Online psychotherapy

Telepsychiatry is clinical evaluation and psychiatric treatment at a distance.  It brings a specialist's expertise to otherwise inaccessible populations in prisons, military settings, and distant rural communities.  Introduced decades ago, it is perhaps the most successful example of the more general field of telemedicine.  Telepsychiatry traditionally treats patients at supervised sites and makes use of secure, special-purpose video conferencing equipment.  A number of companies offer technologies and services to facilitate telepsychiatry.  The patients served by telepsychiatry often suffer significant mental illness, such that diagnosis tends to be based on overt signs and symptoms.  Treatment is usually pharmacologic. More recently, mental health blogs and articles have trumpeted the growth of online psychotherapy conducted by private-practice clinicians.  While this falls under the rubric of telepsychiatry, it differs in important respects from traditional applications of this technology.  Online psychotherapy is usually conducted as part of a private practice, without institutional oversight or standardization.  The patient is typically at home or work, not in a supervised setting.  Off-the-shelf consumer technologies such as Skype and FaceTime are often employed, potentially running afoul of HIPAA privacy regulations.  And perhaps most crucially, the patients are higher functioning, with more subtle problems that demand nuanced discussion and finessed interventions.

The idea of conducting psychotherapy at a distance is not new.  Sigmund Freud often corresponded with his patients in ways he hoped would be clinically helpful.  Telephone sessions were pioneered in the 1960s with the advent of suicide hotlines, and have expanded to cover many area of mental health counseling.  (See this 1993 discussion of telephone counseling by an attorney representing the California Association of Marriage and Family Therapists.)  Psychotherapy by telephone remains extremely popular, often serving as a temporary substitute for in-person sessions, for crisis intervention between regular sessions, and to maintain a therapeutic relationship when one party moves out of the area.  Despite the lack of visual cues, studies suggest that telephone psychotherapy and counseling are effective and liked by clients.

Early efforts to use the internet as a medium for psychotherapy seemed to take a step backward with text-only channels such as email or chat.  In contrast to a phone conversation, text chatting hides vocal prosody and other paralinguistic features, obscuring irony, double-meanings, and similar subtleties.  Email shares these shortcomings and is also asynchronous, i.e., the conversation does not occur in real time.  Despite the severe limitations of a text-only exchange, early computer programs sparked the public's imagination that someday the computer itself would conduct psychotherapy, and not simply facilitate communication between two humans.  With the exception of highly structured cognitive and psychoeducational interventions, this has not yet been achieved.

Computer-mediated psychotherapy most commonly takes place online, over video conferencing apps such as Skype and FaceTime.  These tools are readily available for free, and are easy to set up and use.  Controversy exists over whether Skype and FaceTime are "HIPAA compliant," although there is a strong argument that cellphone conversations with patients, not to mention unsecured email, are far more vulnerable to privacy breaches (Skype and FaceTime feeds are encrypted by default, whereas cellphone calls and email are not).

When the alternative is no psychotherapy at all, the utility of conducting it online seems obvious.  Example scenarios include patients who are bedridden or otherwise immobile, those in inaccessible locations such as Antarctic explorers, and those who are immunocompromised or highly contagious with an infectious disease.  Additionally, online therapy reasonably substitutes for telephone therapy in typical situations such as crisis intervention or when an existing therapy dyad is geographically separated, perhaps temporarily.

It is more potentially problematic to choose online therapy over in-person treatment when both are practical options.  Certain patients, e.g., depressed or agoraphobic, may opt not to venture out of the house when it would be beneficial for them to do so.  In-person treatment is inherently a social interaction, which may be therapeutic in itself — or at least good practice.  Psychotherapy at a distance precludes smelling alcohol on the patient's breath, as well as noticing auditory and visual subtleties such as a quiet sigh or dilated pupils.  Micro-momentary facial expressions, implicated in unconscious interpersonal communication, may be overlooked.  And to underscore the obvious, the therapeutic frame may be harder to maintain when the patient is in swimwear by the pool, and drinking an alcoholic beverage during the session.  The potential for patient acting-out, including with suicidal threats or gestures, can render an online therapist especially helpless, and possibly more easily manipulated, than his or her counterpart in an office setting.

Online psychotherapy has practical advantages in some situations, and as a treatment modality it does not appear bogus or inherently harmful.  It would be interesting to compare telephone and video therapy in a research context, to see whether the visual channel confers additional useful information, and whether it enhances or detracts from the therapeutic alliance.  As with most technological innovations, online therapy also introduces new pitfalls and deepens old ones, so it is best not to choose it merely for its novelty or expedience.  Face to face treatment is still the gold standard.

Resistance: "I have nothing to talk about today"

There comes a time, fairly early in many psychotherapies, when there is nothing left to talk about.  The identified problems have been named and discussed, there is no more need to bring the therapist up to speed on one's history.  In essence, the patient's conscious agenda for coming to therapy has been exhausted.  I tell trainees this often happens around session #7 — truly it's more variable than that — when the patient has voiced all his or her prepared topics, said everything already known or consciously felt about the issues, and offered all the background he or she believes is relevant.  The patient may then appeal to the therapist for guidance, not in any profound sense, but simply to suggest something to talk about, so they don't sit there in awkward silence. A dynamic therapist typically turns this back on the hapless patient:  "Say anything that comes to mind."  This challenge can bring therapy to a grinding halt — or trigger the start of genuine exploration.  For it is only when the patient speaks unrehearsed and without self-censorship, in the moment, that the two can observe the here-and-now workings of the patient's mind.  It has been mere preamble up to this point, groundwork at best and chit-chat at worst, not the real work of dynamic psychotherapy.  Speaking "without a script" allows topics to arise that are impolite, uncomfortable, and awkward, ideas the patient previously thought but chose not to say, feelings that had been brushed aside up to that point.  Some patients unfortunately cannot speak without a script; it is too scary and they are too defensive.  Dynamic therapy ends at that point, although emotional support and cognitive techniques may still prove very helpful.  But for those with the courage to look at themselves, their own defenses, resistance, and unconscious motivation, it's time to dive in and explore the unknown.

In a similar vein, patients at any stage of treatment sometimes arrive to a session with nothing to discuss that day.  They exude an uncharacteristic blandness or boredom, as if to signal: "Nothing to see here, just move along."  With a mildly apologetic tone they claim to have no burning issues, nothing especially vexing or troubling.  In fact, maybe it's time to talk about wrapping up treatment...

If this presentation stands in contrast to the patient's usual enthusiasm, I take it as a very good sign.  Something emotionally important is going on, and the patient's Unconscious is trying desperately to throw us off the trail.  In the language of dynamic therapy, this is resistance: unconscious effort to avoid painful or troubling material in therapy.  Some patients employ this sort of resistance constantly, and for this reason are either very challenging to treat, or they "vote with their feet" and leave treatment early in the process.  But when a new resistance stands in clear contrast to the patient's typical openness, it is easier for the therapist to recognize it, easier to point it out to the patient (who is more open to hearing about it), and easier to identify dynamics that may underlie it.

In my experience, these unusually boring or bland openings lead, more often than not, to the best sessions.  Because the patient is not consciously avoiding a troubling issue, and because I rarely know at first what motivates the patient's avoidance that day, it becomes a shared exploration where new discoveries and insights come to light.  For reasons I can't quite explain, the factors motivating such resistance are not deeply buried or inaccessible.  They usually become apparent to both of us well within the 50-minute hour.  "Making the unconscious conscious" (in Freud's famous words) leads the patient to new and unexpected insights — usually a delightful experience for us both — and also to clearing of the leaden resistance, which is no longer needed to keep the material out of consciousness.  Rather than heralding the end of the treatment, awkward silence at the start of an hour, like the awkwardness near the start of many a dynamic psychotherapy, points the way to important thoughts and feelings.  It turns out there is a lot to talk about.

Psychotherapy branding and marketing

I just read a mildly disturbing article in the New York Times called "What Brand Is Your Therapist?"   The author Lori Gottlieb was a full-time journalist who took six years to retrain as a psychotherapist — her website, but not the article, says she has a master's degree in clinical psychology.  Yet she found herself virtually unemployed after several months and in search of marketing consultants to attract clients.  The thrust of the article is that such marketing involves branding, i.e., defining a niche that promises quick, painless, easily grasped results, and then promoting oneself online and elsewhere using that brand. Gottlieb is clearly uncomfortable about the trade-offs inherent in branding and marketing psychotherapy services.  Traditional psychotherapy is often painstaking, uncomfortable, and lengthy, and thus hard to sell.  In contrast, one-time phone consultations and executive coaching are brief, feel-good interventions that lend themselves to snappy, positive catchphrases that sell better.  Such services may be "fast-food therapy — something that feels good but isn’t as good for you; something palatable without a lot of substance."  Moreover, she notes that many sales techniques clash with the tenets of traditional psychodynamic therapy.  Sharing personal details makes one more approachable and "human," at the cost of complicating and possibly precluding transference work.  Active use of social media such as Facebook and Twitter can attract potential clients and publicize one's "brand," but may also blur relationship boundaries essential for effective psychotherapy.  Gottlieb lays out the dilemmas well in her article, but her practice website illustrates the practical conclusion: Lots of "selling" of various services, few of which are recognizable as psychotherapy.

Of course, I am writing this on my psychiatry blog, which is linked to my own practice website.  I too have grappled with similar trade-offs.  I launched my website over five years ago, and started the blog about a year later.  Several months ago I heeded marketing advice I found online:  I re-wrote my website in the first-person and added photographs.  I expanded the sections on my hospital committee work and past research.  I included more practical information about my practice.

Like Gottlieb, I had mixed feelings about doing this.  On the one hand, helping potential patients make more informed choices sounds innocuous enough.  I want suffering people to be able to find me and to know what I can help with.  I want the process of engaging in psychotherapy to be as transparent as possible.  I explain what I do, and even list my fees on my website (most of my peers don't).

On the other hand, I'm concerned that branding and marketing commodifies a personal healing relationship.  It offers to treat psychological issues in little bite-sized pieces, misleadingly suggesting that therapy to resolve one's indecision about marrying, say, can be completely separate and distinct from therapy to deal with career indecision.  It conflates psychotherapy with counseling and coaching, all of which are useful but different things.  Mainly it risks dumbing down psychotherapy.  Psychotherapy is often complex if done carefully, and in my opinion it can't be conducted as well over the phone, by email, while sitting by the pool with Skype running on one's laptop, or in a guaranteed four-session package.

I haven't availed myself of the whole branding arsenal, since I strive to maintain a psychotherapy practice worthy of the name.  If I ever write a book, offer coaching services, or engage in public speaking, those activities will be clearly distinct from my role as a psychotherapy-oriented psychiatrist.  Moreover, patients and would-be patients seem to agree that informational websites are useful, but that too much branding and self-promotion by a psychotherapist is a turn-off.  That makes good sense, and encourages me to take another look at my own website — I may turn it down a little.  What do you think?

Psychotherapy as generic conversation — Sloppy thinking in psychiatry 4

This fourth installment in my "sloppy thinking" series turns to psychotherapy, or what passes for it in some psychiatric practices.  A very brief history: Sigmund Freud, a neurologist, invented psychoanalysis and its offshoot, psychodynamic psychotherapy, about 120 years ago.  It was, first and foremost, a treatment that involved talking — not merely a conversation that happened to make the patient feel better.  Years later, the object-relations school of psychoanalysis and the humanistic psychology movement of the 1960s partly shifted the focus of dynamic psychotherapy away from technique and toward a healing relationship, a shift prefigured by pastoral counseling and by the ministrations of the nursing profession.  Nonetheless, dynamic psychotherapy remained a treatment: a professional service with clear goals and a coherent rationale, aimed to remedy defined psychological conflicts or deficits.  Meanwhile, over the same century or so, academic psychologists developed the theories and practices of behaviorism via experiments with animals, and later applied behavior modification and various behavioral and cognitive therapies to human suffering.  While such treatments could be offered in a humane and caring manner, the relationship itself was not considered curative. Psychoanalysis and psychodynamic therapy originated in a medical context, and psychiatrists historically have been trained in its theory and practice.  (In contrast, psychologists historically tended to practice the empirically based behavioral and cognitive therapies developed in academia, although this distinction between the disciplines has faded.)  Prior to the advent of psychoanalysis, psychiatry was a medical specialty focused on the management of severe mental illnesses that rendered sufferers incapable of living in mainstream society.  But by the mid-20th century, the field had adopted the new "talking cures" to treat higher functioning patients.  For a few decades, roughly 1950 to 1980, the popular image of the psychiatrist was a psychoanalyst with the trademark couch in the office.

The emphasis in psychiatric training and practice shifted dramatically away from psychotherapy and toward medication treatments in the 1980s as a result of several factors.  Promising classes of medications such as SSRI antidepressants and atypical neuroleptics were developed; federal research funding shifted toward biological psychiatry; psychiatry's new diagnostic manual (DSM-III) encouraged medical-model thinking; managed care tightened the screws on reimbursement; and competition from non-physician mental health professionals heated up.  Psychopharmacology became a defensible niche for psychiatry, unlike psychotherapy which saw increasing competition from psychologists, social workers, marital and family therapists, and others.

Currently, many American psychiatry residencies offer minimal training in psychodynamics, or psychotherapy in general (interesting debate here).  I consider this very unfortunate.  Psychodynamically informed treatment is far richer and more sensitive — ultimately, I have to believe, more effective — even if psychodynamic psychotherapy itself is not offered.  For example, unconscious dynamics can help explain medication non-compliance, and can shed light on difficult psychiatric consultations on medical or surgical inpatients.  It's hard to deny that a mental health professional with a deeper appreciation of human emotions, conflicts, and psychological defenses has an advantage over the same professional without this appreciation.

Where's the sloppy thinking?  It results from the inescapable fact that most psychiatric patients harbor thoughts and/or feelings they want to talk about.  A psychiatrist who avoids all such conversation feels like an "ape with a bone," a medication technician who does his own little piece of work well, but misses the big picture.  So the psychiatrist talks with the patient for 30, 45, or 50 minutes, which makes both the psychiatrist and patient feel better in the moment.  It is billed as psychotherapy, but is it?

That depends on what happens in those 30, 45, or 50 minutes.  Is it well-conducted cognitive-behavioral therapy?  Hardly ever.  Nor is it psychodynamic psychotherapy if it's no more than a conversation that temporarily makes the patient feel better.  Dynamic psychotherapy is a structured treatment that includes a dynamic case formulation, a coherent rationale, strategic interventions, and treatment goals — features uniformly absent in this typical scenario.  Some call these unstructured conversations "supportive psychotherapy," but even that has a technical definition and clear goals.  Supportive psychotherapy is more than letting the patient "vent," or chat as though it were a social visit.  Perhaps all this mislabeling is an unfortunate mistake by well-meaning practitioners who were never trained to perform or recognize actual psychotherapy.  Or maybe it's intellectual laziness.  Or insurance fraud.

An honest profession would call such encounters what they are: Humane medication visits.  Stripped of the pretense of psychotherapy, we might admit that it often takes more than ten or 15 minutes to find out how a patient is doing, and that conversely it doesn't require aimless (yet remunerated) chatting for the better part of an hour either.  By clearly differentiating psychotherapy from generic doctor-patient conversation, we'd regain respect from other mental health professionals who have come to believe that psychiatrists don't take psychotherapy seriously, or that we pompously claim we know what we're doing when we don't.  These criticisms really boil down to irritation at psychiatry's sloppy thinking about psychotherapy, a tragic irony considering the field's long history with this treatment modality.

You guessed it: photo courtesy of Petr Kratochvil.

Movie review: "A dangerous method"

Tonight I was invited to an advance screening of "A Dangerous Method," a film about the early days of psychoanalysis.  It stars Keira Knightley, Michael Fassbender, and Viggo Mortensen, and will be in wide release by Sony Pictures Classics this month.  The invitation was extended to Psychology Today bloggers, among others, in the hope we'll publicize the release.  Since I was gifted with a free viewing, I invite readers to consider this review with my potential conflict of interest in mind. Overall, I was pleasantly surprised by the film, which has received mixed but mostly positive reviews so far.  It humanizes both Freud and Jung, and introduces us to Sabina Spielrein, a real-life patient of Jung who later became a renowned psychoanalyst herself.  Jung's reputed sexual affair with Spielrein is treated as fact in the movie, and serves as the main dramatic focus.  Some reviewers feel Knightley overacted the part of Spielrein.  I thought it was pitched about right: a troubled young woman having illicit sex with her therapist would naturally be agitated and volatile.  I did find Spielrein's willingness, from the first session, to participate in newfangled psychoanalysis to be a bit optimistic.  Also, her suggestion at one point that "there is man in every woman, and woman in every man" too-neatly implies that she gave Jung his idea of the anima and animus.  Nonetheless, Spielrein is very well played.

In contrast, I found Fassbender's portrayal of Jung more vague and wooden.  The film suggests he was a psychic who could foretell the future in dreams and premonitions.  His feelings toward Spielrein seem confused, not merely ambivalent or conflicted.  And he refers to countertransference years before Freud published the term, although it could be argued the two historical figures may have discussed it between themselves earlier.

The decline and fall of Freud and Jung's collaboration is the secondary theme, and here I was particularly impressed with the believable way Freud was portrayed.  A pioneer, pragmatist, and controlling intellectual, he knew his treatment approach was controversial and sought to rein in Jung's more expansive and spiritual predilections, which the elder Freud saw as giving ammunition to his enemies.  Instead of the usual stereotype as a gruff, unyielding father figure preoccupied with sex, Mortensen plays Freud as somewhat authoritarian, but fundamentally smart, affable, and very concerned about the future of his psychoanalytic movement.  Their famous 1909 falling-out on the deck of a ship sailing to America is played with a soft touch: Freud refuses to let Jung analyze his dream for fear of losing his authority (something Jung later recounted as due to Freud's secrecy over his affair with his sister-in-law Minna Bernays).  In the film, Jung is hurt by this non-reciprocity, and goes on afterward to develop his own theories of the psyche.

The film is beautifully photographed, and has a number of nice touches.  The opening and closing credits are shown over a close-up of handwritten correspondence, the main way Freud and Jung communicated with each other.  In one scene Jung conducts a word-association test using physiologic data collection — an accurate depiction of some of his research at Burghölzli, the psychiatric clinic of Zurich University, where he worked from 1900–1908.  I even liked how the film showed the evolution from horse drawn carriages to automobiles, which of course happened in the same time period.

The American physician-psychologist William James was Freud's contemporary and wrote: "I can make nothing in my own case of his dream theories, and obviously 'symbolism' is a most dangerous method."  The film "A Dangerous Method" is not nearly so dismissive of psychoanalysis.  Yet, in its depiction of the dueling dream interpretations of Freud and Jung, and the complex relationship between Jung and Spielrein,  it deftly highlights how symbolism is indeed a dangerous method of transacting human relationships.