To Skype or Not to Skype- Part Three: My Reflections

I was pleased to see the article, “When your Therapist is Only a Click Away,” in the style section of The New York Times this week, highlighting clients and clinicians who use video chat for therapy sessions. I was excited because it made me feel trendy and cool, but more importantly because it shows that there are people out there thinking and talking about the issue.

In my last post I was able to share what I learned about the legality of video chatting a therapy session, explaining what I can and can’t do according to the law. While learning the law was the vital first step (that took about twenty sub-steps), I also did a great deal of additional reading and reflecting. Knowing what I can do got me thinking about what I should do, which got me thinking about what I would want to do.

Here’s What I Think:

Skype or other forms of video chatting can be a great way to provide individual or group psychotherapy to people in rural or remote areas, where access to clinicians is very limited, or where weather can make travel unsafe or impossible. Video chat can also be an ideal way to reach a client whose diagnosis, like Agoraphobia or PTSD make leaving the house or traveling to your office too anxiety provoking.

However, I don’t think video chatting should replace therapy sessions just because it would be more convenient. One could argue that the client is a consumer and we should cater to their needs, it’s their hour to use how they wish, or that for a busy client it’s better to have an on-line session than no session at all. But what about self-care, prioritizing yourself and that one hour a week you designate for therapy? What about having a time and place where you can get a break from the outside world, stop multitasking and dig deep into yourself to reflect, discuss and develop insight into your mood, personality and behaviors? In my opinion, for psychotherapy to be as successful and helpful as possible, both clinician and client need to be giving the session their 100%.

In the Times article they highlight a client sitting in a lounge chair by the pool and sipping a cocktail during a session. The same client discusses how great it is that she can take a break from a shopping trip to have a session. For me these scenarios raise red flags. First there is the boundary issue. If you are drinking cocktails, cooking dinner, or shopping during our session, there is a very high chance that you are going to forget my real role in your life. We are not friends or drinking buddies. I don’t give you advice, compare your experiences to mine, or share my personal issues with you like I do when I am out to dinner with my friends. Those choices are intentional, with the goal of allowing you to feel comfortable sharing your concerns without feeling like I will judge you, without worrying how your problems will impact me, and without wondering if my comments have an ulterior motive. In my work, I like to be accessible and approachable to my clients while maintaining boundaries.

Here are a few ways I conceptualize Skype’s place in individual therapy: Two feet of snow last night and the city hasn’t yet plowed your street? Yes. Raining and you don’t want to go outside and ruin your blow-out? No. Stuck in at the office because you left the lights on in your car all day, the battery is dead and you need to wait for Triple AAA? Yes. Stuck at work for the fifth session in a row because you don’t know how say no when your supervisor asks you if tonight is an okay night for you to stay late at work? No.

How I Plan to Translate My Reflections into Practice:

I plan on using Skype as an adjunct service available to clients I already see for in-person sessions. For example, if a client would like an urgent appointment for support or to discuss an unexpected issue, like a break-up, getting into a car accident, or a family member having unexpected surgery, and we can’t find a time at my office that works for us, I am comfortable using Skype. I will also be using Skype as an alternative to last minute cancellations, when getting to the session is just not possible, but a client still has the availability to meet privately for an hour. For example, if a nor’easter blows into Boston and it would be unsafe for the client or myself to travel I would use Skype. I would also consider using it for short term support while a client was dealing with a health issue, such as home recuperating from surgery, and unable to walk or drive.

Before I roll out this feature, I need to purchase a high-quality webcam for my desktop, if possible, one with enough resolution to allow me to recognize details such as blushing, sweating or shaking hands. I also plan on creating a separate informed consent document and treatment contract for clients who work with me in this way. I see the need for us to sign an agreement including things like, “I will never sign off or abruptly end the session intentionally,” and “I agree that neither party will record the session,” and to decide together how we will negotiate “eye contact” whether we will look at the camera or at the other person’s face on screen.

I will not work with anyone exclusively over Skype, nor will I use Skype sessions  with people who are currently having thoughts of self harm or have any history of suicide attempts or psychiatric hospitalizations. There is just too much risk that a client in distress could log off before I am able to act to keep them safe.

I plan on charging the same rate and conducting my Skype sessions exactly like I would an in-person session, and I expect my clients to do the same. I will wear pants, sit in a room where privacy can be maintained, and do nothing else, except attend to the session.Whether or not we are in the same room, our work needs to be the priority for that hour.

Integrating technology into psychotherapy is both exciting and scary. As with any clinical decision I feel I have done my best to explore the clinical, legal and ethical questions, and can make an informed choice for my practice as a result. I may love this approach or I may hate it, but as with anything new, I can’t know unless I try.