By June, Jessica Liu was feeling overwhelmed. The coronavirus pandemic that had cut short her senior year at Northwestern University was still raging. Protests sparked by the police killing of George Floyd were erupting nationwide, and as one of the few people of color in her Pennsylvania community, Liu was participating in local organizing efforts.
“Everything just kind of converged,” said Liu, 21. At the time, she was also juggling worries about her relatives in Wuhan, China, where the coronavirus was first detected, and the stress of finishing college remotely. “I really felt like I wasn’t going to be able to keep going with my life unless I did something I should have done a long time ago, and that’s what motivated me to seek help finally.”
Like many others experiencing heightened struggles with mental health amid a turbulent year, Liu found the support she needed through teletherapy. The alternative to traditional in-person sessions has emerged as a critical resource during the pandemic, experts say, helping to reduce barriers to mental health treatment that previously may have deterred people from getting help.
“I think of [teletherapy] as a dusty dirt road that no one wanted to take that is now a 16-lane highway,” said Ken Duckworth, chief medical officer for the National Alliance on Mental Illness. And with experts anticipating that the demand for mental health support will only keep rising, even when the pandemic is over, teletherapy is probably here to stay, they say.
“This is a ball rolling down a hill,” Duckworth said. “It’s got a lot of momentum. It would take something material to stop it.”
But although providers and people in need of support have been buoyed by the positive effects of teletherapy on mental health care, what those virtual services will look like in the post-covid-19 era remains “a big unknown,” Duckworth said.
In addition to being driven by the pandemic and the availability of technology, the proliferation of teletherapy in recent months has been aided by covid-related emergency policy changes that have increased accessibility to services in many areas of the country. One of the modifications to existing regulations is the expansion of insurance to better cover more methods of teletherapy, including phone sessions, said Jonathan Shepherd, president of the board of directors for the Black Mental Health Alliance.
“Before the pandemic, we received reimbursement at rates much less for telehealth services” compared with in-person services, said Shepherd, a board-certified child, adolescent and adult psychiatrist in the Baltimore area. “But now it’s on equal footing, and so as long as it remains on equal footing, I can see where organizations would definitely continue it.”
Conducting teletherapy sessions from home can benefit providers as well as patients, Shepherd said.
“There were things that I learned about people that I had not known until I saw them in their home,” he said. “It was amazing what insight I was able to gather just by looking inside their home as a session was conducted.”
Rubina Jain, 35, of Ellicott City, Md., said the convenience of being able to hop on a video call with her therapist from home is one of the main reasons she’s planning to continue with teletherapy, even if there is an option to be seen in person.
“I’ve got a 2-year-old daughter, my husband works nights, and so it’s super easy if I can do it at my home,” said Jain, who started remote sessions about two months ago. “I don’t have to go anywhere for it, and as soon as I’m done, I’m back with my family.”
The question, though, is whether the modified regulations will continue post-pandemic, said Jay Shore, who chairs the American Psychiatric Association’s telepsychiatry committee.
“It may be the emergence from covid doesn’t occur over two to three months but is longer and drawn out. That impacts how we begin pacing ourselves,” Shore said. “Different institutions, depending where they’re located, will begin to blend back into in-person, and then there’ll be these existential organizational questions about, ‘Now that covid’s over, how much of this virtual stuff do we continue to offer?’ ”
Insurance coverage can differ from state to state, leading to a patchwork implementation of emergency orders with varying expiration dates. Recent reports that some major insurers have started to roll back certain aspects of their coverage of telehealth services, which generally encompass therapy as well as other types of doctors’ visits, have sparked concern among some health-care experts. But others, including Shore, say the future is still unclear.
“We don’t know what’s going to happen” to the emergency declarations, Shore said, noting that insurance regulations can be influenced by federal, state and local legislation. He later added: “There is just all this uncertainty. . . . This is obviously the most dynamic and uncertain time I’ve ever seen in health care.”
In the meantime, though, providers and patients should prepare for a future where hybrid offerings of telehealth and in-person services are the norm, said Adam Haim, chief of the National Institute of Mental Health’s Treatment and Preventive Intervention Research Branch.
“When the issues related to social distancing are relaxed once the pandemic is no longer a pandemic, for individuals who have received those mental health interventions remotely, it’s likely that a significant portion of them will continue to receive those interventions remotely by choice.”
A survey conducted between April and May by the American Psychological Association found that about three-quarters of the 2,000 member clinicians who responded reported that they had switched to solely providing teletherapy services. An additional 16 percent said they were offering both remote and in-person sessions. A separate survey of American Psychiatric Association members presented a similarly widespread adoption of telehealth.
Duckworth said he knows of practitioners who have largely abandoned their office spaces or terminated leases during the pandemic. Keeping those environments “sanitized, ventilated, secure is way above their pay grade,” he added.
La Keita Carter’s clinic in Owings Mills, Md., has been solely offering remote care since March and will continue to be “100 percent virtual” for the foreseeable future.
“Every time I had a little whisper of, ‘Maybe you could go back,’ the numbers didn’t stay stable,” said Carter, who is still paying rent and utilities for her 15-office suite. “At this point, I’ve wiped out all of 2020. It’s just done.”
Still, Carter and other mental health experts have recognized that teletherapy may not be the appropriate type of care for everyone.
Although some are more comfortable at home, for others, “sometimes home is the place in your life that has the most angst,” Carter said. Or, she noted, people may feel like they can’t express themselves as freely because they are worried about their family members or roommates overhearing.
Sophie Maccagnone, who started therapy for the first time during the pandemic, said she was initially nervous about doing a remote session from her home in Indianapolis, where she lives with her fiance. Maccagnone, 26, has since gotten more comfortable with the situation by taking the video calls in her basement and scheduling times when she is more likely to be by herself.
“My therapist always checks and says, ‘Do you have privacy? Are you alone?’ And that just establishes another sense of security in it,” she said.
Another issue that has been highlighted by the rapid shift to virtual health care is the “digital divide in America,” Shore said.
“When you don’t have access to that bandwidth, right now you may not have access to health care,” he said. “And the digital divide isn’t just bandwidth, it’s having bandwidth, the equipment and feeling comfortable with whatever technology you’re having to use.”
For telehealth and other remote care delivery methods to be effective, Haim emphasized the importance of constantly adapting technology and an “ecosystem where it’s commercially viable,” meaning that companies can support the platforms, there is insurance coverage, and it’s affordable for consumers.
“That involves providing the right evidence,” Haim said, noting that research needs to be conducted to determine whether teletherapy can be clinically effective and cost-effective. On top of that, Haim said, there should be systems in place to educate consumers and providers about how to best use the various care options.
“Telehealth is here to stay, and I think what we’ve learned is that there’s an appetite for it,” Haim said. “There’s an appetite on behalf of the clinicians who are able to reach more individuals more effectively, more efficiently, and there’s appetite from the consumer side in that individuals don’t need to leave their house. . . . It’s really adapting to the needs of the consumer.”
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