What do you think of online therapy?

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NH14

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I've heard about doing a few therapy sessions over the phone, particularly check up sessions, but has anyone done therapy via the internet?

What do you think of it?

*edited out the link....since I don't want to promote another site* -t
 
I've seen people do this with their current therapist when they were in a pinch, but I'm not sure about doing it on a regular basis. Call me old-fashioned, but I think therapy should be done in person because so much of the communication is non-verbal.

-t
 
i do research involving cbt and bibliotherapy, and there are many studies (don't have refs on me, but lemme know if you want them) that show that for specific problems, mild depression and anxiety, and some specific anxieties (also mild to moderate, and not great results with sub. abuse) online, biblio, and telephone therapies can be about or as effective as short term (2-3 mo) CBT therapy w/ a clinician. but, once again, that's with mild to moderate severity, and we are talking about folks doing well enough and invested enough to complete all or the vast majority of the online/biblio/phone modules for 2-3 months.

as far as psychodynamic or other more indepth forms of therapy, i haven't explored. curious.
 
Overall....very sketchy.

That being said, I think there's some hope for this in the future. Particularly, I think it could be helpful to offer some basic treatment for clients who have difficulties being motivated to come in to the clinic (severe depression/anxiety, agoraphobia). I want to emphasize that any implementation of this would have to be done VERY carefully because many factors would be very hard to catch, and you definitely wouldn't want to miss, say, a suicidal ideation because it was an online interview.

It also depends, how you define online therapy. I definitely think webcams will help with the process of allowing online therapy.

So basically, I'm saying its in NO way ideal, but I think its important to consider for the future.
 
I think the VA is doing some work right now using camera-phone thingies to deliver emergency therapy using some visual component. I agree that it definitely doesn't replace in-person therapy, but I can also see some advantages using it strategically.
 
Interesting...I assume it would just be based on what state the therapist is residing in. I mean, as far as I know, if you are in a city near the border and someone comes across state lines to see you, that doesn't require the therapist to do anything different. At the moment, I think LEGALLY, things would work the same way online since as far as I know we still consider the "service" as being offered whereever it originates from in most cases (though I haven't been keeping up on my business-law-gobbly-gook so don't quote me on this).

Definitely something to think about for the future though, since who knows how APA would handle this.
 
There's just so much communication that gets missed through online interactions.. I'm very skeptical about e-therapy.

On the other hand, many of my clients have my professional e-mail address since I email them the intake forms and directions to my office before their initial appointment. I tell them I won't do therapy via the internet, but we have used it for logistical stuff like rescheduling appointments or reviewing insurance information. A few people have emailed me things that they wrote, or forwarded emails from family/friends that have upset them. My response is "we'll go over this when we see each other", but sometimes it is nice to see those in advance. For one thing, I can read it faster than the client can tell me the story, so it saves some time. Secondly, there have been a few occasions where what I read verified the veracity of statemnets I thought the client might be misperceiving. On the flip, I can also use the emails as a tool to discuss when someone is reading into something that's not actually there.

The one form of communication I WON'T do is text messaging. 🙄 My practice number is my cell phone, and I work with a fair number of 16-25 y/os. That seems to be their preferred way of cancelling or confirming an appointment, so I've had to put the kibosh on that one a couple of times..
 
These are all good points - especially the missing of nonverbal cues that can be picked up in in-office sessions versus e-therapy sessions. And of course the patients would probably have only mild to moderate disorders.

But the proliferation of online services is interesting - I see it as yet another way to diversify a practice, but at the same time I feel that it would be bit more *artificial* than in-office therapy and I personally would veer away from it if possible.

However, it may be useful in rural situations where the commute to a therapist may take more time than the therapy itself. Again, only if the illness is mild to moderate perhaps.

Does anyone have any experience with it? Is it lucrative? Or not worth the time?
 
There is some work that has been done on this topic. An interesting place to start would be with John Suler who has an online book on the "psychology of cyberspace". He deals with issues such as transference and the different nature of the cues that are available to you:

http://www-usr.rider.edu/~suler/psycyber/psycyber.html

There is another site that deals more specifically with internet therapy:

http://www.metanoia.org/imhs/index.html

And there is a book that is a collection of articles that deals with the "theraputic potential of the internet":

http://www.amazon.ca/E-Therapy-Robert-Hsiung/dp/0393703703

So...

There is also an ethical society for e-therapy. To the best of my knowledge there are a lot of 'reccomendations' but I'm not sure how much they have been passed through as laws yet. Part of the problem is, of course, the international nature of the internet. If I live in Fiji, and I'm having therapy with a person from California, for example, then which countries laws are applicable to the therapy that I'm receiving? Much has been written about these issues.

One issue that I'm particularly interested in (an issue that arises in response to the first two links, especially) is how much the cues that are available through internet media (e.g., email, chat, message board etc) are INFERRIOR to face to face cues, and how much the cues that are available through internet media are simply DIFFERENT to face to face cues. It might well depend on circumstances whether a person is better off in face to face therapy or whether a person is better off in some variety of internet therapy.

Internet therapy works better if people are:

- able to verbally express their feelings (since there is the absence of facial and postural and tone of voice cues)
- is verbal in general
- has a fairly rapid typing speed

Some things that might make internet therapy a better option to face to face therapy include:

- the person living in a rural area where they simply don't have access to face to face therapy
- the person being deaf or having hearing impairment
- the person having some pronounced physical disability or disfigurement
- the person suffering from pronounced social anxiety / inability to disclose in a face to face setting.

One idea is that internet therapy can be a useful first port of call to be replaced by face to face therapy as soon as possible (the standard line). I think the standard line is mostly an attempt to reassure therapists. I personally have more hopes for internet therapy than that.

Especially... As new forms of media become more prevalent (such as Skype and the like).
 
As practical and time saving the many new forms of technology brings to all of us, I can't help but feel it has found a way to make it more difficult, in an ironic fashion, for us to have real direct human connection.

It seems this generation of technological gadgetry (ie: Xbox, PC gaming, voice-chat software, texting, email, Im'ing, even cell phones) has made all communications with other people, albeit faster and easier, on a increasingly superficial level. It then becomes harder to orchestrate real human interaction (orchestrating a baseball game in the neighborhood) because we miss our friends less and less.

People play World of Warcraft for 18 hours a day. For days and days and days and tell themselves "most of my friends are e-friends".

Clearly, I am biased here.

Do we really need to let tech in our offices where we provide one of the last few ways to connect with another human on an honest and vulnerable level?
 
internet = superficial.

internet = NOT honest and / or vulnerable

maybe... you are limited in the internet connections that you have experienced???

___________________

transference is heightened in online interactions because of the absense of cues. as such, transference comes to the fore more quickly. for forms of therapy that are based around the idea of working through / analysing the transference it might be that e-therapy is more suited to that.

the online disinhibition effect is basically that people are willing to make more INTIMATE and PERSONAL self disclosures online (due to enhanced feelings of anonymity) than they are able to make in person. those self-disclosures can result in enhanced feelings of intimacy and personal connection. in some respects people may feel more connected with people in an online medium (where they have the courage to self disclose) than they are able to feel connected with people in person (where they are too afraid of blushing or stammering, for example).

(see the first link that i provided for an account of the above phenomenon)

the notion of 'intimacy' is biased towards the feminine notion of intimacy (intimacy is about talking about your feelings). guys often report feelings of intimacy in sharing non-verbal activities, however. a sense of intimacy and connection that results from mastering some move on the football field or a sense of intimacy and connection that results from sitting side by side in silence fishing. or a sense of intimacy and connection that results in a well timed manouver in some x-box game. and with verbal communication via head-sets - why the hell not? why isn't it as intimate as the fishing or football case?????
 
toby jones said:
transference is heightened in online interactions because of the absense of cues. as such, transference comes to the fore more quickly. for forms of therapy that are based around the idea of working through / analysing the transference it might be that e-therapy is more suited to that.
Click to expand...

I think it would be just the opposite. The internet provides the patient another 'barrier' to the world. Transference would be less likely to happen because the patient would be standing behind that barrier (yet another defense), and would not be subject to the same environmental stressors that they would encounter in a face to face meeting.

toby jones said:
the online disinhibition effect is basically that people are willing to make more INTIMATE and PERSONAL self disclosures online (due to enhanced feelings of anonymity) than they are able to make in person. those self-disclosures can result in enhanced feelings of intimacy and personal connection. in some respects people may feel more connected with people in an online medium (where they have the courage to self disclose) than they are able to feel connected with people in person (where they are too afraid of blushing or stammering, for example).
Click to expand...

I'd think that the 'online persona' would be farther from their true self, and another permeation of a defense mechanism. Though people may argue that they would be MORE comfortable in this setting, I'd argue this comfort is further perpetuating their problems.

-t
 
I'm with you that it would further perpetuate their problems if they attempted to do online therapy in the long term.

However, when looking at things in the short-term, there is a HUGE number of depressive/anxious individuals who never seek treatment in the first place because of the social pressures involved in a face to face meeting. If we can get these people in for face to face therapy by hosting an assessment and maybe a few brief sessions online to help establish a rapport, wouldn't that be great?

That being said, regardless of what everyones views on it are, I think the profession HAS to move in that direction. Not to pick on socialcog but I think his views are fairly representative of how most psychologists feel...we're VERY resistant to new technology as a whole, and end up falling behind the times quite often because of it.

If we don't get the ball rolling for online therapy, and set some standards for what it should or should not involve, someone else will. Be they psychiatrist, mid-level practitioners, or some random twit with a website. I'd rather we move in early and establish that "Its a good starting point, but therapy should NOT be entirely online" than have another field establish the (likely less stringent) ethics for it first.
 
I tend to agree with Ollie, which as our professions more forward in this area that we need to set the standards now. I think progress is going to happen, how effective internet therapy is I can not say. I have experience in doing videoconferencing therapy in rural East Texas as a part of a UTMB Galveston research program. I think it can be useful for those settings.

The visual cues are a necessity to providing good therapy. On the internet I can type anything I want to say, and you the therapist would have no real idea how much of it is real. Seeing the person provides a lot of context.

My last point for consideration is this security and privacy of clients/patients. How does a therapist in private practice ensure the security of the system? Very few of us are technologically savvy. Of course we could pay out large amounts of money to someone that is savvy to set up secure systems, but then we lose money from our practice, when a large part of being in practice is to make enough money to stay in practice.

Jeff
 
> Transference would be less likely to happen because the patient would be standing behind that barrier (yet another defense), and would not be subject to the same environmental stressors that they would encounter in a face to face meeting.

Ah. But have you noticed that there can be more conflict in an online setting than there would be if people were talking face to face? The absence of facial cues and bodily gestures (e.g., friendly smiles) can mean that a comment that was intended as a joke can be taken as an insult. Because of the relative absence of cues (a kind of abstinance or therapist neutrality) the person interprets more than they would if more cues were present. It is similar to the notion that if a client doesn't know much about the therapist then the client is freer to imagine and fantasise all kinds of things and if the client will talk about their fantasies then that can clue the clinician into what is going on for the client. In the absense of cues in an online setting the client is freer to imagine and fantasise all kinds of cues (e.g., a person sniggering or laughing while typing into their computer) and if they will talk about that then that can clue the clinician into what is going on for the client.

If you disagree... Take it up with John Suler (first link). ;-)
 
My other concern would be in protecting the patients- what measures would be in place to ensure that the treatment provider is qualified and credentialed to provide the services? I know, I know, caveat emptor and all, but many people who seek treatment are in a vulnerable state and it would be easy for someone to take advantage of that.
 
Pingouin

Great point, there are a lot of concerns in regard to online therapy. I think a huge would be a Joint commission like body with representatives from APA, NASW, and NBCC meeting and laying out some guidelines and then advocating for those to become laws through out every state. This would lead to protecting the consumer, and could lead to appropriate training for clinicians to work in this particular realm.

Jeff
 
pingouin said:
My other concern would be in protecting the patients- what measures would be in place to ensure that the treatment provider is qualified and credentialed to provide the services? I know, I know, caveat emptor and all, but many people who seek treatment are in a vulnerable state and it would be easy for someone to take advantage of that.
Click to expand...

Ah....this entire thread saddens me. I am not tech phobic in the least, incidently.

Those who speak in favor of integrating this layer of tech in our profession may be accurate in their predictions in terms of it being the next stage of evolution of what we do.

However, there is no way I can be convinced that online therapy will actually enhance the therapeutic bonds between therapist and patient. I refuse to believe that.

I am a cognitive therapist. The online option would not only do nothing in terms of therapeutic connectivity, it would perpetuate the symptoms of any patient that complains of any anxiety disorder--as the online option would enable avoidant behavior. There is virtually no efficacious outcome for those with OCD or agoraphobia if they are talking to a therpist on a computer screen. I'd bet my liver on it.
 
SocialCog

I do not espouse the online option as a good move; I just believe that it will unfortunately be the direction that we are going. I think that if we work now as a cohesive group of clinicians (psychologists, counselors, social workers, and MDs) then we can set reasonable standards that will allow for the highest quality of care.

Jeff
 
PsyKardinal said:
SocialCog

I do not espouse the online option as a good move; I just believe that it will unfortunately be the direction that we are going. I think that if we work now as a cohesive group of clinicians (psychologists, counselors, social workers, and MDs) then we can set reasonable standards that will allow for the highest quality of care.

Jeff
Click to expand...
Like I said Jeff, you're probably right and I suspect that is why I'm bothered by this. You can count me out of this movement in our field, however. I rather see myself as 'antiquated' as opposed to an 'anathema'. There is a line of integrity I cannot cross. It'll be interesting.
 
socialcog said:
Ah....this entire thread saddens me. I am not tech phobic in the least, incidently.

Those who speak in favor of integrating this layer of tech in our profession may be accurate in their predictions in terms of it being the next stage of evolution of what we do.

However, there is no way I can be convinced that online therapy will actually enhance the therapeutic bonds between therapist and patient. I refuse to believe that.

I am a cognitive therapist. The online option would not only do nothing in terms of therapeutic connectivity, it would perpetuate the symptoms of any patient that complains of any anxiety disorder--as the online option would enable avoidant behavior. There is virtually no efficacious outcome for those with OCD or agoraphobia if they are talking to a therpist on a computer screen. I'd bet my liver on it.
Click to expand...


Oh, I'm right there with you on this not "enhancing the therapeutic bonds between therapist and patient". I think that's a load of garbage.

For clarification - I'm only saying that if we offer more initial information and contact online, with the intent being to kind of ease social phobics/severe depressives into an in-person interaction with their therapist, we might be able to reach people who otherwise would never consider therapy. THAT is the value of offering some services online in my eyes. Sort of start with the internet, move to the phone, then bring them in to the office. I think its a bit of a slippery slope since I'd hate to see the standard become that ALL clients must have 3 online sessions before they can even see a person, but I think if we can utilize the internet to reach a population who DESPERATELY needs treatment but would never come in to the office...how can we say no to that?

I would never be supportive of a full-blown treatment over the internet (at least not in the form of "therapy" - we offer self-help manuals, referrals and such all the time, don't think anyone has a problem with that). I think its vital to the get the clients into the office. I just see this as a potential outlet for GETTING people into the office when they might not otherwise - which is why I think we need to step up to the plate and make sure that is what happens, rather than a psychiatrist/social worker/whoever else being the one to set up www.e-therapist.com.
 
A bit of a tangent, but it touches on one of my favorite topics, the convergence of applied business and technology:

I've toyed with the idea of an e-referral portal coupled with a hybrid referral network, though scalability is the first issue I ran into, in regard to ethical referring practices (having enough qualified referrals based on geographic location), not to mention the referral fee arrangements....I seem to recall some issues with APA ethical guidelines. The technology side is easy enough (you could make some front-end money on 3rd party static spots and also on the dynamic Google Ads, regardless of how you get compensated by the provider) I'm still considering it for niche work, but I think it would fail for a generalist model for a myriad of reasons. Even in a niche area you'd need to navigate a number of gray areas, and I'm not sure I'd be willing to risk the investment capital for something that may get clipped because of ethical / legal unknowns.

An alternative is to use a more passive system that utilizes the front-end advertisement, and instead act as a pass-through, instead of being the direct referrer. Middle man money is bad if you can show a good conversion rate.

Of course...with all of this being said, we as a profession need to be careful to do what is best for our patients, and not just our pockets. The business is a lot cleaner when it is someone shopping for a product or non-health care service.

-------

So how would you all see this effecting your practice? Would you consider any kind of telephone, e-mail, online support?

-t
 
> However, there is no way I can be convinced that online therapy will actually enhance the therapeutic bonds between therapist and patient. I refuse to believe that.

You sound more like a philosopher than an empirically based scientist...
Don't you want to see how the data turn out?
Some people say that they feel very connected to people who they communicate with solely over the internet.
Whether the internet is 'theraputic' or not is an empirical matter.

There are ethical guidelines for the practice of internet therapy (it is just a problem of who is going to enforce them if they are breeched).

There is information available from the second link that I provided on things that consumers (and practitioners) should be aware of.

For example, the practitioner shuold be lisenced to practice in the area they are in as well as the area their patient is in.
The practitioner shouldn't accept clients who are suicidal (for example) without having people to contact (such as crisis teams) incase physical intervention is needed.
The practitioner should provide their registration number (so the client can check they are legit) along with a physical mailing address and phone number.
The practitioner should ensure that information is encrypted and have a mind to privacy (e.g., not send emails to a clients work account which could result in legal action taken by the clients employers).

And so on and so forth.

There is some society that has ethical guidelines on the conduct of e-therapy. There are, of course, some cranks out there. But there are many 'lifestyle coaches' etc who are similarly cranks...
 
For people who pride themselves on using effective interventions, I'm really very surprised that people are so anti the idea of internet therapy a-priori.

If it turns out that internet therapy isn't effective then then I would understand people not wanting to utilise something that isn't as good as alternative means.

Whether it is an effective intervention or not is an empirical matter, however, and not something that we can figure out a-priori.

It is sounding like people are saying 'we don't care how the data turns out, however, we will NEVER use this approach!'

Surely... People don't mean to say that?
 
toby jones said:
For people who pride themselves on using effective interventions, I'm really very surprised that people are so anti the idea of internet therapy a-priori.

If it turns out that internet therapy isn't effective then then I would understand people not wanting to utilise something that isn't as good as alternative means.

Whether it is an effective intervention or not is an empirical matter, however, and not something that we can figure out a-priori.

It is sounding like people are saying 'we don't care how the data turns out, however, we will NEVER use this approach!'

Surely... People don't mean to say that?
Click to expand...

It would have to be some compelling data. A sound design and heavily, heavily controlled. I will agree with you in one regard...-regardless of the outcome studies, as a practitioner, I would never do it. I think the quality of work as a clinician would drop off dramitically. I really do not feel I would be rewarded in my job if the new standard of human connection included a computer, wifi, speakers, webcam and 4 other windows up running youtube, music, AIM and Halo 2.

Incidently, as an undergrad I was attached to some research that measured faculty attitudes on distance learning waaaay back in 1993. This is shortly after the invention of email. At the time, the response was heavily not in favor of teaching remotely via internet real time feed. Well, 14 years later distance learning is widely accessible and no longer stigmatized --at least to the same degree as initially held by the faculty who participated.

If history is any reasonable predictor of future events (I think it is) then we can expect e-therapy to be widely available to patients sometime in the near future. As classrooms and campuses have not been replaced by the internet, I suspect neither will I and my rigid ideals.

I happen to have strong opinions about other ridiculous non-empirically supported, and some less effective but empirically supported, treatment modalities. I choose not to employ any of those in my practice. I assure you I will opt NOT to employ e-therapy in my practice either. I will gladly hand over that share of my business over to you. 🙂
 
NH14 said:
I've heard about doing a few therapy sessions over the phone, particularly check up sessions, but has anyone done therapy via the internet?

What do you think of it?
Click to expand...

I have conducted a rather high number of sessions in person so far and not even one over the phone or internet.

My main reasons I am inclined to dissuade any distance treatments are:
- way too impersonal and
- client has lots of chances for avoidance.

What I do allow is the intro conversation over the phone or a quick update on the progress of my clients. But thats all.

I really need to have the person right in front of me to really help him help himself.
In addition, clients tend to dedicate and invest more of themselves in the session when they know thats the only form of help I offer.

🙂
 
My experiences are a little different because I've participated in online process groups. Online process groups can be a little like group therapy. For people who are able to verbalise their feelings and share things that result in their being emotionally vulnerable - those people can get a lot out of the encounter.

I know that I certainly did.

Of course that is heavily dependent on the other group members (how willing they are to share, how pyschologically minded they are). And heavily dependent on how the moderation goes, as well.

I can certainly see a role for internet group therapy in the future. Sure it can be used by cranks - but so can face to face therapy. I understand people being concerned that the main motivation for moving to this will be that it is cheaper and that it won't work out so well... But I think that it CAN work in some circumstances and that people should be a little more open to its potential than they currently are...
 
"Albert Mehrabian, a pioneer researcher of body language in the 1950's, found that the total impact of a message is about 7 percent verbal (words only) and 38 percent vocal (including tone of voice, inflection, and other sounds) and 55 percent nonverbal."

from Understanding The Basics, The Definitive Book of Body Language by Barbara Pease and Allan Pease

If this is even remotely true, I highly doubt online therapy will ever be big business. It may have some good niche applications but I can't see it making huge inroads.
 
zeldazelda said:
"Albert Mehrabian, a pioneer researcher of body language in the 1950's, found that the total impact of a message is about 7 percent verbal (words only) and 38 percent vocal (including tone of voice, inflection, and other sounds) and 55 percent nonverbal."

from Understanding The Basics, The Definitive Book of Body Language by Barbara Pease and Allan Pease

If this is even remotely true, I highly doubt online therapy will ever be big business. It may have some good niche applications but I can't see it making huge inroads.
Click to expand...

amen.
 
toby jones said:
My experiences are a little different because I've participated in online process groups. Online process groups can be a little like group therapy. For people who are able to verbalise their feelings and share things that result in their being emotionally vulnerable - those people can get a lot out of the encounter.
Click to expand...

Yes, I can understand that.

I run a discussion board on my main web site, inviting visitors to share their problems, issues, doubts, fears etc...
And it works, at least for those who are willing to open up and speak their hearts.

Of course, such online sharing is one way of making that first step towards permanent progress in live.
But there are many more steps to be taken, more direct and personal ones, IMHO.
 
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