I think that there is a psychological reaction to telepsychiatry that relates to how both the patient and the psychiatrist experience the encounter when it takes place over the Internet rather than in an office.

The first two psychological issues that come to my mind are:

• The patient and the psychiatrist each come with some attitude toward the technology, and
• The patient and the psychiatrist are in the same environment when they are face-to-face, but not when they are doing  telepsychiatry.

Regarding attitudes toward technology, I’ve certainly come to appreciate just how big the differences are between me and some of my patients. I work part time as a psychiatrist, and part time as an engineer. Not much about technology scares me, and I’m intrinsically friendly toward trying something new. Some of my patients share my attitudes, and some clearly do not. There is a clear age effect: I can’t think of one person under the age of 30 who has had trouble navigating my website or printing an Acrobat document. Among people who are age 50 and above though, I find that a substantial fraction don’t really understand hypertext links, what the scrollbar does, or how to use the back button on a browser.

It takes time for people to adjust to new things, and telepsychiatry isn’t any exception. If someone is phobic of technology, I see that as a problem worthy of treatment. I remember an therapeutic interchange I had with a 80 year old patient a few months ago. The patient lived alone in a rural area, and was just barely able to take care of herself. Her daughter, who lived a few miles away, was very worried for her mother’s safety and begged and begged her mother to carry a cell phone with her so that she could call for help if something happened to  her. The patient stubbornly refused to learn how to use her cell phone. I spent about 20 minutes with the patient one session working on this problem. It took 19 minutes to get the patient to overcome her resistance to trying something new and less than one minute to teach her how to push the speed dial key on her phone that would call 911 if she needed help. At the end of the session, the patient said, “I would have learned this a long time ago if I knew it was this easy.”

This isn’t to say that I can’t think of ways that the patient or the psychiatrist couldn’t get justifiably irritated by technical problems or a slow Internet connection. I also can’t see any reason why normal transference and countertransference issues couldn’t relate to the technology for telepsychiatry.

However, I believe the environment is probably more important for telepsychiatry than technophobia. In a face-to-face session, the patient and psychiatrist are in the same environment, while in telepsychiatry the patient and the psychiatrist are in different environments. When a patient comes to see me, we are both in my office together, and I try to keep the office quiet and to avoid interruptions. Because I have a fair amount of control over my office space, I can make sure that patients have a cup of tea or a glass of water if they want and that their session is not interrupted.  The patient has a few moments while waiting in the waiting room to settle down and think about what they want to say before they come through the door to my office.

The “teletransference” is highly dependent, not only on my environment (which I can control to some extent), but on the patient’s environment (which I can’t control at all.) I realize that I need to think about some straightforward things about my environment (such as what is in the background when I’m on Skype.)

A bigger issue though, is that I obviously need to think about how to help a telepsychiatry patient shape his or her environment to make the interaction better. Some obvious things come to mind:

• Privacy,
• Quiet,
• Comfort with the technology, and
• Freedom from interruptions.

I’ll write more about how to help the patient shape his or her environment in a later post.