of practicing “e-therapy,” she’s still amazed by how powerful these online sessions can be. As younger clients who’ve grown up in the age of the Internet shape the future of psychotherapy, she believes technology will play more and more of a role in therapy. “I think it’s therapy, not online communication, whose future may be shaky,” notes Zelvin. “People want quick answers, and Internet users aren’t used to paying for services, so it’s a challenge.”
Although there are many advantages to online therapy, not the least of which are scheduling flexibility and comfort, some therapists may find it nearly impossible to conduct sessions exclusively on their keyboard. Skype is one option that makes online therapy more like a traditional face-to-face session. Increasingly, therapists are using Skype’s free video-chat program to reach clients long-distance or during times that they otherwise would have had to cancel the appointment. For example, when one of clinical psychologist Jonathan Douglas’s clients could no longer travel to therapy because of physical disabilities, the client suggested that they communicate via Skype. Although initially concerned about confidentiality, Douglas soon concluded that it was no riskier than phone therapy. Another of Douglas’s clients prefers webcam sessions to driving to the office, particularly in the harsh, Canadian winter.
For some therapists there isn’t that much difference between treatment via Skype and therapy-as-usual. “With Skype, I’m able to get the cues that I need,” insists one clinical psychologist. “I can see facial expressions, lip movements, and hand movements. I don’t need to see a client’s leg!”
Today there are already tens of thousands of apps—specialized software that can efficiently calculate a tip, check movie listings, provide sports statistics, translate languages, and much more—available for smartphone users. These now include at least a few dozen for mental health issues, some developed to be used in conjunction with therapy, and others intended as free-standing self-help resources.
The mym3 app, by My Mood Monitor, is a questionnaire that asks users
about mood and behavior—including appetite, sleep patterns, and emotions —concentrating mostly on the previous two weeks. Depending on the results, the app suggests that users share their scores with a clinician.
The Mobile Mood Diary, based on cognitive-behavioral therapy (CBT), is a techno-journal created as an adjunct to psychotherapy. It’s aimed at clinically depressed teens undergoing therapy, who may be more engaged in treatment when they can text their thoughts, rather than relying on pen and paper. Gavin Doherty, who worked with Mark Matthews and John Sharry to develop the app, says another advantage of this format is privacy, because adolescents worry that others might see them completing a paper chart, while publicly using a phone is perfectly ordinary. Doherty notes that because the app typically encourages higher completion rates and collects extremely reliable data, clinicians can use it as the basis for therapeutic conversation—even to help prescribe medications in certain cases—which should yield better outcomes.
The self-help positive psychology app Live Happy was created when Ran Zilca, founder of Signal Patterns Labs, teamed up with Sonja Lyubomirsky to craft the mobile program based on key features from her popular book The How of Happiness. Lyubomirsky says that Live Happy is essentially her book in a different format that might be more appealing for some people, especially younger individuals, who may not feel inclined to purchase a self-help book.
Live Happy generates a range of happiness-boosting activities for users, such as setting and tracking goals and journaling. For example, among the exercises it offers is a savoring album, which allows users to take photos of objects surrounding them and write what they appreciate about them. According to Zilca, looking back at photos and journal entries can become an intervention in itself: “It changes the person’s mindset.” The app provides assignments that encourage users to look on the brighter side of life, to appreciate what they already have, and to set—and achieve—goals that will ultimately yield happiness. Zilca compares the use of Live Happy to gym attendance because, “When you do repetitions at the gym, it builds strength. The app builds skills of optimism to challenge negative thoughts.”
Mobile Therapy, which is still in its research stages, is being developed by clinical psychologist Margaret Morris, who’s part of a research group at Intel Corporation. The prototype of the app includes three components: mood mapping, therapy, and trend analysis. When mood mapping, the phone asks questions about emotions and other variables to track how the user’s emotions might be affected by certain people, time of day, or diet. The therapy component is largely drawn from CBT research on anger and depression. Based on its rating of the user’s emotional state, the app creates activities ranging from breathing exercises to considering questions like, “Might I be exaggerating how permanent this situation is?” In the trend-analysis portion, users are asked to review the patterns of how their moods varied over time or in response to specific stimuli, to develop personal insights and experiment with new behavior strategies. Although Mobile Therapy isn’t commercially available, it may well preview the next wave of apps designed to serve as a therapist in your pocket or purse.
For clients suffering from post-traumatic stress disorder (PTSD), anxieties, and phobias, the ever more sophisticated technology of virtual reality (VR) therapy offers possibilities for more enhanced and intensive treatment. Virtual Iraq, a program that was recently developed by Albert Rizzo and his colleagues, is based on the premise that offering experiences to vets who want to go beyond their imagination enhances the impact of treatment and gives them more of a sense of control. Before clients are put into a virtual house of horrors, however, they meet several times with their therapist to establish a connection. In these sessions, they recount the traumatic experiences, and when they feel ready to wrestle with them in this intensely real and dramatic VR form, clients put on goggles and earphones and receive eight sessions of exposure therapy in a virtual Iraqi city.
Imagine a combat vet who’s hearing his therapist’s voice guiding him through a three-dimensional world that engages all of his senses. The therapist tells him to turn left here, and walk up those stairs. He can smell the pungent Middle Eastern spices—not from memory, but from a scent machine. He keeps walking as he hears the noise of helicopter propellers, the sound of sirens, and a dog barking on his right. His heart begins to race. He can almost taste the burning rubber and rotting garbage, and now he’s starting to sweat. He’s walking, walking, and suddenly—BOOM!—there’s an explosion. The work of a VR therapist is to help clients process the memories triggered by such vivid images and discover ways to rebalance their nervous systems. When this treatment is successful, clients learn to distinguish the horrors they went through in the warzone from the realities of their lives back home.
Virtual reality offers countless possibilities for psychological treatment. For instance, the Program for Anxiety and Traumatic Stress Studies, led by JoAnn Difede, is breaking new ground in the treatment of stress-related disorders like fear of heights, storms, and public speaking. Using VR, a client who’s terrified to speak publicly makes a presentation to a virtual crowd—one with the ability to yawn, or to give a standing ovation. For clients with a fear of flying, it’s possible to accompany them through takeoffs, landings, and turbulence in a virtual airplane. It seems clear that VR will continue to extend the range of tools used for treating PTSD, anxieties, and intense fears.
Clients’ Double Lives
VR therapy is available only in a few locations, and is a fairly costly form of treatment, but other much less expensive virtual worlds are accessible at the click of the mouse. Second Life, a website that allows users to “live without boundaries from anywhere in the world,” transports users to a vast range of imaginary, interactive environments. DeeAnna Merz Nagel, an experienced online therapist who cofounded the Online Therapy Institute, explains that although the site is often categorized as a “game,” the goal isn’t to win or lose. In Second Life, users maneuver through avatars—animated representations of whoever or whatever they choose to be. Avatars can move, walk, fly, and engage in scenarios like dance clubs or bookstores. Big-name businesses, nonprofits, publishers, clothing stores, and more—Amazon, Coca-Cola, Toyota, and even Harvard Law School—have now opened outlets inside Second Life. Users can shop, drink a virtually ice-cold Coke, drive a new car, or do almost anything else they desire inside this extraordinary world. Second Life affords myriad possibilities for entertainment, socializing, self-discovery—and even therapy.
Four years ago, researcher Daniel Krawczyk, psychiatry professor Carol Tamminga, and Sandra Bond Chapman, director of the University of Texas at Dallas Center for BrainHealth, came across Second Life. They were interested in developing more effective treatments for clients with ailments such as autism, schizophrenia, or brain injuries that make it difficult to interact socially. This VR environment seemed like a valuable tool because it could provide a more comfortable place for their clients to practice real-world social skills. “Interactions can be intimidating for people who have autism,” explains Krawczyk. “Second Life is more comfortable because there’s a filter when they’re an avatar within a virtual environment.”
Krawczyk says that they have an “island” on the site—a separate area that has streets and commonplace locations like a school, restaurant, and coffeeshop—which only the therapists and clients can access. In this space, the clinicians and clients take on different roles to practice life skills, such as interviewing for a job or negotiating with a landlord. It’s a good environment in which to role-play, Krawczyk explains, because, unlike in video games, it’s clear that the avatars are controlled by humans, making social situations seem much more realistic. Clients learn how to act in specific circumstances without having to worry about penetrating the real-life complexities of facial expressions, gestures, and personal space. Because working inside Second Life makes it easy to record sessions and play them back, clients can review their behavior while the clinician offers feedback.
Although it’s clearly separate from reality, Second Life offers real-world ethical dilemmas, since, along with dozens of credentialed therapists and counselors, the site includes numerous “therapists” who have no training or professional qualifications. Groups like the Online Therapy Institute have been active in educating individuals interested in practicing online about the special skills and ethics involved in this work. The institute offers workshops and training for therapists, as well as an online directory of therapists who are certified to practice on the Internet ethically and effectively.
Despite the obvious limitations and drawbacks, there are some distinct advantages to using virtual worlds therapeutically, says clinical psychologist John Suler, author of the online book The Psychology of Cyberspace. He’s particularly intrigued by the creative flexibility offered by virtual sites. “If you’re a psychotherapist who likes to work with dreams, fantasies, and role-plays, then Second Life is the perfect place to not just talk about such things, but to create them and work therapeutically inside them.”
Face-to-face support and communication aren’t likely to become irrelevant anytime soon, but this wave of new technological adjuncts to therapy is provocative and compelling. Technology offers the prospect of reaching a broader range of people and giving therapists a multitude of options for connecting with clients who have extremely varied needs. “In the future, the therapeutic process won’t necessarily look like what it looks like right now. It’s not going to be as ‘in-the-box’ as it’s been all of these years,” says DeeAnna Merz Nagel. “It’s not that all therapists are going to close their brick-and-mortar offices, but they’ll begin to integrate technology into their practice—that’s what people are going to demand.”
Jordan Magaziner, a graduate of American University‘s School of Communication, is the former editorial assistant of the Psychotherapy Networker.