Colleagues, acquaintances, e-patients, media and others often ask me, “What’s the state of online therapy? Does it have a future?” My answer hasn’t changed significantly in the past decade, for good reason — very little has changed in the field.
For folks who may be unawares, I’ve been a part of the mental health landscape and online therapy since the early 1990s, and e-therapy specifically when it started to hit the scene hard in the late 1990s. In fact, I coined the term “e-therapy” to describe online psychotherapy — a specific modality of psychotherapy that utilizes many techniques and features of traditional face-to-face psychotherapy. In 1999, I joined an e-therapy startup — HelpHorizons.com — as the industry’s youngest COO and led that company to a successful acquisition years later.
There’s no dearth of professionals willing to give e-therapy a try. In fact, when we ran HelpHorizons in the early 2000s, we had over 1,000 professionals at one point who signed up for the service.
What we lacked were people who actually utilized or wanted to utilize the service. And that’s the key problem with online psychotherapy: It’s a great modality that few consumers actually want to use.
One way around this problem, from a business perspective, is to simply get health or employee insurance plans to sign up for an e-therapy service based upon offering this as an “added benefit” for employees or covered lives in the plan. The idea is simple — if X% of insured lives use online therapy over face-to-face therapy, it’ll save the insurance company some money (because typically e-therapy is a little less expensive than traditional psychotherapy — but not significantly so when practiced via live chat or video conferencing services like Skype).
The problem comes when the rubber meets the road. If you look at utilization rates of people who actually use e-therapy services, they’re frightening. Nobody uses it. Nobody cares for it. Okay, that’s an exaggeration, because obviously e-therapy is right for some small percentage of people who need or want psychotherapy services. But the important thing is that it’s neither right nor used by the vast majority of people who have access to it. Once insurance companies review the utilization rates, they cancel the contract. If nobody is using the service, what’s the point of offering it?
Over the years, I’ve talked with dozens of people who’ve tried out e-therapy. I always ask them the same question, “Why did you stop?” Two factors have emerged — cost and face-to-face is more authentic a therapy experience.
People don’t like to pay for services online, unless it is helping them in a game (think Farmville, Cityville or Second Life), or to buy a subscription to an established information source. Even that bastion of pay-for-service model — porn — has given way to free porn. Nobody pays for porn any more, which has devastated the porn industry (or so I hear!). Nobody pays for advice either (since there are hundreds of places you can get free advice online, including our own Ask the Therapist service, and Psych Central Answers).
So all that leaves is paying for a real therapy interaction.
Well, that’s cool — there are some people willing to do that. And many therapists willing to provide that. But when you look at things like cost, you find out that you can see a real therapist face-to-face for either less (because your insurance covers the majority of the cost of care) or just a little more (if you choose to pay out of your own pocket). And trust me, when it comes time for mental health treatment, there is something definitely reassuring in talking to another human being in the same room with you.
Which is the other reason that people stopped with e-therapy service. They used it for a short-term problem, and didn’t need it any longer. Or it showed them that what they really needed was to see a real therapist, face-to-face. The feedback I’ve gotten is that while online therapy can be rewarding and reassuring, it doesn’t compare with the authenticity (at this point, anyway) of a face-to-face therapy interaction.
Additionally, many of the benefits of e-therapy quickly lose their status when you move e-therapy from asynchronous communications (two people are logged on at different times) — secure email, for instance — to synchronous communications (two people must be logged on at the same time). Once you require a therapist to spend the same amount of time talking to you online (whether it’s through Skype, chat room, or text messaging), the therapist is going to charge similar amounts of money as they do for face-to-face sessions. So one of the primary benefits of online therapy in the past — reduced cost, whenever-I-want convenience — flies out the door.
“If I have to schedule my online session just as I schedule a face-to-face session with a real-life therapist, I might as well see the real-life therapist,” is what I often hear. Which is what the vast majority of folks do when confronted with the actual costs and inconvenience of real-time, synchronous online therapy. Add to that that most insurance companies still do not cover the cost of online sessions, then it’s a no brainer. Face-to-face, traditional psychotherapy is often less expensive and more emotionally fulfilling than a comparable online therapy session.
Sometimes it’s hard for a businessperson who doesn’t have a deep background in mental health reimbursement to see the realities and complexities of behavioral healthcare in the U.S. Some appear to have the naive belief they can change a marketplace overnight that’s been formed through decades’ worth of existing treatment, mental health policy and administration, politics, budgets and reimbursement schedules. That a TV commercial and a mention in the The New York Times is all it takes.
Mental health professionals who’ve spent any time actually working and getting reimbursed within the current system know how difficult and convoluted the system really is. Billionaire and AOL founder Steve Case thought it would just take some technology and gumption to change healthcare in the U.S. when he launched Revolution Health in 2004. A few years later, disillusioned, he sold the remnants of his company to Everyday Health.
Healthcare in the U.S. isn’t going to change quickly — or overnight. The ObamaCare bill and Mental Health Parity Act don’t really do much to change the playing field when it comes to online therapy. And there still has been little demand for online therapy from consumers, because they don’t see a cost-benefit ratio that makes sense to them. Media hype notwithstanding, this particular application of telehealth makes the most sense for people who live in rural areas and can’t get to see a therapist locally. That’s a good market, but a small one.
I have a lot of hope for the future of e-therapy making small inroads into the mental health treatment space over time. But this part of telehealth is the least interesting right now from a business perspective because the consumer demand remains extremely limited.
22 comments
“Media hype notwithstanding, this particular application of telehealth makes the most sense for people who live in rural areas and can’t get to see a therapist locally. That’s a good market, but a small one.”
I live in Australia where the mental health system is not keeping up with the demands of rural mental health. To my way of thinking skype therapy is a greater part of that solution, but again, medical insurance both private and public does not cover anything except face to face therapy with a psychologist or a registered psychologist.
With the vast distances needed to travel to/from the outback and the number of country people unable to see a therapist along with with the increase in mentally afflicted rural and aboriginal youth and adults who see suicide as a solution to their problem, the Australian Health System needs to look outside the square and embrace insurance-paid skype therapy as a realistic alternative to health professionals who do not wish to leave the city – as it their right.
I will continue to campaign for skype therapy for non-city dwellers until it actually happens.
agreed. i travel a lot, am never in one place. i need therapy desperately and the first professional in line will get my $.
I think there is a strong parallel to online grocers of the 1990s. I can’t help but consider webvan, a company that many considered would make grocery stores obsolete by delivering online groceries from orders placed over the net. That company and a handful of other online delivery websites are now not existent. I think the overlooked variable is the experience. People need experience and although seeing a youtube video of Italy is exciting, it hardly company’s to the real thing. With that in mind, I do think teletherapy has it’s applications and will continue to grow.
Perhaps there’s a gap between someone who thinks they might need a therapist and someone who knows they need one. An online therapist might be someone they feel more comfortable talking to to begin with for a few weeks while they and the therapist figure out whether they want to start going to see a therapist in person regularly.
A question and a comment.
Why would the cost of telephone therapy or Skype therapy to the therapist be the same as the cost as face-to-face, since either can be conducted from a no-overhead location (say, the bedroom, with the door shut?) There’s no commute cost, no office cost, no nothing. It may not make a diff to the therapist if s/he is “seeing” just one Skype patient a day, but if the practice grows more significant, there really could be “Skype” days from home.
You wrote….
“Which is what the vast majority of folks do when confronted with the actual costs and inconvenience of real-time, synchronous online therapy. Add to that that most insurance companies still do not cover the cost of online sessions, then it’s a no brainer.”
With all due respect, Skype involves no commute time to and from the therapist’s office, Skype is a free program, and there are no other costs involved in a Skype session besides maybe a webcam/mike if you have an older computer that doesn’t have one built in. What costs am I missing? The bigger issue is that insurance companies don’t routinely reimburse. And the bigger problem still is the quality of the session. That one makes sense. It can just feel better to be in the room.
However, that doesn’t mean Skype/phone doesn’t have its place. Imagine a long-standing therapeutic relationship with a career Foreign Service worker who gets posted to Malta and wants to continue therapy. Skype to the rescue!
hi there. I’ve been around alongside you in my own fashion (as a journaling survivor) over these past decades, and I hear what you’re saying here.
My benefit from wifi and online services has definitely come from email. Some things are easier said online. Of course I do have a 3D therapist in real life, but the advent of the internet has helped greatly in being more honest via an email and then responsible to continue discussing that topic in person.
I also am certain that the internet fostered intense survivors groups… people from all over were able to share their stories and find hope for themselves as well as offer hope and help to others.
I definitely believe in e-therapy with the right people. (Both doctor and patient) I think it might be more easily used by younger generations in the future (who might actually be better off with face-to-face therapy)- everything is digital; they’ve grown up digitalized. It will be interesting to see what happens in the future.
btw, thanks for being here all these years. 🙂
Instead of e-Therapy, I used self-therapy (autoterapia) with one of my very old close friends.
It worked very well and is described in my book “ACREDITA EM TI. SÊ PERSEVERANTE!”
I agree truly with your method if you can establish a good comunication channel and empathy with your client.
Mário de Noronha, PhD DtH
psicologiaparaque.wordpress.com
I agree with much of what you say here John. You are one of the early movers and shakers and your work, advocacy and passion for online mental health has influenced me greatly.
I always advise therapists who want to work online to expect few to knock on their virtual office door just because the virtual shingle is hung and an encrypted service is being utilized. It takes as long or longer to build an online presence as an online therapist~ private practice is private practice and marketing and business skills are critical.
But even so- even for the “practice building” savvy among us, I advise that online therapy is great ADDITION to a therapist’s existing suite of services. What I do believe, and my private practice bears this out- is that existing face-to-face clients want the option of meeting via distance technology when they cannot come in for a traditional in-person appointment. I also believe that online methods of delivery such as between-session emails and self-paced programs can be a wonderful enhancement to traditional counseling and psychotherapy services.
I also work with a major EAP company in Canada that has provided online (asynchronous) options to their clients for over a decade. The numbers suggest that roughly 10% of the clients choose the online option. Because this is a large EAP the numbers are quite impressive- but still, it represents 10% of overall services.
The key is for organizations and individual practitioners to be able to provide technology-enhanced options in a cost-effective way. This is feasible with EAPs and insurance companies simply folding in the online options into an existing platform or licensing a platform that offers a various private label options.
I believe the uptake will increase as the internet in general becomes more mainstream AND the stigma about mental health care continues to decrease.
I could go on, but those are my initial thoughts. Thanks for sharing John!
TPG – You’re assuming that a therapist could completely substitute their regular, face-to-face practice for an exclusively online-only practice. A few — very few — therapists have successfully done this. The vast majority of them continue to have a regular, face-to-face practice as well — meaning their fixed costs remain largely the same.
And of course, while many of us take it for granted that everyone has high-speed broadband access at home (wherever you are in the world), the reality is very much different. So there’s that office cost (Internet access isn’t free for most of us), there are still administrative costs (for billing, since every insurance company uses a different form or system of billing), there are still the costs of using an e-clinic (if one chooses to go that route; otherwise the chance of people finding your practice online is much smaller).
Of course, the benefits may be worth it for many practitioners, and I think that’s why there’s never been any problem getting practitioners to sign up for this service. As I said, a decade ago, we broke no sweat getting over 1,000 clinicians signed up.
Until the billing issues are worked out, the technical issues become even more nominal, and the demand for service actually increases, however, I don’t see anything being all that different from 5 or even 10 years ago.
Sonia — Indeed, Australia always seems to be on the cutting edge of healthcare technology and specifically telehealth to service the vast rural population there. I think that’s great, and I think that in cases like this, it’s a no-brainer that health insurers should cover the costs associated with these services. It’s much cheaper to provide a telehealth interaction to a remote rural location than to provide an actual face-to-face human.
So the patient types back he/she is not suicidal, but you do not have the non verbal cues to challenge their verbal response. The patient commits suicide a day or two later, and then the malpractice issues commence.
Why do you advocate for non 1:1 contact as a viable form of clinical treatment of this level of care? And, wouldn’t you agree that the adage “you get what you pay for” does apply here? WHEN the consequences for trying to apply internet care to mental health services play out, what is the defense to pursuing this treatment intervention in the first place?
Yes, I know I said I was done replying here, but really, can any responsible clinician not voice a rebuttal to commentary of this magnitude?
Especially with the tragedy yesterday that probably will conclude mental health issues were a role to the shooter’s choices?
Joel – If you hadn’t noticed, suicide hotlines are staffed primarily by paraprofessionals — that is, non-professionals trained in crisis intervention. Their only tool is usually a telephone. Are you going to tell me these folks don’t help people with that tool, despite the lack of non-verbal communication available to them (all they have is tone of voice; none of the traditional non-verbals typically available in a face-to-face interaction).
In 15 years of online therapy, I’m not aware of a single lawsuit successfully brought and tried in any jurisdiction in the U.S. about the legitimacy of the standard of care of e-therapy. In fact, there’s dozens of research studies demonstrating that online therapy is a valid modality resulting in positive outcomes.
Welcome back! I guess you can’t help yourself but to comment on one of the Internet’s best health blogs!
Dear Joel,
What about skype therapy for those people who live in remote areas. Far more effective than the telephone. Also agoraphobics and the disabled would benefit from skype therapy.
I fail to see the connection between the shooting and e-therapy? Could you enlighten me please?
My therapist conducts skype therapy with a country client and has mentioned to me that he is greatly benefitting from it.
Dr Grohol,
I was hopeful about creating e-therapy website until I read your blog on this issue. I thought providing e-counseling services through a website would be the quickest way to start working as a counselor and gain full licensure. However, it seems like very few people are using e-therapy and gaining enough client contact hours for licensure would be difficult to achieve. Plus, I am worried that a temporary license wouldn’t be given to me because my proposed supervisor doesn’t know much about e-therapy. You are probably wondering why a young inexperienced counselor is trying to create an e-therapy website. Well, since graduating in December 2009, I have not been able to find a job as a counselor in my area (Fargo, ND). It seems employers want individuals who are experienced and already licensed. I could move (like the rest of my classmates), but I would have to go it alone. My wife would have to stay since she’s pursuing tenure at a local college and we are having a baby in June. Needless to say, it would be a significant sacrifice. Do you have any suggestions as to how I could start working as a counselor and work on full licensure when my opportunities are so limited? Would starting a private practice and paying for supervision be wise? As you said, there’s a desire for face-to-face therapy. What do you think of getting around the overhead associated with an office and providing therapy in clients’ homes? Any suggestions or advice would be helpful. I am running out of hope.
Sincerely,
MH
I too began in technologically mediated mental health care in the early/mid 1990s (having begun with telephone provision about 10 yrs previously). I have seen interest in the subject evolve from deep suspicion on the part of practitioners to a growing acceptance to its entry into the mainstream of provision as part – only part – of the range of services. To those for whom John’s post has been off-putting, I would say beware reversing that trend. Do not be discouraged so easily or we will lose the potential that is undoubtedly there.
Much of what you say has truth in it John, and it is valuable anecdotal evidence for the field. I am sure that what you describe is accurate. But I am also sure it is not the only story in town. There are services that have been popular with many thousands of clients a year. One example, the UK Samaritans (paraprofessional suicide prevention crisis help) has found its services vastly in demand even without promoting them (including email and text message). Some commercial services operate well on a large scale too (though few, I get the impression, with self-funded clients – is that so different in the f2f world?)
My thoughts include:
– e-therapy began in response to demand from clients. I was part of an early e-therapy working group when the Internet was still new and we were very cautious – but could not ignore the subject because clients were initiating the work and so guidance for practitioners became urgently required: it was being done so it was best it be done as well as possible. Clients should lead and should do so now so of course we should offer services in the media that are demanded to the extent they are demanded.
– Location plays a key role, as other respondents here have pointed out (many people outside cities, and outside the US, do not have access to face to face alternatives) but there are also relational advantages to online work in addition to the relational downsides (the obvious lack of visual cues) and financial aspects (online is cheaper if the provision savings are passed on to clients). They include the ability to present oneself as one wishes, a potential for equalising power between the parties, greater emotional safety, freedoms in transference and idealisation, disinhibition and so on, now well documented but not well known outside those who already know the subject well. There is therefore a need to educate about the differences so more informed choices can be made.
– therapy should be an evidence based practice (EBP). The therapy world reacted slowly, and in some sectors badly, to the advent of EBP (or EVT in the US) – thus any new intervention or modality needs to be empirically validated before the financial systems can make a rational decision to support it (insurance in the US; governmental bodies in places with more socialised healthcare like the UK). Therapy has a long history of engaging poorly with EBP/EVT, replicated in online provision, I think. There is still insufficient numbers of definitive RCT and cost-benefit research despite, as you note John, some excellent studies that give grounds for believing that online work is good enough to choose (working alliance is equivalent and so on). I have spent years asking for collaborators on studies that will establish the relative outcomes and/or economic benefits of online vs f2f work and am yet to have anyone take me up on the offer. Where research has been done, it has been very encouraging but we have not yet reached the threshold where funders have an easy choice on the subject – but are making progress. It takes 10+ years for a new intervention to be studied and then widely accepted, often more, and it might be argued that this is how it should be. We must progress with the evidence, not ahead of it: so lets get on and definitively answer the remaining questions while educating on the increasingly strong evidence that is available so far. Then self-funding clients (a tiny minority in many countries, like the UK) can make better informed choices and we will be in a better position to assess the ‘market share’ of online provision as part of the mainstream of provision.
– on the same theme, new technologies (including the sense of that word in healthcare, meaning ‘technique’) are almost always subject to early adopters leading the way with only some then being picked up by the mass of the population. iPhones did it. Home computers did it. I wonder whether we are at the stage where early adopters (clients and professionals) have done their part and are now at the cross roads where it will either remain active but relatively small or will grow to be a routine option for everyone to consider. It is too early, IMHO, to be pessimistic because there are dramatic success stories out there as well as practitioners whose expectations of an easy flow of clients have not been met (just as in f2f practice, in my experience).
– SO that leaves me wondering why we have not yet invested in the definitive studies we need to get the online therapy funding to match the f2f situation and take its natural place. Just because it isn’t a heatwave doesn’t mean the sun isn’t shining. Let’s get on with it – anyone wanting to join with research initiatives is welcome to contact me at [email protected]. I will look forward to it. :o)
On one or two occasions in face-to-face therapy, something I have said has brought tears to my therapist’s eyes. These have been extremely powerful moments for me, moments that made me understand that my experiences were not run-of-the-mill. (It’s amazing what we can justify/normalize in our own minds). I don’t think e-therapy would have been as useful.
What I have wished for in the past–and would happily have paid for–was the ability to e-mail my therapist between sessions when I needed a little boost, pep-talk, reframing, reality check…that sort of thing. Of course my therapists were always available via phone for emergencies, but I didn’t want to abuse that. It also entailed waiting around for the return call, and hoping it arrived at a time when I could find privacy to speak.
I understand why doctors and psychotherapists don’t like giving out e-mail addresses–there’s so much room for abuse–but if there were a mechanism to make this feasible as an adjunct to face-to-face, I would have found it useful.
As a consumer I have had the experience of using e therapyish services then opting to see the therapist personally. It was a disaster. Buyer Beware: they may not be what they purport themselves to be!
There are a lot of ethically-questionable companies out there backed by angel investors and VCs who will look to spin almost anything into suggesting telemedicine and telehealth services — delivery of sessions via videoconferencing (something available for over 20 years!) — is going to revolutionize mental health care. Nothing could be further from the truth.
The real power of e-therapy is in asynchronous communications — secure emails and texts.
Can you tell me how an email format can work in etherapy? I have a problem with face to face therapy. I withold my feelings and emotions when face to face and when via live phone.
But i am more able to have clarity with my feelings and sharing and havong a dialogue when i leave a phone message, with texting, email, and skyping (typing, NOT live video. I switch off the live video)
I have wasted time in therapy that was live face to face. But when I began emailing, it was easier to share my stories and feelings. The problem was that it was hard to
explain the experiences or issues and details in the email so that it wasn’t misinterpreted and 75% of the context and body of the emails was not retraced to or acknowledged by the therapist. Now the the therapist uses mobile phone to write and reply, the replies to my emails are usually summaries which never actually refer to various points and observations I am sharing in the body of the email. The result is that it’s unsatisfying and feels like the details are brushed over, ignored, or simply not acknowledged since no reference is made to the content.
Establishing a color for my responses would work but that requires a iPad or lap top and to have access to the therapist when I’m catching myself in a behavioral difficulty and she responds in email, it’s usually a summary. So it becomes labor intensive to write a response that covers all my points.
Have insurance companies covered this mode of thrapy for introverts or shy people who wouldn’t otherwise see a therapitst?
I want to add that there’s alot of frustration having to clarify the email context as it comes out harsh and brief sometimes when that was not the intent.
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