"Webcam" is an abbreviation of the words "World-Wide Web" and "video camera." Computer software allows the user to record, store, and review therapy sessions. The WebCam is a digital camera that can download images onto a computer. The camera measurements vary by manufacturer. The camera may be approximately 2.5 in. in height and 1.25 in. in diameter. The WebCam may be fixed to the top of the computer or rest on a hard surface along with a microphone (see Figure 1).
FIGURE 1.Simple WebCam Devices
The most basic model connects to a personal computer (PC), using a "USB" connection. A number of cameras with accompanying software are available for this type of application. The price of the camera and software also varies. Video Edit Magic (Deskshare,TM Plainview, NY) is an example of the software that processes the data and is used in our department. All products have information and technical support available online.
The standard picture-resolution for web images is low. Higher-resolution images may not improve quality, but will increase the time needed to upload and download images. To maximize viewing, positioning of the WebCam and microphone must be done at the beginning of each session. Adjustments are required as the subject (child) changes location during the session.
Written consent of the parents and assent of the child are required. The therapy sessions are recorded and saved on a designated, password-protected, secure drive within the department of psychiatry.
The branch of psychology that advances the role of innovative technology is called cyberpsychology (1). The areas of interest and research include virtual reality, video games, computer technology, and robotics in therapy. For example, in the treatment of anxiety disorders, cyberpsychology includes cognitive-behavioral therapy, in combination with computer-generated virtual reality.
The therapy room can become a neutral, non-threatening place where the shy, self-conscious child can be self-observant by use of the WebCam. The child can receive support from trustworthy individuals so that he or she develops the capacity for self-reflection and identifies and works-through avoidance and cognitive distortions (2). Also, therapy sessions can be replayed at home (3). The WebCam can be used therapeutically in the treatment of addiction to computers, video games, and communication technologies (4—6).
The WebCam can be used in resident-supervision sessions to evaluate techniques and therapeutic interventions (7—12). For example, psychodynamic psychotherapy or cognitive-behavioral therapy sessions are recorded, and selected clips are reviewed with the supervisor to discuss residents' concerns regarding transference or countertransference issues, techniques, and response to therapy. Brief video clips of children with atypical clinical presentations or adverse reactions to medications can be presented to the supervisor for diagnostic clarification and discussion. Also, the authors use the WebCam as a therapeutic tool. The following cases are examples of the use of the WebCam for interviewing, therapy, promoting social skills, evaluating medication effectiveness, and facilitating family communication.
Case 1: "Smile—you're on TV!"
The therapist may find the WebCam helpful in preschool-to-early school-age children who are "slow to warm up," or shy. Using fantasy and imagination, the child is allowed to assume another role. After the child has become comfortable with the computer screen and the microphone, we encourage the children to watch themselves and allow them to try out different roles. The WebCam may function as part of play and engagement in the preschooler and give the child a sense of control and mastery.
The therapist later introduces himself or herself as a friendly interviewer or reporter and asks identifying questions to engage the child. The questions progress from closed- to open-ended. More direct questioning is integrated into the interview, depending on the response of the child.
Caroline is a 7-year-old girl who presented with physical and verbal aggression toward her mother and separation and social anxiety since the age of 3 years. She was clingy during separations from her single-parent mother. She was angry and avoidant when her mother came and picked her up from school or other places. Her outbursts included kicking, slapping, and biting her mother. She carried a stuffed animal as a transition object everywhere.
When, after two joint sessions, her mother attempted, unsuccessfully, to leave the room, Caroline screamed and held onto her mother's clothes. During the next session, the therapist proposed that Caroline make a movie. She held her stuffed animal tightly and watched herself appear on the screen. She started making faces and noises, and giggling. She then interviewed the stuffed animal. Her mother said that she was going to leave and would be outside the door. Caroline and her stuffed animal engaged in a conversation about visiting "their" grandmother.
The next session, she asked to be a famous person on TV and be interviewed again. She responded to identifying questions and then open-ended questions. The therapist was able to obtain information regarding her fears and feelings. She talked about things that were upsetting her at home and at school.
Case 2: "I Want to Tell You Something."
Children who are having a difficult time sharing their thoughts with others may find that the video facilitates their self-expression.
The WebCam is nonjudgmental and provides a safe distance for the child. They have the freedom to explain situations and express feelings that they want to share with their parents. The content of the sessions may take time to process within the individual or family. Reviewing the sessions and having further discussions may occur at a later date and can be extended to the home.
Paul is a 9-year-old boy who presented with somatic symptoms and school phobia. He was undergoing medical testing for his stomach aches and headaches. His mother was overly concerned, whereas his father was angry and believed his son was faking his symptoms. Paul was unable to talk to his parents during the sessions. He was especially distressed that he could not talk with his father. He was afraid that he would be misunderstood and be a disappointment to his father. During an individual session, Paul revealed the amount of bullying he was undergoing at school, and that he was afraid to tell his father about the situation. He knew his father would tell him to fight back. Paul was afraid of intensifying the situation. He did not want his parents to talk with the teachers or other parents. His anxiety was escalating so that he was starting to get sick before bedtime and had to stay at home at least 2 days every week. Paul considered revealing the bullying issue to his parents via a video session. The direct expression of feelings may be threatening to a child. It may be more comfortable to communicate via a written letter or video session than during a face-to-face interaction. He agreed to try and make a recording that the family could view together. He practiced telling the story several times until we had a copy that he felt was to his liking. He talked freely about the bully and what was happening. We agreed that I would view the tape with him and his parents at the next session. Paul was surprised that his father was hurt because his son was afraid to tell him personally. Paul and the family "gained permission" to talk to each other. They learned to communicate more directly and discuss methods to collectively manage the school bully.
Case 3: "Nasty Faces Are Scary."
Children with temper tantrums may get very violent and appear frightening to other children. Unfortunately, they have no way of seeing how frightening their behaviors can become. One child was shocked to see how angry he looked during a tantrum and decided he did not want to look like that again.
B.J. is an 11-year-old with fetal alcohol syndrome, unilateral deafness, and mental retardation. He has difficulty with impulsivity, social skills, and controlling his anger. He has severe, unpredictable temper tantrums at home and school, which include stomping, self-injurious behaviors, and striking at others. He wants to have more friends, but he is having difficulties with prosocial behaviors. He will grab toys from other children and hit them when he does not get his way. Cognitive-behavioral therapy has been ineffective. His response to positive reinforcement is not predictable. The school reports that some children are afraid of him. The previous therapist would allow B.J. to use his computer during sessions. When told that this was not allowed, he had severe tantrums, requiring his father to hold him for 5—10 minutes. After the tantrums, he was remorseful. The therapy team discussed relocating to a computer-free room. The team educated B.J. about how friendly he is when he is not upset. He had won an award in school for being friendly. B.J. was asked if he would like to try making different types of faces. The team showed him faces associated with different feelings; then we asked him to make some of the faces in the camera, so we could show his family. B.J. agreed that people might be afraid of some of the nasty faces. One explosive outburst was videotaped, and B.J. watched the event with his father. He discussed his feelings, the need for safety, and why an outburst might be scary to other children. During repetitive play, he experimented with different faces, and his nasty expressions softened. His outbursts lessened in intensity and frequency as he discovered the prosocial effects of his smile.
Case 4: "Would You Like to Dance?"
Role-playing and sibling play may help with social-skills training. Children with poor social skills, including those with pervasive developmental disorder (PDD) or aggression, often have a difficult time relating to peers and understanding the reasons for alienation. Role-playing allows the child an opportunity to respond, problem-solve, and discuss reactions and body language. The WebCam allows the child an opportunity to observe himself or herself in a new role as they interact with the therapist. Self-observation may improve self-reflection, mentalization, and the use of social skills. Sibling and family interactions can be reviewed to improve self-awareness. Confidentiality limits the use of the WebCam outside of the office and home; however, reviewing social skills in group interactions could be beneficial.
Jim was a 15-year-old with PDD and mild mental retardation who had a long-standing history of verbal and physical abuse toward his parents, siblings, and peers. Atypical neuroleptics, alpha-agonists, and mood-stabilizers were mildly effective for behavioral and emotional dysregulation. His parents considered residential placement because of his unsafe behaviors in the car and in social settings. Jim developed a therapeutic alliance and responded to role-playing for development of his social skills. He developed a few peer relationships at school and announced that he wanted to attend a school dance. The therapy team discussed the need to prepare for this social function. The WebCam was used to record and review role-play situations so that Jim could learn to tolerate feedback, acquire appropriate methods of communicating, and develop confidence for his first social function. Digital recordings of future family and school functions could be brought to therapy for review and discussion.
Case 5: "This Medication Does Not Work Anymore."
A comparison of a child's behaviors before starting any medication and after successful dosing is useful to help the parents understand the benefits of therapy and/ or medications. Parents tend to forget the severity of symptoms in their children and need to be reminded so as to continue therapy and be compliant with medications. An extremely inattentive and hyperactive child who is able to focus and be attentive during a session after a short course of medication is especially reinforcing to the parent. This is especially true with attention-deficit hyperactivity disorder (ADHD) medications.
Mr. and Mrs. Peters had a 6-year-old son who was referred by a therapist for hyperactivity and distractibility. The parents were also going through a divorce. The teachers and parent reports were significant for the DSM-IV—TR criteria for ADHD. He was started on a stimulant, and the dose titrated over the next month. The family situation was deteriorating, and his anger was increasing; however, he was able to sit, play games, and do his schoolwork. Because of his social situation, the externalizing behavior became worse. The family returned, saying that the stimulant was ineffective. A video recording was available for comparison of present and past behaviors. There was an obvious change in his inattention, lack of focus, and hyperactivity. The video also reminded the parents that the child was able to manage his assignments and function better, despite the sudden increase in family conflict and transition. The parents could also compare the changes in family dynamics and communication.
Case 6: "I Think That We Are Going Nowhere."
During family therapy, change may not be obvious to the family members. The family may have lost a perspective on their initial presentation and the changes that have occurred. The parent—child interactions, including play sessions, can be saved and reviewed. Recordings of sessions with family that have reached a therapeutic impasse could be presented to a reflecting team who could provide immediate feedback (13).
The family presented with an 11-year-old son who was oppositional both at home and school. His mother was anxious and overly protective. She would complete his homework if he did not finish it on time. He resented his father for working many hours and being away from home. His father was inconsistent with his parenting skills and would overlook negative behaviors so that they could attend sporting events. "Keith" was initially noncommunicative and refused to talk during therapy. After 1 month, he was talking about his frustration and disappointment with his parents, and his behaviors and grades improved. Also, his 8-year-old idealized brother developed oppositional behaviors. After 6 months of family therapy, the parents came in and commented that they did not see much progress in their family. Together, the family watched a WebCam session recorded during one of the initial family sessions when Keith was resistant to treatment and the brother was complaining about his older brother. The parents said that they looked and felt extremely stressed at that time. Watching the earlier WebCam session was very helpful because it gave them a sense of how much the family had changed in its function and communication.
The WebCam has been used during supervision to discuss and evaluate patient management and therapy techniques (7—12). The incorporation of the WebCam into patient care and therapy has been useful in the child psychiatry clinic. In Cases 1 and 2, the WebCam was helpful in facilitating patient communication. Cases 3 and 4 demonstrate the use of the WebCam as a mirror by which the child can see himself and reflect upon his social skills. Lastly, progress in treatment may be evident to the participants after case review. Cases 5 and 6 demonstrate the advantages of reviewing tapes with the patient or family. We recommend the WebCam for psycho-education, communication, and treatment with children and families. The applications of this technology may include cognitive-behavior therapy, dialectical-behavioral, and group therapy.