Virtual Psychiatry is Here to Stay

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COMMENTARY

Outpatient psychiatry went online in early 2020 at the beginning of the COVID-19 pandemic. Over the next 2 years, there were robust discussions about whether virtual psychiatric treatment was effective, whether it was as effective as in-person treatment, whether it was more effective for some patients than for others, and finally, whether psychiatrists and their patients would be returning to the office when the pandemic was over. My comments about each of these considerations will be based on my own experiences as an outpatient psychiatrist and having followed and participated in online discussions about this topic. I will end with a couple of predictions.

The Effectiveness of Virtual Psychiatry

Virtual psychiatric treatment was accepted as valid and effective soon after the invention of the telephone (patented in 1876 by Alexander Graham Bell¹) at the beginning of the 20th century. Psychotherapy was conducted by phone when face-to-face treatment was not possible. Even before COVID-19, psychiatrists were treating patients by phone and on audio-visual platforms as a routine part of their outpatient practice. This most often occurred with patients who were too physically ill to come to the office (although home visits took place as well), when patients were out of town on work travel or on vacation, and when patients had relocated out of state but wanted to maintain their therapeutic relationship with their psychiatrist.

The Chinese American Psychoanalytic Alliance (CAPA) has been providing virtual teaching, treatment, and supervision for more than 20 years by hundreds of English-speaking psychotherapists stationed in the United States, Canada, Central and South America, and Europe to English-proficient Chinese mental health professionals in Mainland China. It was begun by New York psychoanalyst and psychiatrist Elise Snyder, MD.² Many CAPA students have graduated from CAPA training programs and have since become teachers and mental health leaders in China. I participated as a voluntary psychotherapist and teacher with CAPA from 2000 to 2010.

The Effectiveness of Virtual vs In-Person Psychiatry

I am reminded of the folk song “John Henry” in which John Henry, a “steel-driving man,” competed with a steam drill to crush rocks used in the construction of railroad tracks. In the song, John Henry lost the competition and “died with his hammer in his hand.” One moral of this song (there are several) is that technological progress will eventually win the day. There have been similar competitions between the horse and the automobile and between grandmaster chess champions and super computers. Such an analogy can now be made between in-person and virtual psychiatry.

Older psychiatrists (and patients) who did not grow up with the internet and social media are quick to point out the “advantages” of in-person psychiatry. They have said meeting in person enhances the doctor-patient relationship, allows for greater observation of body language, provides a fuller sensorial experience on both sides, gives patients an opportunity to mentally prepare for—and to decompress after—their in-person office appointments, etc. I will argue that, just as the horse and buggy gave way to the automobile, virtual psychiatry will remain the treatment modality of choice after the COVID-19 pandemic ends.

Is Virtual Psychiatry More Effective for Some Patients Than for Others?

This question probably cannot be definitively answered because of the difficulties in conducting the necessary double-blind, placebo-controlled study. We can, however, imagine that for certain diagnostic groups, one modality might be more effective than another. For example, a patient with extreme agoraphobia who is afraid of leaving their home might only benefit from virtual psychiatric treatment. A patient without a telephone or internet service would only benefit from in-person treatment. A patient with severe social phobia or autism might strongly prefer (and be able to benefit from) virtual treatment.

In the future, as younger generations of patients increasingly do more of their communication on virtual platforms (social media, other audio-visual platforms, text messaging, etc), they will be supremely comfortable being treated virtually. The same can be said for younger generations of psychiatrists who will have grown up using virtual communication modalities.

My Experience

Over the past 2-and-a-half years of the pandemic, I have worked virtually with all my patients. I meet with, on average, 8 patients a day, 4 days a week, in 45-minute psychotherapy appointments on Zoom, FaceTime, or Google Duo. I recently decided to close my brick-and-mortar medical office (after 40 years) and establish a 100% virtual practice from my home.

Perhaps because my patients are so used to meeting with me on a virtual platform that, after I announced I would not be returning in-person to my downtown office, none of them dropped out of treatment. When there are connectivity issues, these interruptions become grist for the psychotherapeutic mill. I sometimes “mix and match” devices. For example, when meeting with patients on my laptop, if the audio stops working on either side, I call my patient on the phone and we use the phone audio to accompany the computer video, or we switch to FaceTime if we both have iPhones.

Some interruptions are due to text messages or phone calls received by the patient (or the psychiatrist). When these are excessive, they must be viewed as a form of transference (or countertransference) resistance to treatment and addressed in the therapy. Some of the same dynamics that appear in in-person treatment play themselves out when treatment has switched to virtual. One patient who was habitually late or absent for her in-person appointments is almost never ready for the start of her virtual appointments, and she frequently oversleeps and misses her entire morning virtual sessions.

Most therapeutic change and progress that occurs in psychodynamic psychotherapy results from the verbal exchange between patient and psychiatrist. It is primarily the patient’s words that are attended to and analyzed, as well as the pauses between the words, the slips of the tongue, the metonymy and metaphor expressed in the patient’s use of language, and so on. After a while, the novelty of virtual space fades into the background as telepsychiatry becomes the new norm.

Advantages of Virtual Psychiatry

The main advantage of virtual psychiatry is its convenience, for both the patient and the psychiatrist. Virtual treatment saves time and money that was previously spent on travel to and from the office. It is also safer in a variety of ways. With virtual treatment, there is no possibility of sexual or aggressive impulses being put into action as could happen in in-person treatment. Virtual treatment obviates the possibility of having an automobile accident or getting a parking or speeding ticket on the way to or from the appointment.

Patients and psychiatrists save money on cold weather clothing and paying for gasoline or electricity for their cars. Finally, patients and psychiatrists will not be degrading the environment with carbon emissions from internal combustion engines, and climate change will be slowed.

Final Thoughts

I predict that, just as John Henry lost out to the steam engine, in-person psychiatric treatment will increasingly become a thing of the past. As holographic technology is perfected, improved forms of virtual treatment will become available and commonplace. At the same time, even with continued advancements in pharmacological and somatic psychiatric treatments, I predict that the “talking cure” will remain for centuries to come.

Dr Perman is a clinical professor in the Department of Psychiatry and the Behavioral Sciences at the George Washington University Medical Center in Washington, DC.

References

1. Alexander Graham Bell. History. November 30, 2019. Accessed August 8, 2022. https://www.history.com/topics/inventions/alexander-graham-bell

2. CAPA history in China. China American Psychoanalytic Alliance. Accessed August 8, 2022. https://www.capachina.org/capa-in-china