November/December 2020

Mental Health: The ABCs of Telehealth for Mental Health
By Navya Singh, PsyD
Today’s Geriatric Medicine
Vol. 13 No. 6 P. 6

During the coronavirus pandemic, teletherapy has become a vital support system.

Mental health problems carry a significant burden of disease globally and impair the quality of day-to-day life for millions of individuals. In the United States, nearly 20% adults live with a diagnosable mental health condition. Mental illnesses are complex and can have many underlying causes, with complex neuro-biological processes responsible for their onset and maintenance. Problems such as depression, anxiety, and substance use can build up over prolonged periods and cause significant emotional distress and functional impairment.

Despite the high prevalence of mental health problems, there’s a significant gap between mental health needs and the available resources. This gap is more pronounced in rural, semirural, and other underresourced areas. Although recent years have seen a rising awareness of mental illnesses, inadequate and delayed access continue to be barriers to treatment. Compounding this problem are the substantial costs associated with available mental health resources, making them unaffordable for many people whose conditions need to be diagnosed and treated, hence leaving a sizable underserved population.

In the last decade or so there’s been an increasing acceptance of telehealth for mental health and digitally enabled solutions to deliver outpatient care for a spectrum of mental health conditions. Telehealth not only ensures timely access but also can be cost-effective in many instances. Online mental health resources have opened new avenues for individuals to seek help in a comparatively discreet manner. With the global outbreak of the novel coronavirus pandemic, teletherapy has become a vital support system for individuals with preexisting mental health conditions as well as for those dealing with elevated levels of anxiety, stress, loss, and isolation due to economic and social changes.

The dynamics of dealing with mental health conditions in an online environment can be vastly different than those in a face-to-face setting. Accordingly, it becomes necessary for individuals seeking online therapy to be aware of some basic concerns before making an appointment. Providers recommending telehealth should be aware of these concerns and discuss them with their patients.

Deciding if Telehealth Is the Right Solution for a Specific Condition
Typically, teletherapy is a more suitable option for mild- to moderate-severity depression, anxiety, stress-related conditions, sleep problems, and emotional distress. It may not be advisable for emergency or high-risk situations where an individual needs immediate response (or even hospitalization). Teletherapy is beneficial in situations in which individuals find it difficult to cope with emotional distress due to various reasons such as the loss of a loved one, interpersonal conflict, work-related stress, anxiety, and even chronic physical illnesses that can affect emotional health.

Finding the Right Fit
Finding the right therapist can often be a challenge. This is true not only for teletherapy but also in the case of traditional psychotherapy. Qualified and experienced therapists should be able to provide maximum information, including their educational backgrounds, credentials, licensure details, number of years in the profession, area(s) of expertise, and emergency response procedures.

Selecting the Right Communication Medium
The availability of multiple online platforms has made it easier for patients and therapists to communicate with each other. The choice of communication medium will primarily depend on the severity of the mental health condition, the patient’s comfort level, and their need for privacy. Patients who want to maintain strict confidentiality may prefer the anonymity provided by online portals or chat facilities, while those who struggle with expressing themselves in writing may opt for videoconferencing to communicate. For certain people, especially those residing in rural or remote areas, lack of sophisticated digital infrastructure may restrict the options to a few media such as telephonic therapy. Whatever the case might be, it’s important to set specific parameters and guidelines for how to use the communication medium and ensure privacy for the patient. The therapist or provider should also make themselves familiar with and be comfortable using that particular mode of virtual communication.

Being Able to Disclose Sufficient and Relevant Information to Therapists
The success of therapy depends to a large extent on the adequacy and relevance of information shared by patients with therapists. In face-to-face settings, therapists are able to gauge subtle things such as patients’ body language and verbal cues. Such observations become difficult in a virtual environment, even if the communication is conducted via video chat. The decision to seek help from an online therapist is just the first step. In addition to relevant information related to history of the problem, any known triggers, symptoms, and other factors, patients must, at all times, be encouraged and have the willingness to share critical information. This can include changes in mood, behavioral or other symptoms experienced, self-medication or substance abuse, thoughts of self-harm, and any other dimension that will assist the therapist in diagnosing the condition and delivering adequate interventions.

Accepting Limitations and Risks Associated With Teletherapy
The advancements in teletherapy and the proliferation of telephonic or digital therapy services are relatively recent. The COVID-19 pandemic has led to a drastic shift: All forms of health care, including mental health, have moved toward digitized delivery. However, like other modalities of care, this, too, has inherent risks and limitations. Teletherapy is not advisable as a solution for individuals who require a higher level of care, such as during hospitalization or emergencies. Even in the most advanced settings, technology can sometimes be unreliable due to bandwidth and connectivity issues, making it a frustrating experience for both the therapist and patient. Despite these limitations, the entire field of health care appears to be moving rapidly toward this form of care delivery.

Maintaining Privacy
Privacy remains a paramount concern for many patients seeking help for mental health conditions. In the case of teletherapy, privacy concerns become more pertinent for people who are living with family (or even friends and roommates) and do not want to disclose the fact that they are seeking help for mental health conditions. Due to coronavirus-related restrictions, many people have been confined to their homes, which may leave them with little or no privacy to communicate with therapists via telephone or videoconferencing. Individuals who are contemplating teletherapy will need to keep in mind the availability of safe spaces (if they want to keep their discussions confidential) from where they can interact with therapists without interruptions.

Exploring Different Formats
One of the advantages of teletherapy over in-person therapy is the higher degree of flexibility it provides. In some cases, online therapy can take place via a combination of video, telephone, and text messages. This mix of audio, video, and text communication tools can be leveraged by patients to explore different formats and determine the medium (or a combination of media) that works best in their specific situations. In the initial stages, individuals, especially those who are transitioning from in-person sessions to teletherapy, must prepare to adapt to a virtual environment. Getting used to online therapy may take some time; however, keeping an open mind and understanding that the end objective is the same may help in removing any initial ambivalence.

Sharing Feedback With Therapists
As is the case with patients, many therapists may be fairly new to the concept of teletherapy and virtual counseling. Due to its recent proliferation, especially after the novel coronavirus outbreak, therapists, too, are still getting used to providing therapy in digital environments. Thus, it becomes important for patients to share feedback with therapists regarding anything that is inconveniencing them, including communication style, the option to try out alternative communication media, or even the quality of time being spent with patients. Working from home may have unintended consequences for both therapists and patients; this can sometimes lead to distractions. In all such cases, patients are advised to maintain a high degree of transparency and share their concerns with therapists without hesitation.

Dispelling Skepticism Associated With Teletherapy
Teletherapy and in-person therapy are similar in intent. In some ways, teletherapy may be considered a viable alternative for individuals who cannot access traditional therapy due to limited mobility, lack of mental health facilities/clinics, high cost of traditional therapy, or reasons related to protecting privacy or seeking help discreetly. It has been established that meaningful and trust-based relationships can be formed through purely online interactions, and these factors play a key role in increasing the efficacy of treatment. Before embarking on the teletherapy journey, patients should be encouraged to set aside any skepticism associated with it and approach the process with an open mind.

The coronavirus pandemic has brought about sweeping changes in the way people engage with each other. With some forms of physical restrictions expected to continue well into the future, telehealth, including teletherapy for mental health, will play an increasingly important role. Putting off treatment might not be a viable solution for most individuals. Teletherapy is, in fact, a great option for people who are dealing with mental health problems and need immediate as well as effective care.

Although teletherapy has made slow progress over the years, the pandemic has forced both patients and care providers to accelerate the adoption of digitally enabled services. While there will be differences in physical and virtual settings, that should not be a reason to refrain from exploring telehealth as a viable alternative to traditional psychotherapy for much-needed mental health interventions.

— Navya Singh, PsyD, is founder and chief clinical officer at wayForward.io Digital Mental Health (www.wayforward.io), and an adjunct research scientist in the department of psychiatry at Columbia University in New York.