Telepsychiatry, Misconceptions, and the Mental Health Power of Gaming

On-site at last year's Psych Congress Elevate in Las Vegas, faculty member Lucia Cheng, MD, shared insights from her session "Mastering the Virtual Frontier in Telepsychiatry.” In this interview, Dr Cheng discusses practical tips for improving patient engagement in telepsychiatry and clears up common misconceptions about virtual care. Drawing on her personal experience as an avid gamer, Dr Cheng also explores how the virtual world of video gaming—often misunderstood in mental health settings—can serve as a critical source of social connection and support, particularly for neurodivergent patients.

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Psych Congress Network (PCN): What are some common challenges that clinicians can anticipate in a telepsychiatry practice? Could you share a couple of strategies to help navigate these challenges?

Lucia Cheng, MD: A very common challenge with practicing psychiatry via telehealth is patient comfort and quality of care. Obviously, you don't have the patient in full view, so it’s harder to maintain eye contact and pick up on physical cues. A lot of the time, we’re only seeing the patient from the chest up. So it's very important for the clinician to set the tone during telepsychiatry visits. The more comfortable the clinician is, the more comfortable the patient will be. The clinician really is important in setting that tone for the patient.

There are some strategies clinicians can use, such as making sure to face the camera properly and maintain a good eye line. That’s actually a place where a lot of clinicians get hung up because of the way computer systems are set up—the camera is often offset from where the patient's image is on the screen. So even though the clinician feels like they’re looking at the patient and paying attention to the patient’s cues, they’re not looking into the camera, and the camera is picking up the side of the clinician’s face. The patient ends up feeling like, “The clinician isn’t paying attention to me—they never look at me.”

So, the clinician really needs to pay attention to maintaining a good eye line with the camera. A big help with this is using the self-view window that most video platforms provide—it can usually be moved around on the screen. Many clinicians are uncomfortable looking at themselves, so they just get rid of it. But that’s actually a very bad idea, because then you have no idea what the patient sees. Keeping that image gives you cues: How do I look to the patient? Is the lighting too bright or too dark? Am I blending into the background so it looks like I’m a floating head? Am I making proper eye contact with the patient? Just being able to take those steps so that the patient feels like you're actually looking at them can carry a long way in establishing that patient rapport.

PCN: Which misconceptions about telepsychiatry would you like to clarify for our audience?

Dr Cheng: Telepsychiatry is still fairly new to the mainstream, though it’s actually been around for decades now. It’s just really been used in rare cases, like research institutions, for example. Before the COVID-19 pandemic, many people saw telepsychiatry as a separate way of practicing psychiatry. A lot of clinicians would say, “I practice psychiatry” or “I practice telepsychiatry,” but it is not really different.

Telepsychiatry is still practicing psychiatry—we’re just doing it through a different modality. The standards of care remain the same. Your expectations for clinical judgment are still the same. The only difference is that the clinician and patient aren’t in the same room. But I think for a lot of patients too, they still feel like it's a different way of practicing psychiatry, and it's really not.

PCN: Video gaming can be a controversial topic within health care spaces. Could you share how you think about gaming in relation to psychiatric health in both pediatric and adult patients?

Dr Cheng: I need to start with a disclaimer—I’m an avid video gamer. I’m very pro–video games, and part of my practice involves working with adult gamers, which is an underserved population in mental health.

Yes, there are negative views about gaming—concerns about violence, dopamine addiction, screen overuse, and the physical and mental health impact. These are valid, but it’s important to look at the type of screen use, the content of the games, and most importantly, why the patient is playing.

Often, video games provide an escape from real life because there’s something the patient is struggling with—social interaction, work, or academic performance. In games, they can receive positive feedback. They collaborate with friends, form deep, authentic relationships, and gain recognition for their skills. They often have a defined role in their gaming team, which gives them a sense of accomplishment.

There’s also a large neurodiverse population in the gaming community, including people on the autism spectrum. In real life, they may struggle with social cues and face criticism or bullying. But in the gaming world, they don’t have to read facial expressions or body language. Communication happens through voice or text chat, which is easier to interpret. They feel more accepted in that space.

Many gamers experience depression, anxiety, ADHD, and other neurodiverse conditions. They often find peer support in gaming communities that they don’t have access to in real life. But they also face challenges getting mental health care. They may be uncomfortable asking for help, and many providers don’t understand that gaming can be supportive and social.

When providers react by telling patients to stop gaming or cut off internet access, they’re cutting off an important social lifeline. That breaks trust. A better approach is to recognize that video games aren’t going away. They’re mainstream now. Most of the U.S. population plays games. They’re used in education, politics, and professional training. The industry is bigger than film and television.

It's not realistic to keep somebody who's growing up in a modern world from having access to video games. The key is to teach them how to deal with real life so that they don't feel like they have to escape.

Lucia Cheng, MD, is a board-certified psychiatrist specializing in Reproductive Psychiatry. Dr Cheng is also board-certified in Lifestyle Medicine. She attended medical school at Medical College of Wisconsin and completed psychiatry residency at Loma Linda University (LLU) Medical Center. She is an adjunct assistant professor at LLUH Psychiatry Residency and enjoys teaching the psychiatry residents there.
 
Dr Cheng currently owns her multistate telepsychiatry private practice Phoenix Progressive Psychiatric Services. She volunteers as an expert perinatal psychiatry consultant for the Postpartum Support International (PSI) Prescriber Consult Line and currently serves on the International Society of Reproductive Psychiatry (ISRP) board of directors. Dr Cheng is also an avid video gamer and specializes in providing mental health care to other video gamers.

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