11 p.m. Sept. 13, Showtime
Episode: "Whistling While I Work"
The premise: Fiona Wallice (Lisa Kudrow) is a therapist with unspecified credentials who begins seeing clients in three-minute sessions conducted online via video chat. In this episode, she is "treating" her former boss and boyfriend, Robert Lachman (Steven Weber). Robert, an investment executive, is being investigated by the U.S. Securities and Exchange Commission and is under house arrest. An SEC agent interrupts one of their sessions to say that Robert isn't allowed to go online, but Fiona asserts that the sessions are necessary for his treatment. Robert persuades Fiona to lie to the SEC and say that she has been treating him for three years for a range of possible conditions so that he can get a break from the lengthy investigation; in exchange, he sends her a diamond necklace and earrings. Ultimately, Fiona terminates the relationship, stating that she plans to write an unflattering book about her experiences working for Robert's firm. She becomes a witness for the SEC after investigators promise that she won't be prosecuted herself.
The medical questions: Can psychotherapy sessions be effectively conducted via video chat? Are the same professional credentials required? Are such sessions bound by doctor-patient confidentiality? Is it ever OK for a therapist to lie about a diagnosis or the length of time she has treated a patient? Is it possible for a therapist to treat someone if they had a personal relationship in the past?
The reality: Online therapy is a recent incarnation of telepsychiatry, which has been practiced for several decades, says Kate Anthony, an online therapy specialist based in Scotland and co-founder of the Online Therapy Institute, which aims to help therapists incorporate technology into their practices. In the early days, therapists would treat patients via interactive television or satellite hookups; for example, psychiatrists at Massachusetts General Hospital in Boston began seeing patients at remote locations using two-way cable TV hookups in 1969, according to a report in the American Journal of Psychiatry. The Internet makes all of this much easier, and insurance companies in the U.S. are just beginning to embrace videoconference-style therapy sessions as valid, she says.
Counseling is a regulated profession, regardless of how the therapy is delivered, Anthony adds. In general, therapists are licensed to practice only in their own state, so treating patients in another state can be tricky, according to Robi Ludwig, a psychotherapist in private practice in New York City. "The way therapists can get away with that is by offering coaching," she says. "Coaching does not require that a therapist be licensed in a particular state. In fact, coaches don't have to be licensed at all."
Therapists must respect their patients' privacy whether they conduct their sessions in an office or online, says Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania. The content of therapy sessions should be off limits for both tell-all books and plea-bargain deals with law enforcement agencies.
If a therapist cannot guarantee that she has a secure connection with a patient, that is a real problem, he says.
Outright lying about a diagnosis is a form of fraud, Caplan says. However, a good patient advocate can shade the truth a bit in certain circumstances, such as to help a patient maintain access to mental health care. "Fraud is wrong," Caplan says, "but shading an interpretation of a disease in the patient's favor — other things being equal — is an ethical choice." Accepting lavish gifts from a patient in return for special favors is clearly unethical since it violates core principles of standard medical and psychotherapeutic practice, he says.
According to Ludwig, the therapist/patient relationship isn't necessarily doomed by a previous relationship, "although the more intimate the relationship, the less likely it's going to work in real life." In order for counseling to be effective, "the patient needs to be able to say everything and will be less likely to do so if there is a loaded personal history attached," she says. Anthony agrees that treating an ex-boyfriend is certainly discouraged and adds that in the real world (as opposed to on the show), the availability of Web-based therapy actually gives a patient more options for finding a therapist who can be 100% objective.
Siegel is an associate professor of medicine at New York University Langone Medical Center. His new book is "The Inner Pulse: Unlocking the Secret Code of Sickness and Health."