What we don’t know about online therapy

USMC videoconferencing familyLast week, I offered a snapshot of what we know about online therapy. That data shows a great deal of potential for online work. However, there is also a lot that we don’t know about online therapy. In today’s post, I’ll address three of those unanswered questions.

As I mentioned last week, the research base for online psychotherapy is growing quickly. It may be that answers to these questions will be more readily available just weeks or months from now. In addition, the fact that we do not yet have answers to these questions should not stop therapists interested in working online from doing so. But for the time being, these are issues where we as a field are still seeking important information.

We do not know whether online therapy is effective with couples or families

All of the studies described in last week’s post focused on treatment for individuals. There have been very few studies to date examining online work with couples or families, and to our knowledge, no clinical trials comparing online couple or family treatment with similar treatment delivered in person. Some suggestions for specific protocols for online work with couples from particular populations do show promise (here’s an example), but these have not been empirically evaluated.

One specific concern in doing video-based work with a couple or family is the therapist’s ability to see subtle nonverbal cues from the clients. As a practical matter, to fit two or more people into a video frame is likely to require that they sit farther away from the camera than an individual would. Therapists may then not be able to see subtle facial expressions on the clients as well.

In the early days of online therapy, similar concerns were expressed about therapists not being able to detect subtle expressions on individual clients’ faces, and that concern appears to have been overblown. Perhaps the same will be true here. For the moment, we simply don’t know. Therapists working with couples and families online may be wise to caution their clients that online therapy remains experimental when applied to relational work.

We do not know whether therapy is generally effective when done online, or whether only some forms of therapy are effective online

Research so far has tended to focus on specific, manualized treatments applied to specific individual concerns. As more studies are put forward, we may find that such tight controls on treatment are not necessary for online therapy to be effective. (This would match what we know about in-person therapy, where manualized treatments work as well as other treatments, but not necessarily better than those others.) Research so far on the relationships between online therapy clients and their therapists shows those relationships to be as strong as the bonds forged in person, which bodes well for online work.

Along similar lines, we do not yet have strong data comparing various technologies for the application of similar treatment. While many therapists say that they do phone sessions at least some of the time, we do not know whether phone sessions are as productive as video-based sessions. We also have little data on the effectiveness of text, chat, and email-based therapies, though some studies have shown these to improve specific behaviors with individual clients.

We do not know how online therapy will impact the psychotherapy market

In theory, greater access to mental health care should lead to more clients seeking care. That would improve the job market for therapists, with greater demand leading to more jobs and higher salaries. However, as I outlined in my book Saving Psychotherapy, this has not been the case so far. Despite advances in both technology and regulation that should have made care more accessible (particularly in rural areas), the overall number of people seeking mental health care in the US seems to be flat.

It may just be that it takes time for newer technologies to be seen as viable ways of accessing care, and that growth in online therapy over time will mean that more people overall are seeking help. Even in that case, two contradictory forces would be created. The greater overall demand for services should indeed lead to more jobs being available for therapists wanting to provide those services. At the same time, with online services available anywhere, the competition posed to therapists working face-to-face with clients would likely put downward pressure on fees, particularly in private practice settings.

We do not know the future

New technologies will continue to make it easier for therapists and clients to connect. Virtual reality is in its early stages, and could be the next innovative therapy platform. At the same time, the regulatory framework for online therapy could change significantly. Counselors and Psychologists are working on credentialing systems that would allow for online practice across state lines. And any therapist taken to court for practicing across state lines could make an interesting Constitutional argument. If that argument were to succeed, the federal government would need to step in to regulate online therapy.

All of this is speculative, of course — a function of not being able to see the future with any certainty. But the origins of family therapy are ones of radical innovation for their time. And the time is certainly ripe for those MFTs who want to be on the cutting edge of clinical work to be trailblazers again.

Best practices in the online practice of couple and family therapy - coverBenjamin E. Caldwell, PsyD is a Los Angeles-based Clinical Fellow of AAMFT. He chaired the workgroup that developed Best Practices in the Online Practice of Couple and Family Therapy, which is now available from AAMFT. Have questions about online therapy? Join Dr. Caldwell and Jillian Bashore on May 5, 2017 for a webinar on online therapy hosted by AAMFT. More information can be found here.

Cross-posted from the AAMFT blog by permission. Their version is here.

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