House Calls

The other day, I was scooting around a Google map of Manhattan, trying to find The Doughnut Plant, which makes the best coconut cream yeasted doughnut ever. And as I was virtually strolling along 23rd street, I saw this:

House Call Psychiatrists. Hmm. I couldn't help checking out their website.

From their home page:

House Call Psychiatrists is a network of board certified and licensed psychiatrists with extensive experience making psychiatric home visits.  They are available 24 hours a day, 7 days a week for convenient and private house calls within Manhattan, Brooklyn, Queens and North Jersey.

House Call Psychiatrists offer a unique and high level service in the convenience of your home, office or hotel room. They are able to address most psychiatric issues in a timely and private manner avoiding other urgent care centers and hospital emergency rooms.

There's an interesting idea. It's a bit different from TalkSpace, a texting therapy service which I posted about previously. Some of the things I didn't like about TalkSpace were that it's not in-person treatment, and there's no delayed gratification like there is when you have to wait for your appointment.

But these are house calls. So you do have to make an appointment, even if it happens to be in the middle of the night. And it is in-person.

Here's some more information.

There are 7 psychiatrists on the team, all men. A general psychiatrist, two addiction psychiatrists, a bipolar specialist, a geriatric specialist (who doesn't seem to be board certified in gero-psych, so I guess that's why they don't call him a geropsychiatrist), a community psychiatrist, and an anxiety specialist.

Thinking about the "extensive experience making psychiatric home visits," I'm skeptical. How would they get that extensive experience? I can remember my pediatrician coming to my house, but nothing since then-who makes house calls anymore?

"Our psychiatrists have been making house calls for many years on Assertive Community Treatment (ACT) teams which are home-based psychiatric outreach programs.  They are also psychiatric emergency room physicians with admitting privileges to..."

ACT house calls seem very different to me than the house calls they're talking about here. For one thing, ACT is a team, and sees patients as such. Here, my impression is that this is 1 to 1 care. For another, most patients in ACT treatment can't afford the $500 fee that House Call Psychiatrists charge. Or $1000 from 8pm to 8am.

I'm trying to understand the model. I assume they cover for each other, and that someone is always on call.

All the the psychiatrists seem to have separate private practices that provide more typical office visits. Some of their websites indicate that they will also make house calls, but at the $500 rate, rather than their regular rates, which are less. Does this mean that the House Call Psychiatrists only see established patients? I don't get that impression.

They also offer to see patients in their hotel rooms, which implies that they may be visiting NYC, and therefore not established patients.

The house call services provided are:

This makes me wonder about liability. If they provide crisis intervention and safety checks, then they may end up seeing a patient they don't know who is suicidal. What if that patient needs to be hospitalized but refuses to go? One of the individual psychiatrist's websites states that he does make house calls, but that, "A home visit should not replace calling 911 if you are having an emergency." That confuses me.

My fantasy about this model is that some wealthy person feels like he needs to see a psychiatrist, but he is either visiting NYC, or lives here but doesn't want to go to anyone's office. I imagine this as happening in the middle of the night, with patients who suffer from insomnia (they state they treat sleeping difficulties), or who are having panic attacks. Or maybe it's during the day, but it's some CEO who wants his shrink to come to him.

I'm really not sure what to think about this model. I know I wouldn't make house calls with my patients, but my practice has a certain nature that doesn't lend itself to this model. Also, I don't fancy wandering into a stranger's hotel room in the middle of the night, knowing that there's a psychiatric problem.

Home visits are a great idea for patients who function poorly and would be lost to care if they weren't followed by an ACT team, for example. But patients who can afford $500 fees presumably function fairly well. (Incidentally, no insurance is accepted, and the fee is prepaid at each visit via credit card.)

I think that for one-off panic attacks, home visits are probably not a good idea, because they maintain the message that the patient can't manage on his own and tolerate some delayed gratification, similar to TalkSpace.

For naltrexone injection or genetic testing, maybe it does make sense for the shrink to come to your office.

For ongoing therapy, I don't know. Is there some benefit to making time during the day to travel to the shrink's office? Is there a power struggle that gets settled by default when the shrink comes to you? Does it violate the important frame of a treatment to have it in your home, or does it just create a different frame?

I have a lot more questions than answers. What do you think?

Talkspace

I learn a lot on the subway. I spend quite a bit of time commuting. Some days I'm too tired to do anything but play Temple Run2. But I also read recreationally and professionally. And when my eyes aren't otherwise occupied, I look at ads. There's the famous, and recently less present, Dr. Zizmor, the world-renowned dermatologist:

There are all the ads for law firms with track records of successful malpractice suits.

There's the MTA's Poetry in Motion campaign:

Notice that Dr. Zizmor's ad is rectangular, and the Elephant poem is more square. The rectangular ads run across the tops of subway cars, and the square ads run below, to the sides of doors. Often, one company will take up multiple ad spaces in a single car, with different versions along the top and on the side.

There's a company, Manhattan Mini-Storage, that has pretty amusing ads all over the city, including in the subways, that encourage you to clear out your crowded NYC apartment by using their storage, like this one:

and:

A couple weeks ago, I saw a rectangle ad above a square ad, that I assumed were part of the same campaign, since they had the same tag line, "Dream Big", and roughly the same font:  Sorry for the crummy iPhone photo:

Turns out, the bottom ad is for NYU's school of continuing education, and the top ad is for breast augmentation.

But today, I saw an ad for Talkspace:

Talkspace is unlimited messaging therapy for $25/week, billed monthly. (There are other rate plans, as well.)

"...you can now message your therapist every day..., writing as many times as you want..."

There's also live video therapy, $29 for 30 minutes, but this needs to be scheduled ahead of time. And there's couples therapy.

Here's their video:




All kinds of questions, right?

Like, who are these therapists?

There doesn't seem to be anyone I could find with an MD, PhD, or Psy-D. All Masters level. Talkspace says they check the credentials of all their therapists, but the therapists don't work for them, and Talkspace isn't responsible for what they do. They just facilitate the connection.

From their FAQs:

What is Talkspace about?

Talkspace is making therapy available and affordable for all...

We created Talkspace because we strongly believe that in this day and age, everyone should have real-time, simple, and affordable access to professional advice whenever and wherever we need it. get access to leading therapists who can help you overcome your day-to-day challenges. 

Talkspace  is your safe and secure place where with a licensed therapist you can start your journey to fulfillment, empowerment, and happiness. You can share what's on your mind, chat privately with a therapist on your computer or mobile device.


Is online therapy really effective?

Absolutely. If done correctly, by qualified individuals and in the right environment.

Over the last decade numerous prominent research studies have proven the effective potential of online therapeutic conversation. We listed a few on our Talkspace blog research page.


I checked out the list. A lot of the references are newspaper articles, which I'm just ignoring. There are a couple of references to papers having to do with online therapy. These tend to be specific to a condition being treated, or to a specific modality of therapy with predetermined time constraints. They didn't seem to list anything that directly supported the type of "online therapy" they do-unlimited access, text-based.


Is Talkspace a substitute for actual therapy?

No. Talkspace does not aim to create an alternative or competitor to offline therapy.

Rather, we create a doorway for dealing with real life issues that may be an element in our lives, but may not necessarily require full clinical psychiatric process.

Furthermore, therapists are instructed to identify situations where clinical therapy is needed and divert participants towards the most appropriate solution.


So, Talkspace makes "therapy available and affordable for all", but it's not a substitute for actual therapy.



What about my privacy?

At Talkspace your privacy and safety are always the first consideration. We went to great lengths to assure you and your data are always kept safe and confidential

Your safety is our #1 priority. You have the option to remain anonymous. 
Our technology is fully HIPAA compliant. 


I was a bit confused by this part. The site has 141 free therapist-led forums. This is from one called, "How to deal with depression or anxiety":

I guess there's some privacy, since the therapist offers a private chat, but it seems like a lot of information is right out there for anyone to see.


Another comment from the same forum has a lot more information than I'm comfortable with. I suppose if the person posting doesn't mind, it's okay:

I'm also a bit put off by the response:

The therapist seems not to have noticed that the father is dying, not dead.


Call me skeptical, but I have a hard time believing that text therapy can be helpful. Tele-therapy or Skype-therapy is limited enough. Texting makes it completely impersonal.

In terms of therapeutic alliance, it's not even clear to me if you always get the same therapist. I don't see how you could, since they're supposed to be available 24/7.

Also, the responses on the forums are so simplistic, it's hard to imagine anyone finding them more helpful than speaking to a friendly neighbor:

"...it sounds like you are the type of person who likes to please and make others happy but you are not taking care of your own needs."

"...it's about building up your self-esteem and confidence so that you don't have that fear of people liking you or you feeling the need to make others like you."

But mostly, I'm concerned because the whole 24/7 access setup is so anti-therapeutic. The frame is always important to therapy. It creates safety and containment. Scheduling, boundaries, recognizing the limitations in the therapeutic relationship.

What happened to using therapy to learn how not to need therapy? We want patients to carry their therapists around in their hearts and minds, not in their pockets.

And Talkspace completely misses an important aspect of limited access, namely, that the patient learns that other than in a true emergency, he or she can tolerate some anxiety and frustration, and wait until the next session to discuss what seemed like very pressing feelings.

Talkspace will just push people further away from the ability to tolerate delayed gratification.

Addendum: I published this post just a few hours ago, but I just saw the Circa Now column in the NYTimes, and I had to add a link:

Memo to Therapists: It's Not Me, It's You

The author, Henry Alford, writes about wanting to break up with his therapist "on day 2 of our relationship", which takes place on Talkspace. The article is really about awkward and difficult interactions with ones therapist, and how these can be handled well, or poorly. In the cases in the article, mostly poorly.  And it's interesting that the patients quoted in the article have trouble bringing up uncomfortable feelings and thoughts with their therapists, like, "Is it okay to ask my therapist about herself 2 years into the therapy?", or, "Can I mention the fact that my therapist just farted?" without the realization that these are the kinds of things that need to be discussed in therapy, precisely because they're uncomfortable, and politeness has nothing to do with it. And I'm inclined to blame their therapists for not making that clear, or creating an environment that makes it possible to say difficult things.

The article is not about Talkspace, per se, but the timing was so uncanny, I had to include it. And the author does seem to think the activity he's participating in on Talkspace is therapy.