Telehealth: Wait, There’s Online Therapy?

Stop the presses! Randall Stross over at the Digital Domain at The New York Times has just discovered online therapy.

Acknowledging that the idea has been around for a long time, Stross begins the piece by digging up an American Journal of Psychiatry article from 38 years ago, written by Thomas Dwyer describing one of the first telepsychiatry systems ever devised (at Massachusetts General Hospital). How quaint. (Confusing telepsychiatry/telehealth systems — which have been around for decades utilizing private networks and closed video systems, and that are well-researched — with online therapy is a common mistake made by journalists who explore this area.)

The hook, apparently, is to highlight yet some more companies who’ve decided to take the plunge into exploiting this modality:

Today, even with the rise of the Internet, virtual therapy hasn’t been widely adopted. But several start-up companies are trying to make Dr. Dwyer’s decades-old vision a workaday reality.

Despite having little new to say or to add to this topic — for instance, where’s the consumer demand for these services? — I found the article somewhat interesting nonetheless. If for no other reason, to point out how these articles all follow the same tired template: offer a unique hook, point out the opportunity, quote the research, highlight a new service offering a solution, quote some naysayers, and end with a tie-in to your opening hook.

The Times piece mentions two companies. Why they are singled out is anybody’s guess, but the cynic in me might suggest they have better PR than the companies not mentioned.

Cope Today — for only $140/hour — will let you see a therapist online via video, phone or online text chat. HealthLinkNow is focused on the employer market, believing that if they can just get large employers to sign up for this benefit for their employees, employees will enjoy having the additional resource available to them. I would mention at least one other company that should’ve been mentioned, and that’s Breakthrough, which has also enjoyed some success in this round of startups.

Here’s the argument for employers signing onto these services:

Barb Johnston, the chief executive of HealthLinkNow, says: “I think you’re going to see larger companies provide rooms in which employees can seek telemedicine services, including mental health services. That way, the employee won’t lose a half or a whole day of work for a consult.”

Really? I’m going to walk into a special room in the company, spend an hour in there, and then walk out and not have to worry about any prejudicial or weird looks from my co-workers or boss?

This is the delicate and odd balance we have with healthcare in the U.S. Employers often pick up the majority of the costs of health care services, but we want them knowing nothing about our health and well-being. (This problem could be fairly readily solved by disconnecting health payment from employers, giving employees the equivalent money, and having them purchase insurance on their own.)

I also suspect any company pursuing the employer route is going to eventually face the hard realities of these services provided through an employer — low utilization rates. People simply don’t trust these kinds of services offered through their company, because no matter what is said, they believe some or all of the information shared with an online therapy service might make it back to their boss.

While that would be a violation of federal law in the U.S., it doesn’t mean it doesn’t happen, even if sometimes in unintended ways. For instance, aggregated data provided to a company about utilization of services may not be anonymized or “cleaned” properly, making individual identification possible (it’s happened in similar cases).

Getting back to the article, I believe that Cope Today’s pricing is just ridiculous. For $140/hour, you can pay out of pocket to see the best psychologist in your community (in, I’d say, more than 90 percent of the country). The only advantage that Cope Today offers is convenience.

After describing the two startups and their business models, Stross makes the opposite case, pointing out all the problems online therapy faces — the lack of nonverbal communication (although, strangely, this is tied to videoconferencing when it’s much more of a concern with email-based therapy interventions), technology mishaps, and the assertion that getting up and physically going to a psychotherapy appointment is, in itself, an important component of depression treatment. While indeed physical exercise can help people with depression, a person who sees someone online is in no way limited from being asked to engage in such exercise as a part of their treatment plan.

Last, there’s a bunch of words devoted to what to do about people who present online and then have a crisis, where immediate assistance is needed. One simple way to deal with this problem is to ensure online therapists get emergency contact information:

Ms. Malik, of CopeToday, says the therapists she represents […] do not collect personal contact information from their online patients. “If you’re counseling and it escalates, we would call 911,” she says.

What good is the emergency phone number 911 without information about the geography or address of the person you’re counseling or is in crisis? I’m all for pseudonymous psychotherapy interactions — we offered them on HelpHorizons in 1999 — but you can’t pretend you can also offer crisis service backup in such cases.

Last, the issue of reimbursement of online therapy is also raised in the article, which is still very much a patchwork quilt of coverage in the U.S.:

But companies promoting online therapy must contend with uneven or absent support from insurance companies, Medicare and Medicaid. Most states don’t require insurers to pay for “telehealth” services (those not delivered in person). And any reimbursements can be less substantial than for in-person treatment. Medicare offers reimbursement only if providers are very scarce, as in rural areas.

The APA offered a nice summary of the current state of reimbursement of online therapy here in March. Some private insurers pay, most notably Blue Cross/Blue Shield in some — but not all — areas.

I’ll end this online therapy update with the same thing I said six months ago — it’s a great modality that still has little consumer demand for it. People are so used to getting services for free online, the idea of having to pay for professional therapy online is still not something most are willing to do. If it’s going to cost pretty much the same as it would for face-to-face services, many are going to opt for the face-to-face services.

Which isn’t to say there still isn’t potential for online therapy — there is. There are dozens of online clinics like Cope Today, and hundreds of individual providers offering online therapy, seeing thousands of patients every month. But it’s still a drop in the overall psychotherapy bucket — a bucket that continues to decline in utilization year after year. Perhaps online therapy can help slow or even reverse this decline, but it remains to be seen whether the idea can match the market reality.

2020 Update: It’s so quaint to see this article originally published in 2011, nine years later. Online therapy (or e-therapy) is now firmly ensconced as one of the many legitimate, research-backed modalities available to people seeking psychotherapy.

Read the full article: Bringing Therapists to Patients, via the Web