The event reminder on Melissa Weinblatt's iPhone buzzed: 15 minutes till her shrink appointment.
She mixed herself a mojito, added a sprig of mint, put on her sunglasses and headed outside to her friend's pool. Settling into a lounge chair, she tapped the Skype app on her phone. Hundreds of miles away, her face popped up on her therapist's computer monitor; he smiled back on her phone's screen.
She took a sip of her cocktail. The session began.
Ms. Weinblatt, a 30-year-old high school teacher in Oregon, used to be in treatment the conventional way — with face-to-face office appointments. Now, with her new doctor, she said: "I can have a Skype therapy session with my morning coffee or before a night on the town with the girls. I can take a break from shopping for a session. I took my doctor with me through three states this summer!"
And, she added, "I even e-mailed him that I was panicked about a first date, and he wrote back and said we could do a 20-minute mini-session."
Since telepsychiatry was introduced decades ago, video conferencing has been an increasingly accepted way to reach patients in hospitals, prisons, veterans' health care facilities and rural clinics — all supervised sites.
But today Skype, and encrypted digital software through third-party sites like CaliforniaLiveVisit.com, have made online private practice accessible for a broader swath of patients, including those who shun office treatment or who simply like the convenience of therapy on the fly.
One third-party online therapy site, Breakthrough.com, said it has signed up 900 psychiatrists, psychologists, counselors and coaches in just two years. Another indication that online treatment is migrating into mainstream sensibility: "Web Therapy," the Lisa Kudrow comedy that started online and pokes fun at three-minute webcam therapy sessions, moved to cable (Showtime) this summer.
"In three years, this will take off like a rocket," said Eric A. Harris, a lawyer and psychologist who consults with the American Psychological Association Insurance Trust. "Everyone will have real-time audiovisual availability. There will be a group of true believers who will think that being in a room with a client is special and you can't replicate that by remote involvement. But a lot of people, especially younger clinicians, will feel there is no basis for thinking this. Still, appropriate professional standards will have to be followed."
The pragmatic benefits are obvious. "No parking necessary!" touts one online therapist. Some therapists charge less for sessions since they, too, can do it from home, saving on gas and office rent. Blizzards, broken legs and business trips no longer cancel appointments. The anxiety of shrink-less August could be, dare one say ... curable?
Ms. Weinblatt came to the approach through geographical necessity. When her therapist moved, she was apprehensive about transferring to the other psychologist in her small town, who would certainly know her prominent ex-boyfriend. So her therapist referred her to another doctor, whose practice was a day's drive away. But he was willing to use Skype with long-distance patients. She was game.
Now she prefers these sessions to the old-fashioned kind.
But does knowing that your therapist is just a phone tap or mouse click away create a 21st-century version of shrink-neediness?
"There's that comfort of carrying your doctor around with you like a security blanket," Ms. Weinblatt acknowledged. "But," she added, "because he's more accessible, I feel like I need him less."
The technology does have its speed bumps. Online treatment upends a basic element of therapeutic connection: eye contact.
Patient and therapist typically look at each other's faces on a computer screen. But in many setups, the camera is perched atop a monitor. Their gazes are then off-kilter.
"So patients can think you're not looking them in the eye," said Lynn Bufka, a staff psychologist with the American Psychological Association. "You need to acknowledge that upfront to the patient, or the provider has to be trained to look at the camera instead of the screen."
The quirkiness of Internet connections can also be an impediment. "You have to prepare vulnerable people for the possibility that just when they are saying something that's difficult, the screen can go blank," said DeeAnna Merz Nagel, a psychotherapist licensed in New Jersey and New York. "So I always say, 'I will never disconnect from you online on purpose.' You make arrangements ahead of time to call each other if that happens."
Still, opportunities for exploitation, especially by those with sketchy credentials, are rife. Solo providers who hang out virtual shingles are a growing phenomenon. In the Wild Web West, one site sponsored a contest asking readers to post why they would seek therapy; the person with the most popular answer would receive six months of free treatment. When the blogosphere erupted with outrage from patients and professionals alike, the site quickly made the applications private.
Other questions abound. How should insurance reimburse online therapy? Is the therapist complying with licensing laws that govern practice in different states? Are videoconferencing sessions recorded? Hack-proof?
Another draw and danger of online therapy: anonymity. Many people avoid treatment for reasons of shame or privacy. Some online therapists do not require patients to fully identify themselves. What if those patients have breakdowns? How can the therapist get emergency help to an anonymous patient? "A lot of patients start therapy and feel worse before they feel better," noted Marlene M. Maheu, founder of the TeleMental Health Institute, which trains providers and who has served on task forces to address these questions. "It's more complex than people imagine. A provider's Web site may say, 'I won't deal with patients who are feeling suicidal.' But it's our job to assess patients, not to ask them to self-diagnose." She practices online therapy, but advocates consumer protections and rigorous training of therapists.
Psychologists say certain conditions might be well-suited for treatment online, including agoraphobia, anxiety, depression and obsessive-compulsive disorder. Some doctors suggest that Internet addiction or other addictive behaviors could be treated through videoconferencing.
Others disagree. As one doctor said, "If I'm treating an alcoholic, I can't smell his breath over Skype."
Cognitive behavioral therapy, which can require homework rather than tunneling into the patient's past, seems another candidate. Tech-savvy teenagers resistant to office visits might brighten at seeing a therapist through a computer monitor in their bedroom. Home court advantage.
Therapists who have tried online therapy range from evangelizing standard-bearers, planting their stake in the new future, to those who, after a few sessions, have backed away. Elaine Ducharme, a psychologist in Glastonbury, Conn., uses Skype with patients from her former Florida practice, but finds it disconcerting when a patient's face becomes pixilated. Dr. Ducharme, who is licensed in both states, will not videoconference with a patient she has not met in person. She flies to Florida every three months for office visits with her Skype patients.
"There is definitely something important about bearing witness," she said. "There is so much that happens in a room that I can't see on Skype."
Dr. Heath Canfield, a psychiatrist in Colorado Springs, also uses Skype to continue therapy with some patients from his former West Coast practice. He is licensed in both locations. "If you're doing therapy, pauses are important and telling, and Skype isn't fast enough to keep up in real time," Dr. Canfield said. He wears a headset. "I want patients to know that their sound isn't going through walls but into my ears. I speak into a microphone so they don't feel like I'm shouting at the computer. It's not the same as being there, but it's better than nothing. And I wouldn't treat people this way who are severely mentally ill."
Indeed, the pitfalls of videoconferencing with the severely mentally ill became apparent to Michael Terry, a psychiatric nurse practitioner, when he did psychological evaluations for patients throughout Alaska's Eastern Aleutian Islands. "Once I was wearing a white jacket and the wall behind me was white," recalled Dr. Terry, an associate clinical professor at the University of San Diego. "My face looked very dark because of the contrast, and the patient thought he was talking to the devil."
Another time, lighting caused a halo effect. "An adolescent thought he was talking to the Holy Spirit, that he had God on the line. It fit right into his delusions."
Johanna Herwitz, a Manhattan psychologist, tried Skype to augment face-to-face therapy. "It creates this perverse lower version of intimacy," she said. "Skype doesn't therapeutically disinhibit patients so that they let down their guard and take emotional risks. I've decided not to do it anymore."
Several studies have concluded that patient satisfaction with face-to-face interaction and online therapy (often preceded by in-person contact) was statistically similar. Lynn, a patient who prefers not to reveal her full identity, had been seeing her therapist for years. Their work deepened into psychoanalysis. Then her psychotherapist retired, moving out of state.
Now, four times a week, Lynn carries her laptop to an analyst's unoccupied office (her insurance requires that a local provider have some oversight). She logs on to an encrypted program at Breakthrough.com and clicks through until she reads an alert: "Talk now!"
Hundreds of miles away, so does her analyst. Their faces loom, side by side on each other's monitors. They say hello. Then Lynn puts her laptop on a chair and lies down on the couch. Just the top of her head is visible to her analyst.
Fifty minutes later the session ends. "The screen is asleep so I wake it up and see her face," Lynn said. "I say goodbye and she says goodbye. Then we lean in to press a button and exit."
As attenuated as this all may seem, Lynn said, "I'm just grateful we can continue to do this."
