Online psychotherapy: Our mental health series

person taking video call on a tablet with a man

(Updated 2022) Cost and convenience have prevented millions of Americans from seeking access to mental health care. Yet online therapy makes  services more accessible, whether consumers choose fulllblown therapy, seek to connect and share information with fellow patients through online support groups, or use a  apps on the market that help patients fight anxiety and stress.

Online therapy, sometimes called telemental health, uses information technology to connect patients remotely with mental health services. Typically, this is in the form of online psychotherapy; or via live phone chat, video conferencing, or online chat functions.

Online therapy is not new, but its popularity continues to grow. This is thanks to information technologies that ensure privacy and allow for HIPAA-compliant online sessions, as well as the pandemic’s effects in increasing remote medical treatment.

“Online support groups have been around since before the web,” says Dr. John Grohol, founder of PsychCentral.  “I think these kinds of online communities are great. There’s a lot of research showing that these kind of self-help support groups are beneficial – not as a replacement for treatment, but in addition to it.”

These communities where patients can connect, share information, and support each other have another advantage: They are free.

Grohol sold PsychCentral to Healthline in 2020, but split off and kept the PsychCentral online community forums, which now can be found at MySupportForums.

Rapidly changing technologies have profound implications for mental health care, whether patients are seeking online psychotherapy, online support groups, or mental health apps that help with everything from lowering stress levels to battling depression.

“The research tells us it works, and it’s another alternative for people who are too busy to see a therapist in a traditional setting,” says Grohol. “Online makes sense.”

The pandemic also opened up all kinds of online medical treatment, and mental health is no exception.

The Advantages of ONLINE THERAPY

There are multiple benefits to telemental health, not the least of which is opening access to millions of Americans who live far from any mental health providers. According to the U.S. Health and Human Services Health Resources and Services Administration, 80 million Americans live in regions where there is a shortage of mental health care providers.

A recent study showed that providing TMH services to patients living in rural and underserved areas dramatically reduces psychiatric hospitalization rates. The study focused on 98,609 mental health patients receiving telemental health services from the U.S. Department of Veterans Affairs.  It showed that between 2006 and 2010, psychiatric hospital admissions of telemental health patients decreased by an average of 24.2%; the patients’ number of days in the hospital also decreased by over 26%.

Another advantage is convenience. Online therapy opens doors to patients who might otherwise not seek treatment. This includes people who travel frequently for work, members of the armed forces, or those who are too ill to get to a therapist.

Dr. Ann Becker-Schutte, a psychologist in Kansas City who specializes in treating patients dealing with serious medical conditions, frequently uses teletherapy. “For someone with MS or any number of other conditions, to be able to do a session even though they are having a bad day physically is a big deal,” says Becker-Schutte.

And online therapy is a viable option for patients who are too busy for an in-office session. This allows mental health providers to reach more people sooner.  “For our patients it is an issue of access and convenience,” says Julian Cohen, COO of Breakthrough, a California-based online therapy provider. “Maybe it’s because she’s a single mom with two kids, and she’s wondering how she’ll find time to see a therapist.”

Online therapy is also useful in meeting the unmet needs of certain populations. The National Council of State Legislators lists a number of promising TMH initiatives around the country, including:

  • Veterans Affairs is using telemedicine to provide mental health care for veterans.
  • State legislation in California requires the Department of Education to introduce telemental health technology in public schools to provide behavioral health services to students.
  • Providers and health systems are forming partnerships to broaden access to mental health services. The South Carolina Department of Mental Health and the South Carolina Hospital Association partnered with Duke University to launch a statewide telepsychiatry network, the first in the United States.

The Disadvantages of ONLINE THERAPY

However, psychotherapy by telemedicine also has its disadvantages, including:

  • Technical difficulties: The quality of the video teleconferencing equipment ranges widely. Some technical difficulties are bound to happen. Therapists and patients need to have an understanding beforehand outlining what to do if a session is interrupted due to equipment malfunctions (including who will call back, and how the time will be billed).
  • Training: While many of the skills therapists use in traditional settings apply to TMH, some mental health experts argue that certain signals are missed during online therapy. Training is important for newcomers to TMH. Breakthrough, for example, provides training for all of their therapists, each of whom have a private practice. “We screen and select our providers, and make sure they have the skills to do online therapy,” said Cohen.
  • Practicing across state lines: Technology may have no borders, but state regulations do. In many states it is illegal for a provider to treat a patient in a state in which he or she is not licensed.
  • Reimbursement: In-person therapy is more commonly covered than TMH, requiring many patients to pay out of pocket. However, there is some progress in this area. Many leading private insurers are providing coverage and reimbursement for TMH.

How to Find an Online Therapist and How Much Does it Cost?

Just as the cost of in-office therapy varies, so does TMH. Most online therapists charge anywhere from $1.75 to $4.99 per minute, according to a survey conducted by PsychCentral. And while telemental health was not originally covered by health insurance plans, there has been a general shift towards coverage.

Given the growing number of providers, it is easy to find a therapist who offers TMH. Before engaging with a therapist, it is important to ask for his or her state licensing number. The Zur Institute provides a list of online service providers.

We were interested to note that Wirecutter, the New York Times-owned recommendations site that reviews everything from laptops to sheets to home security systems, also reviews online therapy services.  The review begins: “It’s so tricky being a person, and therapy can help. Handling the appointment over video can make the process easier by expanding the number of doctors you can pick from, eliminating the need to get to a physical location for an appointment, and perhaps even reducing your out-of-pocket cost. After putting in more than 50 hours of research and trying appointments on three platforms, we recommend starting your search for an online therapist with Amwell.”

The American Psychological Association also lists a number of popular online therapy providers, including:

7 Cups is described by Wirecutter as “a largely peer-to-peer chat platform that has recently begun offering therapy with licensed counselors.” It offers professional mental health help via asynchronous messaging. $150/month.

American Well, now calling itself Amwell, which offers video conferencing and accepts some insurance. “Psychologists and counselors are here to help you with life’s challenges. Sign up now to speak with the provider of your choice,” the site says. “The cost of the visit varies from $109 to $129 based on the experience and credentials of the therapist.” If an employer is covering your membership, the cost may be lower.

BetterHelp offers asynchronous messaging, live chat, live phone and video conferencing. It’s an online service that calls itself “the world’s largest therapy service — 100% online” and claims “professional, licensed, and vetted therapists who you can trust.” The cost of therapy through BetterHelp ranges from $60 to $90 per week (billed every 4 weeks) and it is based on your location, preferences, and therapist availability.

Breakthrough (also called MD Live) offers video chats with a mental health professional and may allow some insurance companies to reimburse. Rates vary. The site says psychiatry initial visits cost $0 – $284, while therapy is $0 through $108, depending on insurance.

Doctor on Demand, which Wirecutter says “meets our basic requirements of being secure and accredited, but it offers fewer therapists and slightly pricier appointments.” You’ll pay a psychologist $129 for a 25-min. consultation or $179 for a 50-min. consultation, the site says; you’ll pay a psychiatrist $299 for initial 45-min. consultation and $129 for a 15-min follow-up.

Talkspace offers asynchronous messaging, video conferencing and voice messaging. Text, video and audio messaging starts at $69 a week; live therapy, with four 45-minute sessions per month, starts at $99 a week; the two combined start at $129 a week.  Their “approximate pricing” is on this page.

A complicated landscape for ONLINE therapy

But the landscape is changing.

Cerebral, a competitor, is in hot water over executives’ accusations of overprescribing, while Done Health, another online provider, is also struggling with similar issues. They charge people for managing their prescriptions online.

Bloomberg News wrote of Cerebral in March 2022: “No company in this business has grown faster or bigger than Cerebral, which operates in all 50 states and in two years has registered more than 200,000 patients. In interview after interview, Chief Executive Officer Kyle Robertson has touted a commitment to ‘increasing access to high-quality mental health care.’ But 27 former executives, managers, nurses, and other staff say Cerebral is failing on the ‘high-quality’ part of the goal. In its hunt for explosive growth, they say, it has made appointments too short, set follow-up sessions too infrequently, advertised too aggressively, pushed prescriptions too hard, and paid front-line staff too little. In some ways the company, based in San Francisco and funded by venture capital, follows the classic Silicon Valley playbook: identify opportunities among changing rules, move fast, drive employees hard. In psychiatric telehealth, the stakes are heightened by the prospect of patients in crisis and the risks of addictive drugs.”

Teladoc, the parent of Betterhelp,  said in a recent earnings report, that Betterhelp was partly responsible for Teladoc’s lower earnings guidance.

News reports suggested that the field is overcrowded. Teladoc’s stock slide has been blamed on many pandemic telehealth issues, among other factors.

Lantern offered online modules, asynchronous messaging and live phone chats at $49/month. It shut its doors in 2018.

Questions to Ask

The questions you would ask are the same you would ask of any practitioner:

  • What are your credentials? M.D., psychologist, social worker, other?
  • Do you have references?
  • What do you specialize in?
  • What hours do you have available?
  • What will this cost? What will it cost me?
  • Do you take my insurance? (if applicable)
  • What course of treatment do you recommend?

 

This is the fifth piece in our mental health series. The series, in its entirety, is outlined here.