Teletherapy, popular in the pandemic, may outlast it

Jeff Wilser, The New York Times

Posted at Jul 10 2020 09:10 AM

The 10-year-old girl was afraid that her American Girl dolls — buried in the bedroom closet — would come alive and attack her. As the girl pointed her iPad at the scary closet door in a remote therapy session, her therapist, Daniela Owen, was able to coach her in real-time to conquer the fear of the dolls.

“This wouldn’t have been as effective in my office,” Owen, a psychologist based in Oakland, later explained. “Being able to do the exposure in her room was so much more powerful.”

Owen, like the overwhelming majority of therapists, switched from in-person to remote therapy during the coronavirus shutdown. According to a recent survey from the American Psychological Association, three-quarters of clinicians are doing only teletherapy, and another 16 percent are doing a combination of remote and in-person sessions.

Many therapists were initially reluctant. Tamara Greenberg, a San Francisco-based psychologist, dreaded the pivot, for example, because she worried it “wasn’t as real a form of therapy.” And now? “I would say it’s really been one of the most surprising, and in many ways pleasurable, experiences of my professional career,” she said. Interviews with more than 20 therapists reveal similarly positive experiences, even as they also acknowledged some downsides, and that they missed seeing patients in person.

As the nation gingerly begins to reopen, many providers say that remote therapy is working so well and offers such convenience to their patients that they will continue with it even after the pandemic.

Peer-reviewed studies have shown that remote therapy — or “teletherapy,” which is generally done through videoconference — can be just as effective as in-person therapy for treating post-traumatic stress disorder, depression and anxiety, according to Leslie Morland, director of the Regional TeleMental Health Program at the San Diego VA Health Care System. “There’s always a contingent who are pretty convinced that they have to have their patients in the room with them, even though that’s not supported by the data,” Morland said.

Much of the research was driven by the Department of Veterans Affairs, which sees telehealth as a way to expand access to therapy for veterans who live in tough-to-reach areas. “The research shows that clinicians can be as effective in a telehealth environment as they are in face-to-face,” said the chief executive of the American Psychological Association, Arthur C. Evans. Teletherapy could bring therapy to millions of people who need it. A 2017 study from the Substance Abuse and Mental Health Services Administration found that of the 46.6 million Americans with a mental health issue, only 42.6 percent received treatment. Morland says telehealth can help close the gap.

In addition to the obvious benefits of convenience and flexibility, video sessions can give therapists a literal window into the patient’s home. Teletherapy can offer “a much deeper level of knowing the child, and understanding what their world might really be like,” said Lisa Dion, president of the Synergetic Play Therapy Institute, based in Boulder.

Patients — who asked that their names not be published to protect their privacy — also reported benefits. “Receiving treatment is far less cumbersome, which significantly decreases your stress level, which is a huge part of why you’re in there,” said a 43-year-old female veteran, based in South Carolina, who had been seeing a Veterans Affairs therapist for treatment of depression and PTSD. Or as a 23-year-old software engineer, who sees a therapist for social anxiety and depression, discovered, when she no longer needs to deal with the commute, “there’s not as much time to hype yourself up … there’s less time to ruminate.”

Yet most therapists interviewed acknowledge that even if remote therapy is effective, it has its downsides. On top of the baseline Zoom fatigue that many of us experience, therapists must be extra-vigilant for nonverbal cues that are easier to spot in person. “In a room you have more cues, so if you relax and miss one cue, you can pick up the next,” said Dion. According to the APA survey, 76 percent of therapists said that treating patients remotely is more challenging than in-person.

Some things simply can’t be done over video. If a patient is in tears, how do you hand them a tissue? Or if a patient is really struggling with something, as Mirjam Quinn, a Chicago-based psychologist, put it, “Sometimes if there are no words, you can touch somebody’s shoulder, you can sit next to them. That’s gone. And that’s something that I really miss.”

Another drawback: It can be tough to find privacy, especially during the pandemic when everyone else is sheltering in place. Patients may retreat to a car, a closet or even the toilet seat. A 25-year-old living with his parents and brother in Modesto, California, who sees a therapist remotely for anxiety, depression and attention deficit hyperactivity disorder, worries that his family can hear his therapy sessions.

“It’s this weird thing when the doctor asks me, ‘Has the medication given you any sexual problems?’ And I had to answer that.”

Providers can face the same privacy challenges, as their own kids or cats or dogs could come bursting into the frame. As Greenberg described, one day her husband didn’t realize she was on a patient call, and he started pounding chicken in the kitchen. She said her patient asked, “What’s happening to you? What’s that banging?”

Therapy apps like BetterHelp and Talkspace, which allow users to text in silence, both report growth in sign-ups since the pandemic began.

Teletherapy also raises knotty questions over insurance policies (would it be covered?), HIPAA privacy regulations (is it legal and ethical to use Skype?), and state-to-state licensing requirements (could a therapist in Brooklyn see a patient who lives in Hoboken, New Jersey?) In the pre-COVID era, these questions alone were enough to keep most providers from practicing teletherapy. Then COVID slashed the red tape. Medicare quickly changed its policies to cover most telehealth, many private insurance companies followed suit, and clinicians could use FaceTime or Skype without worrying that they were violating HIPAA.

Whether the regulations remain loosened after the pandemic is an open question; the APA sent letters in May to all 50 governors (as insurance regulation differs state-by-state), urging them to grant a 12-month extension of the new policy after the pandemic is over.

“If there’s a silver lining with the pandemic,” said Morland, it may be that “when the dust settles, we will be able to increase the number of people who get care.” Or as Quinn said, laughing a bit, “It’s going to be hard for all of us to go back to putting on pants on a regular basis.”

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