Gabriela (not her real name), a 42-year-old investment counselor, has been receiving therapy by computer chat for more than a year now. She fell into a deep depression after her last breakup and needed an ear she could count on to be consistently supportive and objective. She had face-to-face therapy years ago after she lost a child, and she thinks it is overrated. With chat therapy, she can look back at the e-trail and relive therapeutic moments. She can also see her progress in black and white.
Linda (also not her real name), 57 and divorced, has been receiving chat therapy for more than two years. She participates in one session a week and pays less than half what she would pay for an in-person encounter. “And there’s no wasting time on chitchat about the weather,” she says. “We get right down to business.” Her therapist has helped lift her out of a debilitating depression that began when she was trying to console a grieving friend. But she has never seen her therapist; she has never even heard his voice.
As for the distance aspect of these therapeutic conversations, both Gabriela and Linda have similar and somewhat curious perspectives. As Linda put it, “What distance? He’s right here in my own house! There’s an immediacy to our interaction, and I’ve shared things with him I’ve never shared with any other therapist.” Gabriela says that in face-to-face therapy she sometimes edited what she was saying to avoid negative facial reactions by the therapist; chat therapy has allowed her to be “completely honest.”
Linda and Gabriela are each clients of therapist Carl Benedict, who is based in Hagerstown, Md. Linda is 2,653 miles away in San Diego, Calif., and Gabriela is 4,235 miles away in Munich, Germany.
Can therapy really be effective over a distance of thousands of miles? What is distance, anyway? Can geographical distance be great and psychological distance small? As a research psychologist with a long-standing interest in technological issues, I decided to review the state of the field.
Researchers, patients and mental health practitioners have long applauded some aspects of therapy at a distance: it is low-cost and easy to schedule, protects clients’ privacy, shields both therapist and client from the possibility of physical or sexual abuse, and makes expertise available for rare conditions wherever it is needed [see “The Promise of E-Therapy,” by Beryl Lieff Benderly; Scientific American Mind, December 2005]. Now new research demonstrates that distance therapy is, in fact, effective. Indeed, much of the skepticism that has long surrounded these modes of treatment is disappearing.
Avalanche of Evidence
Studies have repeatedly verified the power of therapy delivered by remote means: chat, e-mail, video, phone and texting. Azy Barak, a counseling psychologist at the University of Haifa in Israel, has compiled a list of studies and commentaries on e-therapy that contains 983 articles dating to 1993. Most of the articles are recent. In 2008 Barak and his colleagues analyzed the results of 92 studies that collectively evaluated nearly 10,000 people who had had some form of electronically delivered therapy and determined that it is about as effective as the face-to-face variety.
In 2009 psychologist Lisa K. Richardson of Murdoch University in Australia and her colleagues, reviewing 148 articles published since 2003, noted that some studies were flawed methodologically (mainly because they lacked randomized controlled trials) but nonetheless concluded that “high levels of satisfaction and acceptance with tele-mental health have been consistently demonstrated among patients across a variety of clinical populations and for a broad range of services.” In another review article from 2009 psychologists at the University of Southern Indiana and the University of Manchester in England concluded that e-therapists and their clients can form real, meaningful therapeutic alliances and that many traditional face-to-face therapists underestimate the warmth and depth of the connections that are formed.
Even more impressive, psychologists Kristin Heron and Joshua Smyth of Syracuse University found in a 2010 study that “momentary” therapeutic interventions using mobile phones are helpful in the treatment and management of eating disorders, alcohol abuse, cigarette smoking, anxiety and other problems. Because such brief communiqus are easy and cheap to deliver, they are ideal boosters for traditional treatment. Imagine helpful periodic tweets from your therapist arriving within hours or even minutes of when you might have lost your temper or reached for a cigarette.
Given the positive findings, the professional associations have been coming onboard. The American Counseling Association, the National Association of Social Workers and other societies now have official e-therapy guidelines for practitioners, and the American Psychological Association has given therapy at a distance tacit approval: the organization now matter-of-factly mentions e-therapy in the introduction to its code of ethics as one of several therapeutic modalities. According to clinical psychologist Gerald P. Koocher of Simmons College, “the important thing is that you’re practicing competently, no matter how you’re delivering the therapy.”
No One Knows You’re a Dog
That said, e-therapy still presents special problems. Although empirical data are not yet available to decide the issue, 2005 and 2009 position statements issued by the American Psychiatric Association claim that distance therapy most likely works best when the initial contact is face-to-face. One client I spoke to, Annie (not her real name), a 45-year-old from Boston, wanted to continue her treatment for an eating disorder after her therapist, Karen Koenig, moved to Florida. The therapy has continued smoothly by phone, but Annie doubts it could have started that way. A singular bond with a provider often forms in person, even if little is said in the encounter.
The challenge, Koocher suggests, is figuring out what works for whom. Some people might take a therapist more seriously if signs of authority are present: a jacket and tie, for example, or a conservative-looking office with framed diplomas on the wall. “If you really need to be in a room with a therapist,” he says, “remote treatment is probably not for you, even if you have a great Skype connection.”
Koocher worries, too, about the potential for fraud, recalling a cartoon in which one dog is talking to another while typing on a keyboard. The caption reads, “On the Internet, nobody knows you’re a dog.” Organizations such as the International Society for Mental Health Online and the newly formed Online Therapy Institute are giving consumers ways of verifying that online therapists are licensed and qualified. But cyberspace is vast and largely unregulated, with ample room for charlatans. One recent survey of 136 Web sites offering counseling found low compliance with standards recently established by the National Board for Certified Counselors.
Licensing regulations create a quagmire as well, because therapists are licensed to practice only in their own state. Does texting or Skyping from an office in a state qualify as practicing in that state? If not, malpractice suits filed against therapists delivering treatment across state lines could freeze all exchanges with remote patients. Umbrella organizations such as the Association of State and Provincial Psychology Boards are trying to iron out these matters. Another downside to distance: a far-flung therapist is in a poor position to handle mental health emergencies.
It’s Only the Beginning
But even as I was becoming more confident about the legitimacy and staying power of e-therapy, I realized that the same forces rapidly spawning these new therapeutic modalities will soon make them seem pass. Research has shown, for example, that blogging and computer games can be therapeutic for some disorders, perhaps because they give people ways of releasing pent-up tensions. Sophisticated artificial-intelligence software is now augmenting or administering some forms of treatment, reducing the need for the human therapist. Autistic children are benefiting from specially designed smiley-faced robots that interact with the kids with a patience no human can muster.
Virtual-reality programs can help treat psychological problems such as phobias, eating disorders and post-traumatic stress disorder [see “Fantasy Therapy,” by Nikolas Westerhoff; Scientific American Mind, October/November 2007]. People can also reap significant emotional and behavioral benefits from the activities of their avatars [see “Your Avatar, Your Guide,” by Samantha Murphy; Scientific American Mind, March/April 2011], and two real therapists have now set up shop in the 90-million-strong Second Life virtual world, where their avatars are tending to other avatars—and the real people behind them.
Within the next five to 10 years upward of a billion people worldwide are expected to spend much of their time in virtual communities, where, undoubtedly, both human and software therapists will have no shortage of virtual customers. Meanwhile other nontraditional therapies are advancing, such as new pharmaceuticals and direct brain stimulation. Although traditional, face-to-face therapy will likely continue to be practiced for decades, it will undoubtedly play a smaller and smaller role in the extraordinary world of therapeutic intervention that lies ahead.