Personal updates and news from neurology, psychiatry, medicine, forensic neuropsychiatry, psychodynamic psychotherapy, basic neuroscience A controversial topic - tele-psychiatry and tele-therapy - http://preview.tinyurl.com/3bk3p5o and my commentary: http://community.nytimes.com/comments/www.nytimes.com/2011/09/25/fashion/therapists-are-seeing-patients-online.html?permid=27#comment27 For those who cannot access tinyurl.com or nyt.com, here is the full text of the article, and my commentary: September 23, 2011 When Your Therapist Is Only a Click Away By JAN HOFFMAN THE event reminder on Melissa Weinblatt’s iPhone buzzed: 15 minutes till her shrink appointment. She mixed herself a mojito, added a sprig of mint, put on her sunglasses and headed outside to her friend’s pool. Settling into a lounge chair, she tapped the Skype app on her phone. Hundreds of miles away, her face popped up on her therapist’s computer monitor; he smiled back on her phone’s screen. She took a sip of her cocktail. The session began. Ms. Weinblatt, a 30-year-old high school teacher in Oregon, used to be in treatment the conventional way — with face-to-face office appointments. Now, with her new doctor, she said: “I can have a Skype therapy session with my morning coffee or before a night on the town with the girls. I can take a break from shopping for a session. I took my doctor with me through three states this summer!” And, she added, “I even e-mailed him that I was panicked about a first date, and he wrote back and said we could do a 20-minute mini-session.” Since telepsychiatry was introduced decades ago, video conferencing has been an increasingly accepted way to reach patients in hospitals, prisons, veterans’ health care facilities and rural clinics — all supervised sites. But today Skype, and encrypted digital software through third-party sites like CaliforniaLiveVisit.com, have made online private practice accessible for a broader swath of patients, including those who shun office treatment or who simply like the convenience of therapy on the fly. One third-party online therapy site, Breakthrough.com, said it has signed up 900 psychiatrists, psychologists, counselors and coaches in just two years. Another indication that online treatment is migrating into mainstream sensibility: “Web Therapy,” the Lisa Kudrow comedy that started online and pokes fun at three-minute webcam therapy sessions, moved to cable (Showtime) this summer. “In three years, this will take off like a rocket,” said Eric A. Harris, a lawyer and psychologist who consults with the American Psychological Association Insurance Trust. “Everyone will have real-time audiovisual availability. There will be a group of true believers who will think that being in a room with a client is special and you can’t replicate that by remote involvement. But a lot of people, especially younger clinicians, will feel there is no basis for thinking this. Still, appropriate professional standards will have to be followed.” The pragmatic benefits are obvious. “No parking necessary!” touts one online therapist. Some therapists charge less for sessions since they, too, can do it from home, saving on gas and office rent. Blizzards, broken legs and business trips no longer cancel appointments. The anxiety of shrink-less August could be, dare one say ... curable? Ms. Weinblatt came to the approach through geographical necessity. When her therapist moved, she was apprehensive about transferring to the other psychologist in her small town, who would certainly know her prominent ex-boyfriend. So her therapist referred her to another doctor, whose practice was a day’s drive away. But he was willing to use Skype with long-distance patients. She was game. Now she prefers these sessions to the old-fashioned kind. But does knowing that your therapist is just a phone tap or mouse click away create a 21st-century version of shrink-neediness? “There’s that comfort of carrying your doctor around with you like a security blanket,” Ms. Weinblatt acknowledged. “But,” she added, “because he’s more accessible, I feel like I need him less.” The technology does have its speed bumps. Online treatment upends a basic element of therapeutic connection: eye contact. Patient and therapist typically look at each other’s faces on a computer screen. But in many setups, the camera is perched atop a monitor. Their gazes are then off-kilter. “So patients can think you’re not looking them in the eye,” said Lynn Bufka, a staff psychologist with the American Psychological Association. “You need to acknowledge that upfront to the patient, or the provider has to be trained to look at the camera instead of the screen.” The quirkiness of Internet connections can also be an impediment. “You have to prepare vulnerable people for the possibility that just when they are saying something that’s difficult, the screen can go blank,” said DeeAnna Merz Nagel, a psychotherapist licensed in New Jersey and New York. “So I always say, ‘I will never disconnect from you online on purpose.’ You make arrangements ahead of time to call each other if that happens.” Still, opportunities for exploitation, especially by those with sketchy credentials, are rife. Solo providers who hang out virtual shingles are a growing phenomenon. In the Wild Web West, one site sponsored a contest asking readers to post why they would seek therapy; the person with the most popular answer would receive six months of free treatment. When the blogosphere erupted with outrage from patients and professionals alike, the site quickly made the applications private. Other questions abound. How should insurance reimburse online therapy? Is the therapist complying with licensing laws that govern practice in different states? Are videoconferencing sessions recorded? Hack-proof? Another draw and danger of online therapy: anonymity. Many people avoid treatment for reasons of shame or privacy. Some online therapists do not require patients to fully identify themselves. What if those patients have breakdowns? How can the therapist get emergency help to an anonymous patient? “A lot of patients start therapy and feel worse before they feel better,” noted Marlene M. Maheu, founder of the TeleMental Health Institute, which trains providers and who has served on task forces to address these questions. “It’s more complex than people imagine. A provider’s Web site may say, ‘I won’t deal with patients who are feeling suicidal.’ But it’s our job to assess patients, not to ask them to self-diagnose.” She practices online therapy, but advocates consumer protections and rigorous training of therapists. Psychologists say certain conditions might be well-suited for treatment online, including agoraphobia, anxiety, depression and obsessive-compulsive disorder. Some doctors suggest that Internet addiction or other addictive behaviors could be treated through videoconferencing. Others disagree. As one doctor said, “If I’m treating an alcoholic, I can’t smell his breath over Skype.” Cognitive behavioral therapy, which can require homework rather than tunneling into the patient’s past, seems another candidate. Tech-savvy teenagers resistant to office visits might brighten at seeing a therapist through a computer monitor in their bedroom. Home court advantage. Therapists who have tried online therapy range from evangelizing standard-bearers, planting their stake in the new future, to those who, after a few sessions, have backed away. Elaine Ducharme, a psychologist in Glastonbury, Conn., uses Skype with patients from her former Florida practice, but finds it disconcerting when a patient’s face becomes pixilated. Dr. Ducharme, who is licensed in both states, will not videoconference with a patient she has not met in person. She flies to Florida every three months for office visits with her Skype patients. “There is definitely something important about bearing witness,” she said. “There is so much that happens in a room that I can’t see on Skype.” Dr. Heath Canfield, a psychiatrist in Colorado Springs, also uses Skype to continue therapy with some patients from his former West Coast practice. He is licensed in both locations. “If you’re doing therapy, pauses are important and telling, and Skype isn’t fast enough to keep up in real time,” Dr. Canfield said. He wears a headset. “I want patients to know that their sound isn’t going through walls but into my ears. I speak into a microphone so they don’t feel like I’m shouting at the computer. It’s not the same as being there, but it’s better than nothing. And I wouldn’t treat people this way who are severely mentally ill.” Indeed, the pitfalls of videoconferencing with the severely mentally ill became apparent to Michael Terry, a psychiatric nurse practitioner, when he did psychological evaluations for patients throughout Alaska’s Eastern Aleutian Islands. “Once I was wearing a white jacket and the wall behind me was white,” recalled Dr. Terry, an associate clinical professor at the University of San Diego. “My face looked very dark because of the contrast, and the patient thought he was talking to the devil.” Another time, lighting caused a halo effect. “An adolescent thought he was talking to the Holy Spirit, that he had God on the line. It fit right into his delusions.” Johanna Herwitz, a Manhattan psychologist, tried Skype to augment face-to-face therapy. “It creates this perverse lower version of intimacy,” she said. “Skype doesn’t therapeutically disinhibit patients so that they let down their guard and take emotional risks. I’ve decided not to do it anymore.” Several studies have concluded that patient satisfaction with face-to-face interaction and online therapy (often preceded by in-person contact) was statistically similar. Lynn, a patient who prefers not to reveal her full identity, had been seeing her therapist for years. Their work deepened into psychoanalysis. Then her psychotherapist retired, moving out of state. Now, four times a week, Lynn carries her laptop to an analyst’s unoccupied office (her insurance requires that a local provider have some oversight). She logs on to an encrypted program at Breakthrough.com and clicks through until she reads an alert: “Talk now!” Hundreds of miles away, so does her analyst. Their faces loom, side by side on each other’s monitors. They say hello. Then Lynn puts her laptop on a chair and lies down on the couch. Just the top of her head is visible to her analyst. Fifty minutes later the session ends. “The screen is asleep so I wake it up and see her face,” Lynn said. “I say goodbye and she says goodbye. Then we lean in to press a button and exit.” As attenuated as this all may seem, Lynn said, “I’m just grateful we can continue to do this.” This article has been revised to reflect the following correction: Correction: September 24, 2011 A caption on a picture in an earlier version of this article incorrectly described the technology used by Marlene M. Maheu to communicate remotely with patients. She uses video conferencing, not Skype. COMMENTARY: 27. Maurice Preter MD New York, NY September 24th, 2011 6:21 pm "She mixed herself a mojito, added a sprig of mint, put on her sunglasses and headed outside to her friend’s pool. Settling into a lounge chair, she tapped the Skype app on her phone. Hundreds of miles away, her face popped up on her therapist’s computer monitor; he smiled back on her phone’s screen." While the article itself is quite a bit more informative, this intro is problematic, to put it mildly. It belittles the level of intense human suffering and distress that most patients seek help for. Further, I do not know of many 30 year olds in the US that can afford quality psychotherapy as it is almost never covered by commercial insurance. According to http://news.yahoo.com/blogs/lookout/battered-downturn-young-americans-pu..., almost half of young US adults are now jobless. Mojitos at the poolside? At any rate rum drinks have no (uncommented) place in a serious story on psychotherapy. "Shrinks"? The practice of psychotherapy is based on expertise acquired through many years of professional work (whether coming from medicine-psychiatry, psychology, social work or other professions) as well as therapy self-experience. New technologies can and should be used (as in CAPA's teaching efforts in China, or expat mental health care), but only after an educated, careful, individualized assessment of the patient's psychological needs and of the patient-therapist relationship. Everywhere in medicine, a proper diagnosis is the basis for proper treatment. In my opinion as a neurologist-psychopharmacologist-psychodynamic psychotherapist, a proper assessment must include medical reasoning. E.g., what depressed people with thyroid disease or sleep apnea need is neither happy pills nor psychotherapy, but first and foremost, proper medical care. All in all, the article properly conveys the risk that tele-therapy become just another facet of the general rush to the bottom in (mental) health care. Maurice Preter, MD www.psychiatryneurology.net Recommend Recommended by 9 Readers ___________________________________________________________________ Bloglink: http://psychiatryneurology.blogspot.com/ ____________________________________________________________ On anxiety and panic disorder: Panic, Suffocation False Alarms, Separation Anxiety and Endogenous Opioids Maurice Preter, M.D. and Donald F. Klein, M.D. (2008) ____________________________________________________________ On “medically unexplained symptoms, “hysteria”, “conversion disorder”, traumatic enactments: Siri Hustvedt’s The Shaking Woman (Interview with Der Spiegel) (Feb. 2010) PDF ____________________________________________________________ Panic disorder research: Controlled cross-over study in normal subjects of naloxone-preceding-lactate infusions; respiratory and subjective responses: Relationship to endogenous opioid system, suffocation false alarm theory and childhood parental loss (CPL) (Psychological Medicine; online May 2010 click here for PDF) ____________________________________________________________ A conversation between Siri Hustvedt and Maurice Preter MD In 2006, the novelist and essayist Siri Hustvedt suffered an inexplicable seizure while speaking at a memorial service for her father. The seizures continued to occur, and the condition remains undiagnosed. Her most recent book The Shaking Woman or A History of My Nerves tells the story of her condition and explores her symptoms through the lenses of several disciplines: medical history, psychiatry, psychoanalysis, contemporary neuroscience, philosophy, and literature. Hustvedt has a PhD in English literature from Columbia and has worked as a writing teacher with psychiatric patients at the Payne Whitney Psychiatric Clinic in New York. Her web site is sirihustvedt.net. Maurice Preter, MD is a practicing neurologist, psychiatrist, and psychotherapist. Dr. Preter received his training in neurology and psychiatry at the Albert Einstein College of Medicine, and is board certified in both specialties. He has done neuropsychiatric research in stress, anxiety, panic disorder, and psychological trauma. A member of the psychiatry faculty of Columbia University’s College of Physician’s and Surgeons, his particular interest is in the treatment of conditions that cross the conventional and limiting borders of psychiatry, neurology, and general medicine. His web site is psychiatryneurology.net. Please join us for a discussion between Siri Hustvedt and Dr. Maurice Preter on unexplained medical symptoms, their meanings for patients and for doctors, and the vital importance of viewing illness, no matter how mysterious, in a narrative context. Hosted by Dr. Rita Charon and the Program in Narrative Medicine. Wednesday May 12th at 5:00 PM in the Faculty Club in the Physicians & Surgeons Building, 4th floor, Room #446. Click here to listen ____________________________________________________________ Letters - Perception and Distortion - NYTimes.com Review of Books April 18, 2010 Letters Perception and Distortion Published: April 15, 2010 To the Editor: 'The Shaking Woman,' by Siri Hustvedt: Seized (April 4, 2010) As is the case in most presentations of “unexplainable” neurological-psychiatric symptoms, there are unspeakables in Siri Hustvedt’s book “The Shaking Woman” (April 4): the horror of a vague, transgenerationally transmitted memory of a witnessed wartime atrocity; the pain and fear of cumulative loss. Any attempt to put the unspeakable on paper will necessarily fall short, but Hustvedt’s sustained argument in the book is precisely that all categories — medical and philosophical — are in themselves subject to ambiguity. Criticizing it for its failure to address the pain of caregivers is a non sequitur. The reviewer, I am afraid, fell into the same fallacy she accuses Hustvedt of: seeing and hearing only what she wanted to see and hear. In my work as a clinical and forensic neurologist-psychiatrist, I am used to seeing unspeakable emotional pain causing perceptual distortions. Neither literary creation nor its criticism are exempt from this fundamental observation. MAURICE PRETER New York The writer is an assistant professor of clinical psychiatry at Columbia University and an adjunct associate professor of neurology at SUNY Downstate Medical Center. ____________________________________________________________ July 5, 2010 China Daily Op-ed by Dr. Maurice Preter Cross-posted from http://www.chinadaily.com.cn/opinion/2010-07/05/content_10056660.htm and http://psychiatryneurology.blogspot.com/2010/07/quality-psychiatric-care-is-needed.html Quality psychiatric care is needed By Maurice Preter (China Daily) Updated: 2010-07-05 08:00 Comments(0) PrintMail The recent spate of attacks on schoolchildren and the workers' suicides at the Foxconn factory in Shenzhen have again highlighted China's urgent need to balance economic progress with care for those left behind, and unable to cope with, the lightning speed of development. Sustainable development is an avowed goal of Chinese government policy, and from a medical-psychological perspective, accessible, quality general medical and psychiatric care is a fundamental part of long-term, ecologically minded, peaceful societal progress. However, it is an open secret that the medical profession in China is in disarray and rather ill-equipped to contribute to the solution of China's larger societal problems. Chinese physicians are overworked. They routinely see several dozen, if not a hundred patients a day, including those in urgent need of expert mental health treatment. [click to continue] [PDF version] The Shanghai Movement Disorder Conference Oct 2010: 编辑部消息 2010国际帕金森病和运动障碍VPP学术研讨会会议纪要信息来源：发布日期：2010-12-9 14:28:05 2010国际帕金森病和运动障碍VPP学术研讨会会议纪要 2010国际帕金森病（PD）和运动障碍VPP学术研讨会于2010年10月29日—2010年10月31日在上海交通大学附属上海第一人民医院南院隆重举行。此次会议由国际帕金森病运动障碍协会（Movement Disorders Society，MDS）及上海第一人民医院主办，华东地区六省一市神经病学协作委员会及上海医学会脑电图和神经生理学协会协办，会议得到了上海交通大学国际交流中心重点项目基金支持，上海交通大学国际会议专项资助基金资助，中国教育部985项目部分资助。会议邀请了来自美国、法国、加拿大、新西兰、新加坡5个国家的6位运动障碍疾病领域知名专家讲者，邀请了国内包括北京、上海、广州、南京、苏州、杭州、合肥等全国各地专家讲者20余名，参会人数300多名。新闻晚报、青年报、解放日报和新华社、凤凰网、网易网等多家媒体均对会议进行了报道，取得了良好的社会反响。开幕式上，大会荣誉主席上海市第一人民医院院长刘国华教授致欢迎辞；大会学术顾问美国国立卫生研究院NIH神经病学和卒中研究所临床主任、美国临床神经生理协会主席、世界神经病学联盟WFN执行主席、前任MDS主席Hallett M视频致辞；大会组委会主席卫生部北京医院神经内科主任、中华医学会帕金森学组副组长陈海波教授，上海市科委国际交流中心主任朱军浩博士，大会执行主席上海市第一人民医院神经内科王晓平教授分别致辞；另外，来自北京301医院匡培根教授、王鲁宁教授，广州中山大学附属第一医院刘焯霖教授等国内神经内科著名专家发来贺电、贺信祝贺大会圆满成功。会议分3个会场同时举行。会议中，国际讲者新加坡国立大学Lim E教授就帕金森病的深部脑刺激（DBS）治疗、肉毒毒素治疗肌张力障碍、步态失调的评估等专题进行了主题报告；法国庇卡底大学（Université de Picardie）副校长Wallois F教授结合病例录像对肌肉痉挛疾病的临床表现及治疗进行了生动的讲解；新西兰奥塔哥大学（University of Otago）Anderson T教授（MDS的AOS秘书长）就震颤的机制和治疗、皮质基底节综合征（CBS）与进行性核上性麻痹（PSP）的鉴别诊断进行了专题报告；加拿大蒙特利尔大学Lassonde M教授报告了神经心理学在运动障碍神经病学中的应用；美国哥伦比亚大学Preter M教授就心因性运动障碍的机制和进展进行了专题报告。国内讲者安徽中医学院神经病学研究所杨任民教授进行了二巯基丙磺酸钠与青霉胺为肝豆状核变性初始治疗的再检讨专题报告。上海新华医院刘振国教授、苏州大学附属第二医院刘春风教授、卫生部北京医院陈海波教授、广州医学院第一附属医院绍明教授、上海华山医院邬剑军教授、上海市精神卫生中心肖世富教授、上海市公共卫生临床中心卢洪洲教授分别就PD的药物治疗、PD的非药物治疗、PD的认知改变、内科医师开展DBS等微创手术治疗的展望、帕金森精神症状、PD肺部感染的治疗等主题进行了专题报告；上海瑞金医院神经外科孙伯民教授、上海长海医院神经外科胡小吾教授分别就运动障碍疾病的功能神经外科治疗、PD的DBS治疗进行了专题报告。同时，北京协和医院万新华教授进行了肉毒毒素治疗肌张力障碍专题报告；南京脑科医院张颖冬教授报告了PDD新观念；上海长征医院黄流清教授报告了阿尔茨海默病（AD）的诊断和治疗进展；上海市精神卫生中心潘桂花教授进行了基底节相关的强迫症的内科治疗专题报告。会议专题报告过程中，讲者与听者就相关问题展开了热烈的讨论交流，营造了良好的学术氛围。本次会议的一大亮点在于举办了“中国科学院系统神经退行性疾病基础论坛”，该论坛由中国科学院上海生命科学研究院神经科学研究所徐进教授、徐天乐教授、周嘉伟教授，美国康纳尔大学Yi Wang教授，上海曙光医院魏江磊教授主持，国内外多名相关领域知名教授就神经退行性疾病、PD痴呆的基础领域及神经影像学领域等研究进展进行了热烈的讨论，产生了一系列创新性的想法，周江宁教授就脑切片研究中胚胎神经干细胞改善神经元的生存及和神经营养因子基因表达等研究做了专门交流。该论坛正是通过基础和临床专家们之间的学术交流、思想接触、自由争辩，达到了沟通情况、取长补短、相互促进、共同提高的目的，当时就有中科院和华山医院专家间的合作协议并付诸设施。本次会议的另一大亮点在引进世界帕金森大会（WPC）新会议模式上，设置了“医患交流专场讨论会”独立栏目，该讨论会由杨任民教授、张颖冬教授及王晓平教授主持，同时，上海市第一人民医院多名具有丰富临床经验的神经内科医师和护士长参与解疑答惑。约50名PD、肝豆状核变性患者及家属向与会专家教授及病友讲述了患病经历、治疗过程与心得、疑难困惑提问及意见建议等，其中一位主持人是70岁的肝豆状核变性病友，目前刚从上海某一大学教授岗位上退休。这一创新之举的目的在于，以病患为老师，切实聆听病患心声，加强医患沟通，形成医患之间治疗疗效的正性反馈机制，从而更好地指导医疗工作，服务患者，解除患者病痛；另一方面也达到医疗知识普及教育目的。本届会议国内外多名相关领域知名教授共济一堂，本着交流与传播运动障碍疾病领域基础和临床新进展，加强基础临床及海内外的沟通与合作的宗旨，通过讲座与讨论的形式，引发对 PD、肝豆状核变性及其他运动障碍疾病临床诊治新方案、科研进展及未来发展的思考与讨论。通过本次会议，在攻克PD、肝豆状核变性及其他运动障碍疾病的道路上，国内外医生、患者携手并进，有理由相信，在不远的将来我们一定能取得进一步的进展！（李文杰、王晓平整理）

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A controversial topic - tele-psychiatry and tele-therapy - http://preview.tinyurl.com/3bk3p5o and my commentary: http://community.nytimes.com/comments/www.nytimes.com/2011/09/25/fashion/therapists-are-seeing-patients-online.html?permid=27#comment27

For those who cannot access tinyurl.com or nyt.com, here is the full text of the article, and my commentary:

September 23, 2011

When Your Therapist Is Only a Click Away

By JAN HOFFMAN

THE event reminder on Melissa Weinblatt’s iPhone buzzed: 15 minutes till her shrink appointment.

She mixed herself a mojito, added a sprig of mint, put on her sunglasses and headed outside to her friend’s pool. Settling into a lounge chair, she tapped the Skype app on her phone. Hundreds of miles away, her face popped up on her therapist’s computer monitor; he smiled back on her phone’s screen.

She took a sip of her cocktail. The session began.

Ms. Weinblatt, a 30-year-old high school teacher in Oregon, used to be in treatment the conventional way — with face-to-face office appointments. Now, with her new doctor, she said: “I can have a Skype therapy session with my morning coffee or before a night on the town with the girls. I can take a break from shopping for a session. I took my doctor with me through three states this summer!”

And, she added, “I even e-mailed him that I was panicked about a first date, and he wrote back and said we could do a 20-minute mini-session.”

Since telepsychiatry was introduced decades ago, video conferencing has been an increasingly accepted way to reach patients in hospitals, prisons, veterans’ health care facilities and rural clinics — all supervised sites.

But today Skype, and encrypted digital software through third-party sites like CaliforniaLiveVisit.com, have made online private practice accessible for a broader swath of patients, including those who shun office treatment or who simply like the convenience of therapy on the fly.

One third-party online therapy site, Breakthrough.com, said it has signed up 900 psychiatrists, psychologists, counselors and coaches in just two years. Another indication that online treatment is migrating into mainstream sensibility: “Web Therapy,” the Lisa Kudrow comedy that started online and pokes fun at three-minute webcam therapy sessions, moved to cable (Showtime) this summer.

“In three years, this will take off like a rocket,” said Eric A. Harris, a lawyer and psychologist who consults with the American Psychological Association Insurance Trust. “Everyone will have real-time audiovisual availability. There will be a group of true believers who will think that being in a room with a client is special and you can’t replicate that by remote involvement. But a lot of people, especially younger clinicians, will feel there is no basis for thinking this. Still, appropriate professional standards will have to be followed.”

The pragmatic benefits are obvious. “No parking necessary!” touts one online therapist. Some therapists charge less for sessions since they, too, can do it from home, saving on gas and office rent. Blizzards, broken legs and business trips no longer cancel appointments. The anxiety of shrink-less August could be, dare one say ... curable?

Ms. Weinblatt came to the approach through geographical necessity. When her therapist moved, she was apprehensive about transferring to the other psychologist in her small town, who would certainly know her prominent ex-boyfriend. So her therapist referred her to another doctor, whose practice was a day’s drive away. But he was willing to use Skype with long-distance patients. She was game.

Now she prefers these sessions to the old-fashioned kind.

But does knowing that your therapist is just a phone tap or mouse click away create a 21st-century version of shrink-neediness?

“There’s that comfort of carrying your doctor around with you like a security blanket,” Ms. Weinblatt acknowledged. “But,” she added, “because he’s more accessible, I feel like I need him less.”

The technology does have its speed bumps. Online treatment upends a basic element of therapeutic connection: eye contact.

Patient and therapist typically look at each other’s faces on a computer screen. But in many setups, the camera is perched atop a monitor. Their gazes are then off-kilter.

“So patients can think you’re not looking them in the eye,” said Lynn Bufka, a staff psychologist with the American Psychological Association. “You need to acknowledge that upfront to the patient, or the provider has to be trained to look at the camera instead of the screen.”

The quirkiness of Internet connections can also be an impediment. “You have to prepare vulnerable people for the possibility that just when they are saying something that’s difficult, the screen can go blank,” said DeeAnna Merz Nagel, a psychotherapist licensed in New Jersey and New York. “So I always say, ‘I will never disconnect from you online on purpose.’ You make arrangements ahead of time to call each other if that happens.”

Still, opportunities for exploitation, especially by those with sketchy credentials, are rife. Solo providers who hang out virtual shingles are a growing phenomenon. In the Wild Web West, one site sponsored a contest asking readers to post why they would seek therapy; the person with the most popular answer would receive six months of free treatment. When the blogosphere erupted with outrage from patients and professionals alike, the site quickly made the applications private.

Other questions abound. How should insurance reimburse online therapy? Is the therapist complying with licensing laws that govern practice in different states? Are videoconferencing sessions recorded? Hack-proof?

Another draw and danger of online therapy: anonymity. Many people avoid treatment for reasons of shame or privacy. Some online therapists do not require patients to fully identify themselves. What if those patients have breakdowns? How can the therapist get emergency help to an anonymous patient? “A lot of patients start therapy and feel worse before they feel better,” noted Marlene M. Maheu, founder of the TeleMental Health Institute, which trains providers and who has served on task forces to address these questions. “It’s more complex than people imagine. A provider’s Web site may say, ‘I won’t deal with patients who are feeling suicidal.’ But it’s our job to assess patients, not to ask them to self-diagnose.” She practices online therapy, but advocates consumer protections and rigorous training of therapists.

Psychologists say certain conditions might be well-suited for treatment online, including agoraphobia, anxiety, depression and obsessive-compulsive disorder. Some doctors suggest that Internet addiction or other addictive behaviors could be treated through videoconferencing.

Others disagree. As one doctor said, “If I’m treating an alcoholic, I can’t smell his breath over Skype.”

Cognitive behavioral therapy, which can require homework rather than tunneling into the patient’s past, seems another candidate. Tech-savvy teenagers resistant to office visits might brighten at seeing a therapist through a computer monitor in their bedroom. Home court advantage.

Therapists who have tried online therapy range from evangelizing standard-bearers, planting their stake in the new future, to those who, after a few sessions, have backed away. Elaine Ducharme, a psychologist in Glastonbury, Conn., uses Skype with patients from her former Florida practice, but finds it disconcerting when a patient’s face becomes pixilated. Dr. Ducharme, who is licensed in both states, will not videoconference with a patient she has not met in person. She flies to Florida every three months for office visits with her Skype patients.

“There is definitely something important about bearing witness,” she said. “There is so much that happens in a room that I can’t see on Skype.”

Dr. Heath Canfield, a psychiatrist in Colorado Springs, also uses Skype to continue therapy with some patients from his former West Coast practice. He is licensed in both locations. “If you’re doing therapy, pauses are important and telling, and Skype isn’t fast enough to keep up in real time,” Dr. Canfield said. He wears a headset. “I want patients to know that their sound isn’t going through walls but into my ears. I speak into a microphone so they don’t feel like I’m shouting at the computer. It’s not the same as being there, but it’s better than nothing. And I wouldn’t treat people this way who are severely mentally ill.”

Indeed, the pitfalls of videoconferencing with the severely mentally ill became apparent to Michael Terry, a psychiatric nurse practitioner, when he did psychological evaluations for patients throughout Alaska’s Eastern Aleutian Islands. “Once I was wearing a white jacket and the wall behind me was white,” recalled Dr. Terry, an associate clinical professor at the University of San Diego. “My face looked very dark because of the contrast, and the patient thought he was talking to the devil.”

Another time, lighting caused a halo effect. “An adolescent thought he was talking to the Holy Spirit, that he had God on the line. It fit right into his delusions.”

Johanna Herwitz, a Manhattan psychologist, tried Skype to augment face-to-face therapy. “It creates this perverse lower version of intimacy,” she said. “Skype doesn’t therapeutically disinhibit patients so that they let down their guard and take emotional risks. I’ve decided not to do it anymore.”

Several studies have concluded that patient satisfaction with face-to-face interaction and online therapy (often preceded by in-person contact) was statistically similar. Lynn, a patient who prefers not to reveal her full identity, had been seeing her therapist for years. Their work deepened into psychoanalysis. Then her psychotherapist retired, moving out of state.

Now, four times a week, Lynn carries her laptop to an analyst’s unoccupied office (her insurance requires that a local provider have some oversight). She logs on to an encrypted program at Breakthrough.com and clicks through until she reads an alert: “Talk now!”

Hundreds of miles away, so does her analyst. Their faces loom, side by side on each other’s monitors. They say hello. Then Lynn puts her laptop on a chair and lies down on the couch. Just the top of her head is visible to her analyst.

Fifty minutes later the session ends. “The screen is asleep so I wake it up and see her face,” Lynn said. “I say goodbye and she says goodbye. Then we lean in to press a button and exit.”

As attenuated as this all may seem, Lynn said, “I’m just grateful we can continue to do this.”

This article has been revised to reflect the following correction:

Correction: September 24, 2011

A caption on a picture in an earlier version of this article incorrectly described the technology used by Marlene M. Maheu to communicate remotely with patients. She uses video conferencing, not Skype.

COMMENTARY:

27.

Maurice Preter MD

New York, NY

September 24th, 2011

6:21 pm

"She mixed herself a mojito, added a sprig of mint, put on her sunglasses and headed outside to her friend’s pool. Settling into a lounge chair, she tapped the Skype app on her phone. Hundreds of miles away, her face popped up on her therapist’s computer monitor; he smiled back on her phone’s screen."

While the article itself is quite a bit more informative, this intro is problematic, to put it mildly. It belittles the level of intense human suffering and distress that most patients seek help for.

Further, I do not know of many 30 year olds in the US that can afford quality psychotherapy as it is almost never covered by commercial insurance. According to http://news.yahoo.com/blogs/lookout/battered-downturn-young-americans-pu..., almost half of young US adults are now jobless. Mojitos at the poolside? At any rate rum drinks have no (uncommented) place in a serious story on psychotherapy.

"Shrinks"? The practice of psychotherapy is based on expertise acquired through many years of professional work (whether coming from medicine-psychiatry, psychology, social work or other professions) as well as therapy self-experience. New technologies can and should be used (as in CAPA's teaching efforts in China, or expat mental health care), but only after an educated, careful, individualized assessment of the patient's psychological needs and of the patient-therapist relationship. Everywhere in medicine, a proper diagnosis is the basis for proper treatment. In my opinion as a neurologist-psychopharmacologist-psychodynamic psychotherapist, a proper assessment must include medical reasoning. E.g., what depressed people with thyroid disease or sleep apnea need is neither happy pills nor psychotherapy, but first and foremost, proper medical care.

All in all, the article properly conveys the risk that tele-therapy become just another facet of the general rush to the bottom in (mental) health care.

Maurice Preter, MD

www.psychiatryneurology.net

Recommend Recommended by 9 Readers

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Bloglink:

http://psychiatryneurology.blogspot.com/

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On anxiety and panic disorder:

Panic, Suffocation False Alarms, Separation Anxiety and Endogenous Opioids

Maurice Preter, M.D. and Donald F. Klein, M.D. (2008)

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On “medically unexplained symptoms, “hysteria”, “conversion disorder”, traumatic enactments:

Siri Hustvedt’s The Shaking Woman (Interview with Der Spiegel) (Feb. 2010)

PDF

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Panic disorder research:

Controlled cross-over study in normal subjects of naloxone-preceding-lactate infusions;

respiratory and subjective responses: Relationship to endogenous opioid system, suffocation false alarm theory and childhood parental loss (CPL) (Psychological Medicine; online May 2010 click here for PDF)

____________________________________________________________

A conversation between Siri Hustvedt and Maurice Preter MD

In 2006, the novelist and essayist Siri Hustvedt suffered an inexplicable seizure while speaking at a memorial service for her father. The seizures continued to occur, and the condition remains undiagnosed. Her most recent book The Shaking Woman or A History of My Nerves tells the story of her condition and explores her symptoms through the lenses of several disciplines: medical history, psychiatry, psychoanalysis, contemporary neuroscience, philosophy, and literature. Hustvedt has a PhD in English literature from Columbia and has worked as a writing teacher with psychiatric patients at the Payne Whitney Psychiatric Clinic in New York. Her web site is sirihustvedt.net.

Maurice Preter, MD is a practicing neurologist, psychiatrist, and psychotherapist. Dr. Preter received his training in neurology and psychiatry at the Albert Einstein College of Medicine, and is board certified in both specialties. He has done neuropsychiatric research in stress, anxiety, panic disorder, and psychological trauma. A member of the psychiatry faculty of Columbia University’s College of Physician’s and Surgeons, his particular interest is in the treatment of conditions that cross the conventional and limiting borders of psychiatry, neurology, and general medicine. His web site is psychiatryneurology.net.

Please join us for a discussion between Siri Hustvedt and Dr. Maurice Preter on unexplained medical symptoms, their meanings for patients and for doctors, and the vital importance of viewing illness, no matter how mysterious, in a narrative context.

Hosted by Dr. Rita Charon and the Program in Narrative Medicine.

Wednesday May 12th at 5:00 PM in the Faculty Club in the Physicians & Surgeons Building, 4th floor, Room #446.

Click here to listen

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Letters - Perception and Distortion - NYTimes.com

Review of Books April 18, 2010

Letters

Perception and Distortion

Published: April 15, 2010

To the Editor:

'The Shaking Woman,' by Siri Hustvedt: Seized (April 4, 2010)

As is the case in most presentations of “unexplainable” neurological-psychiatric symptoms, there are unspeakables in Siri Hustvedt’s book “The Shaking Woman” (April 4): the horror of a vague, transgenerationally transmitted memory of a witnessed wartime atrocity; the pain and fear of cumulative loss. Any attempt to put the unspeakable on paper will necessarily fall short, but Hustvedt’s sustained argument in the book is precisely that all categories — medical and philosophical — are in themselves subject to ambiguity.

Criticizing it for its failure to address the pain of caregivers is a non sequitur. The reviewer, I am afraid, fell into the same fallacy she accuses Hustvedt of: seeing and hearing only what she wanted to see and hear. In my work as a clinical and forensic neurologist-psychiatrist, I am used to seeing unspeakable emotional pain causing perceptual distortions. Neither literary creation nor its criticism are exempt from this fundamental observation.

MAURICE PRETER

New York

The writer is an assistant professor of clinical psychiatry at Columbia University and an adjunct associate professor of neurology at SUNY Downstate Medical Center.

____________________________________________________________

July 5, 2010

China Daily Op-ed by Dr. Maurice Preter

Cross-posted from

http://www.chinadaily.com.cn/opinion/2010-07/05/content_10056660.htm and

http://psychiatryneurology.blogspot.com/2010/07/quality-psychiatric-care-is-needed.html

Quality psychiatric care is needed

By Maurice Preter (China Daily)
Updated: 2010-07-05 08:00

Comments(0) PrintMail

The recent spate of attacks on schoolchildren and the workers' suicides at the Foxconn factory in Shenzhen have again highlighted China's urgent need to balance economic progress with care for those left behind, and unable to cope with, the lightning speed of development.

Sustainable development is an avowed goal of Chinese government policy, and from a medical-psychological perspective, accessible, quality general medical and psychiatric care is a fundamental part of long-term, ecologically minded, peaceful societal progress.

However, it is an open secret that the medical profession in China is in disarray and rather ill-equipped to contribute to the solution of China's larger societal problems. Chinese physicians are overworked. They routinely see several dozen, if not a hundred patients a day, including those in urgent need of expert mental health treatment.

[click to continue]

[PDF version]

The Shanghai Movement Disorder Conference Oct 2010:

编辑部消息

2010国际帕金森病和运动障碍VPP学术研讨会会议纪要

信息来源：发布日期：2010-12-9 14:28:05

2010国际帕金森病和运动障碍VPP学术研讨会会议纪要

2010国际帕金森病（PD）和运动障碍VPP学术研讨会于2010年10月29日—2010年10月31日在上海交通大学附属上海第一人民医院南院隆重举行。此次会议由国际帕金森病运动障碍协会（Movement Disorders Society，MDS）及上海第一人民医院主办，华东地区六省一市神经病学协作委员会及上海医学会脑电图和神经生理学协会协办，会议得到了上海交通大学国际交流中心重点项目基金支持，上海交通大学国际会议专项资助基金资助，中国教育部985项目部分资助。会议邀请了来自美国、法国、加拿大、新西兰、新加坡5个国家的6位运动障碍疾病领域知名专家讲者，邀请了国内包括北京、上海、广州、南京、苏州、杭州、合肥等全国各地专家讲者20余名，参会人数300多名。新闻晚报、青年报、解放日报和新华社、凤凰网、网易网等多家媒体均对会议进行了报道，取得了良好的社会反响。

开幕式上，大会荣誉主席上海市第一人民医院院长刘国华教授致欢迎辞；大会学术顾问美国国立卫生研究院NIH神经病学和卒中研究所临床主任、美国临床神经生理协会主席、世界神经病学联盟WFN执行主席、前任MDS主席Hallett M视频致辞；大会组委会主席卫生部北京医院神经内科主任、中华医学会帕金森学组副组长陈海波教授，上海市科委国际交流中心主任朱军浩博士，大会执行主席上海市第一人民医院神经内科王晓平教授分别致辞；另外，来自北京301医院匡培根教授、王鲁宁教授，广州中山大学附属第一医院刘焯霖教授等国内神经内科著名专家发来贺电、贺信祝贺大会圆满成功。

会议分3个会场同时举行。会议中，国际讲者新加坡国立大学Lim E教授就帕金森病的深部脑刺激（DBS）治疗、肉毒毒素治疗肌张力障碍、步态失调的评估等专题进行了主题报告；法国庇卡底大学（Université de Picardie）副校长Wallois F教授结合病例录像对肌肉痉挛疾病的临床表现及治疗进行了生动的讲解；新西兰奥塔哥大学（University of Otago）Anderson T教授（MDS的AOS秘书长）就震颤的机制和治疗、皮质基底节综合征（CBS）与进行性核上性麻痹（PSP）的鉴别诊断进行了专题报告；加拿大蒙特利尔大学Lassonde M教授报告了神经心理学在运动障碍神经病学中的应用；美国哥伦比亚大学Preter M教授就心因性运动障碍的机制和进展进行了专题报告。国内讲者安徽中医学院神经病学研究所杨任民教授进行了二巯基丙磺酸钠与青霉胺为肝豆状核变性初始治疗的再检讨专题报告。上海新华医院刘振国教授、苏州大学附属第二医院刘春风教授、卫生部北京医院陈海波教授、广州医学院第一附属医院绍明教授、上海华山医院邬剑军教授、上海市精神卫生中心肖世富教授、上海市公共卫生临床中心卢洪洲教授分别就PD的药物治疗、PD的非药物治疗、PD的认知改变、内科医师开展DBS等微创手术治疗的展望、帕金森精神症状、PD肺部感染的治疗等主题进行了专题报告；上海瑞金医院神经外科孙伯民教授、上海长海医院神经外科胡小吾教授分别就运动障碍疾病的功能神经外科治疗、PD的DBS治疗进行了专题报告。同时，北京协和医院万新华教授进行了肉毒毒素治疗肌张力障碍专题报告；南京脑科医院张颖冬教授报告了PDD新观念；上海长征医院黄流清教授报告了阿尔茨海默病（AD）的诊断和治疗进展；上海市精神卫生中心潘桂花教授进行了基底节相关的强迫症的内科治疗专题报告。会议专题报告过程中，讲者与听者就相关问题展开了热烈的讨论交流，营造了良好的学术氛围。

本次会议的一大亮点在于举办了“中国科学院系统神经退行性疾病基础论坛”，该论坛由中国科学院上海生命科学研究院神经科学研究所徐进教授、徐天乐教授、周嘉伟教授，美国康纳尔大学Yi Wang教授，上海曙光医院魏江磊教授主持，国内外多名相关领域知名教授就神经退行性疾病、PD痴呆的基础领域及神经影像学领域等研究进展进行了热烈的讨论，产生了一系列创新性的想法，周江宁教授就脑切片研究中胚胎神经干细胞改善神经元的生存及和神经营养因子基因表达等研究做了专门交流。该论坛正是通过基础和临床专家们之间的学术交流、思想接触、自由争辩，达到了沟通情况、取长补短、相互促进、共同提高的目的，当时就有中科院和华山医院专家间的合作协议并付诸设施。

本次会议的另一大亮点在引进世界帕金森大会（WPC）新会议模式上，设置了“医患交流专场讨论会”独立栏目，该讨论会由杨任民教授、张颖冬教授及王晓平教授主持，同时，上海市第一人民医院多名具有丰富临床经验的神经内科医师和护士长参与解疑答惑。约50名PD、肝豆状核变性患者及家属向与会专家教授及病友讲述了患病经历、治疗过程与心得、疑难困惑提问及意见建议等，其中一位主持人是70岁的肝豆状核变性病友，目前刚从上海某一大学教授岗位上退休。这一创新之举的目的在于，以病患为老师，切实聆听病患心声，加强医患沟通，形成医患之间治疗疗效的正性反馈机制，从而更好地指导医疗工作，服务患者，解除患者病痛；另一方面也达到医疗知识普及教育目的。

本届会议国内外多名相关领域知名教授共济一堂，本着交流与传播运动障碍疾病领域基础和临床新进展，加强基础临床及海内外的沟通与合作的宗旨，通过讲座与讨论的形式，引发对 PD、肝豆状核变性及其他运动障碍疾病临床诊治新方案、科研进展及未来发展的思考与讨论。通过本次会议，在攻克PD、肝豆状核变性及其他运动障碍疾病的道路上，国内外医生、患者携手并进，有理由相信，在不远的将来我们一定能取得进一步的进展！

（李文杰、王晓平整理）

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