For over fifteen years I led a supervision group of practicing therapists in San Francisco. During our third year we accepted a new member, an analyst relocating in San Francisco after a long career back east. The first case she presented to the group was a patient living in New York, whom she was continuing to meet via phone sessions. Phone sessions! I was appalled! How can one possibly do decent treatment without actually seeing the patient? Wouldn’t the therapist miss all the nuances—the mingled glances, the facial expressions, the smiles, the nods, the handshakes at departure—so absolutely essential to the intimacy of the therapeutic relationship?
I told her, “You can’t do long-distance therapy! You can’t treat someone who is not in your office.” God, what a prig I was! She held her ground and insisted that the therapy was proceeding quite well, thank you very much. I doubted it and continued to eye her suspiciously for several months until I conceded that she knew exactly what she was doing.
My opinion about long-distance therapy evolved further about six years ago when I received an email from a patient pleading for help and requesting therapy by Skype. She lived in an extremely isolated part of the world where no therapist was available within five hundred miles. In fact, because of an overwhelmingly painful rupture in a relationship, she had deliberately chosen to immigrate to such a remote place. She felt so raw that, if she lived nearby, I’m certain she would not have been willing to meet me, or any other therapist, face-to-face in an office. I had never done therapy via Skype before, and, given my doubts about the method, I hesitated. But since there was no other option for her, I finally decided to accept her for video therapy (but without mentioning this to any of my colleagues). For over a year, she and I met via Skype weekly. With her face filling my computer screen, I began to feel close to her, and within a very short time, the thousands of miles separating us seemed to evaporate. At the end of our year together she had made much progress in therapy, and since then I have seen a great many patients from such faraway countries as South Africa, Turkey, Australia, France, Germany, Italy, and the UK. I now believe there is little difference in outcome between my live therapy and my video therapy. However, I do make a point of selecting patients carefully. I do not use this medium for severely ill patients in need of medication and possible hospitalization.
Three years ago, when I first heard about text therapy, in which therapists and clients communicate entirely by texting, I was once again repelled. THERAPY BY TEXTING! YIKES! It seemed a distortion, a dehumanization, a parody of the therapy process. It was a step too far! I wanted nothing to do with it and moved back into my full prig mode. Then Oren Frank, the founder of Talkspace, the largest online text-therapy program, called and told me his company was now offering therapy groups that met via texting and asked me to consult with his therapists. TEXTING THERAPY GROUPS! Once again I was shocked. A group of individuals who never saw one another (to maintain anonymity, their faces were never shown on the monitor, but were represented by symbols) and communicated entirely by text—this was too much! I could not imagine group therapy working via texting, but I agreed to participate, almost entirely out of curiosity.
I observed a few of the groups and this time I was right. The group therapy I witnessed turned out to be too cumbersome, and the project was soon abandoned. Instead, the company then concentrated entirely on using texting for individual therapy. Soon other text-therapy companies opened up in the United States and several other countries, and three years ago, I agreed to supervise therapists who were responsible for Talkspace staff training.
Now in my eighties, I rarely read journals or travel to attend professional conferences in my field, and I feel increasingly out of touch with new developments. Even though texting seemed the epitome of impersonality and the very opposite of my highly intimate approach to therapy, I sensed that texting was to play a significant role in the future of therapy. As a way of combatting personal obsolescence, I elected to keep current with this rapidly expanding method of delivering psychotherapy.
The platform’s format offers clients the opportunity to send and receive texts (daily if desired) with a therapist for a modest fixed monthly fee. The use of such therapy is expanding exponentially and, at this writing, Talkspace, the largest of the US companies, engages over a thousand therapists. Many such platforms are opening in other countries—three companies in China have contacted me, each claiming to be the largest Chinese Internet therapy company.
The innovation evolved quickly. Soon Talkspace offered not only text therapy, but also the possibility for clients and therapists to leave voice messages to one another. Then, a short time later, the client was offered the option of meeting via live videoconference. Soon only 50 percent of the sessions were via texting, 25 percent by phone-messaging, and 25 percent by videoconference. My expectation was that there would be an inevitable sequence, that clients would use texting only during the initial phase of therapy and gradually progress to audio, and then finally to video—the real stuff. But how wrong I was! That was not what happened! Many clients prefer texting and decline phone and video contact. That seemed counterintuitive to me, but I soon learned that many clients felt safer with the anonymity of texting, and, moreover, that younger clients were extremely comfortable with texting: they grew up with texting and often prefer texting to phone contact with their friends. As of now it appears that text therapy will continue to play a robust role in the future of our field.
For some time I continued to feel dismissive of text therapy: it appeared to me like a feeble facsimile of the real thing. As I examined the work of supervisees, I was certain this modality did not offer the kind of therapy I offered my patients. Gradually, however, I have come to understand that, though it is not the same therapy offered in face-to-face encounters, it does offer something important to clients. Without doubt, many clients value text therapy and undergo change. I urged Talkspace to launch some careful outcome research, and the initial findings indeed support the presence of significant change. I’ve read patients’ comments in their texts expressing how much they value the process. One patient texted that she had printed out some of her therapist’s words and pasted them to the refrigerator door in order to review them regularly. If clients have a panic attack in the middle of the night, they can immediately text their therapist. Though the therapist will not read the text for hours, there is still a sense of immediate contact. Furthermore, clients can easily review their entire therapy, every word they have told their therapist, and thus gauge how much progress they have made.
The supervision of therapists using text therapy feels different from supervision of traditional therapists. For one thing, when I supervise the work of a text therapist, I do not have to rely on the therapist’s sometimes unreliable recollections of what transpired in the hour; instead, I have available the entire transcription of everything, every word that passed between therapist and patient—there is nothing hidden from the supervisor’s eyes.
Lastly, I’ve so strongly urged text-therapy practitioners under my supervision to be attentive to the human, empathic, genuine nature of the client-therapist relationship that an odd, paradoxical result has occurred: in the right hands of well-trained therapists, the texting approach may offer a more personal encounter than face-to-face meetings with therapists who rigidly follow mechanized behavioral manuals.