Teletherapy is a mixed bag for clients and clinicians alike, but ultimately a useful tool

This article from Watershed Voice is part of Mental Health Workforce Crisis: Effective approaches to improving the pipeline, a solutions-focused reporting series of Southwest Michigan Journalism Collaborative. The collaborative, a group of 12 regional organizations dedicated to strengthening local journalism and reporting on successful responses to social problems, launched its Mental Wellness Project in 2022 to cover mental health issues in southwest Michigan. 

After a suicide attempt in 2014 and a nearly two-week hospitalization, Packy Earnest needed help in the worst way. What she got instead was another mental health professional she didn’t connect with, who didn’t provide the kind of care Packy felt she needed.

“I was spilling my heart out to her, and I (told her) I was standing on the street corner after work, and I was just feeling like absolute shit,” Packy says. 

“And I was thinking in my head, ‘What's stopping me from jumping in front of this car right now? What's stopping me from jumping in front of this train right now?’ Then she asked me, ‘What was the difference between that feeling and the feeling you had when you tried to commit suicide?’ And then she was like, ‘Okay, well, it's time to go.’ And so I was left with this thought for two or three weeks, and it really f----d me up.”

It wasn’t until later that Packy, who has tried upwards of 20 different therapists while living in Arizona, Florida, and now Michigan, found what she was searching for thanks to teletherapy. After giving Better Help a try until “it got too expensive,” Packy got what she needed from Illume Wellness Group in Sturgis. 

She has been seeing Connecticut-based counselor Sarah Findlay, M.A. for the last year through teletherapy, and says Findlay is the best therapist she’s ever had.

“We just have a really good relationship. I ended up meeting her because my best friend passed away last summer, and I was going through a grief journey or whatever. And I hooked up with her and she helped me through that. And I don't know, we just hit it off. She just has a kindness about her, like she cares.”

Packy Earnest Packy is far from the only person using telehealth for therapy, as there’s been a rapid increase in the use of telehealth for both physical and mental health services since the COVID-19 pandemic began (Kaiser Family Foundation, 2022). Nearly four in 10 Americans (38%) have used telehealth services to meet with a medical or mental health professional, up from 31% in the fall of 2020.

With nearly three in 10 adults in the U.S. reporting symptoms consistent with depression or anxiety disorder since April 2020, telehealth has played a role in meeting the need for mental health services. 

Some with private insurance have received improved coverage for mental health and substance use after providers removed pre-pandemic restrictions on coverage for those services via telehealth. Medicaid also expanded coverage of telehealth services during the pandemic, with many state Medicaid programs reporting telehealth has helped maintain or improve access to mental health services during the pandemic.

‘Too impersonal’

While telehealth is convenient and helpful for some, it isn’t for everyone. Patients can face three overlapping barriers to accessing telehealth: the lack of technology, digital literacy, and reliable internet coverage. These factors disproportionately affect older people of color and those with low socioeconomic status.

It can also feel impersonal. Teletherapy creates physical separation between therapist and client, limiting non-verbal communication, as it’s more difficult to utilize body language to connect and build trust.

“My husband hates it,” Packy says. “He says he doesn’t want to bring that type of energy into the house. And my best friend hates it too. She likes the face-to-face therapy. She says telehealth feels too impersonal.”

Ashton Smith of Three Rivers has similar feelings about teletherapy, and while he uses it for his trans-specific group therapy that meets once a month, he prefers to visit the therapist he sees more regularly in-person.

“It was kind of nice because I was able to be at home and do it; that was more convenient timewise so I could choose a better time that worked for me. But in-person therapy versus telehealth at home — it's so different,” he says.

Ashton Smith looks through pictures on his laptop on a Saturday afternoon at Scidmore Park in Three Rivers. He participates in group therapy once a month online, and sees another therapist on a biweekly basis who specializes in gender affirming careAshton started telehealth therapy while he was still living at home with his parents, which made opening up more difficult.

“I wanted to open up about stuff but because I felt so comfortable in the space I was in, opening up about that just didn't feel normal,” he says. “When I'm in my therapy office now I'm able to just word vomit because that's what that space has always been for. That's why I go there but like being at home and doing that, it's very hard.”

Teletherapy got easier when Ashton moved into his own place but he still prefers the in-person experience. “Living on my own helped a lot because then I knew I was the only person home, and I didn't feel the anxiety of someone (potentially) being at the door listening.”

Ashton started using telehealth when searching for a gender therapist to help him medically transition, and simultaneously wanted to find an in-person therapist to work on his childhood trauma. 

“There was a lot of confusion with (my parents) in the beginning, and then slowly they've come around,” he says. “It's been a long journey. It's been a lot of me pushing and asking them to just listen to me rather than to focus on what their beliefs are. And it's gotten a lot better the past couple years, especially after medically transitioning, which I thought was a little weird, but after doing the medical part I think that's when it started to really click for them.”

A combination of online and in-person therapy could prove to be a good long-term solution post-pandemic. One study (conducted before the pandemic) found that a hybrid approach improved how quickly clients could be seen and the likelihood that they would continue regular visits, according to Mental Health America

Ashton says if it weren’t for the combination of online group therapy, and in-person care, it would have been “ten times harder” to talk about transitioning with his parents. Therapy has not only given him the courage to talk with his parents, it’s given him the tools to go about it the right way.

“Therapy has made it easier for me to bring up transitioning topics by finding the right words to bring it up rather than coming from the very aggressive ways I was using when I was a teenager,” Ashton says. “I used to not answer my parents unless they used the right name for me. After working with a specific therapist that specializes in gender-affirming care, I found better ways to bring it up to my parents in ways that would help them understand, and better the relationship between us, (instead of) feeling like I had to put a higher wall up than before.”

Telehealth for a clinician

As there are for patients who use teletherapy, there are benefits and drawbacks for therapists as well. Dr. Chris Barnes, a licensed clinical psychologist and founder of Kalamazoo Counseling and Assessment Center, says 30 to 40 percent of the center’s sessions are done via telehealth following the pandemic.

“Not many people did telehealth therapy before COVID but fortunately, in our field, we were able to pivot quite quickly,” he says. 

Barnes says in order to continue to generate revenue, his offices had to offer more telehealth services, which also enabled his staff to provide vital services at a time when more and more people needed them.

“COVID didn’t discriminate on people's situation,” he says. “There were some people going through some crazy stuff, and then it got crazier, and to be able to continue to offer support to them, and to remain a constant in an otherwise super ambiguous situation, I think was beneficial in both ways.”

Prior to the pandemic, Barnes had multiple offices, including one with “a 50/50 partner” in Three Rivers, before consolidating and moving operations to Kalamazoo after the pandemic began. 

Telehealth made the transition easier, as Barnes was still able to provide services to his St. Joseph County clients, while removing many of the barriers that previously stood between people living in rural communities and therapy. 

“In fact, the no-show late cancellation rate went from a little bit (of the time) to very few moments where there was some headcount on the calendar of who didn't show, because it removed all the barriers,” Barnes says. “It removed a lot of inconveniences. I think it was a really good thing.”

While teletherapy has been good for business, there have been plenty of drawbacks. Teletherapy has made it easier for therapists to go independent, as it cuts much of the overhead costs most mental health professionals would incur in order to make such a move.

“It's way easier for someone to go independent now because they don't need the infrastructure that they once did,” Barnes says. 

“Telehealth is so accessible, there are clinicians working in their guest room. I mean, they did it for two years, three years (during COVID) and so you know, why go spend X amount of dollars on a space and a separate phone line? And could you effectively be a clinician with a $300 laptop or even just an iPad? Sure. And so it's the cost of entry into the private practice sort of independent practice has been significantly reduced.”

Going independent isn’t bad in itself but the consequences of so many taking that route when the country is already facing a psychiatrist shortage, is taking a toll on the potential hiring pool for practices like Barnes’.

“There's not as much community,” he says. “We're seeing a lot of individual practitioners, not necessarily improved practitioners. And the pool of available clinicians has significantly reduced, it's impossible to find help these days. I've been looking for additional clinicians for months.”

Staff shortages also mean heavier workloads for the clinicians Barnes does have. Barnes estimates he sees an additional one or two clients a day with telehealth, which has a “whole list of consequences.” 

“Like everyone I know, which again, is a small sample of the overall clinician population, we're just getting crushed,” he says. “It's good for business, but it's not looking so rosy for us as humans; we're all suffering.”

Ultimately, Barnes says telehealth is a good thing, and the way the psychiatry community was pushed into it, benefitted the industry.

“I think telehealth has always been a good thing, and forcing our hand into it made it like a flooding exposure,” Barnes says. “You just had to hold your breath, and then figure it out. Instead of being nervous, delaying our initiation of it, and then getting to a place where it was OK, we were just pushed into the deep end, and I don't think that was a bad thing.”

Enjoy this story? Sign up for free solutions-based reporting in your inbox each week.