Online therapy, or teletherapy, became a necessity in 2020 when the COVID-19 pandemic made in-person meetings unsafe. Today, most mental health therapists continue to see clients online either because of health concerns or because one or both parties prefer it. Some therapists have fully embraced teletherapy and exclusively see clients online. For those with internet addiction or digital media overuse issues, however, teletherapy is often contraindicated. Read on to learn why.
In This Article
Is Teletherapy the Same as In-Person Therapy?
At the heart of mental health therapy is the relationship between therapist and client. It’s a relationship the 2000 book A General Theory of Love describes as, “a living embodiment of limbic processes as corporeal as digestion or respiration.”1 Those limbic processes are hardwired into all mammals. As humans, we gain our sense of self and our emotional wellbeing through our interaction with others. This starts from the time we are born. How our parents or caretakers interact with and respond to us when we’re infants creates measurable neurological changes that direct many of the emotional attributes we possess and rely on for the rest of our lives.
The importance of interactive coordination between infants and their caretakers has been demonstrated in numerous experiments conducted by Dr. Edward Tronick since the 1970’s. In the below video, his so-called still-face experiments illustrate how quickly infants become destabilized when their mothers suddenly stop interacting with them.
The fact that a tiny infant who can’t speak, sit up, or crawl yet has the sophisticated ability to detect another’s emotional state speaks to how fundamental emotionality is to our survival.
“The mammalian nervous system depends for its neurophysiologic stability on a system of interactive coordination, wherein steadiness comes from synchronization with nearby attachment figures,” A General Theory of Love says.
In other words, mammals regulate by sensing the emotional state of other mammals and then synchronizing their own internal emotional state to match. This synchronization is what the authors call limbic resonance.
Limbic Resonance: A state of deep emotional and physiological connection between two mammals.
After infancy, we begin to perform some regulatory processes autonomously. But human beings never become fully autonomous. Even as adults, we continue to require a stabilizing source outside ourselves. Which means that, in many important ways, people cannot be stable on their own. “Stability means finding people who regulate you well and staying near them,” A General Theory of Love says.
But what if we can’t locate those people who regulate us well and we find ourselves hurting and out of balance?
If limbic connection establishes our neural patterns when we are very young, it takes another limbic connection to revise them. This, say the authors, is the role of the therapist.
When a person engages in therapy, they aren’t just engaging in empty conversation with a therapist. They are entering into a somatic state of relatedness. One as physiologically based as eating or breathing. Only through the process of achieving limbic resonance with the therapist can the client begin to revise neural patterns (albeit, not consciously) to patterns that better regulate them.
For this reason, the book’s authors say, a relationship is a physiologic process as real and as potent as any pill or surgical procedure.
“Psychotherapy changes people because one mammal can restructure the limbic brain of another.”
—A General Theory of Love
Obstacles to Limbic Resonance Inherent in Teletherapy
The therapist’s job is to become a stabilizing force for the client’s limbic system. This begins by establishing limbic resonance as the therapist and client build a rapport of mutual trust and understanding through verbal and non-verbal communication. Without limbic resonance, it’s impossible for the client’s neural settings to be revised. But online therapy has some inherent potential to thwart the process of limbic resonance.
- Real-time, mutual eye contact between two people isn’t currently possible with common videoconferencing systems since a user must look at their camera lens in order to appear as if they are making eye contact. Users are more often drawn to stare at the face on their screen which means they are not looking at the camera lens and they appear with an averted gaze. Eye contact elicits involuntary physiological responses that facilitate limbic resonance, so this inability to look into each other’s eyes at the same time during a video conference impedes the therapeutic process.
- Therapist and client can’t see each other’s body language below the shoulders. Body language is an important source of client information for therapists as well as an important part of creating limbic resonance.
- Not all clients have a private space in which to express themselves openly to the therapist.
How In-Person Therapy Facilitates Limbic Resonance Between Client and Therapist
Therapy conducted in person helps facilitate limbic resonance between client and therapist in the following ways.
- The therapist’s office provides a quiet space, free from distractions, for the therapist and the client to focus on the client’s needs and emotions.
- The client has complete privacy in the therapist’s office where they can express themselves openly and honestly.
- The therapist and client can make eye contact.
- The therapist and client can read each other’s body language and other non-verbal.communication.
Not All Teletherapy is the Same.
- Asynchronous means the client and therapist communicate by leaving each other messages either through text, recorded video, or voicemail. With asynchronous messaging, the therapist and client are unable to see one another, or at least unable to see one another in a live, spontaneous exchange.
- Some online therapy services dock therapists’ pay if their messages to clients are too long or too short.
- Some online therapy services impose word limits on text messages between clients and therapists when text messaging is the primary mode of communication between them.
- Some services deny the therapist access to the client’s identity and location, which can make emergency situations, such as a suicidal or homicidal client, even more risky.
Factors Commonly Co-Occurring with Internet Addiction that Make In-person Therapy Better
Those who struggle with internet addiction, gaming disorder, and other digital media overuse issues usually contend with one or more of the following co-occurring factors that can make teletherapy contraindicated.
- Youth – Children and teens are at greater risk for developing digital media overuse issues. Many therapists who specialize in treating children report that holding a child’s attention during a video call ranges from challenging to impossible. Many of the tools child therapists rely on to do their work, such as shared play using toys in the therapist’s office, are unavailable in a telehealth session. Therapists are also reporting a change in the way adolescents assert themselves in online sessions vs. in person. “He can switch off his video. He can show me rude pictures if he wants to. He can be, actually, very bullying online in a way that he would never be able to be if he were in my room. So the dynamics between us have shifted enormously and have been really very tricky at times,” one therapist says in a recorded webinar from the British Psychotherapy Association where therapists discuss adapting to teletherapy due to COVID-19 lockdowns.2
- Lack of Privacy—The highest risk groups for internet addiction are college students followed by teenagers, two groups that often live with parents or roommates. When clients don’t have privacy, they don’t feel free to express themselves openly and honestly to the therapist during an online session, which defeats the purpose of therapy.
- Social Anxiety — One of the most common reasons people find themselves spending all their time online is because they suffer from debilitating social anxiety. Interacting with online “friends” buffers feelings of loneliness that arise due to their lack of in-person relationships. For these clients, meeting in person with a therapist is a critical first step towards overcoming social anxiety. As the client slowly learns to trust and open up to the therapist with positive results, they can begin to contemplate doing so with others in their life.
- Autism — People on the autism spectrum are at greater risk than the general population for developing internet addiction or digital media overuse issues. Due to difficulties regulating their nervous systems around others or because of prior rejection from their peers, many people on the autism spectrum demonstrate a preference for solitary play as children and solitary leisure time as adults. This can cause them to feel socially isolated and overly reliant on online interactions to buffer feelings of loneliness. While online therapy can be used to triage clients diagnosed on the autism spectrum when geography or health issues are a concern, or to educate family members and caretakers, it’s not always advisable for long-term treatment. As stated earlier, clients who overuse the internet to distract themselves from feelings of loneliness and isolation benefit from seeing a therapist in person to begin their emotional healing journey. Additionally, many clients come to therapy unaware they’re on the autism spectrum and require a diagnostic assessment to address their autism. Studies show that teletherapy’s suitability for diagnostic assessment of autism spectrum disorder is acutely limited.3
- ADHD – People with attention deficit hyperactivity disorder (ADHD) are also at greater risk than the general population for developing internet addiction or digital media overuse (DMO) issues. Distractibility is a particular vulnerability for those with ADHD and online therapy provides more avenues for distraction. Clients can find themselves engaging in other activities on the side such as playing video games, checking social media, or looking up information online. ADHD can also be an underlying contributor to a client’s social anxiety, which often co-occurs with digital media overuse or addiction. Clients who overuse the internet to compensate for feelings of loneliness due to social isolation can begin to trust others and learn to form in-person social bonds when they connect with a therapist in person.
- Often clients don’t realize they have ADHD when they seek treatment for DMO and therapists can overlook the need for an ADHD diagnostic assessment in an online therapy setting. Online diagnostic assessment for ADHD can also be problematic. Many patients surveyed by the ADHD publication ADDitude reported they were rushed through the ADHD assessment process, misdiagnosed, and prescribed dangerous drugs with negative effects when they sought treatment with online startup mental health platforms.4 At least one such platform, Cerebral, is being investigated by the US Department of Justice for “possible violations of the Controlled Substances Act” after audits by CVS and Walmart pharmacies raised concerns that Cerebral and another online provider, Done, could be overprescribing medications.5,6
When Teletherapy Works
Live, online, talk therapy can work for many people. It can be a lifeline for those without access to qualified professionals due to geographic, health, or mobility issues. Online talk therapy is especially effective when:
- The intake process happens in person so the client can establish a rapport with the therapist and they periodically schedule in-person sessions to reconnect in this way.
- Online sessions are conducted live, in real-time and not asynchronously (by sending messages back and forth).
- The client is able to attend online therapy sessions in private and feels free to speak openly and honestly to the therapist during online sessions.
- The client is not suicidal, homicidal, or in some other emergency situation.
- The client is not seeking treatment for internet addiction, gaming disorder, or other digital media overuse issues or any of the factors that commonly co-occur with those conditions
Considering Whether Online Therapy is In the Best Interest of the Client
While teletherapy has its merits, such as the ability to increase mental health access for those with geographic, health, or mobility issues, it’s important to carefully consider whether online therapy is in the best interest of each client. For those clients seeking help for digital media overuse and internet addiction, we advise in-person treatment whenever possible.
Resources to Learn More About Why In-Person Therapy is Better for Internet Addiction
- A General Theory of Love by Thomas Lewis, Fari Amini, & Richard Lannon [Amazon]
- Person-centred interventions for problem gaming: a stepped care approach [BMC Public Medicine]
- Telehealth Addiction Treatment Rose Rapidly During Pandemic; But Potential Benefits Still Unclear [APA] —
- PsiAN Speaks: Natasha Reynolds and Todd Essig [YouTube] – Psychotherapy Action Network advisor Dr. Todd Essig, a clinical psychologist, psychoanalyst, and writer, discusses the importance of psychotherapies of depth, insight, and relationship as well as the complexity of losses, benefits, and risks of virtual therapy and algorithm-based therapies.
- Remote Therapy Webinar: Presented by Gillian Isaacs Russell and Todd Essig – 11/07/2020 [YouTube]- In this webinar from the British Psychotherapy Foundation recorded in July of 2020, Gillian Isaacs Russell, author of Screen Relations: The Limits of Computer-Mediated Psychoanalysis and Psychotherapy and Todd Essig, co-chair of the American Psychoanalytic Association’s COVID-19 Advisory Team, share their thoughts with and lead a discussion between clinicians about the sudden shift to screen-mediated treatment during COVID-19 lockdowns.
- What you don’t know about Better Help [Reddit] — Reddit post by an anonymous user claiming to be an MSW and LCSW living in Oregon that worked for BetterHelp in 2020. dTEC® cannot verify the veracity of certain content on Reddit due to the anonymous nature of the platform. However, the claims made by the original poster in the post linked are corroborated by the Counselor Guide on the BetterHelp website as of June 2022.
- The Spooky, Loosely Regulated World of Online Therapy [Jezebel]
- We’re the researchers who looked into the privacy of 32 popular mental health apps and what we found is frightening. AMA! [Reddit] – nlike most Reddit content, the users who posted this were verified as real researchers for Mozilla, the company that makes the search engine called Firefox.
- Mental health app privacy language opens up holes for user data: Policies can change at any time [The Verge] — After seeing multiple mental health app privacy scandals crop up over the last few years, one reporter decided to look into why this keeps happening.
2. British Psychotherapy Foundation. (2020, July 16). Remote Therapy Webinar: Presented by Gillian Isaacs Russell and Todd Essig – 11/07/2020. YouTube. Retrieved June 27, 2022, from https://www.youtube.com/watch?v=HfebHoYLES4
3. Goldstein, F. P., Klaiman, C., & Willliams, S. (2017). Bridging Care Gaps: Using Tele-health to Provide Care for People With Autism Spectrum Disorder. International journal of developmental disabilities, 63(4), 190–194. https://doi.org/10.1080/20473869.2017.1322342
4. Rodgers, A. L. (2022, June 20). The Tattered Promise of ADHD Telehealth. ADDitude. https://www.additudemag.com/cerebral-adhd-telehealth-diagnosis-medication-report/
5. Landi, H. (2022, May 7). Cerebral under federal investigation for possible violations of controlled substances law. Fierce Healthcare. https://www.fiercehealthcare.com/health-tech/cerebral-under-federal-investigation-possible-violation-controlled-substances-law
6. Nassauer, R. W. A. S. (2022, April 28). Walmart, CVS Pharmacies Have Blocked or Delayed Telehealth Adderall Prescriptions. WSJ. https://www.wsj.com/articles/walmart-cvs-pharmacies-have-blocked-or-delayed-telehealth-adderall-prescriptions-11651082131
Introduction to Digital Media Overuse, A Clinical Training for Counseling and Related Professionals October 7, 2022
Approved by NBCC for 6 CE hours.