Gordon, R.M., Wang, X., & Tune, J. (2015). Comparing Psychodynamic Teaching,
Supervision and Psychotherapy Over Video-Conferencing Technology with Chinese
Students, Psychodynamic Psychiatry, 43, 4, 585-599.
Comparing Psychodynamic Teaching, Supervision and Psychotherapy Over Video-
Conferencing Technology with Chinese Students
Robert M. Gordon, Ph.D. ABPP, Independent Practice, Allentown, Pa. U.S.A., Xiubing
Wang, M.A. Linzi Clinic, Shenzhen, China, and Jane Tune, M.A., Viquan Clinic,
How do experts compare teaching, supervision and treatment from a psychodynamic perceptive over the Internet with in-person work? Our methodology was based on the expert opinions of 176 teachers, supervisors and therapists in the China American Psychoanalytic Alliance (CAPA) who use video-conferencing (VCON) with Chinese students. The results from our on-line survey indicate: 1.The longer teachers teach, the more effective they rate teaching over VCON; 2. Teaching, supervision and treatment were all rated in the range of “slightly less effective" than in-person, with supervision rated significantly more effective than teaching and treatment over VCON; 3. When doing psychodynamic treatment over VCON the issues of symptom reduction, exploring mental life, working on transference, relational problems, resistance, privacy issues, countertransference, are all equally rated in the range of "slightly less effective" than inperson treatment; 4. The highest significantly rated indications for treatment over VCON are: "To offer high quality treatment to underserved or remote patients" and "When patient is house-bound or travel would be impractical;" and 5. The highest significantly rated contraindication for treatment over VCON is: "Patient needs close observation due to crisis or decompensation." Overall, this survey suggests that VCON teaching, supervision and treatment from a psychodynamic perceptive is a worthwhile option when considering its unique contribution to extending services where needed.
This research was approved by the IRB of the Washington Center of Psychoanalysis and was supported by a grant from the China American Psychoanalytic Alliance. We would like to thank Drs. Elise Snyder, Ira Moses, Cathy Siebold, Ralph Fishkin, Lana Fishkin, and Jill Savege Scharff for their invaluable feedback. Also thanks to Marieke Jonkman for help with editing.
Contact corresponding author, Robert M. Gordon at: firstname.lastname@example.org
Psychological education, supervision and treatments over Internet video-conferencing technology (ex. Skype, ooVoo, etc.) provide services to students and patients who may live in areas that are remote, have a lack of qualified specialists, have impaired mobility, lack transportation or have geographic barriers. However, there is currently an uncertainty about how on-line services differ from the same process in the in-person relationship.
While video-conferencing (VCON) psychological services have been an emerging twenty-first century phenomena since Skype began in 2003, universities began using the Internet for remote learning soon after the beginning of the Internet with a great deal of success. Cowart (2010) reported that from 1991 to 2004, online university enrollments have grown from virtually 0 to over 2.35 million students.
The teaching of psychotherapy over Internet also has empirical support. Tantam, Blackmore, & van Deurzen, (2006) combining internet-based theory teaching with inperson supervision and personal experience, found that both student performance and student satisfaction were higher in the eLearning psychotherapy program when compared with a traditional in-person program.
Supervision of treatment over Internet has also been found effective. Jacobsen & Grünbaum (2011) studied situations in which distance supervision may be necessary and concluded that supervision via video-conferencing (VCON) offers a good alternative to in-person encounters, and in certain ways it even seems to boost the growth of the supervisees. Savin, et al. (2013) describes the collaboration between the Departments of Psychiatry at the University of Colorado School of Medicine and the University of Health Sciences in Cambodia. They conclude that VCON offers effective and inexpensive approaches to address disparities in global mental health by enhancing psychiatric training across cultures and international boundaries.
Psychological treatment over the Internet is far more complex than distance learning and supervision. Treatment involves a more intense subjective, therapeutic relationship and a greater need for privacy, than didactic education or supervision.
There is clearly a place for VCON therapy services for patients who do not have easy access to treatment. Godleski, Darkins, & Peters (2012) assessed clinical outcomes of 98,609 mental health patients before and after enrollment in remote clinical videoconferencing of the U.S. Department of Veterans Affairs between 2006 and 2010. They found that psychiatric admissions of VCON therapy patients decreased by an average of approximately 24% and length of stay decreased by an average of 27%.
Backhaus, et. al (2012) conducted a systematic literature review of the use of videoconferencing psychotherapy (VCP) and found 65 studies for their analysis. Their results indicate that VCP has been used in a variety of therapeutic formats and with diverse populations, is generally associated with good user satisfaction, and is found to have similar clinical outcomes to traditional face-to-face psychotherapy.
However, the more the treatment depends on a therapeutic relationship, as in the case of the psychoanalytic relationship, the more there may be problems with VCON treatment. There are few studies on the nature of the on-line therapeutic relationship. Sucala et al. (2012) reviewed the literature on “E-therapy” defined as providing mental health services via e-mail, video conferencing, virtual reality technology, chat technology, or any combination of these. The authors searched PubMed, PsycINFO, and CINAHL through to August 2011. From the 840 reviewed studies, only 11 (1.3%) investigated the therapeutic relationship.
Internet would seem to create an interpersonal distance that might weaken the therapeutic alliance. However, Holmes & Foster (2012) found that online counseling clients perceived a significantly stronger working alliance on the total Working Alliance Inventory-Short Form, than did those who received in-person only counseling. Still, it is not clear from this study if the definition of a “working alliance” in counseling is generalizable to how psychoanalysts use the term.
Cognitive Behavior Therapy with less emphasis with the working alliance and more emphasis on technique with cognitive learning as the goal, would seem to be a natural treatment for the Internet. Empirical studies support this. Johansson, Frederick & Andersson, (2013) report studies showing no differences between Internet-delivered, cognitive behavioral therapy and in-person cognitive behavioral therapy for mild to moderate depression, anxiety disorders, and somatic problems.
But Donker et al. (2013) found that for the brief on-line treatment of depression that both CBT and interpersonal psychotherapy (IPT) are both effective treatments. Though they do not report studies showing that IPT on-line is as good as in-person IPT. Bayles (2012) wrote that since therapeutic action is grounded in implicit, procedural, nonverbal communication, the entire body is implicated in the analytic dialogue. She believes that psychotherapy by VCON may limit the access to the information communicated by the body and the various sense modalities.
Although psychoanalysis and psychodynamic treatment requires more of a therapeutic “presence” than other psychotherapies, Internet can still convey enough therapeutic effect to people who would not have such treatment otherwise. Several papers demonstrated the advantages to providing psychoanalytic treatment to remote areas lacking expert providers. Edirippulige, Levandovskaya, & Prishutova (2013) looked at the use of Skype for delivering psychotherapy services in the Ukraine. Most of the practitioners thought their clients considered the services received on Skype were good or excellent. The majority of clients and providers showed high satisfaction with the use of Skype for psychotherapy services.
Fishkin, Fishkin, Leli, Katz, & Snyder (2011) reported on the China American Psychoanalytic Alliance (CAPA) which provides treatment, education, and supervision to Chinese mental health professionals over the Internet. The lack of enough Chinese analysts and mentors has created an intense demand for psychodynamic psychotherapy training and treatment that CAPA is addressing by using Internet communication technologies. They discussed not only the success of the program, but also the cultural issues as well as aspects of the transference and countertransference that are shaped by the virtual nature of the technology.
The issue of privacy with providing treatment on-line is another area of debate. Churcher (2012) was concerned that we have knowledge about our immediate physical and social environment to make reliable judgments about whether a conversation is private, but this is less true of our virtual environment in cyberspace. However, Scharff (2013a) replied that we need to work on weighing the benefits against the risks with teleanalysis. She argues that there will be fewer concerns with more discussion at our association meetings, and more systematic research as to whether teleanalysis can provide a secure setting and can meet the standard of being clinically equally effective.
Scharff also reports a recent study by the American Psychoanalytic Association that found that 28% of respondents reported using the phone, 9% using Skype for psychotherapy, and 4% using Skype for psychoanalysis. Scharff states that online supervision, online analyses are part of the repertoire of current practice, and when used with care, the Internet has the potential to allow teaching and treatment to occur when it would otherwise be impossible.
Paolo (2013) wrote that psychoanalysis over the Internet reflects on what we mean by communication between patient and analyst. He feels that online therapy is simply a different form of therapy.
Dettbarn (2013) discussed Skype as a third “secret sharer” in the analytic process. She wondered what feelings, fantasies, and thoughts do analyst and client entertain when they hear each other's disembodied voices from a loudspeaker and observe the video transmission on a screen. Dettbarn posed these important issues: the absence of spatial and physical proximity and the development of trust, denial of the reality of separation and mourning, Internet as a protection against the real dangers in a physical presence (violence, aggression, sexual seduction), and if transference, resistance, and regression will seem more magical.
The less sense of propinquity in treatment may be why despite the effectiveness of online treatment, there might be a higher drop out rate as compared to in-person treatment as reported by King et al. (2014).
Caparrotta (2013) claims that digital technologies need to be embraced responsibly and with an open mind by the psychoanalytic profession. This seems to be occurring as indicated by two recent books on the topic, Psychoanalysis online: Mental health, teletherapy and training edited by Scharff (2013b), and Psychoanalysis in the technoculture era edited by Lemma, & Caparrotta, (2013). Scharff’s (2013b) book emerged from an international workgroup of colleagues from the International Psychoanalytical Association (IPA) and the International Institute for Psychoanalytic Training (IIPT) studying the practice of psychoanalysis and psychotherapy conducted on the telephone and over the Internet.
While there are a few empirical studies on the perceived effectiveness of teaching, supervision and treatment over the Internet, presently, there are no studies comparing them with each other. Teaching, supervision and psychodynamic treatment over the Internet each involve different roles, tasks, and degrees of intimacy. It would be useful to compare them in regards to the issue of object relations over VCON and the effectiveness of the services. It might take training and experience to become proficient in delivering these services over VCON. There is also a need for research that takes a more in-depth comparison of psychodynamic therapy on-line vs. psychodynamic treatment in-person with the issues of symptom reduction, exploring mental life, working with transference, working though relational problems, working with resistances, privacy concerns, countertransference issues, and indications and contraindications for doing VCON treatment.
We hypothesize that 1. The more experienced at teaching, supervising or treatment, the higher the service it will be rated. 2. Over all, VCON technology should compare favorably to in-person work in teaching, supervising and treatment and the nature of the relationship should affect the perceived effectiveness of the VCON work. That is, supervision, with the more personal relationship (as compared to trying to hold the attention of many students when teaching over VCON) and without the attachment and transference issues of the therapeutic relationship, should make supervision perceived as more effective than teaching and treating. 3. VCON technology presents special problems for psychodynamic treatment, but the over-all the issues of symptom reduction, exploring mental life, working with transference, working though relational problems, working with resistances, privacy concerns, and countertransference should compare favorably to in-person work. 4. The main indications for VCON psychotherapy should be about making it available to people who do not have access to quality care, or when meeting in-person is not practical. 5. The main contraindication should be when the patient is in a crisis and needs closer observation.
Since these hypotheses involve the interaction of several complex variables, we felt that using expert opinion was an appropriate method for testing our hypotheses. Expert opinion can synthesize complex variables that are difficult to study with controlled experimentation. Laboratory methodology of complex systems that isolate variables out of context would also lack ecological validity. Cook (1991) argued that the use of expert opinion in scientific inquiry and policymaking is often the best methodology for understanding complex systems and technologies. Mosleh, Bier, & Apostolakis, (1987) found in their review that expert opinion works best in practical decision making settings. While case study is based on the expert opinion of one person, we used a high number of experts in the area of concern for greater reliability.
Participants and Design
Our expert participants were recruited from the email list of 300 past and present China American Psychoanalytic Alliance (CAPA) teachers, supervisors and therapists. There were four consecutive email requests for participation. The email notices stated that participation is voluntary and anonymous. They were given a link to the online survey on SurveyMonkey where their responses to the questions were automatically stored and exported to SPSS for analysis. The survey was kept very short, generally less than 5 minutes in the hope to increase participation. We stated in the survey: “Answer only the questions as they apply to your work with CAPA. There may be issues with differences in education, language and cultural between your CAPA students/supervisees/patients and your in-person American students/supervisees/ patients. For the sake of this research, please assume ‘all other things being equal’ though this is not easy to do.”
From the 300 email addresses, 176 took the online survey, roughly a 59% response rate (we could not be sure that all the email addresses were current). The respondents were 65% female, 37 % were psychologists, 33% were social workers and 22% were psychiatrists. The teachers (n = 130) had an average of 18.35 years of experience (SD = 9.72), supervisors (n = 152) had an average of 18.63 years of experience (SD = 10.21), and the therapists (n = 163) had an average of 23.84 years of practicing psychoanalytic treatment (SD =7.44). Seventy-nine percent (n = 175) stated that they have been using videoconferencing (VCON) for 3 or more years for doing teaching, or supervisor or treatment (M = 4.21, SD = 2.14). The executive members of CAPA initially screened all the participants for their expertise before they were allowed to offer their services to CAPA. Additionally, the results indicating the many years of teaching, supervision and treating, support our methodological assumption that this is a survey of expert opinion.
1. We hypothesized positive correlations between years of experience at teaching, supervising or treatment, with the perceived effectiveness.
Our hypothesis is partially supported. The Pearson product-moment correlation coefficient is significant between years of teaching with their ratings of perceived effectiveness of their teaching (r = .286, p < .05, n = 79). The correlations of years supervising and treating are in the positive direction, but are not significant with their ratings of perceived effectiveness.
2. Over all, VCON technology should compare favorably to in-person work in teaching, supervising and treatment and the nature of the relationship should affect the perceived effectiveness of the VCON work. That is, supervision, with the more personal relationship (as compared to trying to hold the attention of many students when teaching over VCON) and without the attachment and transference issues of the therapeutic relationship, should make supervision perceived as more effective than teaching and treating. All the ratings went from 1 = much less effective, 2 = less effective, 3 = slightly less effective, 4 = no difference (from in-person treatment), 5 = slightly more effective, 6 = more effective, and 7 = much more effective. Respondents were asked how much their teaching or supervising or treating over VCON differs from their in-person work in perceived effectiveness. (We used ANOVA with unequal n’s to analyze these survey questions, and focused Paired T-Tests for testing specific Post Hoc comparisons.)
Our hypothesis is supported. There was a significant main effect, F (2, 8.45) = 8.53, p < .0001). All three (teaching, supervising and treating) are in the “slightly less effective” than in-person range. Focused Post Hoc analysis with Paired T-Tests analysis shows that supervision is significantly rated as more effective than both teaching and treating (p < .0001). Teaching and treating were not rated significantly different from each other: supervision (n = 114, M = 3.16, SD = .97), teaching (n = 84, M = 2.62, SD = .88) and treatment (n = 101, M = 2.72, SD = 1.11). Supervision and teaching are most similar (r = 7 .78), then supervision and treating (r = .68) and least similar are teaching and treating (r = .51).
3. The over-all the issues of symptom reduction, exploring mental life, working with transference, working though relational problems, working with resistances, privacy concerns, and countertransference should compare favorably to in-person work.
a. How does video-conferencing compare to in-person treatment in reducing symptoms? (n = 109 , M = 2.86 , SD = 1.05)
b. How does video-conferencing compare to in-person psychotherapy in exploring the mental life of the patient? (n = 112, M = 2.89 , SD = 1.04)
c. How does video-conferencing compare to in-person treatment in working on transference? (n = 110, M = 2.88 , SD = 1.16)
d. How does video-conferencing compare to in-person treatment in working through relational problems? (n = 112, M = 2.89 , SD = 1.06)
e. How does video-conferencing compare to in-person treatment in working with resistance? (n = 112, M = 2.70 , SD = 1.19)
f. How does video-conferencing compare to in-person treatment in creating a sense of privacy? (n = 111, M = 3.03 , SD = 1.34)
g. How does video-conferencing compare to in-person treatment in countertransference issues? (n = 111, M = 3.08 , SD = 1.19)
Our hypothesis is supported. The ANOVA results do not indicate any significant differences between these psychotherapy factors in the VCON condition. They were all rated in the range of “slightly less effective” than in-person treatment.
4. The main indications for VCON psychotherapy should be about making it available to people who do not have access to quality care, or when meeting in-person is not practical.
We asked, “What do you think are indications for doing video-conferencing treatment? (1 = not much, 2 = somewhat, 3 = definite indication, 4 = Strong indication).”
a. To offer high quality treatment to underserved or remote patients (n = 105, M = 3.51, SD = .69)
b. Comfort and convenience of environment (n = 100, M = 1.90, SD = 1.03)
c. Expectation that it will be more effective than in-person treatment (n = 102, M = 1.16, SD = .52)
d. Feel safer with a hostile patient (n = 100, M = 1.51, SD = .82).94).
e. When patient is house-bound or travel would be impractical (n = 102, M = 3.38, SD = .83)
f. Continuity of care when the therapist or patient is traveling (n = 103, M = 2.91, SD = .94).
Our hypothesis is supported. The ANOVA results indicate significant main effects, F (5, 103.54) = 153.03, p < .0001.
Focused Post Hoc tests show that both indications: “To offer high quality treatment to underserved or remote patients” and “When patient is house-bound or travel would be impractical” are not significantly different from each other, but they are each significantly higher in their ratings than the other indications (p < .0001).
5. The main contraindication should be when the patient is in a crisis and needs closer observation. We asked, “What do you think are contraindications for doing videoconferencing treatment? (1 = not much, 2 = somewhat, 3 = definite contraindication, 4 = Strong contraindication).”
a. Patient needs close observation due to crisis or decompensation (n = 102, M = 3.32, SD = .90)
b. Patient needs the supportive feeling of “a mommy in the room.” (n = 101, M = 2.56, SD = 1.14).
c. Patient is very resistant and may use Internet problems as an excuse (n = 102, M = 2.68, SD = 1.09).
d. Patient is too concerned about privacy (n = 100, M = 2.74, SD = 1.10)
e. Legal issues about practice in other regions (n = 101, M = 3.01, SD = 1.08)
f. Malpractice concerns (n = 100, M = 2.74, SD = 1.17) g. Problems with the reliability of service (n = 102, M = 2.90, SD = 1.03)
h. Language problems are too serious (n = 101, M = 2.92, SD = 1.12)
i. Bringing the therapist “home” can be seen as seductive (n = 101, M = 2.12, SD = 1.17).
Our hypothesis is supported. The ANOVA results indicate a significant main effect F (8, 11.16) = 9.39, p < .0001. Focused Post-Hoc paired T-tests showed that the highest rated contraindication for treatment over VCON is that the “Patient needs close observation due to crisis or decompensation.” This is significantly higher than the other 8 contraindications (p < .0001 compared to b, c, d, f and i; p = .001 compared to h; p = .001 compared to g and h; p = .012 compared to e.)
Comment boxes were included in our on-line survey. We received 91 comments from the respondents with a wide range of concerns. The most consistent theme is that the effectiveness of teaching, supervising and treating over VCON varies widely and is highly dependent on the client characteristics (n = 19). The following are comments we feel are particularly helpful:
“In some ways the virtual world allows for more recognition of separation anxiety... But in other ways it disconnects the in-person experience of being with someone, heat, body posture, sense of a whole context. So it is not more or less efficacious, rather it impacts the treatment differently.”
“On the whole I have been surprised at the effectiveness of treatment using videoconferencing, including the fact the patient has chosen to use a couch. It is possible it worked with my patient so spectacularly because of her particular dynamics. I don't know how it would work with a lower functioning patient”
“The two patients I have treated over Skype seem to feel freer to express their negative transference feelings toward me over Skype. Maybe because we are a half a world apart.”
“I actually believe it makes no difference as I have experienced this material with the same amount of intensity as when working in embodied sessions. However, I do think some people need embodied therapy for many reasons.”
“It depends on the patient. I have had some patients who find it initially easier over Skype to talk about some things in the transference - especially erotic transference. But overall I think Skype is less effective than in person -- for instance, over Skype there is no possibility of actual physical touch, which alters the pull of the erotic.”
“Depends on the patient and the defensive organization.”
“Face to face (over Skype) feels very intimate as opposed to sitting across the room or lying on the couch.”
“With working with transference, I was surprised that I could still experience both the transference and countertransference with the same amount of feeling/intensity as if poor video etc quality would somehow make it impossible.”
“I would personally suggest that teletherapy is most helpful when there has been a period of face-to-face therapy that allows for the establishment of a solid alliance, that then can "carry" the long-distance treatment. With patients in China, of course, this is not possible; and so it just might take a longer length of time to develop a solid alliance.”
“Most of the problems with teletherapy can be dealt with by interpretation and working through.”
“All resistances and transferences that are treatable can be addressed and should be address, regardless of video-conferencing or in-person. We handle crises at a distance all the time. Language a problem? Seems a contraindication- period, in-person won't solve that problem.”
We asked 176 experts to compare the delivery of teaching, supervising and treating from a psychodynamic perceptive over video-conferencing technology (VCON) with Chinese students with their experience with their in-person population. This poses a difficult task with the confounding variables of language, culture, and perhaps different stages of education in psychoanalytic training.
We used the methodology of a large number of expert opinions that is likely to be able to account for “all other things being equal” when asked how VCON work compares to inperson work. Expert opinion has a long history of validity in both jurisprudence and in science and is a methodology fitted to discover an understanding of complex interacting variables that cannot be easily studied under strict laboratory conditions.
Since this study is not a randomly controlled trial (RCT) study of service efficacy, it cannot address the cause and effect issues. However, a RCT methodology would involve a need for a manualized, time-limited treatment and the parceling out of a great many interacting variables (i.e. in-person vs VCON, culture, client characteristics, amount of sessions, nature of work, etc.), difficulty with comparable dependent measures across the different conditions, that would require a very high number of clients, high cost and may result in questionable generalizable validity given the complexity of the variables.
Our experts feel that over-all VCON minimally reduces effectiveness. Individual client characteristics may be a significant factor in effectiveness. Ethically maintained frames can be flexible and its variations can be grist for the mill, if there is empathy, respect and knowledge of cultural differences. There is no perfect frame and our psychotherapeutic techniques are robust and reliable.
Another methodological concern is that our scales compared teaching, supervision and treatment of Chinese students with the cultural differences, language problems and Internet problems, with an in-person American client point of reference. This is likely to negatively bias our results, by pushing the responses to the lower end of the scale. We also helped to control for a positive bias by using a scale with the mid-point as “no difference (from in-person treatment).” We would rather have a conservative finding, than to bias in favor of the obvious. Most of our experts are currently involved with VCON teaching, supervision and treatment and would have rated them as effective. We wanted to look beyond the question of simple perceived effectiveness and into how the VCON medium, differentially affects different types psychoanalytic relationships (teaching, supervising and treating). Also, it is unlikely that these findings are due to bias since the teachers, supervisors and therapists were not simply reviewing their work over VCON, but comparing it to their in-person work. The results showed that all three (teaching, supervising and treating) are in the “slightly less effective” as compared to “no difference” than in-person range. We also found that supervision was perceived more positively than teaching and treating. Supervision enjoys a more intimate mentoring relationship, without the problems of diffusion of focus as in a class of many individuals, or the problems with doing therapy with discerning nuanced non-verbal communication, the bodily sense of being with the therapist, and less transference and attachment issues.
The theoretical issues that these results raise goes to the very nature of psychoanalytic treatment and the issue of attachment in the analytic space. The object relations of the supervisory situation can foster professional identification through the process of idealization (Gordon, 1995) making VCON supervision an excellent resource that could be more utilized by training programs. There is a need for psychoanalytic supervision to psychotherapists who do not want to become psychoanalysts, but do want to enhance their skills and insight. VCON psychoanalytic supervision can become a popular form of education.
We found that the issues of symptom reduction, exploring mental life, working on transference, relational problems, resistance, privacy issues, countertransference, are all equally rated in the range of "slightly less effective" than in-person treatment. The highest significantly rated indications for treatment over VCON are: "To offer high quality treatment to underserved or remote patients" and "When patient is house-bound or travel would be impractical." The highest significantly rated contraindication for treatment over VCON is "Patient needs close observation due to crisis or decompensation."
Of course statistical findings let us know about the typical finding and is insensitive to the ideograph situation. Our finds are valuable in making general statements about how VCON teaching, supervision and treatment compares to in-person teaching, supervision and treatment according to the opinion of our large sample of experts. However, the most consistent comment was that the effectiveness varies widely depending on the client characteristics.
A logical next step would be to test our hypotheses with the other side of this study, that is the students, supervisees and patients that have received the VCON services. It would also be valuable to discover which personality variables correlate with greater satisfaction with VCON services. Overall, this survey suggests that VCON teaching, supervision and treatment from a psychodynamic perceptive is a worthwhile option when considering its unique contribution to extending services where needed. There are few opportunities for many professionals who desire psychoanalytic education, supervision and treatment in many areas of the world. The Internet can fulfill that need.
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