Online Therapy, Booming During the Coronavirus Pandemic, May Be Here to Stay

Mental health flows from the ceramic jug psychotherapist Lori Gottlieb keeps on her desk. There’s nothing special about the jug—a minor accessory in an office designed with the sort of tidy impersonality common to her field. And there’s no special elixir in it—just water. But all the same, the jug provides a certain kind of healing. When patients are struggling, crying, overcome in some way, Gottlieb, a Los Angeles based practitioner and author of the book Maybe You Should Talk to someone, will offer up a cup of water, pour it for them and hand it across.

In that small gesture is a whole constellation of meaning: concern, care, protectiveness, generosity. It’s a little grace note that’s possible only in person—only when two people are in the same room, sharing the same space, face to face across just a small physical gap. Ever since March, however, when much of the U.S. went into lockdown as a result of the COVID-19 pandemic, such in-office intimacy became impossible across nearly all professional disciplines. Psychotherapy sessions—like so very much else—have become virtual, conducted on-screen, at a remove, riding the electrons of Zoom or Skype or Google Meet. And that comes at a price.

“There’s the ritual of coming in every week, sitting in that room on the same spot on the same couch in the same office,” says Gottlieb. “It feels incredibly comforting and safe. I think the environment part of it is very important for people.”

That’s not true just of mental health, of course. Most of us aren’t getting a fraction of the person-to-person interaction we’re accustomed to, and most of us are pretty well fed up with it. Virtual birthday parties are no party at all. Virtual happy hours have everything but the happy. Call it Zoom fatigue, cabin fever, flat-out loneliness—many today are suffering from isolation to one degree or another and long for the moment that the virtual lives we’ve been forced to live can be tossed aside.

But telepsychology (or telepsychiatry or tele-mental-health, as it’s been variously called) may have a stickiness to it that other aspects of virtual living lack. In recent years there’s been more and more talk in the health care professions about the potential for telemedicine. For some kinds of care, it’s easy to see how routine “office visits” that allow doctors and patients to meet without the need for an actual office could work: the orthopedic surgeon checking a patient’s range of motion and inquiring about pain after knee replacement surgery, say. But too many other visits require hands-on contact—palpating, blood draws, suturing—to make telehealth a universal practice.

Tele-psych, though—with its talk-and-listen simplicity—is a different matter. If ever there was a caring discipline that was poised to jump aboard the telemedicine train, it’s mental health.

“In February of 2020, before COVID-19 really hit our country, telepsychiatry was beginning to be widely available but only sporadically adopted,” says Dr. Jay Shore, a professor at the University of Colorado Anschutz Medical Campus and the chair of the American Psychiatric Association’s Telepsychiatry Committee. “Now it’s been a tsunami. At the University of Colorado maybe 10% to 20% of [mental health] visits were over video before. Now, outside of inpatient stuff, we’re at like 100%.”

That has been true pretty much everywhere else in the country, where therapy sessions have been happening either online or not at all. In mid-May, the American Psychiatric Association surveyed its members on how frequently they held tele-psych sessions both before and after the onset of the pandemic. The results were striking: Prior to COVID-19, 63.6% of respondents did not use virtual sessions at all. After the onset of the pandemic that figure plunged to just 1.9%. Conversely, before COVID-19 hit, only 2.1% reported using tele-psych 76-100% of the time. During the pandemic that figure has soared to 84.7%.

It was a change made by necessity, not by choice, but there are plenty of people who like what they’re experiencing. There’s convenience for one thing: a 50-minute session is a 50-minute session, not two or three times that as the patient wastes part of the day just getting to and from the appointment. That’s especially important in rural communities that might have been mental health deserts before—with the nearest caregivers requiring a long drive to the closest big city.

Patients are able to have their appointments pretty much anywhere. “If you were going to go drop your kids off at soccer practice, you could sit in the car and have a relatively private session with your therapist while you’re waiting for the soccer match to be over,” says psychologist Jared Skillings, chief of professional practice for the American Psychological Association. “This provides a significant increase in access and quality of life.”

Tele-psych also allows for more enduring doctor-patient relationships. If your job transfers you to another city, you can always find another doctor to tend to your physical ills, but you didn’t spend years confiding your most intimate secrets to your cardiologist or ophthalmologist and now have to start over with an entirely different person. Your psychologist is another matter entirely. “The advantage is clearly that you get to have continuity of care,” says Gottlieb.

All of those plusses have some in the community convinced that not only are tele-sessions the future of mental health, but that that future is now. “I think that anyone who tries to prognosticate comes across as a fool,” says Shore. “But what I can say is that we will never be the same, we won’t go back to where we were.”

And yet, what about that water jug? What about the sense that a therapist’s office is a third place, a safe space, neither work nor home but a place that, for those 50 minutes at least, feels like the patient’s own? Not every patient is the same and for many there is a comforting ritual in the opening of the doctor’s door and the gathering in that follows. Shore may indeed be right that the forced experiment with tele-psych that the quarantine months have necessitated has dramatically changed the game. Just how much and how enduringly it’s been changed is the real question.

Teletherapy may seem very much of the moment, but it’s not a new idea. As long ago as 1959, the University of Nebraska began a pilot project using mid-century video technology to allow patients and doctors to meet remotely. But the system was expensive and impractical and it lent itself poorly to the Freudian era of lying on couches and free-associating to a silent therapist whose face you didn’t even see. It wasn’t until the late 1990s, with the Internet fully entrenched and two-way video platforms coming online that the telehealth gained any traction. Even then though, it was used in a limited way.

“We started to see big systems like the Department of Defense and the Veteran’s Administration and jails develop sustainable larger scale telepsychology services to serve their populations,” Shore says.

Still, that was enough to prove the technology’s potential—if not its immediate appeal—and practitioners adopted it unevenly. While Shore reports that well before the pandemic he already had patients he’d worked with for 12 to 15 years and had never met in person, Gottlieb wanted no part—or at least very little part—of telehealth.

“I didn’t do telehealth at all unless there was a circumstance like I already had an established patient and that person was going to be on a work assignment for a few months,” she says. “But I would never meet somebody doing telehealth.”

Then the pandemic forced the profession’s hand and even doubters like Gottlieb have seen some of its advantages. She concedes that she likes the leveling effect of both patient and doctor getting background glimpses into each other’s homes—a sort of intimate equality of behind-the-scenes access. She likes the insight she gets when a patient Zooms from a bedroom and she catches sight of what’s on the nightstand.

“Usually what people keep on their nightstand tends to be the most personal of things, what means the most to them,” she says.

And she likes, too, the spontaneity and humor that a tele-session can provide. A surprising number of people, Gottlieb says, will have a session in the bathroom, sitting on a closed toilet—looking for a private spot in their homes. During one session, a patient was crying because her mother was in a nursing home where COVID-19 had been detected, and she was worried. She sat back and accidentally hit the handle of the toilet causing it to flush loudly.

“She was embarrassed and said, ‘Am I the only person who does therapy from the toilet?’ And I said, ‘No, actually the toilet has become the new couch.’” They both laughed—which the patient later said was the best and most helpful moment in the session.

Whether all sessions will be so effective depends at least in part on the kinds of issues the patient is struggling with. Obsessive-compulsive disorder, for example, lends itself comparatively well to tele-psych sessions because the standard of care for it is what’s known as skill-based therapy—learning behavioral tools that help break the OCD cycle—which may require less intimacy than other kinds of therapy, and instead calls for rigorous practice and discipline. Post-traumatic stress disorder patients may similarly benefit from online therapy, at least at first, since the home might feel like a safer space than a doctor’s office.

But there are downsides in treating these and other disorders online—in the form of cues missed due to the limited frame of a computer screen. The jiggling foot, the knotted hands, the subtle shifting in the chair that telegraphs unease with a topic of conversation are all lost to the doctor in tele-sessions. For patients battling substance abuse it’s hard to get away with the telltale gait of intoxication or the smell of alcohol on the breath in an in-person session. Not so hard on Zoom.

Group therapy can present its own challenges. A key part of the dynamic of the group involves eye contact—who’s listening, who’s not, who’s offering an affirming nod or shifting uncomfortably at someone else’s story that may hit a raw nerve in the listener. On a Zoom screen with a dozen faces arranged in Brady Bunch tiles, all of that is missing.

Even when the group is just two people, things get lost. Gottlieb recalls counseling a couple in a telehealth session and suddenly noticing their mood going from comparatively detached to warm and compassionate. “I was trying to figure out what had shifted there and then one of them said they were holding hands,” she says. “But I didn’t see it. They were holding hands under where I could see.”

If tele-psych is going to have a wide, post-pandemic future, it depends on more than just the acceptance of patients and providers. As with so much else in the U.S. health-care system, things come down to who will pay. During the pandemic, Medicare, many state Medicaid programs and commercial insurers have loosened rules or allowed waivers to cover telehealth sessions. When the pandemic ends, however, so could the payments.

Those in the field want to stop that from happening, making sure we don’t lose the lessons we’ve learned from the experience. “We are advocating for Medicaid, Medicare, and private payers to keep telehealth turned on at least for 12 more months after the coronavirus pandemic is officially declared to be over so that we can better evaluate the impact that has had on patients,” says Skillings. In a live June 9 event with STAT News, Seema Verma, the Administrator for the Centers for Medicare and Medicaid Services (CMS), offered support for that kind of sentiment, arguing that coverage for most forms of telemedicine, including tele-psych, should indeed continue after the pandemic ends. The dramatic increase in overall access to care—with telemedicine visits increasing 40-fold in some parts of the country during the pandemic—is, all by itself, an argument for maintaining the system, she said. In August, the CMS issued new guidelines that provide physicians nine new billing codes to cover telemedicine going forward.

The portability issue is another unsettled question that will endure beyond the pandemic. It’s true that one of the advantages of tele-psych is that patients who move from state to state can continue to work with their original doctor—but that’s only if each state’s licensing rules permit that kind of cross-border practice, and so far most don’t.

In 2011, the Association of State and Provincial Psychology Boards—one of the profession’s governing bodies—created a task force to promulgate tele-psych guidelines for practitioners. From that came a proposal for what became known as PSYPACT, a national reciprocity system under which states would accord tele-psych privileges to practitioners living in other states. Joining the group requires action by state legislatures, and currently 15 have passed the necessary laws, with approval pending in 12 more states and the District of Columbia.

“At the end of the day,” says Skillings, a vocal PSYPACT advocate, “this is actually about providing care to our community, to improve their health.”

Improving community health is, of course, what all medicine, virtual or otherwise, is about. Mental health, which lacks the clarity of other medical disciplines—the blood tests and CT scans and MRIs that can make diagnosing illnesses and prescribing treatments so straightforward—has always needed more options in its therapeutic toolkit. Tele-psych, even with its doubters and its drawbacks, is easily one of the newest. In time, it may also prove to be one of the best.