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TV Screen, Not Couch, Is Required for This Session By KIRK JOHNSONFLAGSTAFF, Ariz. ??? Dr. Sara Gibson looked into the television screen and got right down to it. "What's keeping you alive at this point?" she asked her patient, a middle-aged woman who asked to be identified only as D. D grimaced, looked down, then to the side and finally into Dr. Gibson's face, which filled the screen before her in a tiny clinic three hours east of here in the Arizona desert. "Nothing," said D, who Dr. Gibson says suffers from bipolar disorder and post-traumatic stress from the sexual abuse she suffered as a child. It is Wednesday in the hinterlands of rural Arizona, and the psychiatrist is in. Sort of. Actually, Dr. Gibson was here in Flagstaff in a closet-size office of a nonprofit medical group, with a pale blue sheet behind her as a backdrop and a cup of tea at her side. She is one of a growing number of psychiatrists practicing through the airwaves and wires of telemedicine, as remote doctoring is known. Psychiatry, especially in rural swaths of the nation that also often have deep social problems like poverty and drug abuse, is emerging as one of the most promising expressions of telemedicine. At least 18 states, up from only a handful a few years ago, now pay for some telemedicine care under their Medicaid programs, and at least eight specifically include psychiatry, according to the National Association of State Medicaid Directors. Six states, including California, require private insurers to reimburse patients for telepsychiatry, according to the National Conference of State Legislatures.Growing prison populations have a lot to do with the trend. Since reimbursement for prison care is easy and safety issues for doctors are significant, many telemedicine programs, notably an ambitious one in Texas, started there. Now, the falling price of technology is making care available to far-flung rural residents like D. Dr. Gibson rides a disembodied circuit through this terrain. On Wednesdays, she sees patients in the tiny community of Springerville near the New Mexico border through a firewalled T1 data line, and on Thursdays in St. Johns. Each side of the exchange has its own television-mounted camera, angled so that doctor and patient can maintain the illusion of looking into each other's eyes in real time.And so, through illusion and delusion, depression, anxiety, paranoia ??? and here and there a laugh or two ??? a day in the life of a rural telepsychiatrist and her patients unfolded."Is there self-harm going on, too?" Dr. Gibson pressed D, typing notes into the computer and glancing back at the screen. D paused, then quietly said, "Yeah." Dr. Gibson, 44, was a pioneer in the field. She has been seeing patients only this way for 10 years and is still one of a handful of doctors in the country who practice telepsychiatry exclusively. Her territory is Apache County, which is about the size of Massachusetts and Connecticut combined, but which lacks even a single psychiatrist on the ground for its 69,000 residents despite widespread problems of poverty, drug use, child abuse and a suicide rate that is twice the national average. The American Psychiatric Association says on its Web site that it supports telemedicine, "to the extent that its use is in the best interest of the patient," and practitioners meet the rules about ethics and confidentiality. But in places like Apache County, where the alternative is no treatment at all, most mental health workers say that every new wire and screen is to be deeply cheered."Basically, doctors can do, surprisingly, almost everything," said Don McBeath, the director of telemedicine and rural health at the Texas Tech University Health Sciences Center in Lubbock. "The difference is they can't touch you or smell you." Dr. Gibson said the lack of smelling and touching, at least when it comes to psychiatry, has proved to be a good thing. Being physically in the presence of another human being, she said, can be overwhelming, with an avalanche of sensory data that can distract patient and doctor alike without either being aware of it."Initially we all said, 'Well, of course it would be better to be there in person,' " she said. "But some people with trauma, or who have been abused, are actually more comfortable. I'm less intimidating at a distance."Some of the doctor's patients, who agreed to allow a reporter and photographer to observe their therapy sessions over two recent days ??? one day in Flagstaff with Dr. Gibson, the second day in a field clinic in St. Johns, population 3,000 ??? said they were in fact perfectly happy with the doctor's being hundreds of miles away, though some were quick to add that no offense was intended."Some people don't want to have to deal with a real person," said one patient, a 63-year-old woman who has dementia and bipolar disorder. One thing Dr. Gibson has learned over the years is that she should not wear stripes or zigzag patterns, which can look strange on television, especially to already disturbed people. For patients with paranoia, she regularly pans the camera around her little room to prove that no one else is lurking and listening. (A white-noise machine purrs outside Dr. Gibson's office door, muting the exchanges within, and no session is ever recorded.) She worries, sometimes, about the children she sees, almost all of whom immediately and enthusiastically embrace the idea of a talking to the nice, chatty woman on the television. "Do they understand that the TV doesn't always talk to them?" Dr. Gibson said.Another patient, Mike Kueneman, who allowed his full name to be used, has seen Dr. Gibson for about five years, through the periods with the voices in his head and what he calls the "psychotic episode" that landed him in jail this year on burglary charges. Mr. Kueneman said he felt more comfortable with Dr. Gibson, even though they have never met in person, than he does with most of the people he knows.Like most of Dr. Gibson's patients, he pays little or nothing to see her. State programs for low-income and mentally ill people pay for the $120 psychiatric evaluations and $40 follow-up visits ??? and for the medicines she prescribes, which can cost thousands of dollars."It's hard for me to trust any other doctor," said Mr. Kueneman, who attended a telesession in the St. Johns clinic in leg shackles and handcuffs, accompanied by an Apache County sheriff's deputy.Some things did not happen as expected. Dr. Gibson predicted, for example, that at least one patient would incorporate the teleconferencing technology into his or her delusions and come to believe that telemedicine could be used to read people's thoughts or get inside their heads.To the contrary, in matters of the psyche ??? two people in two rooms looking at each other across a cool electronic medium ??? it is still all about human connection. "I just feel like she's here," said a 24-year-old mother of three who asked to be referred to as C. C was struggling with depression, anxiety and fantasies of suicide. "I sometimes forget we're not in the same room."Dr. Gibson spoke up from her room in Flagstaff: "That's funny, I would say that I feel the same way."Dr. Gibson and C have known each other across the telewaves since C became a single mother on her own at age 17. The emotions ran deep as they spoke and C described the dark thoughts that sometimes come at night. Gripped by insomnia, convinced that someone else is in the trailer she lives in, her mind races, she said, and the fantasy rolls out of how she might take her youngest child with her and disappear, driving off into the night."I don't want you killing yourself," Dr. Gibson said with a ma
tter-of-fact tone. "So that means talking."Apache County had a genuine, in-the-flesh psychiatrist once, Dr. Julia Martin, who practiced there for about 10 years until her retirement in 1996. Dr. Martin was trained as a pediatrician and went back to school for psychiatry in her 50's. For more than a decade, she was it, the county's solo psychiatrist and also the only one serving the nearby Fort Apache Indian Reservation."You did get to know your patients pretty well ??? sometimes better than you'd like," Dr. Martin, 74, said in a telephone interview from her home in a remote corner of the county. Sometimes people would show up in the middle of the night, she said, desperate to see her. Other times, they delivered brownies.What Dr. Gibson's patients imagine of her life and what she is like when she is not on camera is unknown. She sometimes mentions her children to them, and her passions for music and singing. She speculated that telemedicine has probably in some ways amplified and enlarged her image in the minds of some patients ??? that if she is on television she must be really important, larger than life. She has been to Apache County once, for a "meet the psychiatrist" event in St. Johns years ago. Many of the patients who showed up remarked, she said, about how much shorter she was than they had expected.