In January 2020, Americans were largely unaware of and unaffected by COVID-19. In a brief two months, all that had changed. What would the pandemic mean for the millions of people receiving mental health services?
For many therapists and their clients, the time-tested method of in-person talk therapy in a controlled office setting was no longer feasible. Thankfully, many providers were quick to respond, with little if any disruption in care. They were helped by a relaxation of longstanding government restrictions on telepsychology. But what did they need to do and know to deliver therapy in this new format . . . and would it prove as effective as in-person care?
Telepsychology (sometimes called teletherapy) has been around for decades, but until recently, it was used and studied only minimally. While teletherapy can employ a variety of digital tools, including phone and instant messaging, health insurers have generally defined it more narrowly as the use of live video to remotely treat and monitor patients. Most psychotherapists use Health Insurance Portability and Accountability Act (HIPAA)-approved video technologies such as ZOOM for Healthcare or Doxy.me to conduct their sessions.
Dr. Michelle Byrd, a psychologist licensed in the state of Michigan, points out that before the pandemic providers were very cautious about teletherapy. It was generally believed to put both patients and therapists at risk because of privacy and confidentiality issues. “With COVID, we had an unintentional randomized study,” she said. “I think everyone was surprised by how quickly and successfully we could transition to teletherapy. There weren’t the dire consequences people had predicted.”
Since the pandemic, interest in this nascent field has burgeoned, prompting policymakers, insurers and healthcare providers to look for ways to meet the growing demand without compromising on treatment effectiveness and ethical standards. The federal government has taken steps to make providing and receiving telehealth easier. For instance, the Department of Health and Human Services loosened insurance coverage restrictions for telehealth in Medicare and other federal health insurance programs, allowing beneficiaries to access some telehealth services without worrying that these services won’t be covered.
In addition, in March 2020, Congress passed the Coronavirus Aid, Relief and Economic Security (CARES) Act, which boosted support for expanded broadband services, encouraged the use of remote patient monitoring for home healthcare services in Medicare, and funded new telehealth initiatives for the Indian Health Service and the Department of Veterans Affairs. Perhaps most importantly, the CARES Act made it easier for employers and health insurers to provide pre-deductible coverage for telehealth services, making it much more likely that such services will be used.
Meanwhile, all 50 states and the District of Columbia allow Medicaid reimbursement for at least some telehealth services. Forty-three states and the District also require private insurers to cover some types of telehealth. And 27 states have joined the Psychology Interjurisdictional Compact, an interstate compact intended to facilitate the practice of telepsychology across state lines.
The Learning Curve
There are well-documented benefits to telemedicine. But in the field of mental healthcare, it poses some unique challenges, ranging from privacy and confidentiality issues to concerns about boundaries and patient safety.
Dr. Jeanmarie Amiri, a psychologist who has been in private practice in Washington, D.C., for three decades, talked about some of the technological challenges she faced in the early months of 2020 as she began to consider offering teletherapy to her patients. “At first I wasn’t happy about doing teletherapy. This was mostly related to technology. I’m not a computer-savvy person, and I didn’t like being in front of a computer for such long periods of time.” In addition to getting up to speed on Zoom and making sure she had encrypted software in place, Amiri had to reach out to the American Psychological Association for its findings on telehealth and to her malpractice insurer for its input. “I must have invested 20 hours in learning the ethics and legalities of telehealth,” Amiri said.
Therapists must comply with state licensing board regulations, not only in the state in which they practice, but also in the state where their client is located. This requires a level of legal knowledge and vigilance that can be daunting. Although prior to the pandemic some therapists had already been using digital and cloud-based technologies to document their sessions, they still needed to acclimate themselves to the new technology for virtual therapy sessions. Security was a considerable concern. Some mental health professionals who worked at universities and clinics experienced hacking incidents or worried that, in spite of their precautions, confidentiality was not being maintained.
Most patients, understanding the unusual circumstances of the pandemic, were open and responsive to the possibilities of teletherapy. All the patients interviewed for this article (their names have been changed to protect their privacy) talked about how important it was to be able to maintain or even reinitiate contact with their therapist during COVID-19 shutdowns, especially with the additional stresses and isolation brought on by the pandemic.
Federico, a 31-year-old grant processor from Northern Virginia, shared how much it meant to him to be able to reconnect with a former therapist once interstate restrictions had been lifted: “I had a long-standing relationship with a therapist from New York. During the pandemic, I was able to meet with her via telehealth because there were no longer any restrictions on interstate services. I wasn’t confined to working with someone in D.C.”
Continuity and Convenience
Dr. Jonathan Perle, director of telepsychology at West Virginia University School of Medicine, notes that teletherapy makes it easier for people to access care while also saving time and money:
Consider a single parent who can’t get off work during the day. They would need to make their appointments in the evening or early morning, perhaps driving an hour each way during rush hour, spending money on parking, gas or public transport. Teletherapy not only reduces or eliminates these costs, but it can reduce the stress and headaches as well, especially if you have to take care of another family member or if you have a disability.
Byrd noted that the logistical benefits have also increased usage of therapy. “As a consequence of telehealth, I saw a huge reduction in no-shows, and it is clear that people are using their healthcare benefits more.”
Amiri was pleasantly surprised by how open her older patients were to the new virtual format. “They enjoy the ease and convenience, as traveling to the office can be quite an endeavor for them. With telehealth they can sit in the comfort of their own homes, in their special chairs, without having to deal with traffic and parking, etc.”
Breaking Down Barriers
By making it easier for all patients to see a therapist, telehealth programs help equalize access to quality care. In particular, telehealth has allowed people in rural or remote areas to get excellent care from experts in their field. “Where you live shouldn’t impact the level of care you receive,” Byrd stresses. “In a way, it removes barriers.”
Teletherapy may also eliminate some of the embarrassment and shyness felt by people who are new to therapy. Perle pointed out that mental healthcare can still be stigmatizing:
The number of people suffering from anxiety, social isolation, depression, substance use, etc. has increased significantly during the pandemic. While there have been attempts to increase the reach of mental health resources to address these issues, I do think there is still a stigma about mental health. In a weird way one of the benefits of COVID is that it has normalized therapy a little bit. (Teletherapy) can act as a foot in the door for people who may have been wary before.
Indeed, teletherapy can have what psychology researchers call a disinhibition effect, encouraging patients to be more forthcoming and honest. In the privacy of their home, with the additional protective screen of the computer, patients are often more willing to disclose their feelings, beliefs and attitudes in a telehealth session than in an in-person session.
But How Effective Is Teletherapy?
Prior to the COVID-19 pandemic, a lot of the research on teletherapy had been done in randomized, controlled clinical studies, often focusing on unique patient populations, such as those in rural areas, those with disabilities or those with substance-abuse problems. Since the pandemic, a lot of the information on teletherapy’s efficacy is still derived largely from special problems and populations. Studies published in 2021, for instance, have shown the efficacy of telehealth for individuals in family therapy, for veterans, for parents of autistic children and for geriatric patients suffering from social isolation and COVID-19-related worry and stress.
Measuring the overall effectiveness of teletherapy is much harder than, say, testing the efficacy of a new drug. Much COVID-19-era research has focused on how teletherapy is implemented, on satisfaction outcomes, and on best practices, and it is gleaned from things like patient questionnaires and self-reporting. However, researchers are slowly but surely acquiring new data. According to a literature review published in the journal Telemedicine and e-Health in 2019, most controlled studies reported no statistical differences in efficacy between videoconferencing psychotherapy and in-person therapy. This study and others show that, as with face-to-face therapy, teletherapy can significantly decrease self-reported mood and anxiety symptoms.
Still, as Byrd points out, teletherapy is in its infancy and more research is needed. “We have an opportunity to slow down a bit now and make evidence-based decisions about the future of telehealth. I see incredible new demands for teletherapy. But we need a stronger empirical basis for these practices.”
Perle agrees that much more research is needed, but he thinks there is enough information out there now to see trends:
We know enough to say, “Can it be done safely? Yes. Can it be done ethically? Yes. Can it be done legally? Yes. Can it be efficacious? Yes, but it requires a little more leg work and flexibility.” You can’t just take what works in a face-to-face session and throw it into a video or telephone session and hope that will work.
All the patients interviewed for this article said they preferred in-person therapy to teletherapy, but they also noted that they were still able to do the work of therapy once they got over their initial skepticism and adjusted to the delivery method. Fran, a 34-year-old from Washington state, took a while to get acclimated to the new online format. “I wasn’t thrilled at first, but I got used to it,” she said, adding: “My therapist is still able to hold me accountable. We’re still able to get good therapy done. ”
Lost in Translation
The relationship between client and therapist, sometimes called the therapeutic alliance, is a complex, intimate partnership. It means that patients within a safe, trusting environment engage with their therapist in a collaborative approach to healing. What happens to the therapeutic alliance when patient and therapist can’t be in the same room together?
“Initially, I was skeptical that I could have the same impact as face-to-face,” shared Dr. Richard Shadick, a psychologist in private practice in New York City. “However, I do think it can be an effective way of working with people, and that I am comparably effective in my remote sessions. Given the crisis we’re in right now, this is a suitable alternative.”
Suitable, but perhaps not always preferable. Kate, a 61-year-old from San Diego and one of the first people in the country to be diagnosed with COVID-19, has experienced teletherapy both as a patient and as a provider (she is a tobacco cessation counselor). “I had reservations,” she explained. “In-person is better, as so much can be missed when all you see is a floating head. I’m not sure this is a long-term solution.”
Therapists also spoke of not having the same control measures with teletherapy as they have during in-person sessions. Shadick noted, “The two-dimensional experience is subpar. Often the nonverbal cues are lost.” For example, therapists can’t observe the hygiene and the physical health of their patients. They can’t observe a patient’s gait or smell their breath. Has the patient lost weight? Is the patient overly tired? Is the patient fidgeting or anxious? Most of these signs are not observable, or are far less observable, online.
Byrd voiced what many therapists are feeling: “I value the authenticity required to be with someone who is suffering and their willingness to be vulnerable with me. It is much harder to get to that level of intimacy over Zoom. But I do find that it can happen over time.”
To work around some of these challenges, therapists have had to modify their style. For example, therapists have needed to reconsider their office setup, adjusting their cameras so that they are able to observe both broad behaviors as well as tears. Therapists have also had to be more overt in their assessments and in what they observe. They have had to pay more attention to tone, to how a patient is breathing and to how quickly or slowly the patient speaks. Byrd talked about how video sessions changed the way she communicated: “I became much more expressive with my hands, my eyes and face because people had a harder time seeing those things online.”
In addition to the typical problems associated with digital technologies, such as video and audio lags, failing Wi-Fi connections and old, unreliable computers, the teletherapy format presents other, less obvious challenges to both providers and patients. For instance, therapists can actually peer into the patient’s home, something never available to them before. There is an informality to this that can be uncomfortable for both patients and therapists, sometimes requiring both to set new boundaries.
One of Perle’s colleagues had a patient who called in a for a session while riding his bicycle, which the therapist didn’t realize until he saw cars whizzing by. In another case a couple called in for couple’s therapy while in bed together. Patients have asked to do sessions from the playground, their car or the nearest coffee shop. Perle said, “While I understand the importance of being flexible, especially if there is no other space where the patient can find privacy, there is a limit to how far you should bend.”
Patients, in turn, spoke of therapists who seemed to have a more cavalier attitude about scheduling and appointments after they switched to teletherapy. Ginger, a 48-year-old from the Boston area, had been seeing her therapist for five years. She became frustrated with the online arrangement because her therapist would forget appointments or want to reschedule right before a session was due to begin. She felt conflicted about ending the relationship because of their strong bond.
Some providers will ask to meet with their patients at odd hours, while they are on vacation or when they are they are sick. As Perle points out, this is a medical visit. “You’re not talking to a friend. How you present to your patients really influences whether they will take teletherapy seriously or not.”
For some therapists, this means expecting a basic standard of decorum during telepsychology sessions. Amiri said, “I ask that my patients dress appropriately for their appointments. You’re not going to have the same attitude and thought processes when you’re in your slippers and pajamas.”
Privacy and Safety
During the COVID-19 pandemic, some patients had trouble finding a solitary, private space in their home for a session. Stay-at-home orders meant living and working in close proximity. And while teletherapy can offer greater access to quality care, some disenfranchised populations were suffering. Kate, from San Diego, spoke of the difficulties in providing teletherapy to some of the people she worked with as a counselor. “We have a 24-hour help line that offers patients assistance, but for people who are homeless, who experience domestic violence or who live in less-than-ideal surroundings, it was very difficult for them to find private spaces in which to have a session.”
For therapists with high-risk patients—those with suicidal or homicidal ideation—teletherapy means greater vigilance about safety planning. Providers must ensure not only that patients are calling in or logging on from a quiet, safe space, but that they can take appropriate action if those patients are thinking of harming themselves.
Amiri has a code for where each of her patients is located. She knows the nearest hospital to the patient and the hospital phone number. Before each session, she asks where the patient is calling from. Although such procedures are vital for patient safety, they mean that therapists must invest much more time and attention in risk management.
Not a One-Size-Fits-All Solution
Research regarding the efficacy of teletherapy should also take into account the type of patient. For example, there is very little research available on whether remote care is adequate or appropriate for the treatment of more serious mental illnesses such as schizophrenia or psychotic disorders.
Amiri, who works with patients suffering from PTSD and dissociative disorders, spoke of some of the issues associated with clients who might be triggered during a remote session:
Trauma work is very complicated, heavy-duty work that requires you to be in the same room with the patient for safety reasons. Subsequently, I made the decision to not offer EMDR (eye movement desensitization and reprocessing) or hypnotherapy over Zoom. I was concerned about safety, if something should happen and I wasn’t there.
Amiri also felt she had to be more cautious with her patients during a Zoom session. She didn’t feel she could confront them the way she would have in an in-person session.
For Byrd, it was her younger patients who proved the most challenging:
I found it hardest to do treatment with children, especially those who were also using their computer extensively for school because they were now at home all day. It was just too much time in front of the computer for them. This was especially true with my ADHD patients. I had one session where a child asked to take a bathroom break. I said, “of course,” and then the child never came back! I could hear the child in other rooms of the house watching TV, getting a snack, etc. In the office I have better means to keep younger patients engaged. I can play games with them or play catch or color together. It is much harder to engage with them online.
However, as Perle pointed out, some of these issues can also come up in an in-person session. “If a patient leaves your office upset, do you know where they go or what they do afterwards? Probably not. You may need to have more of a cool-down period in a teletherapy session, but the same concerns are there in an in-person session.”
Demystifying the Experience
The success of therapy, whether in person or virtually, has much to do with the confident, trusting relationship between therapist and client. Amiri noted that nearly all her patients were open to teletherapy because she had worked with them for years and there was long-established trust.
This does raise questions, however, as to how well teletherapy can work for short-term relationships or for those pursuing therapy for the first time. Since COVID-19, more and more therapists have never laid eyes on their new patients except through a computer screen or behind a mask.
However, Perle, who recently published “A Mental Health Provider’s Guide to Telehealth,” thinks many of these concerns can be allayed by anticipating patient anxieties and allowing time to answer their questions. He pointed out that research shows more discomfort and anxiety both on the part of the practitioner and on the part of the patient before they start teletherapy for the first time. After they begin, they tend to report high levels of satisfaction. However, he concedes that teletherapy certainly isn’t for everybody. A key to making it work is to demystify the experience.
When a therapist meets with a patient for the first time, the therapist typically goes over the patient’s history, discusses confidentiality issues and gives recommendations. Now therapists need to address crisis management as part of the informed-consent process. Anticipating and having a plan for the unexpected can go a long way toward making the transition to teletherapy seamless. Perle said, “Patients don’t like it if something comes up and they don’t know how to deal with it. Clarify for them up front what teletherapy is and what it is not, and then let them ask questions. ‘What do I do if Zoom goes down?’ Well, here’s the plan.”
The Future of Teletherapy
The psychosocial consequences of the pandemic (job loss, fear of illness, isolation, etc.) continue to manifest themselves across the population, increasing the demand for mental health services at a pace that has been challenging for psychotherapists to keep up with. Indeed, even before the pandemic, there was a shortage of psychiatrists that was more severe than provider shortages in any other health specialty.
This might suggest that the future looks positive for teletherapy, but for it to work on a large scale, certain things will need to change—in training, in technology and in legislation.
According to Perle, more research on efficacy will need to be done and a greater emphasis will need to be placed on training. “Right now, there is no universal, formal, explicit training in competency,” he said. “We need to catch up to where the world went! Graduate training programs and licensing programs will be pushing more for telehealth competencies. I think that’s the next wave. Starting this in graduate school will be especially powerful.”
Meanwhile, more work needs to be done on the political and legislative front. For instance, at the beginning of 2022, the telehealth provisions of the CARES Act will expire. In spite of intensive lobbying, efforts to extend these provisions have so far failed. A number of bipartisan bills aimed at expanding the use of telehealth have been introduced in Congress. These include the Ensuring Telehealth Expansion Act of 2021, which would make permanent many CARES Act provisions, including rules exempting telehealth visits from meeting deductible requirements in high-deductible health plans. But, so far, none of these measures has advanced in Congress.
Telehealth is just one of the many paradigm shifts brought about by COVID-19. With more and more people working at home, we have had to adjust our ideas about how and where we will earn our living. For teletherapy to move from a crisis response to the norm, we will need to change our expectations about how mental healthcare is done and address the complex and myriad factors that might be holding it back.