Can telepsychiatry really work?

I have been asked one question about my work in telepsychiatry more that any other, hands down.

“Can you really help a mental health patient like that, through a television screen?”

The quick and dirty answer? Yes, absolutely.

The extended answer? Read on.

Psychiatry is an intensely personal specialty. It requires knowing yourself as a doctor, as a therapist, as a consultant, and as a person more than any other kind of medical practice I have ever been exposed to.

It requires four years of residency after four years of medical school to train to become a psychiatrist for a reason. You must not only master the big picture and the fine points of the specialty. You must understand what makes you tick. You must know how you respond to stress, challenge and adversity. Without this knowledge and training, one makes a very marginally competent psychiatrist at best.

As a psychiatric consultant, I ask questions that in normal social discourse would be considered forward, intrusive, even bordering on abusive. I ask about the intimate details of your medical history. I ask about your work history and why you were fired from your last job. I ask about your sexual history and yes, I usually want to know if you’re straight or gay. Not to pry, but because it gives me a tremendous window on your life, how you perceive yourself, and how others perceive you.

I want to know about your legal history. I ask how many DUIs you’ve had and what lead to the criminal domestic violence charge. I want to know the details of your last suicide attempt. Why did you cut yourself instead of overdosing this time? Was your intent to die, or just to reach out and make a statement to someone who had wronged you?

Think about the last really deep conversation you had with a very close friend, a sibling, a parent, a spouse, a lover. What made it special? What made it real? What made it possible for you to let that person have access to a very deep part of you that no one else knows about?

It is the connection, the intimate connection between two people that allows these kinds of conversations to happen. Pure and simple. You know it. I know it. In our friendship, if you are not willing to let me in, to share your hopes, your fears, your dreams with me on the very deepest levels, we might as well be two strangers who met in an airport bar and had a chat during a layover.

Now, several of you have argued with me over the last few years that relationships on social media cannot be real in that sense. You cannot have that kind of deep, emotional and spiritual connection with another human being over Facebook, Twitter or any other social media platform. Many of you have said the same about telepsychiatry. You can’t possibly talk to someone and learn enough about them over a television screen to help them.

All I can tell you is that over the last four years my colleagues and I have done almost fifteen thousand consults via high speed lines and high definition video monitors. Personally, out of the thousands of consults I have completed myself, only two patients that I can recall now refused to talk to me over this medium. Both were very ill and their level of paranoia precluded them connecting on a meaningful level with anyone, in person or via video.

The flip side of that coin? I remember very well, with great pride and a very deep sense of fulfillment, the father of the emotionally sick child I had just interviewed. He was at the end of his rope. His child was suffering, dying in a very real way before his eyes. He did not know what else to do.

After our interview I went over the treatment plan with him. I told him that there were things that could be done to help his child, and that we were going to do them, starting at that very moment. His face changed. He smiled a very weak smile. I could see the hope in his eyes.

Spontaneously, he jumped up out his seat, two hundred miles away from me, and reached out to shake my hand.

I knew at that moment that the medium was powerful, the connection real and the intervention worthwhile.

We had seen each other through a glass darkly, and then face to face.

Greg Smith is a psychiatrist who blogs at gregsmithmd.

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