The Psychiatrist Will See You Online Now

“She said,’ ‘Why not?’” Dr. Yellowlees recalled, in an interview. “She was disappointed. She wanted a copy; she said that she’d never been on TV before and wanted to show her community. It taught me about people’s attitudes. Patients have always liked being treated on video — it’s the providers and physicians who were the major obstacles.”

Many Freudian-based therapists have been particularly skeptical, concerned that going virtual might alter or weaken a therapeutic bond built, often painstakingly, through the shared physical space of analysis. Others worry that a rich dimension of body language is lost in video interactions.

“In terms of trauma, one of the things many of us track is micro-expressions, these flickers of emotional tone, when people are talking,” said Dr. Andres Sciolla, a psychiatrist in the U.C. Davis clinic. “I cannot tell you how many times I have noticed a flicker of tears or fear in the gaze of a patient, perceived a shift in feeling, and explored that — and found a lot behind that change.”

If widely used approaches such as cognitive-behavior therapy lose something crucial by being virtual, it is not evident from the studies done so far. In one study, for instance, a team led by researchers based at the Baltimore Veterans Affairs Medical Center tracked more than 100 veterans being treated for depression over six months, half of them engaging in traditional, in-person therapy, the other half receiving care online. Both groups improved, on standard measures, by the same amount. Another study, led by Leslie Morland of the Department of Veterans Affairs, Pacific Islands Healthcare System, compared in-person and virtual talk therapy for 120 veterans with post-traumatic stress. It reached a similar finding: improvement across the board, no difference between the groups.

“The evidence so far from these equivalency trials, comparing face-to-face versus over video — every trial I’ve seen shows no difference in clinical outcomes,” said John Fortney, director of population health in the University of Washington’s psychiatry department. For more than a decade, Dr. Fortney has been trying to get telepsychiatry and telepsychology adopted in rural areas, where people have little or no access to mental health specialists. “About 90 percent of patients report being satisfied with the experience,” he said.

And with the threat of coronavirus at large, safety has become a paramount concern.

“My psychiatrist literally saved my life, about 10 years ago, when I had a couple of suicide attempts,” said Margaret, 70, a retired nurse, who, like Mr. Raymos, received in-person care at the U.C. Davis clinic and had to go virtual in March. “I know how powerful those office visits can be. But I don’t want to go out. I don’t want to be exposed to this virus; I like that I can do this from home. My therapist, I feel his personality online; that still comes through. He’s listening very carefully. He’s really present to me.”

Not everyone who could benefit from psychiatric care is a candidate for the virtual variety. For people who are deeply delusional, who are scared, paranoid and alone, for instance, a Zoom call in these situations can be an invitation to confusion, or much worse. The rich sensory experience of full human interaction with a gifted therapist — that quality that defies measurement and study, in any randomized trial — is what many such people need.

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