With more than 90% of the U.S. population under stay-at-home orders this spring, telepsychology quickly became the sole option for many Americans in need of mental health care. To facilitate that care, Medicare, Medicaid, private insurance companies, and state and federal regulatory agencies temporarily relaxed rules on telehealth.
“The pandemic has accelerated the shift toward telehealth,” says clinical psychologist Adam Haim, PhD, who heads the Treatment and Preventive Intervention Research Branch at the National Institute of Mental Health (NIMH). “The whole paradigm of sitting in a room with a clinician and receiving an intervention in a 45-minute session has essentially been flipped on its head.”
Even in non-pandemic times, delivering care remotely allows mental health providers to reach more people, including those who are geographically isolated or lack access to child care or transportation. It can also help address stigma for patients seeking psychological services for the first time, says Dhara Meghani, PhD, an assistant professor of clinical psychology at the University of San Francisco.
“For patients who have never before sought care from a therapist due to various barriers —including concern about being seen at a physical clinic—the option to obtain services online can be a port of entry into mental health care,” she says.
And research to date shows mental health care delivered remotely—also known as telepsychology or teletherapy—is effective. Psychologists—along with psychiatrists, social workers and others—have built a substantial literature base on telehealth interventions that work for a variety of problems and populations. But experts say the COVID-19 crisis has revealed areas where the literature can be strengthened. More important, the attempt to rapidly roll out remote care has exposed the field’s lack of readiness to broadly transition to the new modality.
“There’s a lot of good that can come from this sudden uptake of telehealth,” says Tim Heckman, PhD, senior associate dean for research and faculty affairs at the University of Georgia’s College of Public Health, who has studied telehealth for decades. “But while we’ve spent a lot of time looking at what works, we got completely caught off guard in terms of disseminating and implementing telehealth on a large scale.”
Research to date
Research on telepsychology—which includes care delivered via phone, video or both—began around 1960. It grew out of a need to treat hard-to-reach populations, for instance when a forensic psychologist assessed a person in jail and referred them to a geographically distant provider for specialized care.
Since then, psychiatry research has tested remote care among veterans (Godleski, L., et al., Psychiatric Servicesopens in new window, Vol. 63, No. 4, 2012) and a range of age groups and conditions (Hilty, D.M., et al., Telemedicine and e-Healthopens in new window, Vol. 19, No. 6, 2013), showing that the modality can be effective and increase access to care. Psychologists have also studied a range of populations to determine whether telehealth works, who it best serves and how to deliver it most effectively—with promising results. The U.S. Department of Veterans Affairs, for example, has conducted numerous trials comparing PTSD interventions delivered in person versus by videoconference, finding that the two methods are equally effective in the majority of cases (Turgoose, D., et al., Journal of Telemedicine and Telecareopens in new window, Vol. 24, No. 9, 2018). Systematic reviews have also found that telepsychology delivered by video and phone is effective for depression, anxiety and adjustment disorder (Varker, T., et al., Psychological Servicesopens in new window, Vol. 16, No. 4, 2019), as well as for substance use, eating disorders and other problems in children and adolescents (Slone, N.C., et al., Psychological Servicesopens in new window, Vol. 9, No. 3, 2012).
“What we’ve seen is that telehealth is essentially just as effective as face-to-face psychotherapy—and retention rates are higher,” says David Mohr, PhD, director of the Center for Behavioral Intervention Technologies at Northwestern University’s Feinberg School of Medicine, who has spent his career studying telepsychology and digital mental health.
One question is whether audio-only care delivered over the phone is as effective as videoconferencing. Audio-only interventions have rarely been reimbursed by insurers, but received temporary approval from Medicare, as well as Medicaid and private insurers at the state level, during the pandemic. They are particularly useful for reaching lower-resource populations who may not have access to a smartphone or reliable internet connection, says Lynn Bufka, PhD, senior director for practice transformation and quality at APA.
“We don’t have sufficient head-to-head comparisons to know exactly how audio-only compares to video, but we do know that treatment conducted over the phone has shown positive benefits across a range of studies,” she says.
In one randomized controlled trial Mohr conducted comparing cognitive-behavioral therapy (CBT) delivered face-to-face versus over the telephone to 325 patients with major depressive disorder, he found equivalent outcomes at the end of treatment (JAMAopens in new window, Vol. 307, No. 21, 2012). In fact, though treatment effects were slightly more lasting in the face-to-face population, those patients were also more likely to drop out of therapy.
Audio-only telepsychology was also found to reduce depression symptoms among geographically isolated HIV-positive adults with depression (Behavioral Medicineopens in new window, Vol. 43, No. 4, 2017). In that study, Heckman looked at the effectiveness of eight phone-based psychotherapy sessions. About a third of the patients treated experienced clinically meaningful reductions in their depressive symptoms.
“When you don’t have the person in front of you, you pay attention to different things—the tone of their voice, the tempo of words and the breaths they’re taking,” says Colleen Stiles-Shields, PhD, a clinical psychologist and assistant professor at Rush University Medical Center in Chicago.
A study she conducted with Mohr and other colleagues found that therapeutic alliance did not suffer when CBT for depression was delivered by telephone as opposed to in person (Journal of Consulting and Clinical Psychologyopens in new window, Vol. 82, No. 2, 2014).
Still, some psychologists point to challenges with phone-based care. Clinical psychologist Marlene Maheu, PhD, founder and executive director of the Telebehavioral Health Instituteopens in new window, says both patients and providers can easily become distracted by emails, text messages or the desire to multitask.
Platforms that offer text-based telepsychology services are even more problematic, Maheu says, and may actually prevent clinicians from fulfilling their legal and ethical obligations. For one, clinicians delivering text-based care through programs such as Talkspace and BetterHelp have very little information about a patient’s surroundings, including where the person is located and who might be reading or influencing written exchanges. Clinicians also face the challenge of conducting assessments, establishing informed consent and fulfilling other professional obligations without visual and audio cues. And robust research supporting such platforms is limited—a study sponsored by Talkspace found its interventions were effective for 46% of participants but did not compare the platform with other ways of delivering care (Hull, T.D., & Mahan, K., Telemedicine and e-Healthopens in new window, Vol. 23, No. 3, 2017).
Meghani says such platforms, which are not reimbursed by health insurers, may hold value for some consumers, such as patients with subthreshold symptoms or those contemplating entering therapy, “because they may provide adequate mental health maintenance or demystify ‘talk therapy,’” but that stronger evidence is needed to support their widespread use.
Whether care is delivered by phone, video or otherwise, best practices start with ensuring that the client is in a safe and private location. Therapists should know the exact address where a patient is located so that they can notify the authorities if the person reports suicidal intention or another emergency occurs. To ensure confidentiality, therapists should work with their clients to find a quiet space where they won’t be overheard, Maheu says.
Persistence is also key for reaching certain populations through telehealth, says Meghani, who founded Parentlineopens in new window, a free telepsychology service based at the University of San Francisco for expectant and new parents.
“We offer flexibility with length and frequency of sessions and let them know that it’s okay if they need to stop midway, which is an unconventional way of thinking about therapy,” she says.
Further research needed
Even before the pandemic put telehealth center stage, there were unanswered questions in the literature. For one, more studies are needed to determine whether remote care is sufficient to treat serious mental illnesses such as schizophrenia and psychotic disorder, Meghani says. In addition, Heckman says more randomized controlled trials comparing the same treatment delivered in person versus remotely could further strengthen the evidence base for telehealth, specifically in the areas of group therapy and for individuals with comorbidities.
But when COVID-19 hit, a whole new set of questions arose. “We’ve established the efficacy of telehealth and we’ve shown in trials that it’s safe,” Mohr says. “We know a lot less about what’s going to happen now that we’re rolling it out systemwide.”
Practitioners are now facing decisions about which teleconferencing platform to use, how to accommodate clients with older devices and unreliable internet connections, how to minimize security risks, and how to supervise trainees and interns remotely, says Heckman.
New questions are also surfacing around patient engagement with teletherapy. While research so far has shown high levels of patient satisfaction with remote care (Jenkins-Guarnieri, M.A., et al., Telemedicine and e-Healthopens in new window, Vol. 21, No. 8, 2015), those switching over abruptly from in-person sessions may express concerns about adjusting to the new technology and mode of interaction, Meghani says. Future research should explore best practices for transitioning existing patients to teletherapy, as well as onboarding new patients.
The pandemic has also revealed gaps in provider competencies. Training that providers received to deliver in-person care may not translate to confidence—or competence—with telepsychology, says Maheu.
“It’s as if the entire workforce was trained to drive automobiles and switched to 18-wheelers overnight,” she says. “You may understand the rules of the road, but you don’t know how that applies to the technology you’re now using.”
Clinicians must master the technology itself, including how to troubleshoot quality and connectivity issues. They may also need to adjust their workflow and ergonomic setup to accommodate the recent changes.
On top of that, navigating the psychotherapeutic process remotely requires specialized skills. For example, it can be difficult or impossible to pick up nonverbal cues such as fidgeting, or an odor that could indicate a patient is intoxicated, when delivering services via phone or video, Meghani says. Additional training, such as the 36-hour program provided by Maheu’s Telebehavioral Health Institute, can teach psychologists to conduct hygiene checks and gait analyses virtually to assess a patient’s physical well-being.
Psychologists may also need to seek supplemental training on how to comply with legal and ethical obligations when delivering services by phone or video, as well as federal and state rules on interjurisdictional practice and mandated reporting.
But in the COVID-19 era, even those rules are in flux. The federal Centers for Medicare & Medicaid Services is now reimbursing mental health providers for delivering services via videoconferencing and phone. Many states are requiring private insurers to allow the same. The Office for Civil Rights in the U.S. Department of Health and Human Services is temporarily relaxing its enforcement of the Health Insurance Portability and Accountability Act, allowing providers to use less-secure platforms such as Skype and FaceTime. Some states are even temporarily suspending licensing requirements so that practitioners can treat patients across state lines.
While most federal agencies, state governments and private insurers may revert to their pre-pandemic policies once stay-at-home orders are lifted, Deborah Baker, JD, the director of legal and regulatory policy in APA’s Office of Legal and Regulatory Affairs, predicts that we could see lasting effects from some of these shifts.
“States and private insurers may find that telehealth works pretty smoothly, which could open up an opportunity for advocacy to make some of those changes permanent,” she says.
APA has partnered with state psychological associations and other organizations to advocate for extended coverage of telehealth at both the state and national levels.
Though widespread evidence-based telehealth is still a work in progress, psychologists agree that the current crisis is likely to accelerate the paradigm shift.
“If I had a crystal ball, I’d say that once the pandemic is over, delivery of care will not just return to the way it was before,” Haim says. “Individuals now have an appetite for receiving care remotely, and that’s likely to fundamentally change our care environment.”
