Teletherapy Aimed to Make Mental Health Care More Inclusive. The Data Show a Different Story

For years, teletherapy has been pitched as the next frontier in mental-health care. Unlike medical disciplines requiring a more hands-on approach—say, physical therapy or surgery—talk therapy has long seemed a natural and effective fit for telehealth. And by taking appointments off the therapist’s couch and into patients’ homes via their devices, advocates argued, telehealth could make counseling more accessible and convenient for everyone, with particular benefits for those who lived in health care deserts or who couldn’t regularly drive back and forth to see a clinician. The hope was that virtual therapy could help democratize a system that allowed almost 20% of white Americans to receive mental-health care in 2019, but fewer than 10% of people identifying as Black/African American, Hispanic/Latino, Asian or Pacific Islander.

Then, of course, the pandemic hit, sending the U.S. health care system into a panic and shuttering clinics and private practices nationwide. Telehealth, once psychiatry’s up-and-comer, was suddenly its lifeline. With impressive speed, a system built around face-to-face visits shifted almost exclusively online. By May 2020, 85% of the American Psychiatric Association’s (APA) surveyed clinician members said they were conducting the majority of their sessions virtually, up from just 2% prior to the pandemic. It was the perfect pressure test for the promise of virtual mental-health care. If there was ever a time for teletherapy to shine, it was during the pandemic.

But the data aren’t so shiny. Telehealth has indisputably improved mental-health care access—but not to such an extent that it delivers on promises of revolutionizing the mental-health system. The same problems that kept many people—particularly those who are lower-income or of color—from seeking care before the pandemic still exist, even with the expansion of telehealth. As a result, mental-health usage in the U.S. hasn’t changed as drastically as many advocates would have liked.

In a series of TIME/Harris Poll national surveys conducted this winter and spring, about half of respondents reported using telehealth since the pandemic began, compared with about 25% who said they had beforehand.

But only about 5% said they’d gotten mental-health care for the first time during the COVID-19 crisis. That suggests the expansion of telehealth didn’t bring in an influx of new patients to the mental-health system. Government data show a similar picture: about a quarter of U.S. adults received mental-health care in the winter of 2021, according to the U.S. Centers for Disease Control and Prevention (CDC), up from about 19% in 2019. That’s an improvement, but not an enormous one.

Similarly, a March 2021 study from California’s Kaiser Permanente health system found that telehealth allowed clinicians to conduct 7% more psychiatric visits in spring 2020 than 2019—but most of those were with patients who already had a psychiatric diagnosis. Among people without a pre-existing diagnosis, volume declined by more than 40%, suggesting that virtual appointments were more helpful for people already served by the mental-health system than those outside it. On the opposite U.S. coast, telehealth allowed McLean Hospital, a psychiatric institution near Boston, to increase outpatient volume by about 15%, counting both new and existing patients, but psychiatrist-in-chief Dr. Scott Rauch says there’s “absolutely the recognition that there are some populations,” like certain older adults, “that are having difficulty accessing the technology.”

In fact, despite the increased availability of telehealth, the share of American adults with an unmet mental-health need increased from August 2020 to February 2021, from 9% to almost 12%, according to CDC data. That’s understandable, given elevated levels of anxiety, depression and stress during the pandemic, but it also suggests teletherapy is not a panacea. And that means the harder work is still ahead.

There are lots of ways to think about access to care. The most obvious—making it easy for a patient to speak directly with a clinician, either in person or via a device—is only one.

There are also financial barriers. A single therapy session can easily top $100 (without insurance) in many parts of the country, and telehealth has done little to change that. Rightly so, argues Dr. Joe Kvedar, a former president of the American Telemedicine Association, since there’s no evidence to suggest virtual therapy is lower quality than face-to-face. Be that as it may, high price tags mean both therapy and teletherapy remain unattainable for many.

Another limitation: there are simply not enough therapists to go around. More than 125 million people in the U.S. live in an area with a shortage of mental-health practitioners, according to U.S. Health Resources and Services Administration estimates. Whether they’re seeing patients virtually or in the flesh, there are a finite number of mental-health professionals with a finite number of hours in their days. Rauch, from McLean Hospital, says telehealth can increase appointment capacity somewhat, mainly because patients are less likely to cancel or no-show, but “as long as it requires an hour of clinician time to deliver an hour of clinical service, expanded access won’t be drastically enhanced.”

To meet demand, the U.S. needs not only more therapists generally, but also more therapists from diverse backgrounds. A 2020 study concluded that just 10% of U.S. psychiatrists identify as Black, Hispanic, American Indian, Alaska Native, Native Hawaiian or Pacific Islander. That means many patients of color can’t find a therapist whom they trust and with whom they can form a close rapport, a barrier that dissuades many people from getting the help they need or prevents them from reaping the full benefits of therapy, says Dr. Amanda Calhoun, a psychiatry resident at Yale and a fellow on the APA’s Council on Minority Mental Health and Health Disparities.

“There are many patients who want a Black therapist and they can’t get it,” Calhoun says. “If we truly want to reduce the gap [in mental-health care usage] we need to make it a trustworthy system where people feel they can connect with their therapist or psychiatrist.”

Patients who do not speak fluent English, or who feel more comfortable using another language, may also struggle to find a therapist with whom they can communicate freely. Increased use of language interpretation could be an essential tool for expanding access, Calhoun says.

It seems naive, or at least wildly optimistic, to think telehealth could overcome some of these entrenched structural issues. And in some cases, virtual care actually worsens disparities. Some people don’t have a reliable Internet connection or a smart device, for example. About 7% of American adults don’t use the Internet at all, according to Pew Research Center, and those without advanced education and people of color—i.e., those already often underserved by the mental-health system—are least likely to be “digitally literate,” according to a 2020 Health Affairs article. Further, elderly adults, an estimated 20% of whom have some sort of mental-health condition, may struggle to navigate virtual platforms even if they have quality Internet access. And online platforms aren’t perfect. Some people feel uncomfortable sharing their most intimate thoughts through a screen, and any digital system runs the risk of malfunctioning or being hacked. That recently happened in Finland, when a data breach led thousands of patients’ sensitive appointment notes to land in hackers’ hands.

Plus, teletherapy is only convenient if you’re able to step away from work and other responsibilities to conduct the call in a private place. While the pandemic has many white collar workers drowning in time at home, surrounded by devices, that’s far from a universal experience. For essential workers, a disproportionate number of whom are people of color, it may be only slightly easier to steal away for a teletherapy appointment than it would have been to schedule an in-person visit with a clinician. Perversely, teletherapy may be making it easier than ever for people who already had access to mental-health care to get it, while leaving behind the people who arguably need it most.

If teletherapy isn’t doing the trick, the question then becomes how to better serve those still not getting the mental-health care they need. Calhoun says any real solution needs to take a step backward and investigate why many people either cannot or choose not to seek help.

For people of color, centuries of neglect and mistreatment by the medical institution are not easily forgotten. In the 1700 and 1800s, influential American doctors coined since-discredited diagnoses like “drapetomania” (psychosis or madness causing an enslaved person to run away) and “negritude” (essentially, the “disease” of not being white). Many contemporary providers aren’t aware of those offensive diagnostic frameworks, Calhoun says, but the cultural legacy of that racism is still widely felt in communities of color.

Training more clinicians from underserved backgrounds is the single most impactful way to encourage people of color to get help, Calhoun says. But that process takes time. In the interim, she says, all clinicians need to be educated about psychiatry’s problematic past so they can acknowledge and understand why some patients may not feel comfortable seeking help, and then hopefully address those issues in their own practices. Looking beyond telehealth and focusing on community-based programs—like church-run mental-health groups or the Confess Project, a nationwide initiative that trains barbers to be mental-health advocates—may also help build that trust.

Case studies also suggest teletherapy can work well when it’s integrated into the traditional, in-person medical system. For the past decade-plus, Massachusetts has run a program that allows participating primary-care providers to teleconference in a psychiatrist during a child’s checkup, for example. Such programs don’t eliminate mistrust of the medical system, but they can at least make it easier to introduce people to the mental-health system.

Mental-health apps—while not appropriate for patients with serious diagnoses, and clearly not an option for those without a smartphone—can also provide a cheap (or even free) stopgap measure for people struggling to find or afford an appointment with a clinician, Rauch says. And in some cases, adds Dr. Adrienne Robertson, a family medicine physician who works with the online medical startup Nurx, through which people can request prescription medicines and diagnostic tests simply by filling out a form, eliminating face-to-face interactions with providers can actually put patients of color at ease, because they can “just [be] a patient like everyone else.”

Policy also plays a role. Nordic countries, like Sweden, have among the most robust and widely used telemedicine programs in the world, boosted by affordable, state-sponsored medical networks. Unlike in the U.S., where insurance limitations and out-of-pocket costs are roadblocks for some patients regardless of platform, many people in Nordic countries have a public option for virtual care. Last year, the Centers for Medicare and Medicaid Services made it easier for Medicare holders to use telehealth services, a policy that allowed more than a quarter of Medicare beneficiaries (and more than 30% of Black and Hispanic beneficiaries) to use telehealth during the fall and summer of 2020, but it’s not clear what will happen after the pandemic ends. Permanent federal action for Medicare and Medicaid holders—many of whom are low-income or elderly adults—could open up therapy to millions of people who can’t currently afford it. And changing federal policies that currently limit clinicians to treating patients located in the state where they are licensed could help even out distribution of the mental-health workforce.

All of these fixes are considerably more complex than bringing appointments online; they require rebuilding the system, rather than simply shifting it to a new platform. That work needs to happen sooner rather than later, Calhoun says. Already, according to TIME/Harris Poll data, many people are returning to in-person medical appointments, both psychological and physical. In May, more than half of respondents who’d received mental-health care said they’d had an in-person appointment since the start of the pandemic, up from 37% in February. While some patients and clinicians are sure to stick with teletherapy after the pandemic, much of the system will seemingly revert back to how it was—and without concerted effort, the same problems may persist for years to come.