Traditional image of doctor-patient relationship implies physical presence i.e., direct face-to-face contact (or rather called "in-person" contact). However, the use of telecommunication technology brings us to a different type of "presence". The issue of "presence" is particularly important in psychotherapy, where the technology mediated interaction between patient and therapist introduces new parameters more relevant to consideration about the setting [1] [2] [3]

Clinicians' concerns regarding "presence" and virtual environment should not be underestimated as these are common arguments against the use of video conference in clinical settings. A virtual environment created in audio-video sessions might indeed increase the risk that some information cues present in the physical environment are not available in the virtual environment [4].

Commonly, professionals prioritize direct contact with the patient referring to a number of potential obstacles that might occur during video conference ("what about body language?", "I miss a smell", "what about the internet connection problems?", etc ). Mental health professionals' attitudes towards e-mental health (eMH), factors that affect the frequency with which they use the technology, and their perceptions of individual characteristics that make patients more or less suitable candidates for eMH has been explored and discussed. Findings suggest that mental health workers have overall positive attitudes towards the use of eMH; particularly for clients in remote and rural locations [5].

It sounds logical that increased acceptance of eMH is associated with more frequent use. In contrary, clinicains' reluctance is commonly explained by the fact that "some patients are unsuitable candidates for telemental health". There is no doubt that some patients will prefer remote consultations due to controlling the presence of the psychotherapist, so as to feel less influenced by him/her i.e., having the opportunity to "switch off" the therapist. In contrary, regarding counter transference issues, it has been noticed that some psychiatrist are reluctant to carry on technology mediated psychotherapy, which might deter the patients from asking or exploring for this possibility [6] .

Narratives from clinical practice may contribute to further understanding of the implications of technology on doctor-patient relationship. Clinical cases may significantly increase the understanding and acceptance of telepsychiatry among professionals with no eMH experience or professionals that are still in doubt.

That is why the following story is particularly interesting:

A 28-year-old female, refugee from my Bosnia-Herzegovina, ex-Yugoslavia (home country of DM). In Bosnia, during the war, She was unfortunately raped several times while her husband was in the army. After immigrating to Denmark, the patient was refered to a psychiatrist due to occurred post traumatic stress disorder symptomatology. As her Danish language abilities were poor, the communication was provided via an interpreter. Consequently, she received psychiatric treatment with medication and psychotherapy via interpreter for around three years prior to our first telepsychiatry session. The video equipment was installed at psychiatric department where the patient used to come and speak with her psychiatrist in-person. I was in Copenhagen while she was located 245 km away in outskirts of Denmark. At the first consultation via telepsychiatry, the first question she asked was, "Can all of Denmark see us now?" When assured that no one follows our conversation and the session will not be recorded, she replied, "Then I have a secret I would like to disclose" and so she started her story about traumatic events in home country. The patient cried while speaking in a stream without a break except to wipe her tears and blow her nose. She said that it was not possible for her to speak about it with her past psychiatrist as all communication runs via the interpreter. The presence of the interpreter for her changed the dynamic of the interview and more tangibly, it increased the risk that her husband would find out about the rape and consequently divorce her. While speaking about her painful experiences the Internet suddenly disconnected. When that happens, the last frame remains on the screen as a frozen picture. So she could see me as a still image and I could see her frozen in the middle of a movement and of course we could not hear each other. I panicked, thinking what she would say to this, or fearing that she probably would never come again (i.e., use the video). My technician was in the office next door, so he restored the connection. The break varied about 30 seconds in total, but it felt like much longer. To my surprise, when the connection was restored, I could see and hear her who spoke in a stream and cried at the same time. She did not even notice that I was gone for a while.

Lesson learned: Prior to every use of the eMH, it is crucial to inform the patients about the technological setting, safety and confidentiality related issues. These informations provides by the referring doctor, both verbally as well as in written form, so that the patient have opportunity to read it carefully and understand what it is about. Further, written consent requires prior to the first remote session. The consent clearly underlines that the involvement in remote consultation is voluntarily and that the patient may discontinue the contact whenever he/she wants.

Updated guidelines for behavioral emergency management have been published recently and clinicians practicizing eMH have to be familiar with it [7] .

For me, personally, the story mentioned above was an experience that marked over the last 15 years of dedicated work on developing of the "cross-cultural telepsychiatry" concept where the treatment of ethnic minorities provides with no use of interpreters [8].

Telepsychiatry assessments of hospitalized suicidal patients are particularly interesting and even to recommend especially when it comes to patients that had a telepsychiatric contact prior to unvoluntarilly admission, as the next clinical case describes:

A, 38-year-old male, refugee from Bosnia-Herzegovina, diagnosed with PTSD and treated via telepsychiatry for 1 year prior to involuntary hospitalization caused by increased suicide risk and suicidal threats that he presented for his general practitioner who decided to send him to psychiatric emergency department located on the island where the patient lives. There he was assessed by a Danish psychiatrist via Bosnian interpreter and involuntarily hospitalized. A day after, he was seen by the psychiatrist who treated him via telepsychiatry approximately once in a month. It was very convenient for psychiatric department located on isolated island to call the psychiatrist that speak the same language as the patient and who knew the patient best in order to assess the patient's mental state, including the current risk of suicide. Despite the fact that the consultation had been done remotely where the patient could disclose much more via TV on native language than via interpreter under face to face consultation the day before.

After telepsychiatry consultation the patient remained on the ward for the observation but was discharged the following day.

Lessons learned: Continuity achieved and remained by seeing the same doctor no matter where the patient is located is probably one of eMHs most important advantages compared to traditional mental health care provision. Further conclusion is that emergency situations in psychiatry are not an obstacle for the use of eMH [9] [10] .