Back in March, only 2 or 3 percent of Americans got mental health treatment online. Thanks to COVID-19, that number is now 100 percent. Millions of people have transitioned from in-person therapy to remote therapy—therapy by Zoom, Doxy, FaceTime, or other video platforms. Many of us were skeptical at best. How could teletherapy be anywhere near as good as in-person?
But happily, an unscientific sampling of opinions from both sides of the couch suggests that not only are things going better than anticipated, but that teletherapy may finally be addressing some major problems in the world of mental-health treatment, especially when it comes to access and cost. And many of us may never go back.
While technology-enhanced therapy has been around since the 1990s, it never caught on in a big way. “In psychology circles there was a lot of resistance, not evidence based, just based on the fact that it’s not a ‘real’ relationship,” explains Rodrigo da Cunha Teixeira Lopes, a clinical psychologist and senior research associate at the University of Bern, who studies online mental health treatment. “You have to be in the room for that.”
Experts like Marlene Maheu, a clinical psychologist and executive director of the Telebehavioral Health Institute, have argued for decades that video therapy can be just as effective—and a hell of a lot more convenient—than in-person therapy. The research suggests they’re right. A 2012 study of telemental health treatment by one of the biggest groups to use teletherapy, the United States Department of Veterans Affairs, found it reduced psychiatric hospitalizations by 25 percent compared to no treatment at all. A number of other studies and meta-analyses have found that under certain conditions, telepsychiatry works just as well as face-to-face treatment.
The switch to teletherapy has improved availability of mental health resources, even for people who live in remote places. One reason so few people get treatment is lack of access: Sixty-five percent of the rural counties in America have no psychiatric treatment available at all, and still more areas are limited in options. “One of the participants in our project was saying there’s one psychotherapist in my town, which is my cousin,” says Lopes. With teletherapy, he adds, “You don’t have to look [for treatment] just in your neighborhood. You have other countries, other states.” Many states have loosened the restrictions on doing therapy across state lines, at least for now.
Unlike in-person therapy, teletherapy requires no commute or appointment. “To be able to take 45 minutes out of your day as opposed to three hours to catch three bus lines is a real game changer for a lot of low socioeconomic status folks and racial and ethnic minorities,” explains Cook.
Matia Kelly, a psychotherapist in Portland, Oregon, noticed that since she switched her practice to virtual therapy, none of her patients have cancelled appointments or failed to show up. “That tells me it's removing barriers that were there before,” she says. “For clients experiencing more anxiety, sometimes everything that's involved with getting fully dressed and driving and all that might feel overwhelming, especially at a challenging emotional time.”
Only about half the people who need mental health treatment in America actually get it, according to Dr. Ben Lê Cook, a professor of psychiatry at Harvard Medical School and director of the Health Equity Research Lab at Cambridge Health Alliance. Those numbers drop even lower for marginalized groups. “When you look at Blacks, Latinos, and Asians, that number goes to 20 to 30 percent,” says Cook. Even when racial and ethnic minorities do get treatment, it’s often worse than the treatment white people get, leading to big disparities between white people and people of color when it comes to mental health care.
Evan Rhoda, 31, of New York City, also likes avoiding some of the stigma related to treatment. “I like the fact that [with teletherapy] I don't have to travel to an office and sit in a waiting room and be with other people who can see that I’m there for psychological services.”
So teletherapy comes with lots of positives, says Cook, and could help more people access treatment. There is a flip side, though, starting with technology. “The software has to be there,” acknowledges Cook. “You have to have a reliable Internet source for video calls. We have to make sure the vulnerable folks who are left behind already won’t be further left behind because now they don’t have the right Wi-Fi or bandwidth or whatever.”
“The biggest constraint I hear is ‘I don’t have a safe space to be completely myself and not be heard on the other side of the wall,’” says Lopes. “You pay for the attention of the psychotherapist, you pay for his knowledge, but you also pay to have this space.”
Not all therapists thrive on video therapy, either. Melissa Fabello, a consultant in Philadelphia, sees two different therapists right now. One is loud and a bit brash, and her personality works well in a virtual format. “She laughs a lot, she curses a lot, she gets really into what I’m saying,” says Fabello. She says the other therapist, who’s quieter and more traditional, doesn’t come across as effectively onscreen.
Physical presence has historically been a huge part of the therapeutic relationship. Tasha Boyer, a therapist in Columbus, Ohio, misses being in the same room as her clients. She feels it’s harder to push them, to create the kind of tension needed to facilitate change. “It’s almost like there’s an innocence lost,” she says. “Therapy is communication and bonding. It’s not touch necessarily but it’s emotional touch, and we live in a society now that’s afraid to be around anybody. So it feels—like an oxymoron almost.”
Fabello agrees. “There is some type of magic that happens in a room with another person where you’re talking about stuff that’s hard and someone is holding space for you in your presence,” she says. “There’s an energy in the space that I think is really hard to re-create over a video.”
It’s definitely harder to read social and physical cues through a screen, especially if your view is limited to someone’s head and shoulders. “Body language, even just shaking your leg a lot if you're anxious or impatient, can be a telltale sign,” says Rhoda. “There's no way you can see that through the teleconference. It relies a lot more on what I say than on how I am or how I behave, and I don't know if it's as effective.”
Most people interviewed for this story said they’d want to keep doing teletherapy, at least in some capacity, once the pandemic has passed. Soleil Young, a graduate student in Madison, Wisconsin, misses seeing her therapist in person but likes the convenience of teletherapy. “If I had a choice I’d alternate between face to face and teletherapy like maybe every other week, just because the aspect of saving time at work is very helpful,” she explains.
Fabello shares this ambivalence. “There is a sense of spaciousness I have right now because I’m cutting down on the travel time, the getting ready time, whatever,” she says. “When things go back to being able to go outside, how can I use things I’ve learned in this process to better my experience in the world? Are there things I can do online so I can continue to feel some of that spaciousness? But overall my preference would be to see a therapist face to face.”
Maheu is convinced teletherapy is here to stay. “A lot of people were forced to realize that the research is true, that this is effective. You can get what you want done this way,” she says. “A lot of people were reluctant to try it, but now it's been forced adoption.”
It seems likely teletherapy’s going to stick around, and many therapists and patients are glad. “I had assumptions that I wouldn’t be able to connect over teletherapy,” says Matia Kelly, a therapist in Portland, Oregon. “Those assumptions have been blown out of the water.”
But that doesn’t mean it’s perfect. To get the most out of therapy by video, Kelly suggests these tips:
• Schedule a little extra time before and after a teletherapy session so you can prepare for and process the appointment. It’s convenient to just hop on and off, but you’ll get more out of the treatment if you give yourself a little emotional breathing room.
• Treat the session like an in-person appointment—turn off your phone, eliminate distractions, give it your whole focus. “Really try to to be present,” suggests Kelly. “What do you need to do to be able to do that?”
• Delays and glitches are inevitable, so let your therapist know if you miss something she says or does. You have to be a little more explicit in teletherapy than in person.