Putting an Unhappy Face on Telepsychiatry


Does telepsychiatry lessen the therapeutic alliance?


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I read with interest Gerald Perman, MD, DLFAPA, DLFAAPDPP’s article, “Psychodynamic Telepsychiatry After the Pandemic.”1 It is clear Dr Perman is very comfortable with telepsychiatry and its benefits for patients. But what about the possibility of long-term job dissatisfaction that may accompany telepsychiatry?

During the pandemic, I continued my schedule from my practice office (albeit without my patient’s physical presence) maintaining a division between professional and home life. The long-anticipated return to practice with in office patients separated by masks eased the isolation, but augmented the delicate emotional balance between myself and my patients. I missed the reactivity of their faces. Most, including my older patients, were ready to return to office normality; a few needed coaxing; some were content to continue remotely. Surprisingly, over time I became lazy with my remote patients; my emotional battery ceased to be charged and my energy to strengthen the therapeutic alliance waned. Although I realized my presence benefitted my patients, I had underestimated the importance of their presence for my well-being.

Articles abound about the effectiveness of online therapy. However, the authors of pilot study, “Psychotherapists’ perception of their clinical skills and in-session feelings in live therapy versus online therapy during COVID 19 study,”2 point out that despite the effectiveness of online therapy, “most therapists continue to prefer traditional live therapy”3 or they have relevant reservations about online therapy.4 Notably significant differences in outcome in live therapy over online therapy were noted in the study’s sub scale flow (inspired, stimulated, engrossed, challenged) while more boredom (absent, bored, drowsy) reported in the online group.2 Similarly, with my own group of online patients, I had to work harder to engage and facilitate connectedness and maintain my focus and motivation. Without the presence of COVID-19, I sensed the only reason some of my patients wanted to continue remotely was inertia. After 2 years, it became too difficult to change a learned behavior.

Social scientist and Harvard professor Arthur C. Brooks, PhD, wrote, “Switching to Zoom forever might be convenient, but it’s a recipe for loneliness.”5 He reflected on his return to the classroom for the first time in 10 months: “We were all avoiding contact and wearing masks, so normal human contact was almost nonexistent. But for me, it was like springtime in Paris. I started sleeping better; my mood improved; I became more energetic and optimistic.”5 His reflections sounded similar to my own.

Clearly there is a place for telepsychiatry in our field. However, the longitudinal studies have not yet been conducted that adequately examine the long-term effects on job satisfaction and the happiness quotient of psychiatrists who practice remotely.

Dr Varas is a psychiatrist in Westwood, New Jersey.

1. Perman GP. Psychodynamic therapy after the pandemic. Psychiatric Times. September 13, 2023. https://www.psychiatrictimes.com/view/psychodynamic-telepsychiatry-after-the-pandemic
2. Messina I, Loffler-Staska H. Psychotherapists’ perception of their clinical skills and in-session feelings in live therapy versus online therapy during the COVID-19 pandemic: a pilot study. Res Psychother. 2021;24(1):514.
3. van Der Vaart R, Witting M, Riper H, et al. Blending online therapy into regular face-to-face therapy for depression: content, ratio and preconditions according to patients and therapists using a Delphi study. BMC Psychiatry. 2014;14:355.
4. Cipolletta S, Frassoni E, Faccio E. Construing a therapeutic relationship online: an analysis of videoconference sessions. Clinical Psychologist. 2018;22(2):220-229.
5. Brooks AC. The hidden toll of remote work. The Atlantic. April 1, 2021. Accessed September 21, 2023. https://www.theatlantic.com/family/archive/2021/04/zoom-remote-work-loneliness-happiness/618473/#

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