On the Couch Online: Does Tele-Therapy Work?

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Vikki Stark thought she had the perfect marriage. She and her loving husband of 21 years seemed unbreakable. Stark, a family therapist, had nursed her husband through a harrowing liver transplant, and he had patiently encouraged her as she wrote her first book. Then, one day in 2006, returning from a three-week book tour, Stark told her husband she had picked up fish for dinner. He responded, "It's over."

Stark's husband, it turns out, had been having an affair for six years. "I can't tell you how shocked I was," says Stark. "In a million years, I never thought he would leave. I was blown away."

To cope with what she describes as the "torments of hell," Stark did what she does best: research. She spent months on the Internet reading about long-term marriages, what makes them work, what makes them turn sour and fall apart. She came up with a name for what she was going through, Wife Abandonment Syndrome — the pain and trauma of being left, after a lengthy and outwardly happy marriage. In November, Stark will launch a once-a-week online workshop and group-therapy session called Bouncing Back Better for women like her. Stark says, "I thought, if I'm suffering this much" — she, a therapist specializing in family and marriage counseling — "what about the women who have to send their seven-year-old [son] to his father's house, with the girlfriend? What about the women who are isolated, and don't have careers and friends to lean on?" In three days, a dozen women from around the world — Australia, Israel and Canada, where Stark lives — registered for Stark's six-week program.

Stark plans to facilitate the same kind of support, camaraderie and advice that the women might have gotten from a real-life therapy group. Stark will also give professional advice, including seven tips for recovery — including exercises that will help women focus on their future and on themselves, rather than on trying to find an explanation for their husbands' behavior. The hope is that participants will receive enough validation and the right skills to overcome their anguish and move on.

Stark's brand of distance healing is not unique. It's called telemental health — the burgeoning field of online and remotely delivered mental-health services — and while many people say they benefit from it, some experts remain unconvinced of its long-term merit. Certainly, more and more doctors and patients are taking advantage of the convenience and, in most cases, the lower cost of Web- or phone-based sessions. Organizations such as the Veterans Administration have employed e-mail and online video conferences to connect doctors with patients in isolated areas, primarily to answer questions or refill prescriptions. But live video is also being used to counsel patients with post-traumatic stress disorder, agoraphobia and eating disorders; so far, the few scientific studies on this new service show that patients and doctors are satisfied with the quality of care, and that the patients do no worse than those attending in-person sessions.

Stark says the convenience and comfort of Web-based counseling are indispensable. The Internet allows her to reach otherwise unreachable people: Many women whose marriages end unexpectedly are so devastated and ashamed of what they view as their own failure that they may never be able to face a therapist in person. Further, an interactive online setting lets therapists disseminate counseling to many people at once. "The Web offers tremendous potential," says David Mohr, a psychologist at Northwestern University. "We know from research that certain procedures in psychotherapy are likely to be effective for most people. The Web allows that type of standardized material to be presented in a way where it is available 24/7, and patients can access them whenever they want, and from anywhere they want." The principles of cognitive behavioral therapy, for example, which relies on step-wise learning to change behavior (think of habituation exercises routinely used to cure people of phobias of, say, heights or spiders), are particularly suited for such online distribution.

While remote services may break down physical barriers, say some skeptics, they may erect emotional ones to the detriment of the care provided. "All day long, I pay attention to the disconnect between people's words and what they are really feeling," says Dr. Eric Plakun, chair of the American Psychiatric Association committee on Psychotherapy by Psychiatrists. "Tuning in to nonverbal communication is an essential part of the psychotherapy process, and even with a video interface, that seems to be a pretty complicated burden to put on a limited means of communication." Even silences during a therapy session, notes Plakun, have meaning; understanding it often increases patients' self-awareness, helping them to achieve mental and emotional well-being.

That's why, despite its obvious benefits, even advocates of online therapy don't consider it a substitute for in-the-flesh sessions. "Hell, no," says Dr. Alexander Obolsky, a psychiatrist at Northwestern University School of Medicine and a proponent of remote services. "Nothing is going to replace a well-trained psychiatrist providing face-to-face treatment. But it may bring a different set of patients to mental health who can benefit." Patients like the women Stark has reached. Even if the only advantage of telemental health were to bring like-suffering people together on the Web, say experts, that's an essential first step in mental healing — recognizing that you need support.

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