Telebehavioral Health During COVID-19

There’s a chance that this lockdown will persist or will be periodic over the next couple of years. We’re just experiencing the beginning of a potentially traumatic experience for therapists and clients and a challenge to treatment.

Dr. Kirk Honda, Marriage and Family Therapist and Professor at Antioch University

In May, Michael Phelps, the American swimmer that won 23 gold medals and became the most decorated Olympian in history, sat down for a televised video call with an ESPN reporter to talk candidly about his mental health.

“For me, personally, it’s been probably the toughest stretch that I’ve ever gone through,” Phelps said in the interview. “There are so many uncertainties and we’re just basically fighting to stay in some kind of routine to try to keep it as normal as possible. I’ve run into a couple of scary times where I’ve had some thoughts that I probably shouldn’t have had and weren’t good to have.”

Phelps has spoken openly about drug use, depression, suicidal thoughts, and seeking treatment in a mental rehabilitation facility in the past few years—topics that could have easily been career-enders for star athletes of a previous generation. But in the new era of transparency about mental wellness, Phelps is just one prominent voice in a sea of people that have begun to speak out about their experiences.

The millennial generation has played a major role in reducing the stigma that surrounds mental health. Psychiatric Services in Advance performed a study polling more than 150,000 college students on 196 campuses around the U.S. between 2007 and 2017. It found that rates of both perceived and personal stigma decreased from 64 percent to 46 percent and from 11 percent to 6 percent, respectively.

The generation’s openness and transparency about mental health are likely attributable to their bad luck in entering the job market during the economic recession of 2008 and its struggle with unprecedented rates of student debt, Business Insider writes.

But the increasingly digital world in which the millennial generation has grown up could also be a boon to the growth of the movement to fight stigma. For all the negative effects attributed to the use of social media, digital communication platforms have also been a positive tool for many, by increasing users’ exposure to others’ stories of similar experiences and creating a sense of comradery, as well as providing an environment separate from individuals’ day-to-day lives to vocalize their own mental health issues.

The Rise of Teletherapy

As the stigma surrounding mental health has begun to decrease in tandem with the rise of the digital era, online therapy (or telebehavioral health) has seen massive growth in popularity.

You’ve probably heard of services like BetterHelp, TalkSpace, and ReGain during the commercial breaks of your favorite podcasts, or seen them being promoted by content creators on YouTube.

Comparable to Uber or Airbnb—companies that reimagine old-school business models and create a new space of themselves as a middle-man between customer and client—these digital platforms connect licensed therapists and counselors with clients and provide a platform for video chatting, audio calls, emailing and texting communication.

But the onset of the anxiety-fueling era of the pandemic (and the necessity to stay home as much as possible) has accelerated these already-thriving digital services to reach a new level of success.

TalkSpace, which is endorsed by Michael Phelps, saw a more than 10 percent growth in requests between mid-February and early March. Dr. Neil Leibowitz, TalkSpace’s chief medical officer, told Business Insider that the “number [of requests] is accelerating.”

In 2020 alone, the market size of the telehealth services industry is expected to increase 9.2 percent.

Sure, the pandemic has necessitated access to digital mental health services for the time being, but could the current shift toward teletherapy be the impetus of a long-lasting trend? And can the medium provide the same support that traditional therapy and counseling do?

“In Seattle, there’s a chance that this lockdown will persist or will be periodic over the next couple of years,” Dr. Kirk Honda, a professor, marriage and family therapist, and host of the podcast “Psychology in Seattle” said. “We’re just experiencing the beginning of a potentially traumatic experience for therapists and clients and a challenge to treatment.”

Meet the Experts: Dr. Kirk Honda and Emily Kircher-Morris, LPC

Both Dr. Kirk Honda and Emily Kircher-Morris, LPC have been outspoken in their respective podcasts about how to manage anxiety and fear that is being triggered by the pandemic. CounselingSchools asked them about their experiences navigating the pandemic for a mental health professional’s perspective.

Dr. Kirk Honda is a licensed marriage and family therapist, a professor within the school of applied psychology at Antioch University in Seattle, and the host of the “Psychology in Seattle” podcast. He has been treating individuals, families, and couples since 1996.

Emily Kircher-Morris is a licensed professional counselor (LPC) in St. Louis specializing in the area of giftedness throughout the lifespan. She is also the host of the podcast “Mind Matters.” She has a private practice in the western St. Louis suburb of O’Fallon, where she has a private practice specializing in gifted and family counseling, group counseling, testing, and education services.

Overcoming Challenges of Teletherapy

Like many counselors and therapists, in the last few months, Kircher-Morris has had to move her client meetings online. Prior to the pandemic, she had only offered digital therapy on a case-by-case basis with clients.

For many, video chatting, talking over the phone and especially corresponding via text message are just not the same as meeting with someone in person—especially if there is no established rapport between the mental health professional and the client.

“I think that there’s definitely something that is lost as far as just being in the same space with somebody,” Kircher-Morris said. “There are those subtle non-verbal interactions that you notice and react to, sometimes not even consciously, that makes it more difficult to get that same connection [online].”

While Dr. Honda is more focused on his students and podcast these days, he has also conducted teletherapy from time to time, when a client or he was traveling.

“It’s a whole different set of skills and set of things to consider—it’s a very different kind of treatment,” he said. “In person, therapists are trained and supervised and learn how to convey empathy to build a relationship that works for therapy. How do you translate those skills to video conference or phone? It’s very different. Sometimes when you’re video chatting you get ‘all business.’ It feels cold. As a therapist, you can kind of feel like you’re in a cold space.”

Dr. Honda talked about the struggles that his students and supervisees have found in trying to connect with clients online and over the phone, particularly those that have never met in person before. But just because there are barriers to connecting at a distance doesn’t mean it’s impossible.

“One of the things I’m telling my students is that it begins in their own heart,” Dr. Honda said. “If you as a therapist really dig down deep and find your compassion and your care for the other human on the other side and extend yourself through the video conference, that can inspire your heart, which then you can translate that into behavior that translates into the client feeling that connection, which translates into a better relationship which translates into better outcomes.”

Kircher-Morris said she has been resistant to offering online counseling, especially because most of her clients are younger. “I wasn’t convinced you could get the same level of engagement and make as much progress,” she said.

But she adds breaking through to make those connections online has required her to be more thoughtful in how she is engaging with her clients.

With clients of all ages, she says it helps to keep a running PowerPoint that is screen-shared during sessions that she and her clients can refer back to and modify in order to keep goals and progress in mind. With children, having online one-on-one games to play while talking helps engage and relax her clients.

“The pandemic really forced me to stop digging in my heels and look at things in a different way,” she said. “I’ve had some clients that are brand new, who I’ve never met in person, and we have been able to develop that rapport, and I don’t necessarily think it’s taken any longer.”

So, while teletherapy does present some challenges, it’s still possible to connect with clients—even without an established rapport, but it requires some extra effort and creativity.

How Is the Pandemic Affecting Demand for Therapy?

Teletherapy is not only changing the logistics of counseling and therapy; it’s changing the market, as well.

While the demand for online services like TalkSpace and BetterHelp has grown since the onset of the pandemic, the demand for traditional one-on-one mental health services has actually decreased, according to a recent report about mental health from the World Health Organization (WHO).

Of course, a big part of this is due to stay-at-home orders, which have prevented people from seeing their therapists or counselors in person, prompting many to simply suspend their treatment for the time being.

But the fact that demand for online platform-based therapy has increased suggests that a majority of individuals that have sought therapy since the start of the pandemic are choosing platform-based services instead of local counselors and therapists.

This may be because googling search terms like “online therapy” or “digital counseling” yields top results for websites like BetterHelp and TalkSpace. Local therapists and counselors like Kircher-Morris that are now offering their services online (but are not registered on platforms like BetterHelp) are not prioritized by the algorithm.

“Trying to go out and market during this time has been difficult,” Kircher-Morris said. “You can imagine what kind of budget you’d have to have to compete with a large organization [like BetterHelp or TalkSpace]. They have much larger marketing budgets than small businesses do.”

Kircher-Morris went through a period of seeing fewer clients and receiving fewer inquiries from potential clients at the start of the pandemic, which happened to “quite a few of the local counseling businesses I have been in contact with,” she said. Her practice is also likely affected by the fact that she majoritively treats children and teens.

“It’s purely anecdotal at this point, but in my circle, there is an uptick in adults and couples, but there has been a downtick in children and teens,” Dr. Honda said, adding that the situation in Seattle might be a bit unique because of the local economy, which is home to Amazon, Microsoft, and other prominent tech companies.

“Seattle’s economy is pretty strong and so many of the tech people can work from home, so perhaps people here, in comparison to other areas of the country, have the security to afford therapy because a lot of people just pay for therapy out of pocket,” Dr. Honda said.

But Kircher-Morris added that in St. Louis, it looks as though things are beginning to return to normal.

“I know that in our area now, people are starting to get out a little bit more. I had clients who suspended counseling who now want to come back in,” she said. “That gives me some optimism that things are going to get back to where they were, but it’s been interesting to see.”

The Challenges of Teletherapy Platforms

One of the biggest downsides of platform-based services like BetterHelp is that they are generally not covered by health insurance, Medicare, or Medicaid.

Weekly sessions will still run you $160 to $280 a month if you are seeking weekly sessions. Sessions cost clients $40 to $70 per session, which is much less than the average cost of traditional therapy or counseling (before insurance.)

This may appeal to patients who are looking for a licensed counselor or therapist, but don’t want to bother with insurance and can afford to pay out of pocket.

But from a mental health professional’s standpoint, having a middleman introduced between the client and therapist, which essentially charges a finder’s fee, means counselors and therapists that choose to participate in this model make much less money per session than they do normally.

“It is reported that BetterHelp pays around $30 per hour and TalkSpace pays around $20 per hour. Compare that to the average hourly fee of a therapist running their own practice, around $100, and it averages out to a 75 percent pay reduction,” Therapy News reports.

The option to be able to offer services through online platforms can expand one’s potential client base, which is appealing and perhaps necessary for some professionals during the pandemic that need more clients. But obviously, making less money per session creates the need to work more hours to reach the same monthly income, which can cause burnout and potentially reduce your quality of care, which is something to consider.

Looking Forward: The Future of Telebehavioral Health

Is teletherapy a replacement for in-person services? No, not entirely. Despite your best efforts as a mental health professional, the truth is that digital sessions aren’t going to be effective for every client.

As the WHO said in its report, digital approaches to mental health services “can be effective and scalable, though their limitation is that illiterate, poor and older populations have much less internet or telecommunications access, and such approaches are not an answer for all mental health needs. Other modalities of care continue to be important.”

But offering services online—whether through Zoom or a platform like BetterHelp or TalkSpace—is a tool that can be useful for some, especially during this time of crisis in which mental health services are more important than ever.

“I feel like the thing that this pandemic has required all of us to do is really face our discomfort with uncertainty,” Kircher-Morris said. “I think that a lot of times people go through life creating a sense of continuity and structure, sometimes it’s almost like a perception—whatever that routine is, it gives us that comfort. We all seek that.”

For many counselors and therapists, this perspective-altering time of crisis has been the push to be open to incorporating new mediums to their services.

Nina Chamlou

Nina Chamlou

Writer

Nina Chamlou is a freelance writer from Portland, OR. She writes about healthcare, psychology, economic trends, business, technology, digitization, supply chains, education, aviation, and travel. You can find her floating around the Pacific Northwest in diners and coffee shops, or traveling abroad, studying the locale from behind her MacBook. Visit her personal website at NinaChamlou.com.