A Crisis Creates a Natural Experiment
The coronavirus crisis in this country is going to result in the largest natural experiment in the delivery of technology-based mental health services the field has ever seen. In late March of this year, thousands of behavioral health practices in the U.S. began transitioning from in-person therapy to telephone and online therapy. This has not been an easy transition for practitioners because new technology, training, and protocols have often been needed to make this transition. It has been an especially difficult transition for practices that never used technology-based therapy services, but they are making it work. This natural experiment will give us a lot to think about related to the future of mental health technology.
Not only are mental health providers all over the country stepping up to the challenge of transitioning to technology-based mental health services, but many are also offering these services on a volunteer basis. For example, in late March, New York’s Governor Andrew Cuomo sent a letter to all licensed mental health therapists in the state asking for volunteers to provide tele mental services to New Yorkers trying to cope with the trauma of the public health threat, job loss, family upheaval, and institution-wide closures. Over 6,000 license mental health professionals heeded the call and committed to helping staff the state’s emergency mental health hotline.
Filling a Gap in Services
Even before the crisis, interest in technology-based mental health service delivery was growing because of unmet mental health service needs across the country. Those living with physical disabilities, who lack access to easy transportation, or who live in sparsely populated rural areas with few to no behavioral health providers, need more access to behavioral healthcare and technology-based mental health care was starting to be viewed as the cure to a serious problem.
According to Mental Health American, over fifty percent of Americans with any mental illness (AMI) are unable to access care. People in certain states in the U.S, many in the southeast, for example, have more difficulty accessing care. The high cost of mental health care prevents many Americans who lack health insurance, or adequate mental health coverage, from accessing care. The lack of treatment for specific disorders in certain regions is another challenge, as is the scarcity of mental health providers, including psychiatrists. A lack of providers is especially a problem in some rural areas and low-income urban areas across the country.
Barriers to Implementation
There are some key barriers to the adoption of technology-based mental health service delivery for many providers including not having funds available to invest in technology and training, concerns about effectiveness, and concerns about client confidentiality. Providers often need to purchase special software to provide remote psychotherapy. This software enables providers to integrate the delivery of remote therapy sessions, electronic recordkeeping, HIPPA compliance, and payment. Telemental Health Comparisons provides a comparison of leading tele mental health software products.
If a practice does not immediately have the funds for software or to train providers, they may be able to transition in stages. There are some government and private grants that can help support providers in making the transition, but competition for funding will be very high at this time. There are also government-sponsored training programs to support providers in expanding or beginning to offer online therapy.
Another barrier to implementation is resistance to change and questions about the efficacy of remote therapy. Some therapists worry that without having a client in front of them they will be unable to effectively observe a person’s body language and affect. Others are not confident about using remote therapy technologies.
Some providers also have ethical concerns about security and confidentiality in delivering therapeutic services remotely. Providers must ensure their computers and internet connection are secure to prevent the breach of client data. Software programs can help ensure the practice conforms with HIPPA and that online records are secure. Ethical guidelines related to the delivery of technology-based therapy and the electronic storage of records must be followed. The National Association of Social Workers Code of Ethics have been updated to provide guidelines on the use of technology in clinical social work (see ethical standards).
Despite these challenges, some practitioners who were forced to make the switch to technology-based service delivery in a hurry have found their clients are adapting well to technology-based mental health services, and in some cases, are even more engaged using these new modalities. Joanne Iorio, LCSW-R, is an experienced private practitioner based in Queens, NY. She had to quickly switch to telephone-based appointments when the pandemic hit NY in mid-March. This was her first-time ever meeting with clients by phone and noticed something interested. She explained, “despite the negatives of initiating a brand-new relationship with a client exclusively by phone, surprisingly some clients seem to open up more on the telephone!” She said she’s not sure if this increased sharing is because clients are more comfortable in a non-clinical, home environment or whether some are simply more comfortable talking over the phone. Whatever the reason, she said, the comfort level and quality of sharing via this modality were unexpected.
Different Modalities for Delivering Technology-Based Mental Health Services
Technology-based mental health services include teletherapy (conducted by phone), therapy delivered via video conference, and therapy and services delivered via apps, texting, or chatting. Services are delivered by individual therapists, behavior health practices, or online companies. There has been a proliferation of online companies that offer easy access to mental health counselors whom you can chat with online or meet with via phone or video conference. Consumers pay for a bundle of appointments or pay a set fee per week. Online Medical Care has ranked their choices for the top five online mental health providers.
There are some challenges with online mental health services as well. Some online therapy providers have said clients sometimes simply stop responding to their messages. Others have said they do not have enough time, or find it difficult, to establish an effective therapist-patient relationship via texting, chatting, or online meetings. There are also inter-jurisdictional issues that arise when providers are asked to work with clients from other states where they are not licensed.
There also has been a proliferation of apps designed to help users manage anxiety, panic attacks, and other mental health problems through step by step relaxation techniques, psycho-education, or personalized recovery plans. Chatbots may simulate check-ins from a therapist. These apps can be conveniently accessed on various mobile devices, but there are concerns about the effectiveness of these apps as well.
The Effectiveness of Mental Health Technology
Technology-based mental health services have been around for longer than people realize. For example, “telepsychology” has been around for several decades and was initially pioneered and widely used within the military. But are technology-based mental health therapy as effective as face to face therapy? A growing body of research suggests that remote and online therapeutic services are living up to their promise.
Online and remote mental health services have expanded access to care for specific groups such as young people, who have expressed a preference for online services, and veterans. For young people, online counseling can be a gateway to more intensive, in-person treatment if needed. For veterans, online counseling can be a lifeline. “A four-year Johns Hopkins study that included close to 100,000 veterans found the number of days patients were hospitalized dropped by 25 percent if they chose online counseling.”
As for online apps that guide consumers through breathing exercises, provide psychoeducation, and use chatbots, there also are some promising data, but it is more mixed. One app was found to deliver “measurable improvements on the nine-item Patient Health Questionnaire, the seven-item Generalized Anxiety Disorder scale, and the Positive and Negative Affect scale among college students. ….. however, that these students had not been officially diagnosed with depression or anxiety.” Not all apps use evidence-based techniques, and this is a concern.
A 2018 article on mental health apps founds four specific features that make certain apps more effective for uses. These features include: high patient engagement; simple user interface and experience; the ability to address several different diagnoses through one program; and allowing users to self-monitor their mood and emotions through regular reporting of their thoughts, behaviors, and actions.
The Future of Mental Health Technology
The Anxiety and Depression Association of America provides a list of tele mental health providers by state on their website. Tele mental healthcare offers great promise for greater access to mental healthcare in the U.S. and around the world. We may not be able to fully assess the benefits of these new modalities for several years, but judging on recent studies and consumer feedback, they seem to be having a positive impact.
Stephanie Bosco-Ruggiero
B.A. Political Science| Vassar College
M.A. Urban Affairs | University of Delaware
Social Policy | Fordham University Graduate School of Social Service Doctoral Program
March 2020
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