How the pandemic forced mental health care to include online therapists

When the Covid-19 pandemic forced Pari Baker, a clinical social worker and therapist in rural Bath County, Virginia, to switch to seeing clients over video in April, she wasn’t sure how it would go. She’d never worked with clients that way before; the small hospital in the Allegheny Mountains where she works didn’t offer it.

But after she started seeing her clients online, bad weather and transportation snafus were suddenly no longer issues. No-show rates for appointments plummeted. She also got new clients living in the surrounding communities, which have historically been underserved by mental health care.

“So many barriers to treatment … we just blew through them because of telehealth,” Baker says. “The majority of the new clients had never had mental health services at all before.”

She noticed her long-standing clients would relax a bit more in their own spaces. “It was really eye-opening to see how much people benefited from being in a space that was really comfortable for them,” Baker says. They weren’t worried about exiting her office and awkwardly seeing someone they knew in the waiting room. Telehealth, in a way, felt more confidential.

Now, she says, “I can’t imagine going back. I think that would be really devastating, and really doing a disservice to our people.”

For years, the tools to conduct mental health care remotely have existed. But there were extreme disincentives for providers and clients alike to use them. Medicare didn’t pay for teletherapy services under most circumstances, and with private insurance and Medicaid, it was a crapshoot. Some plans paid for it, others paid at rates less than in-person sessions, meaning a therapist would either have to charge their clients more or take a pay cut.

With the pandemic, the insurers and government programs largely relented: Many therapists are now being paid in full for teletherapy.

Other obstacles have fallen away too. Therapists have to be licensed in every state they see clients in, but now many therapists can offer teletherapy, temporarily, for people across state lines.

“I definitely think it’s expanded the number of people who are able to be seen,” says Katie Gordon, a North Dakota-based psychologist. She can see clients who are based in nearby Minnesota, even though she isn’t licensed to practice there. “It would be a shame if we returned back to the way things were,” she says.

The pandemic has given mental health care a much-needed kick forward into the 21st century. It’s also a chance to reflect not just on how the world is changing in response to the current crisis but also how it ought to change.

It’s clear in talking to clinicians and mental health care access experts that the pandemic-induced changes should become permanent. Teletherapy should become a regular option for care, offered alongside in-person sessions, and covered by insurance.

But they also say these changes are just the beginning. To truly meet the needs of the present, we’re going to need more technological innovation, new science, new mental health care platforms, more equitable access to technology, and a delicate mix of software and a human touch.

“The status quo wasn’t ethical,” Jessica Schleider, a psychologist who runs the Lab for Scalable Mental Health at Stony Brook University, says. It kept too many people out of the mental health services they needed. “We can’t go back to it.”

Here’s how to go forward.

New therapy options were desperately needed before the pandemic

Two facts overshadow all discussions of mental health care in the US.

One is the high and growing demand for it. In 2019, according to data from the Substance Abuse and Mental Health Services Administration, 16.5 million adults said they felt like they needed mental health treatment or counseling but didn’t get it. Forty percent of these Americans said the reason they didn’t get care was that they couldn’t afford it.

With the stress of the pandemic, the mental health needs of the country have likely only grown. Nationally, around 31 percent of Americans reported recent symptoms of anxiety and depression in an August survey by the Centers for Disease Control and Prevention. For comparison, in the first three months of 2019, just 11 percent of Americans reported these symptoms on a similar survey.

The second fact is that there’s a dire mental health care provider shortage that’s forecast to grow in the coming decades, as demand for mental health services continues to outstrip supply. The National Center for Health Workforce Analysis estimates that, by 2025, there will be shortages of psychiatrists, clinical counseling and school psychologists, marriage and family therapists, school counselors, and mental health and substance abuse social workers that number in the tens of thousands.

That’s the future, but the present situation is dire too. “One in three counties don’t have a single licensed clinical psychologist,” says Stephen Schueller, who studies how mental health care can be provided over the internet at the University of California Irvine. What’s more, the low supply is unevenly distributed. A 2018 survey found that in urban counties, there are 33.2 psychologists for every 100,000 people. In rural counties, there are only 9.1 psychologists per 100,000.

So there’s a great and growing need for mental health care that’s being unmet. Yet the professionals trained to care for those needs are thin in number, and will struggle to keep up with demand.

Increased teletherapy can address these problems — but only to a small extent. It can help clinicians find new clients in underserved areas and expand their practices to cover people who previously couldn’t travel for an appointment. “If we are able to make teletherapy more broadly available for the long term, we’re going to start serving people who are desperately in need of good mental health services who are currently unable to see providers,” Jill Holm-Denoma, a professor of clinical psychology at the University of Denver, says. “I think that’s huge.”

Even with the expansion of teletherapy, it’s important to note that many have lost access to care during the pandemic. Some college students, who received mental health care on campus, lost access when campuses shut down. Schleider has also conducted a survey (not yet published) of those who use mental health services in the Stony Brook University community, finding “more than 60 percent lost some or all access to those services,” she says. “And the numbers for minoritized individuals were especially bad.” (This happened despite the university’s counseling center going virtual in March.)

The good news here is that where teletherapy can be expanded, it will likely help people. Studies have found that switching to teletherapy doesn’t come at the cost of efficacy — which is infuriating when you consider how private insurance and the government have failed to pay for teletherapy. The hesitance was likely due to status quo bias. “Therapist training instilled in us that ‘in-person is better’ and that you need to have that face-to-face interaction for therapeutic change to occur,” Schleider says. “The data doesn’t support that.”

So teletherapy is seemingly effective, therapists like it, and it’s often more convenient for the clients. “Just this morning, I heard from a client who said, ‘I’ll stay in therapy a lot longer now that I don’t have to commute an hour on either side of it,’” Holm-Denoma says.

Teletherapy can’t replace all in-person sessions

While teletherapy has meant first-time or easier access for many people, there are instances where an in-office visit is still needed.

“In my clinic, we’ve had a couple of people who don’t feel like they’re in a safe home environment,” Holm-Denoma says. “They’re wanting to talk maybe about domestic violence. If they come to my office, it’s pretty safe for them to talk candidly. If they’re in their own home, like hiding in their closet trying to tell me what’s happening, it actually might be more dangerous for them, right? So there are certain problems for which teletherapy is not practical, and it’s maybe not even smart.”

Baker, in her practice in rural Virginia, has found that teletherapy can also be tricky for kids seeking privacy from their parents. “If they’re having trouble with a parent,” Baker says, “and that parent has come into the room, how am I going to know that? To protect them and be able to, you know, change the subject really quickly before it becomes an issue with the parent?”

There are also some issues with teletherapy and client safety that still need to be worked out.

Right now, there’s a push to make it easier to conduct teletherapy across state lines. Currently, 15 states are part of a pact to grant practicing reciprocity for teletherapy across state lines, and 11 more have legislation pending to join. There are, though, more considerations here. Sometimes, a therapist needs to call local authorities if a client is in an emergency. “If you’re not in the same state with somebody, how do you work with the local authorities when they’re in danger?” says psychotherapist Bedford Palmer II. “That’s kind of the main issue there.”

There’s no one clear solution for this.

“I hear a lot of clinicians raise it as a concern, but I actually think it’s an easy issue to solve,” Holm-Denoma says. “Most telemedicine laws indicate that you need to start each session by confirming the client’s physical location. Assuming you have that information, if you have imminent safety concerns, you can either quickly Google the emergency phone number for first responders in the client’s location or call 911 and ask to be transferred to the 911 dispatch location for which your client is located.” (She also mentions the same challenges arise in large states. “If I am a licensed psychologist in California who lives in San Diego, I could be conducting telehealth with a client who is north of San Francisco,” she says.)

Ideally, Schleider adds, “there needs to be a clear set of guidelines and a well-considered plan for how therapists are expected to deal with such situations.”

If clinics expand teletherapy, many people may still struggle to access it

We can’t rely on teletherapy alone to solve the mental health care crisis.

Ideally, when in-person visits become safe again nationwide, they’ll be offered alongside teletherapy options. But roadblocks to doing this remain. A huge one: 21 million Americans still don’t have access to broadband internet, as Vox’s Emily Stewart recently explained.

“One of the big pieces” to greater access, says Palmer, is “making sure people have access to the internet as a right instead of just being something that’s a luxury.”

What teletherapy and expanded internet options can’t solve: the clinician shortage. Teletherapy may allow some clinicians to see more clients, but there’s only so much to squeeze out of the current mental health care workforce.

“The challenge is we’re still relying on trained professionals,” says Adrian Aguilera, a UC Berkeley researcher who studies how to use technology to face unmet mental health care needs, particularly for low-income and ethnic communities. “There’s a lot of need, but there’s also not enough trained professionals to provide care to address all that need.”

Baker says her volume of clients has “never been higher.” But her profession’s high burnout rate is never too far from her mind. “If you’re trying to take on more and more people just to make sure that nobody is going without the help they need, that’s at a sacrifice of something, and most of the time it’s the therapist,” she says.

To fill the provider shortage gap, Aguilera and his colleagues are trying to find new ways to use technology.

One promising solution is using text messaging support to supplement in-person therapy sessions. “We’ve developed an automated text messaging intervention for folks that are in therapy for depression,” Aguilera says. “People are getting messages throughout the week while they are in treatment.” The text messages help them through their therapy “homework,” and practice what they learned with the clinician. “The idea is to utilize automated texting to help encourage people to actually practice these things,” he says.

So far, he finds this type of text engagement leads to people staying in treatment twice as long. But this approach, too, doesn’t completely solve the problem of provider shortages. It just takes some of the follow-up work off the shoulders of providers.

“We need to find the right balance of automation versus personal contact,” Aguilera says.

Another promising approach to finding that balance is to use peer support groups. These are non-clinicians trained to give support to other people in treatment, and research finds potential in them to help supplement therapy. “There’s a couple of apps that have tried that approach, although I’m not sure they have gotten a ton of traction,” Aguilera says. There’s still room for innovation here.

In her Lab for Scalable Mental Health at Stony Brook, Schleider and her colleagues are trying to innovate, trying to find short or computer-based mental health care interventions that have maximum impact. She’s trying to determine: What’s the smallest dose of therapy you can give a person for maximum impact? “It’s not about how long can we keep this person here, it’s about what’s the least we can give them and still be useful,” she says.

In pilot studies, she found bite-size sessions of therapy can make an impact on teens dealing with anxiety and depression.

Her lab’s website has several programs that anyone can use for free. She’s been pleasantly surprised by who is finding them. Black and Indigenous kids of color, she says, and LGBTQ+ and non-cisgender minority youth have been flocking to these programs. “It seems that when this alternative route is offered, the people who are least likely to access even teletherapy are able to access something,” she says.

It’s not exactly “if you build it, they will come,” Schleider says. Her lab has advertised these programs on Reddit and Instagram. But she’s been heartened when she looks at user feedback on her programs. “A lot of people are saying, like, ‘My parents don’t believe in mental health; they wouldn’t have gotten me treatment if I had asked them,’” she says.

How to build on the success of teletherapy

The expansion of teletherapy is a rare bright spot in America during the pandemic. But mental health authorities and insurers need to do much, much more.

For instance, there’s a lot of innovation and diversity in mental health care approaches right now — a slew of mental health apps (of varying quality, evidence base, and profit motive) — and more options for different types of care (even though the number of providers isn’t growing with them). For a consumer seeking care, the glut of options might be overwhelming and confusing.

Because of this, the public needs something of a triage layer: When might an app or therapy workbook be enough to deal with a mental health stressor? When is it time to see someone, either in person or via webcam? In crisis, people can always call the National Suicide Hotline (800-273-8255) or text Text HOME to 741741 for a text-based crisis hotline. But short of a crisis, the landscape of options grows varied and confusing. If clinicians are able to work across state lines, the options grow even more. (Websites like Psychology Today can help you find a therapist.)

It’s not clear what the ideal triage layer is, or should be. But overall, the public could benefit from greater education about mental health care, what services different providers give, and how to find them.

Meanwhile, it’s clear that the pandemic-induced expansions to telehealth coverage should remain in place after the pandemic, but it’s unclear if they will. States or the federal government would need to enact legislation to mandate teletherapy be covered and paid for by insurance and Medicare and Medicaid.

“Congressional action would be the most direct path” to universal teletherapy coverage, says Jacob C. Warren, who studies health disparities at Mercer University School of Medicine. “If done state-by-state, the states in which it might be needed the most may not take the action.” When states were given the option of expanding Medicare along with the Affordable Care Act, some of the states with the highest health care needs declined. “I’m hopeful that the temporary coverage put in place for Covid will be a catalyst for this,” he says. “It has opened people’s eyes to the power of home-based teletherapy.”

But congressional action alone wouldn’t be enough to bolster the future of mental health care.

“Telehealth is not going to be able to solve the mental health crisis in America,” Baker says. “It’s just not. But I think it’s a huge step in the right direction.”

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