I have been working with patients online for about 6 years, and even now I have some interesting surprises in the work. Recently I was meeting online with one of my long-term patients for their regular session. I use my laptop but have a better web camera and monitor hooked up to it. The bigger monitor allows me to see the patient’s image, but also keep an eye on my image so I can see what the patient is seeing. The laptop monitor stays dark, and the laptop’s built-in webcam goes unused, at least most of the time. But this particular day the laptop webcam decided to switch on 15 minutes into the appointment, and hijacked the webcam I was using. So from what my patient could see, one minute I was there listening empathically, and the next minute I had disappeared.
Those of you who enjoy object relations theory should be enjoying this story by now. Wait, it gets better.
As I was explaining to my patient why I’d disappeared, I was trying to turn off the laptop’s built-in webcam. Instead I turned on a special program the laptop has that replaces the screen with the image of a kitten, the one seen above in fact. Suddenly I was not invisible, but a kitten. Better yet, the kitten was lip synching and moving its mouth when I spoke. Fortunately this wasn’t happening at a particularly delicate moment in the therapy, and we both had a good laugh at it. I apologized to my patient and said, “you know, I studied a lot of things at grad school, but they never taught me what I’m supposed to do if I turn into a kitten when I’m with a patient.”
Many psychotherapists have the sort of relationship with technology that resembles the folks they treat with Borderline Personality Disorder: They alternately overidealize and devalue tech, often in the same breath. “Skype” will be the way we salvage our dwindling practices, we’ll be able to reach people all over the planet, make our own hours and go completely self-pay because most insurance doesn’t cover it. It will be wonderful. That’s the overidealizing part, the devaluing part is more subtle.
Because I do a growing amount of therapy and supervision online, I often get requests for a consultation session to help therapists who want to do online therapy and “need my help getting on Skype.” At this point I try to explain that Skype is not HIPAA-compliant, and that there is more to it that getting a webcam, but here’s where the devaluing of technology comes in. It’s as if some folks think that the only thing one needs to know in order to be an online therapist is how to download a program and turn on the camera.
Most therapists who decide to get Basic EMDR training wouldn’t bat an eye at needing to go through two weekend trainings and a minimum of 20 didactic and 20 hours of supervised practice in order to be certified. And yet many therapists don’t consider that working online and with emerging technologies requires more than learning how to flick a switch. It’s sort of the way people often treat the IT guy at the workplace: With one breath we describe ourselves to him as “clueless” about technology; and yet we really want him to stay in that basement office until we need him to come up and fix our email.
Graduate programs teach us next to nothing about how to use technology in our practice, except perhaps to warn us to avoid it at all costs. Think about it. Do you know what to do if you disappear in the middle of talking with a patient? Do you know what to do if you turn into a talking kitten? More importantly do you know how to prevent yourself from turning into a talking kitten, or turn yourself back from one if you do? And perhaps most importantly, do you know how to help patients anticipate the glitches with virtual therapy, process the unique empathic failures that can arise, and create a good-enough holding environment online?
People like my colleagues DeeAnna Merz-Nagel and Kate Anthony founded the Online Therapy Institute for just this reason. They offer dozens of different 5 hour courses on various technologies, from video conferencing to text chat to conducting therapy in virtual realities like Second Life. The takeaway here is that there is a lot more to learn about online therapy than downloading Skype.
Look, I am not trying to discourage people from doing online therapy, in fact the opposite. I know that it can be a very effective treatment modality, and easily accessed by a growing global population. I’m not even trying to get you to sign up for consultation with OTI or me or anyone in particular. The point I am trying to make is that it is an additional skill set that needs to be learned and integrated into your clinical repertoire.
Psychotherapists don’t just buy chairs and a couch and start talking. EMDR isn’t just wiggling your fingers in traumatized people’s eyes. Both take time, case supervision and specialized training.
Online therapy, and integrating social technologies into your therapy practice is no different.