Abstract
When most businesses temporarily closed, and people were confined to their homes to stop the spread of coronavirus disease 2019 (COVID-19), the shock was dire. Many, even those with no history of mental illness, felt anxious and isolated, worried for themselves and their loved ones. And most had no access to their typical coping mechanisms: exercise, nature, social interactions, or even therapy.
As the pandemic progressed, people adapted. They found virtual substitutes for in-person activities such as online group exercise classes, Zoom book clubs, and even teletherapy appointments. Now that some of the stricter lockdowns have eased, people are adjusting yet again. There are socially distanced yoga sessions in the park, drive-through Church celebrations, and patio dining at restaurants—which all leads to the question: how will therapy continue to adapt as we make our way into this “new normal” of pandemic life?
In a survey conducted soon after COVID-19 triggered shelter-at-home orders all over the country, more than one third of Americans claimed that the pandemic was having a “serious impact” on their mental health. 1 A more recent international review found multiple reports that the pandemic aggravated symptoms for those who previously struggled with their mental health. 2
One can see the increase in symptoms by looking at the statistics surrounding requests for mental health resources. In the early weeks of the pandemic in the United States, the National Alliance on Mental Illness saw calls and e-mails to its helpline leap 40%. Demand for the U.S.-based Crisis Text Line rose by the same amount. 3
The need and demand for teletherapy has long been clear, but many professionals in the field were somewhat slow to jump in. COVID-19 changed that. A recent survey 4 of mental health professionals conducted by the American Psychological Association revealed that while prior to COVID-19, 63.6% of respondents did not offer virtual sessions at all, now that figure has dropped to just 1.9%. Most practicing psychologists, stimulated by pandemic precautions, have stopped seeing patients in person completely, and most are instead providing remote services to their patients. In fact, as of the survey collection, conducted in spring 2020, three-quarters (76%) of clinicians were only treating patients remotely. Most of these services were being provided by phone, videoconferencing software, or through a designated telehealth platform. On the patient side, before COVID-19, only 2.1% reported using teletherapy for their psychological needs 76–100% of the time. During the pandemic that figure climbed to 84.7%.
Teletherapy has long suffered from critiques that have hindered wider adoption of the medium. Many of these concerns stem from preconceived notions about technology, such as that it is impersonal and cold, or that it is vulnerable, unreliable, and prone to glitches. This may have been the case years ago. But today's technology, in terms of both hardware and software, is much more reliable, secure, and realistic than that of yesterday. Other concerns center around privacy, for both the client and the therapist. Especially during these times, it may be difficult for both parties to find a location that is quiet and private enough to discuss the sensitive topics necessary for treatment. I have heard recently of therapy conducted from cars, closets, and even bathrooms. Creativity and ingenuity can tackle this criticism.
And yet, some critiques of teletherapy are quite valid. There can be more outside interruptions when therapy is performed in different locations: pets, family members, loud noises, and even work or other duties can pull both the therapist and patient out of the therapeutic space. There are also those concerns that center around nonverbal cues and feedback. Therapists are trained to read the body language of their patients, and patients, as human beings, are trained to do the same. Some of these nonverbal cues can be more difficult to observe over the phone or on a screen. Because of this, three-quarters (76%) of clinicians say that treating patients remotely is more challenging than seeing them in person. 4
Yet, none of these critiques has stopped the boom in teletherapy that came along with COVID-19. The increased adoption of the practice has enabled researchers to continue to examine the efficacy of distance treatment in behavioral health care, building on previous research. A recent large international study 5 concluded that online cognitive–behavioral therapy is “effective, acceptable, and practical health care.” The study found teletherapy to be effective for conditions including major depression, panic disorder, social anxiety disorder, and generalized anxiety disorder.
Beyond being an effective modality, teletherapy provides multiple benefits to both the patient and the clinician. Patients often note more convenience and flexibility in scheduling their sessions because they do not have to factor in travel time. They are able to remain in a comfortable environment, do not have to worry about encountering others as they enter or exit the office, and can complete exposure activities in their own real-world environment. Most importantly, they can access the care they need regardless of their location. A 2019 analysis by the Kaiser Family Foundation found that nearly 40% of Americans live in areas with critical shortages of mental health professionals, with poor and rural areas the least well served. 6 Through technology, teletherapy bridges that gap by offering that vital care to those who need it right where they live.
There are benefits for therapists too. In addition to a more flexible schedule, clinicians have found that they receive far fewer cancellations and no shows when doing teletherapy. They are sometimes able to gain insight into a patient's environment and are better able to assess how they are completing activities of daily living. They can provide skills practice and a continuity of care that is sometimes not possible during face-to-face office visits. All in all, the innovations encouraged by using technology in this way can be helpful on both sides of the therapeutic relationship.
Teletherapy is clearly an effective mode of treatment for many of the most common mental health conditions. It provides access to care for many who cannot participate in in-person sessions. And medical professionals warn that demand for treatment will only increase as the pandemic wears on.
So, what happens now that many therapists are going back to offering at least some in-person treatment? With all of these benefits, can teletherapy remain the predominant mode of treating mental health issues? And even if it can, should it? These are the questions that government and health-care agencies and researchers are now considering as pandemic living becomes less of an emergency and more of a way of life.