When the parents of a bright, 7-year-old girl were informed that their daughter’s delays in social and emotional development were likely indicative of Autism Spectrum Disorder (ASD), they responded in a manner similar to many other parents who have received such news. They began seeking medical and developmental specialists to obtain comprehensive information and appropriate, individualized treatment to address their daughter’s unique needs. Her meltdowns and anxiety about change were beginning to interfere greatly with her ability to participate at school. Unfortunately, these parents quickly learned that the providers available around the small city where their family resided had little, if any, experience in working with such difficulties. Their frustration intensified as a series of phone calls and internet searches revealed that ideal services for their daughter did indeed exist – just not in a location that was plausibly accessible to their family. How could they possibly secure efficient and effective treatment for their daughter without disrupting the entire family’s functioning?
Technology’s rapid advancement has vastly impacted the process of planning, seeking, and participating in services that foster optimal everyday functioning, such as the concerns presented in the scenario above. Among the range of diverse supports that individuals on the autism spectrum and their families may seek, psychotherapy is a valuable tool for addressing short- and long-term concerns ranging from school struggles to emotional difficulties to interpersonal relationships. However, the movement towards computerization across mental health services has led to a controversial, yet inevitable, shift.
The past decade has been characterized by a push to make therapeutic services increasingly accessible, universally affordable, and, especially for individuals with ASD and social learning difficulties, less characterized by stigma and general discomfort. Consequently, therapy seekers and providers alike have been drawn to the possibility that electronic communication may be a forum for facilitating therapeutic growth without leaving home. At the same time, the gains obtained in psychotherapy have a long-standing link to the interactions between client and therapist. Can the goals of therapy possibly be reached through a computer screen? Moreover, how can regulatory organizations and insurance companies keep pace with these alternative technological approaches to therapy?
Continually expanding research and practice in teletherapy has directly sought to answer these questions. Interventions and studies are primarily aimed at clarifying the means by which technology can enhance participation in psychotherapy without negating its fundamental tenets (Bischoff et al., 2004; Hill et al., 2001; Oliver & Demiris, 2010). The American Psychological Association recently released guidelines for teletherapy practice, and some state licensing boards have begun to publicize their expectations for licensed providers (APA, 2013).
A brief review of informational materials illustrates the varied terminology used to describe computer-based therapy. Although we use “teletherapy” for the purposes of this article, interchangeable or related approaches may be referred to as telepsychology, tele-mental health, remote treatment, videoconferencing, online therapy, computer-assisted therapy, or internet-mediated therapy. The most widely used format entails conducting sessions through live video messaging (e.g., Skype), but email exchanges, online chatting, telephone sessions, and text messages are also sometimes encompassed in teletherapy.
The practice of teletherapy within the scope of its potential reach is still in its infancy, yet psychology researchers are scrambling to gather clear information about its feasibility and effectiveness. Most studies have pointed to similar client success rates between in-person and teletherapy in terms of goal attainment, satisfaction (with the exception of occasional technical frustrations), and client-therapist relationship (Backhaus et al., 2012). Exceptions have primarily centered around less success in teletherapy with a group of clients (Kallay & Michlea, 2010) and quicker success in teletherapy with individuals diagnosed with anxiety disorders (DeAngelis, 2012). When it comes to children and adolescents, their universal engagement with technological tools may actually enhance the appeal of participation in therapy. Furthermore, proponents have highlighted opportunities for accessing therapists, particularly within specialty areas such as ASD, whom individuals would normally be deterred from contacting due to geographical constraints. Indeed, research has consistently demonstrated that such connections can be facilitated by teletherapy arrangements, as can greater choice in mental health providers overall (Herbert et al., 2012).
Teletherapy and ASD in Action
Within the context of our practice at ASPIRE Center, we have found substantial benefit in the opportunity to provide services to clients who may be reluctant to engage in face-to-face sessions or are unable to find similar specialty services in their area. For example, Dr. Nichols has a specialty practice working with females with ASD. As such, she is currently seeing four women for individual therapy via the computer who live in different states. For two of these women, there are no local providers who have experience treating adults with ASD, let alone who understand the nature of ASD in females. Overall, the experience of participating in teletherapy has been highly positive for Dr. Nichols, and by feedback, for her clients. The anxiety one woman feels while outside of her apartment can create a heightened state of arousal and discomfort that lasts for hours. Being able to participate in therapy from home enables her to be more focused and engaged in the therapeutic process, even when discussing the goal of leaving her apartment. Most therapeutic activities can be modified for presentation via computer (e.g., materials emailed ahead of time), and for some purposes, the teletherapy format is most beneficial (e.g., being able to see a room when a therapy goal is directly related to that room – organization, sleep hygiene).
At the same time, our firsthand experience, in combination with concerns that have been raised among colleagues and regulatory agencies, underscores the inherent dilemmas associated with reliance upon technology during therapeutic interventions. Challenges Dr. Nichols has experienced include losing a connection during a particularly salient moment in therapy, and encouraging her clients to be able to see the virtual “therapy room” as the same safe place for sharing intense emotions and experiences as during an in-person session. Unexpected interruptions can occur (e.g., a client’s cat knocking over their laptop), as can the potential for therapy to be perceived as less serious (e.g., a client is highly anxious and avoidant when particular topics are raised).
In the interest of providing ethical and appropriate services, Dr. Nichols has had to seek licensure in each state in which her clients reside, including having had to fly to one state in order to complete an in-person jurisprudence examination. She has been fortunate in that three of the four women visited New York for consultation or an assessment prior to starting teletherapy services. However, the current status of state licensure regulations poses a significant barrier to families and individuals who desire to receive services from a practitioner whose home state is different than theirs. Again, this directly affects individuals for whom services from a specialist are most appropriate, or who live in rural areas. Take for example in the medical field, a patient who has a highly rare form of cancer and needs to see a specialist oncologist in Oregon despite their living in Florida. Dr. Nichols is currently licensed in NY, CO, MO, and IA, each of which have their own fees, requirements for licensure, continuing professional education, etc. It is unfortunately not feasible for a single clinician to become licensed in every state within which potential clients seek therapy.
As a culmination of the aforementioned research findings, practical experiences, and general considerations, we hope to equip interested parents and teletherapy-seekers with tools to ensure a comfortable and constructive experience. When beginning a relationship with a therapist who provides teletherapy services, it is sometimes helpful to hold an initial in-person meeting when plausible (Maheu, 2013). More importantly, however, a well-matched therapist should be identified through careful assessment of proficiency in techniques specific to both psychotherapy with individuals on the autism spectrum and exclusive to teletherapy. Policies related to payment, cancellations, interruptions in internet connection, and contact between sessions should be clearly outlined.
Concerns regarding privacy should be carefully considered, foremost in terms of security breach risks associated with general internet use. Programs have been developed explicitly for facilitating teletherapy, and that are HIPAA compliant, but confidentiality must be directly assessed. In the context of broader options for therapy setting, it is essential to identify a computer-accessible location that is free from distraction. Parents should negotiate an arrangement that includes a balance of privacy and monitoring based on therapist recommendations. Furthermore, the sensitive and stimulating process of psychotherapy may occasionally trigger emotional or behavioral incidents that, under traditional circumstances, would be managed by the therapist. In the case of teletherapy, proactive planning is necessary and may reduce emergency occurrences and severity.
Psychotherapy, whether conducted in a traditional clinical setting or utilizing the expanding range of technological tools, often provides monumental benefits in the growth, adjustment, and well being of individuals on the autism spectrum (Gaus, 2011; Scarpa & Reyes, 2011; Scarpa, White, & Attwood, 2013; Sze & Wood, 2007; Wood et al., 2008). The impending establishment of clear practice guidelines, privacy safeguards, and evidence-based interventions in teletherapy promises to allow wider psychotherapy access in combination with individualization of treatment. Awareness of this therapeutic approach, especially in its potentially unique appeal to children and adults with social learning concerns, may be influential in paving the way for future development and success.
Alyson H. Sheehan, PhD, is a Post-Doctoral Fellow and Shana Nichols, PhD, is the Director and Licensed Psychologist at ASPIRE Center for Learning and Development.
ASPIRE Center for Learning and Development is a multidisciplinary practice in Melville, NY that specializes in assessment, consultation, and treatment for Autism Spectrum Disorder, disruptive behavior disorders, and other social learning difficulties. Detailed information can be found on our website at www.aspirecenterforlearning.com, by calling (631) 923-0923, or by sending an email to firstname.lastname@example.org.