I was recently asked to take part in a debate about “cyber-psychiatry” (I prefer the term tele-psychiatry). My task (with others) was to oppose the motion, to argue against seeing people virtually rather than face-to-face. I have to confess to some mixed feelings about this.

In a pandemic, things are different. It has been safer, in most circumstances, to see people online, both for the people concerned and for the practitioners involved. But this doesn’t mean that we should continue with that practice without evaluating its implications. And I worry that cost savings and time-savings for organisations may perversely privilege online work over face-to-face work.

My main concern about tele-psychiatry is that the foundation of psychiatry is the relationship between practitioners and their patients/ service users. The relationship between practitioner and patient relies on trust. And I believe that the relationship we have online is different from the relationship we have face-to-face. Practitioners need to get to know their patients, their situation/ context, their history, what is important to them, what their priorities are, and more, in order to assess and co-construct with the person and their family, if appropriate, a plan for what might help. Establishing a relationship and building up trust are so much harder to do online, particularly with someone we don’t know and who doesn’t know us. That’s not to say it can’t be done: I do a lot of work online at the moment and I know that people can establish good online relationships, but, although most people will feel that the online working relationship is good-enough, they often admit that it’s still different from meeting face-to-face.

I have found a quotation that encapsulates some of what we miss out on online in words much better than I could come up with:

“How odd it felt to be suddenly deprived of – and made to appreciate – those countless tiny cues, the sighs, the diverted gaze and its flinching return, and, most of all, the silences. It was not easy to gauge the pain and poignance of those quiet moments that are the stock of our trade. Like musicians, so much of our work goes on in between the notes.” (MS Salter, BJPsych Bulletin (2021) 45(2): 122-123).

I have other reservations that include concerns about technical aspects, confidentiality etc, but I’m interested in what other people think. I wouldn’t like anyone to rush into redesigning services along pandemic lines without assessing what might be lost in the process.