The Rise of Distance Therapy

For many, psychotherapy is still a rarefied, face-to-face encounter outside the normal rhythms of the world, a time in which cell phones are turned off, and we’re uninterrupted by an ever-replenishing email inbox. But we no longer live in a world in which we can so clearly partition ourselves off from the electronic information grid. Many occupations no longer require a clearly defined workplace or a physical presence. Many employees never see their boss in person. Increasingly, surgeons are slicing patients open from hundreds or even thousands of miles away. Why should psychotherapy be any different?

More and more clinicians today are adapting to meet the demands of the digital world and fit into the schedules and lifestyles of clients no longer willing to follow the traditional pattern of once-a-week sessions in a therapist’s office. In a consumer-driven mental health marketplace, individuals with anxiety disorders want services from the comfort of their homes. For veterans living in rural areas, remote group and individual psychotherapy for trauma offers treatment possibilities that weren’t available even a few years ago. But although telehealth has been around for decades, many clinicians are still unsure about the clinical, ethical, and legal issues that emerge as distance therapy becomes a more accepted practice.

Telemental healthcare can include emails, texts, web chatting, and video-conferencing. In a 2013 meta-analysis of a decade’s worth of research on telemental health, published in Telemedicine and e-Health, Donald Hilty and colleagues found that across many populations and disorders, its effects are comparable to in-person care. For populations wary of the physical immediacy of face-to-face encounters, such as young people and autism-spectrum patients, remote services might even be preferable.

This finding appears to fly in the face of a central conviction of many therapists: that it’s the therapeutic alliance forged in the proximity of the consulting room that makes therapy work. Can that chemistry be summoned across the Internet? According to a 2012 meta-analysis by Autumn Backhaus and colleagues conducted by the Veterans Health Administration and published in Psychological Services, it can. Examining 65 individual studies on video-conferencing psychotherapy, they found positive clinical outcomes and user satisfaction among diverse populations with diagnoses including depression, anxiety, addiction, and post-traumatic stress disorder.

“Face-to-face is a self-serving mythology,” says Ofer Zur, psychologist and author of Dual Relationships and Psychotherapy. “Therapists who hold onto the old images of the traditional way psychotherapy ‘should be’ are refusing to recognize the realities of the world in which they live.” Adapting effectively to the use of digital platforms for therapy involves recognizing the ways in which these platforms differ from face-to-face interaction, especially being mindful of what’s known as the disinhibition effect. Communicating with a professional via Skype or text lowers one’s reservations and reduces the social restrictions that might be present inside the therapist’s office.

Roy Huggins, a professional counselor who built an online practice by working with Americans living in Japan, recalls a client with an abuse history who struggled to trust men. When he asked her what she thought he looked like, she guessed a full foot shorter than his looming 6 foot 4 inches. “She told me she never would’ve talked to me if she’d seen how tall I was, how physically imposing,” he says. Because of the safety she felt with me online, she was even able to transition to another male therapist, who helped her in person, when she moved back to the United States.

Because Japan doesn’t regulate licensing, Huggins could practice there from his home state of Oregon, but clinicians who want to practice online in the United States have found that many states are moving backward, tightening restrictions in attempts to protect their consumers. Lawmakers in Texas recently introduced a bill that would forbid therapists licensed in the state to do online therapy with clients outside its borders. That means a therapist licensed in Texas working with a client in Texas couldn’t do online therapy from a conference in Oklahoma.

An ever-increasing powerful force within that new digital reality is the smartphone. A 2012 TIME magazine poll found that 84 percent of people couldn’t spend a single day without their mobile device in hand, and a good half of us sleep with them like a teddy bear. The use of Skype, though still unquantified, has been well established in psychotherapy, but new applications of smartphones and their apps are emerging every day. An increasing number of therapists are tracking data from smartphones through apps like Mobile Therapy to monitor their clients’ thoughts, feelings, and behaviors between sessions.

Jonathan Schooler, a professor of psychological and brain sciences at the University of California Santa Barbara and senior research advisor for that app, sees smartphones adding an additional dimension to psychotherapy and increasing its effectiveness. “There’s so much effort in standard therapy to excavate what happened since the last session, what was significant, and what caused it. Then you have to determine how much of what’s being told is true or false due to mood or memory bias,” he says. Smartphone therapy platforms work by providing data about clients’ experiences between sessions that can give a quicker, more accurate picture of their moods and behavior.

“Of course, you still need the therapist to make sense of triggering events, interpret changes, and know what questions to ask,” says Schooler, but receiving the ongoing data increases the efficiency of the therapy process. A therapist might review a client’s data for salient events right before a session, direct questions and observations to the client between sessions, and send messages of encouragement when appropriate.

But therapists have good reasons for hesitating to work online. You can’t detect subtle changes in body language via video or control the client’s environment, and technical difficulties abound. Furthermore, it may be illegal, depending on what platform you’re using. “Skype is inappropriate for healthcare,” warns Marlene Maheu, executive director of the TeleMental Health Institute. It doesn’t provide the audit trails or breach notifications required by the Health Insurance Portability and Accountability Act (HIPAA), and an insurance company isn’t going to pay a clinician to use technology that doesn’t protect the client.

As therapists’ use of technology becomes more casual, another growing problem is a loss of focus and a dilution of the therapeutic alliance. A therapist conducting a video session from the backseat of a car or checking a client’s dashboard in line at airport security can’t give the full attention demanded by a face-to-face encounter. “My big fear comes from my observation of how our culture regards technology,” says Huggins. “We don’t see it as something to be thought about. In fact, many people go to great lengths to avoid thinking about their relationship to digital tech, even while deepening their use of it.”

Our technological distractions aren’t going away. The app company Locket reported that the average smartphone user unlocks his or her phone 110 times a day. Psychotherapists will have to adjust to that reality. If they hope to keep their practice afloat, they’ll use it to their advantage. Zur predicts that traditional therapy is already on the run. “The train has left the station. It won’t be five-times-a-week psychoanalysis or once-a-week CBT. It’ll be 20 minutes before a date, or 5 minutes into a panic attack. People want to communicate with their therapist the same way they talk to a lover or a friend, and that’s not good or bad. It just is.”