Frame Trade-Offs: On Some Therapeutic Implications of Telepsychiatry

The Coronavirus 2019 (COVID-19) pandemic has undoubtedly accelerated the shift to telepsychiatry, defined as the delivery of psychiatric care via videoconferencing.^1,2 As we adapt to social distancing and modify our work practices, the additional benefits associated with the increased use of telepsychiatry become self-evident, such as increased convenience and greater attendance.³ The benefits and feasibility of telepsychiatry have been studied for over two decades, with practice guidelines developed from a foundation of empirical support.^2,4–6 Focused mostly on populations with limited access to in-person care (rural or home-bound populations), research comparing telepsychiatry with in-person care has shown patient satisfaction and therapeutic alliance to be at least equivalent.^7–9 While such findings contribute to a solid foundation for telepsychiatry, the magnitude and breadth of its recent uptake highlight the need for further research to clarify for whom telepsychiatry is most appropriate and how it may be optimized in given contexts. The present essay sheds light on some of the implicit features of practice that may be altered by telepsychiatry––and proposes different paths that could be taken to appropriately tackle this clinically relevant research gap.

We propose that subtle changes to the frame brought by telepsychiatry may affect treatment delivery and outcomes. Broadly, the frame represents the boundaries and ground rules within which the therapist-patient dyad operates, allowing for the development of a secure, consistent, and unambiguously therapeutic relationship. Although wide variations of opinion exist regarding its flexibility and constitutive factors, the role and importance of the frame in psychiatry is generally well accepted. Langs,^{10(p 798)} whose theorizing was pivotal in emphasizing the importance of the therapeutic frame, stated that psychotherapy should be carried out in a soundproof consulting room, in a private office, in a professional building. Many aspects of the frame as defined originally are still widely used in day-to-day psychiatry, including, in most cases, the definition of its physical space. Spatiotemporal elements of the frame––far from being confined to psychotherapy––now require renewed exploration, given that the “space” in which psychiatry is practiced has increasingly become a virtual one. To our knowledge, the potential impact of virtual frame aspects––for different patients and contexts––requires further research, with no previous work being identified on the subject, from either a quantitative or qualitative perspective. Hence follows a reflection on the modifications to psychiatric practice––most notably involving changes to the frame––brought about by a transition to telepsychiatry, and consideration of their potential effects.

An increasingly technology-based frame can thankfully narrow many gaps associated with health care accessibility, particularly for individuals with mobility limitations or transportation difficulties, or from rural areas. At the same time, however, other health care inequities––stemming from underlying disadvantages––may inadvertently be widened. Individuals who are of lower socioeconomic status, cognitively impaired, challenged by learning or sensory disabilities, suffering from specific psychiatric or medical disorders, or simply less “tech savvy” may find telepsychiatry daunting.³ Limited access to high-quality devices and internet connections with large bandwidth may affect care quality.⁵ These factors underscore the importance of understanding the implications of telehealth for a variety of patient populations, especially through research comparing in-person and telepsychiatry consultation in different contexts.

The absence of a “brick and mortar” location may affect the patient’s mindset entering the clinical encounter. During the physical preparation and travel required for in-person appointments, a mental transition may parallel the physical one between the patient’s home and the clinic; patients may ponder the upcoming encounter, clarifying their goals, hopes, and expectations of the assessment. By contrast, simply logging in to a virtual appointment may curtail this transition to a therapeutic process. Furthermore, confidentiality and trust are core features of psychiatric practice, as patients are asked to share a wealth of private and sensitive personal information. The professional office implicitly protects the content of the session within its walls; while excerpts may be documented and shared among professionals, the granularity of the patient’s narrative is confined to this distinct space. The move from physical to virtual space may influence the patient’s sense of trust, particularly given the hypothetical possibility of sessions being video recorded or cloud stored. Moreover, an encounter in the clinician’s office offers a fairly neutral milieu in which relatively little of one’s personal environment is revealed. Telepsychiatry brings a wider range of possibilities for different meanings and interpretations of the space in which the session occurs, given the higher variations brought by virtual offices. These variations may act as a catalyst for some, rapidly creating a sense of familiarity and closeness that facilitates disclosure and reflectivity. For others, they may be inhibiting. The physical office affords the clinician a measure of control over the therapeutic environment; use of home or other personal environments for virtual visits creates new opportunities for self-disclosure and associated meanings or interpretations. Alternatively, the accessibility of videoconferencing and its novel forms of intimacy could provide occasion for boundary violations, such as surreptitious recordings or image captures of participants, provocative behaviors, or intrusion by loved ones. While guidance is available to navigate the constructs of privacy and confidentiality in telepsychiatry, the intersection of the virtual frame with patients’ unique contexts suggests a need for further investigation into these factors as potential moderators of telepsychiatry effectiveness.^3,4 See Text Box 1 for suggested ways of optimizing telepsychiatry outcomes.

Text Box 1 Suggested Practices for Optimizing Telepsychiatry

-

Prioritize access	Inquire about access to quality devices, Wi-Fi connections Inquire about access to a private space Prioritize in-person care when possible if limiting vulnerabilities Engage associated health professionals and social services to provide support when needed
Secure a space	Encourage patient beforehand to secure the most confidential space available Encourage patient to create protected time from interruption
Ensure trust	Provide clear explanations about the security and confidentiality of the platform used at the outset Invite patients to share their thoughts on the matter
Reinforce transition	Invite patients to create a deliberate transitional experience prior to the sessions Suggest that patient arrive to the virtual waiting room ten minutes prior to appointment

Restricting the interpersonal interaction to a screen between the patient and the psychiatrist significantly limits the depth of information available.⁵ Both psychiatrists and patients have reduced access to nonverbal cues in virtual care, which may increase the potential for misunderstanding and obscure the detection of misinterpretations. These limitations may lead to a delayed or impaired ability to repair a jeopardized therapeutic alliance. One may wonder how the reduced availability of nonverbal cues and constant change of visual background––a new room with each patient––affects the psychiatrist’s clinical fluency, particularly regarding patients with communication challenges, personality vulnerabilities, or psychotic or other severe and complex presentations. Traditionally, psychiatrists are trained to make their assessments and clinical encounters within a relatively stable environment, which allows one to focus on the specific clinical and interpersonal variabilities that occur within its parameters. The screen encounter alters the depth of information available to clinicians.^4,5 Further mixed-method research that specifically investigates clinicians’ subjective proficiency at assessing complex mental states and promptly perceiving signs of interpersonal withdrawal or rupture in a telepsychiatry practice will be needed to inform advanced training in the field. Several next steps lie ahead in continuing to advance telepsychiatry through research and practice innovations. An important first step will be to ensure that a broad range of clinical populations with particular characteristics be represented and that outcome measurements focus on an array of targets such as symptom amelioration, patient satisfaction, and social functioning. Particular attention could be given to patients with underlying disabilities and to populations underrepresented in the current telepsychiatry literature, such as individuals with bipolar, psychotic, substance use, or personality disorders.^5,6 It would also be useful to examine patients’ (and providers’) previous experience with, and expectations of, telepsychiatry as potentially influential variables. While expert opinion is available to guide online group therapy, empirical study of this complex form of interpersonal, yet virtual, treatment remains limited. In addition to clinical trials and observational studies, much could be gained from further qualitative and mixed-methods inquiry, addressing subtle and often difficult-to-quantify elements of therapeutic encounters.

In conclusion, further investigating and accounting for the potential implications of our collective shift toward telepsychiatry is important for its advancement. While the expertise of the practitioner may be unchanged in telepsychiatry, everything surrounding it may be changing––prompting a need for critical reflection. Perhaps more so than in other health care domains, the psychiatrist’s work is deeply embedded in human connection. While the gold standard thus far remains in-person psychiatry, we believe that thorough investigation and understanding of the different processes at play––moderated by patient and contextual differences––will allow telepsychiatry to reach beyond many of its frame trade-offs.