What psychologists need to know about online therapy services

Technology use has become an integral part of psychologists’ routines. In APA’s 2021 Covid-19 Practitioner Impact Survey, 96% of psychologists reported treating patients remotely. As demand for mental health clinicians continues to grow—and as technology advances —we have seen the creation of numerous platforms that offer to connect patients with providers who take their insurance.

Though concerns remain about some aspects of companies providing online therapy services, many psychologists feel that the advantages of reaching patients desperate for care outweigh some of the rough edges. And with increasing numbers of experienced clinicians cautiously joining the ranks of these companies and sharing good and bad experiences, the more they can help influence the fledgling industry, boost their own careers, and connect with the patients whom they are best suited to help.

[Related: Is there a better telehealth platform for your practice?]

Online therapy services that pair people with clinicians for therapy, often practiced through live video, have grown astronomically over the past few years. A 2021 market analysis valued the online therapy market at more than $2.6 billion. In an APA survey from the same year, only 9% of surveyed psychologists reported seeing patients through a digital platform or app. This suggests that there is tremendous opportunity to expand mental health services via digital means while addressing the challenges that in-person care may present, such as burnout and provider shortages.

Online therapy services—Headspace Health, Uplift, and Headway, to name a few—aim to provide a “one-stop shop” for people seeking mental health support. For a monthly or per-session fee, or using a member’s health insurance, these services connect members with clinicians ranging from wellness coaches and therapists with master’s degrees to psychiatrists and psychologists. Some of these companies (Lyra and Headspace Health, for example) employ psychologists on staff, while others hire psychologists as contractors. Some online services also hire psychologists to oversee clinical operations and develop evidence-based content for members.

Amid a clinician shortage, these services can help people access therapists who match their needs and are in-network providers with their health insurance. Online therapy services can also make it easier for people to connect with therapists of similar identities.

“It’s important that we hire and retain diverse clinicians so our members can ask to be matched with someone from a similar identity, which can improve outcomes,” said Dana Udall, PhD, Headspace Health’s chief clinical officer. Headspace Healthopens in new window, which was formed as a result of the 2021 merger between Headspaceopens in new window, a global leader in mindfulness and meditation, and Gingeropens in new window, a leader in on-demand mental health care, helps its clinicians pursue (and pays for) licensure in other states so that they are able to help people in underserved areas. Further, more than 40% of its clinicians identify as people of color.

For busy psychologists at risk of burnout, online services may reduce the administrative burden as they grow their practices. For example, Headway, based in New York but whose therapists are located throughout the United States, handles benefits verification, claim submission, and payment collection, along with simplifying the insurance panel credentialing process for providers.

While the field continues to grow, clinicians may have concerns about these services’ implications on their business practices and, more important, ethical standards. If a company isn’t led by psychologists, the leaders may not be on the same page about ethical duties. “Psychologists are responsible for their own ethical obligations in any environment,” said Lindsay Childress-Beatty, PhD, APA’s interim ethics director. “It could be a higher risk to work for someone who doesn’t have the same ethical lens you do.”

APA has not taken an official stance regarding online therapy services, and with the sheer number of options, navigating them can prove challenging. Sarah Adler, PsyD, a clinical associate professor of psychiatry at Stanford University, equity adviser at UpLift, and CEO and founder of Wave Life, suggests looking for the same things you’d look for when building your own private practice or joining a group practice. “There’s a high variance of companies out there, so make sure you understand the policies and procedures, and that they are in line with your values and standards of practice.”

Here’s advice from fellow psychologists, legal and ethical experts, and psychologists in leadership positions at these services, about what to consider before getting involved.

Just as you would carefully review a contract before signing on with a group practice, be sure to understand your rights and risks as an employee or contractor of an online therapy platform.

Connie Galietti, JD, APA’s director of state advocacy and leadership, suggests hiring an attorney to review the fine print to ensure you understand what you are agreeing to.

For example, because online therapy services often connect patients with out-of-state providers, be sure you won’t be matched with someone in a state where you’re not licensed if you’re not part of PsyPact, a program that allows clinicians to practice telehealth in other states without licensure in those places. Be clear about your performance expectations, how you will be compensated, and whether you are able to negotiate your fee.

Look for restrictive covenants that may affect your ability to continue seeing a patient if you leave the organization. Understand, too, the notice requirements for resignation, who takes over with a patient when you leave, and whether you can access records if you’re subpoenaed for a court case.

Additionally, not all companies require employees to maintain their own malpractice insurance, so consider maintaining yours as an added layer of protection.

While hiring your own lawyer can help protect you, you may be part of a member organization that can offer guidance. Rebecca Resnik, PhD, president of the Maryland Psychological Association, said many state psychology associations have consulting attorneys to advise on contract matters.

Understand privacy and security practices

Patient confidentiality is one of a psychologist’s most critical obligations. Online therapy services should have clear privacy and security practices that allow you to adhere to state and national privacy laws.

Adler suggests creating a compliance checklist with the same items you’d implement as a private practitioner. Ensure that the technology is HIPAA compliant, for example, and understand who has access to patients’ electronic health records within the company and how the company handles the release of information. You should also feel confident about measures the company takes to prevent data breaches.

Ideally, Adler said, you shouldn’t have to go searching for this information; services that value privacy should provide this information up front. “Maintaining your responsibilities as a psychologist protects your license,” she said. “A company that is not forthcoming with this information is not protecting your license, which would ultimately hurt their business.”

Look for a platform with psychologists in leadership roles, particularly at the executive level, if you’re considering joining a company as a clinician. “That’s important because it means psychologists are helping to drive company-level decisions about how an organization operates and evolves, and a focus on ethical principles and best practice will be part of every decision,” said Udall.

Psychologists can serve in different roles that help spread their expertise across online therapy services, including heading up content, driving the clinical model, advising on business and operating decisions, and ensuring clinical and product quality assurance. Some organizations, including Headspace Health, hire psychologists to train other clinicians on everything from measurement-based care to ensuring care is culturally responsive and affirming.

If an online platform offers multiple levels of care, you may be concerned about where you fit in.

Look for an organization with a clear stepped-care model you feel good about. “Know who’s providing care for patients and how they get through the different layers,” said Nicole Owings-Fonner, MA, PMP, former director of operations and innovation at APA’s Office of Health Care Innovation.

At Headspace Health, Udall said the opportunity for a patient to initially meet with a mental health coach can buffer any stigma the patient may feel about seeking mental health support. When necessary, coaches perform motivational interviewing that prepares the patient to meet with a licensed therapist, which can help make therapy sessions more effective. Headspace Health also trains its practitioners to recognize the need to escalate a member to a higher level of care, and clinical leadership regularly reviews cases to ensure members are receiving the appropriate level of care. “Psychologists should always be part of that process,” said Udall.

Private and group practices typically have clear protocols for handling patient crises. When you’re researching online therapy services, look for organizations with similarly clear guidelines. “You want to make sure you know who is ultimately responsible for the patient,” said Galietti. For example, would you, as a therapist for an individual with suicidal ideation, be expected to be on call for that person between appointments, and would you have resources to help a patient in crisis get immediate treatment? It’s also important, Galietti said, to understand whether the company has a plan for continuity of care when therapists leave the company.

If you’re concerned about clinical quality and outcome measurement, Udall also suggests looking for an organization that has published research in peer-reviewed journals.

June Feder, PhD, a clinical psychologist in New York, chair of the NYSPA insurance committee, and chair of APA’s Division 42 (Psychologists in Independent Practice) Advocacy Committee, said it’s important to understand whether the clinical model allows psychologists to follow evidence-based therapy approaches. Some services may prioritize expediency in treating symptoms, which may not allow patients to fully benefit from the therapeutic relationship.

“Certain approaches to treatment are fast, and while there may be some studies to indicate their efficacy, many patients benefit from more in-depth, ongoing treatment,” Feder said. “We need to be sure the therapy model is set up so psychologists can meaningfully apply the full range of their skills and the array of research-based interventions in which they are trained.”

Also, ensure you’ll have the same work-life boundaries that allow you to do your job well without succumbing to burnout. “Some services advertise therapists on tap, available to communicate all the time, so understand what the expectations are for you,” said Resnik.

Before joining any practice, including a virtual one, psychologists should understand the business model—starting with the salary or pay rate and terms under which you’ll be paid. Will you be paid by how quickly patients are being treated? According to Adler, some companies have quotas for clinicians to meet financial goals.

If you know other practitioners who work for a certain platform, ask about their work-life balance. Get a sense of whether you’ll be expected to do more work than you’re comfortable with, which could compromise your standards of practice. “Be sure to understand what kind of control you’ll have over your own schedule and the progression of treatment,” said Owings-Fonner.

To learn more about the work environment, Feder suggests turning to your APA division or your state association to find out what other members are experiencing. Adler said it’s also a good idea to look at sites like Glassdoor, which review work environments.

No matter where you work, it’s vital to prioritize your ethical and legal obligations and to maintain your minimum standards of practice. Part of that means ensuring psychological science is factored into an employer’s clinical model. “That being said, we need to remember that creating more avenues for access is also important, especially for marginalized communities,” said Adler.

While it’s appropriate to be wary—especially if psychologists aren’t leading the charge—bear in mind that many evidence-based practices and protocols have been tested on people with very different identities from the ones that these services serve. As a result, some services may adapt evidence-based tools to better connect with people of diverse backgrounds—perhaps with shorter or fewer sessions than you’re used to, or meeting with coaches as a way into or instead of therapy, depending on the symptoms.

For Adler, the ideal balance is one that’s informed by psychological science while remaining open to adaptations that increase people’s ability to get the support they need. “If we wait until someone does a trial on a specific population, one that may not even get funded, we won’t get care to the people who need it,” Adler said. “I’m behind the idea that evidence-informed, responsibly, and ethically designed online services are one of the biggest levers we can pull to increase access.”