Telehealth-Based Therapy Is Having a Moment

A lot of mental health treatment is taking place through telehealth now, a delivery method that got turbocharged during the pandemic. Often, patients receive their therapy—and their prescriptions—by way of their smartphones. There’s a lot of good, and a fair amount of bad, about this trend.

The good news

Let’s start with the positive news about telehealth delivery. As the chief medical officer of a large addiction treatment center based in Jacksonville, Florida, and as a psychiatrist who does the vast majority of my work with patients in person, I nevertheless believe there absolutely is a place for telehealth delivery of mental health care.

Yes, it has its limitations. Less patient accountability is a big one, as is the diminished ability of the provider to “read” a person’s body language on a video screen. But for me, those and other drawbacks are outweighed by telehealth’s convenience and accessibility (among other benefits), especially for people living in rural areas where a bricks-and-mortar mental health practice may be hundreds of miles away.

More telehealth options are certainly needed in my field. In 2019, just over 20 million Americans aged 12 and older reported having substance use disorder (SUD), according to SAMHSA. Of that number, only 2.6 million—just 12 percent—received treatment for it at a specialty facility. If telehealth offers another treatment path for those millions of Americans who aren’t getting it, I’m all for it.

Happily, people are choosing this option. From 2016 to 2019, the years just before the pandemic, telehealth appointments for SUD treatment rose from 13.5 percent of all treatment visits to 17.4 percent. Once COVID hit, that number increased dramatically. Even with the COVID threat now receding, the number of telehealth visits remains high.

Telehealth benefits for patients include:

• Increased access to providers whose practices may be far away.
• More convenience, as care can be provided in the comfort of home.
• Less time off of work or school is needed for a virtual visit.
• Reduced stigma when accessing treatment from home.
• Less worry about infections or other sicknesses that may be present at clinics, rehabs, or other healthcare facilities.
• Lower cost for many virtual visits versus onsite.

Telehealth benefits for providers include:

• Increased patient appointments as providers can schedule more people.
• More effective coordination of care as it’s easier and more seamless to link patients to other services.
• The ability to visually assess a patient’s home environment, which can aid in treatment.
• Reduction in provider workforce shortages, as practices in rural areas can retain more patients.
• Reduced rates of provider burnout as they benefit from more flexible hours, and less commuting.

The not-so-positive news

Again, there’s a lot of good to say about telehealth as it relates to mental health delivery, but there are some pitfalls. Among them:

There’s less regulation. And there's a looser clinical environment in general. Is the provider you’re meeting with on-screen properly credentialed? Are they licensed in your state? Do they have a chief medical officer or other senior provider overseeing them? With telehealth, it’s harder to know. It’s also easier for telehealth-based providers to bypass such guidelines, or to be less rigorous about them.

It's easier to make money on prescriptions. Telehealth-based practitioners are able to see more patients; therefore they’re also able to write more prescriptions. A Wall Street Journal expose that ran in August on telehealth-based ADHD treatment found that a San Francisco-based company purportedly offered financial incentives for every prescription refill their network providers wrote. The company is now reviewing its practices and procedures.

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Telehealth clinicians are often independent contractors. Independent contractors are not more dishonest than full-time clinician employees at health clinics. Absolutely not. However, there is less provider oversight with this model. It’s just harder to have oversight with a contractor network spread across the country than it is with employees under one roof in the same practice.

Telehealth companies often follow a different business model. A lot of telehealth companies getting into the mental health field like to say they’re actually tech companies rather than medical or healthcare entities. Again, as with the independent contractor setup, there’s nothing innately wrong with the tech company model. On the other hand, it’s reassuring to work with a medical enterprise (hospital, clinic, rehab center, etc.) that is led by medical professionals trained in medical ethics and practices.

It's more difficult to “read” a patient in a virtual setting. When a provider does an evaluation, checks in with a patient during a follow-up session, or is considering a medication adjustment, there’s no substitute for an in-person visit. When you’re in the same room as your patient, you can pick up on body language, see how they’re dressed, get a sense of their hygiene, and so on. I often learn a lot about how a patient is doing just by watching them walk into the room.

Patient oversight is harder to maintain. Accurate drug testing, for example, can be problematic with telehealth. You can’t simply have your patient come in for a saliva or urine test. Mental status exams are important as well, and it’s a lot easier to do them, and to have trust in the results, when you conduct them onsite.

People tend to be less accountable. I’ve always thought that when a person receives therapy at a treatment center, there’s less chance that they will “hide” during their sessions. Or deceive. Or spin. Or deflect. It’s easier to do all those things during a virtual visit because there’s more distance between you and your therapist, and you and your fellow patients. It’s easier to think: “They’re not here with me, so they don’t know what’s really going on in my head. I’m just going to fake it this session; they’ll never know.”

Words of advice

Telehealth is a great option, but as with any healthcare delivery system, you need to be vigilant and advocate for yourself or your loved one. Please don’t think of the telehealth option as “mental healthcare lite.” It isn’t. Keep these four things in mind:

1. Be sure you get a thorough evaluation at the start. If the intake person or primary therapist only takes 10 or 15 minutes with you, and the personal health questionnaire you fill out is only a page long, those are two red flags. Consider going elsewhere.
2. Find a reputable telehealth organization. The NAMI and SAMHSA websites both have resource guides to help you check up on places you hear about on social media or elsewhere; you can be confident that their listed telehealth services are legit.
3. Check on your clinician/therapist. When you get matched with a provider, be sure that person has the proper training and credentials before you start treatment. Look for their bio on the organization’s website, and maybe do a Google search on them as well. A little detective work up front could save you heartache down the road.
4. Be suspicious if you get prescription refills or dosage changes too easily. This is a little tricky for patients because it asks you, not the provider, to exercise proper judgment about medication. But my bottom line is this: Patients and their loved ones always need to advocate for themselves, and stay vigilant. Providers are not infallible. They sometimes make mistakes in judgment. If something smells fishy about the way medications are being prescribed, ask about it. Push back. Make inquiries. Get a second opinion.

Final thoughts

As a way to deliver and receive mental healthcare, telehealth is here to stay, and will become even more prominent in the future. That’s great news for the most part, especially for those who cannot or choose not to access onsite treatment. Just be careful. And as you would with any provider using any treatment delivery system, hold that professional to the highest possible standard. This is about your (or a loved one’s) mental health, and there’s nothing more important than that.

To find a therapist, visit the Psychology Today Therapy Directory.