Online Therapy

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Online therapy is booming, which probably isn't surprising amid the fears and concerns associated with the coronavirus pandemic and looming recession. Talkspace, one of the frequently advertised platforms, has raised more than $100 million from investors since it was founded in 2012, and it estimates that it now covers over 5 million lives through its partnerships with various health insurance companies and employee assistance programs. BetterHelp, another online therapy platform, has an estimated annual revenue of over $70 million, and its app was downloaded 80,000 times in April 2020. And these are just two of many online service providers. One listing of Internet Mental Health Services includes over 50 entries, and another estimate suggests that there are more than 100 online entities. If you're one of many people wondering if you should try online therapy, we've outlined the pros and cons of this growing field, along with some other important considerations, to help you make your decision. 

Why Online Therapy Is a More Accessible Option Now

There are several factors driving this trend toward online services:

  • Online therapy has been boosted by the perception of many people that office-based psychotherapy is difficult to access, more expensive, or just less familiar than the existing resources on their smartphone, such as email, text, apps and the internet.  

  • Insurance companies, such as Anthem, Aetna, Optum, and Magellan, often encourage subscribers to use online therapy platforms. This benefits their bottom line as these services provide a cheaper alternative to more costly psychotherapy services they would otherwise have to cover.  

  • Recently, this explosive growth in online psychotherapy has been further accelerated as therapists who normally practice in office settings are providing online therapy to new and existing clients due to public-safety concerns amid the coronavirus pandemic. While this online usage may be temporary, some therapists and clients may be re-thinking the need for in-person meetings.

Which Online Therapy Service Is Right For You?

Online therapy actually encompasses a wide range of services. You might see terms like telehealth, teletherapy, cybertherapy, e-therapy chat, live chat, text therapy, videoconferencing, and asynchronous and synchronous messaging. It is confusing to navigate, but it's important to understand what you are being offered. One major distinction is between online therapy platforms and teletherapy.

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What Is the Difference Among Various Online Therapy Platforms?

Online therapy platforms were developed by entrepreneurs in technology who created their own proprietary software that connects therapists with clients.  Many of these entrepreneurs describe themselves as technology providers rather than providers of mental health services. Like Uber and Lyft, which define themselves as platform producers rather than transportation companies, these entrepreneurs are changing the traditional psychotherapy delivery model.  

The key difference between these platform online providers and teletherapy providers is their exclusive reliance on internet-based interventions rather than offering the option of in-person meetings. Some platforms use email and text as their only form of communication between client and therapist, while others offer access to a therapist via videoconferencing or phone.  Those live phone or video contacts are often limited and cost a lot more per month for subscribers.     

Many online therapy platforms say that they are offering "unlimited" access to a therapist. What they often provide is the option of texting, emailing or using a chat-bot rather than a real-time conversation with a therapist. A client might email or text a question or concern, and the therapist would respond, sometimes a few hours later. This is called asynchronous messaging. 

What's the Difference Between Telehealth and Teletherapy?

Insurance companies describe telehealth services as those that are live communications ("synchronous") between healthcare providers and subscribers that use HIPAA-compliant audio (telephone) or video (online video conferencing) services. HIPAA refers to the Health Information Portability and Accountability Act that ensures that private medical information is legally protected.  

Teletherapy is a form of telehealth specific to mental health providers. These teletherapy contacts are sometimes paid at lower rates by insurers, but these contacts are treated as equivalent to office visits during public health emergencies. Therapists who are providing teletherapy as a temporary alternative to office visits are using phone and video-conferencing platforms as their primary form of contact with clients, as opposed to relying on email or text.

The Pros and Cons of Online Therapy

Online therapy platforms are exploding in popularity, but is that a good thing? It is important to consider the benefits and the risks before starting therapy online. Here's a closer look at some of the advantages often cited for online therapy.

1. Online therapy reduces geographic and logistical barriers.

Pros: There are major advantages of online therapy for people who live in areas with limited mental health resources or for those who have physical, visual or auditory disabilities that restrict their access to care. Online resources also benefit people who have challenges in managing child or elder care, and for workers who struggle with issues such as finding and paying for parking, getting across town for therapy meetings, or juggling their work schedule.   

Cons: There are benefits to having a defined and separate meeting place for therapy. The journey to and from your appointment provides time for reflection and a buffer from the rest of your daily routine. Office meetings provide a neutral and professional space to explore important aspects of your life. You are assured privacy and freedom from interruptions in that environment that might not be possible at home. It can also be more difficult to discuss disappointments and conflicts in your relationship when you know the person is sitting nearby.   

2. Online Services Are More Affordable Than Traditional Psychotherapy

Pros: Some online services offer unlimited access on weekly or monthly plans at costs that are lower than psychotherapy rates in private practice settings. Some insurance plans also compensate for certain affiliated online programs, or they sponsor their own free psycho-educational interventions.  

Cons: If you have insurance coverage for psychotherapy, seeing a provider in your network may actually be cheaper than services from online platforms. BetterHelp and Talkspace, two of the popular online platforms, both currently charge $260 per month for their unlimited plans, and there are plans with even higher costs. 

If your copayment is below $50 dollars, you could see a therapist five times in a month and still pay less per month than many of the online programs.  Many of the online service providers encourage use of text and email contacts as their primary form of treatment, rather than the personal and live services that you might have expected when you enrolled.

If you have a high deductible and copayment that makes psychotherapy unaffordable, or you don't have any insurance coverage at all, you can still meet with a therapist in person through a community counseling service or a graduate training program in psychology at a comparable rate to online therapy.

Related: 24 Ways to Get Free or Cheap Mental Health Care

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3. Online Services Reduce The Stigma of Seeking Help

Pros: Many online programs allow users to access their platforms anonymously. All that is required is an email address and a method of payment. People who are concerned about privacy and those who fear being shamed or judged by a therapist can locate providers while protecting their identity. 

Cons: While it might be easier to initially seek help through using an avatar or nickname, continued anonymity can perpetuate the sense of stigma. A powerful benefit of in-person psychotherapy is the transformative moment when you see acceptance and compassion in a therapist's face instead of the judgment or revulsion you might have predicted. It is precisely that human-to-human moment that provides essential healing from pain and shame-bound isolation. This benefit is less likely to occur when receiving a text or email response.

4. Proprietary Online Therapy Platforms Use Advanced Technology 

Pros: It is important to ensure that any online therapy service you obtain provides adequate security.  Many online platforms use 256-bit symmetric encryption technology comparable to that required by financial, military and medical institutions. In contrast, some of the HIPAA-compliant platforms available to therapists during the public health emergency have experienced significant problems with audio and visual quality due to the sudden surge in usage. Sessions can become disjointed or marred by sudden disconnections.  

Cons: Technology is easier for some people to access and utilize than others. Younger clients may navigate technology far more comfortably than older adults. As many as 84% of the users of Talkspace were under the age of 45. Geography can also still be a factor. If you don't have reliable internet access, the quality of the platform software makes no difference.

As a client, the confidentiality of your important personal information may be jeopardized if your own online privacy settings are not secure. You still need to take precautions like regularly downloading updates to your software, using strong passwords, and limiting access to your computer from other household members. While these advanced technologies offer some protections, both you and your therapist still risk identity theft, malware intrusions, and hacking. 

5. Online Platforms Can Accelerate Therapy By Offering Frequent or Unlimited Contact

Pros: Providing unlimited text and email contact between online or face-to-face sessions can augment support at essential times and provide in-the-moment interventions tailored for your experience. For example, in the midst of a panic episode, you might be sent a text with a breathing exercise to reduce your symptoms.   

Cons: There are reports about the unsatisfactory quality of many text and email interventions, with users complaining that they appeared generic or poorly targeted to their needs. If you are hoping for instant feedback, you might also be disappointed by long time-lags before receiving a response.  

In some cases, therapists suggest that you delay the impulse to immediately request help from others when you experience mild to moderate distress. Taking the time to mobilize your own internal resources and problem-solving skills when you encounter challenges builds resilience, confidence and self-reliance. Relying on outside help to solve problems may inhibit that important growth experience and keep you in a state of ongoing dependency.

6. Online Therapy Is Particularly Suited for Some Diagnoses

Pros: Supporters of online therapy have suggested that it is particularly helpful for people who have social anxiety disorder, agoraphobia or paranoid features. The implication is that online access removes barriers to treatment related to overwhelming levels of anxiety or mistrust that might prevent clients from getting treatment.  

Cons: Since voice tone and non-verbal communication (body language, gesture, eye contact, facial expression) have a significant impact on effective communication, it seems that online therapy which uses primarily email or text forms carries a significant risk of missed cues and misunderstandings.  

Some widely cited findings suggest that as much as 55% of the meaning in a communication is conveyed in non-verbal ways, another 38% is determined by tone, and only 7% is based on actual words.  While the applicability of these results from laboratory studies to real life transactions has been disputed, researchers still agree that voice tone and non-verbal behaviors strongly influence interpersonal communications.    

Related: 25 Mental Health Conditions You Might Not Know About

7. Online Therapy Improves Access to Specialists 

Pros: Proponents of online therapy suggest that it provides access to specialists who would otherwise be geographically out of reach. This allows you to see a provider who has expertise in specific issues rather than to be limited by the local resources and providers.

Cons: This is true as long as the expert provider is in your state. Most states have laws that prohibit treatment across state lines due to different licensure requirements. Some states allow for contact to occur across state lines on a limited basis, such as 10 days per year, but do not allow for open-ended services.  

These laws also protect you as a consumer from potentially fraudulent practitioners who may have lost their license due to unprofessional behavior. If something goes wrong in your treatment, you may have difficulty filing a legal complaint if the provider is out of state. Often, insurers will also not pay for services rendered in other states. If you are considering online therapy, find out where the practitioner is based and always obtain information about their licensure status.  

8. Online Therapy Provides a Gateway to More Intensive Services

Pros: If you have a positive initial experience with online resources and services, you might be inclined to seek additional services. This was the finding of one study at Stanford University. Clients with eating disorders who had a positive experience with an internet-based intervention program eventually sought treatment from other providers and programs.      

Cons: There is little data on how many users of online services continue on to seek necessary help. There are significant numbers of users of online services who simply drop out of programs and stop responding. Given that many of these users are anonymous, it is hard to know whether the experience of online therapy was more or less helpful to them. If your first experience of online therapy is unsatisfying, you might be as likely not to seek help again as to continue pursuing more.

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9. Online Therapy Has Been Empirically Validated

Pros: Multiple studies have compared online therapy to therapy offered in person. While the results of individual studies differ, many have found that online therapy resulted in reductions in symptoms for people with anxiety, depression, and other disorders.   

Cons: Many studies on psychotherapy have small sample sizes, lack control groups, and are not peer-reviewed. In addition, a large portion of the studies performed on the effectiveness of treatment use cognitive behavioral training (CBT) modules as their model for psychotherapy.  These training modules are valued by researchers because they are highly standardized packets of material that teach CBT concepts. This standardization makes it easy to ensure that researchers in different institutions and at different levels of training can use them. Participants in these studies are carefully screened to ensure that only those who meet strict diagnostic criteria are selected for inclusion in the research protocol.  Many participants drop out of studies, so the researchers then base their findings on the participants who completed the protocol.  

This is very different from psychotherapy in the real world. Psychotherapy is tailored to individual circumstances, needs, and goals, as opposed to offering one treatment protocol. Therapists also don't exclude clients because they have more than one diagnostic issue. There is a continuing need for research to clarify whether online services are equivalent to in-person psychotherapy. 

10. Online Therapy is a Better Delivery Vehicle for Psychotherapy

Pros: The traditional delivery model of psychotherapy is not working for many people. Subscribers are complaining to their insurance companies about a lack of access to therapy. Some who can afford to do so are hiring life coaches and wellness advisers to fill in the gap, but a lot of people can't afford these options. For almost 70% of Talkspace users, for example, the platform was their first experience with a therapist.

As a prospective client, you might have to call a list of therapists and leave a message describing your situation. You might not hear back from some of them, or you might hear that the therapist is too busy to accept new referrals. This experience can be very demoralizing, and it creates a perception of the psychotherapy profession as insular, indifferent, and uncaring.

Cons: It is important to be cautious about using platforms designed by entrepreneurs as opposed to healthcare professionals. This is especially true for people who are new to psychotherapy and unaware of ethical and professional standards maintained by therapy professionals. The platform owns the treatment records (not you or your therapist). What happens to the written, verbal and video information shared by you over the course of therapy, how is your information stored and managed, and does record-keeping comply with state and federal guidelines for protecting healthcare data? Some companies reserve the right to review transcripts of sessions. They may also use data collected during the course of treatment to quantify the most effective interventions. Are you comfortable with participating in their research process?

There are also other problems with the online therapy delivery model. The anonymity it promises raises ethical concerns about safety. In the event of suspected child or elder abuse and domestic violence, the anonymity provided by online platforms can jeopardize intervention required by law. Assessments involving potentially life-threatening situations, like suicide or in cases of danger to others, are also difficult to perform based on text or email data. These assessments are best performed in person where subtle non-verbal behavioral cues can provide the most complete picture of the situation.

What to Know Before Starting Online Therapy

  1. Make sure that you understand the type of contact (in person, videoconferencing, phone, email, text or online chat) that is being offered.  

  2. Ensure that any communication technologies are HIPAA-compliant.

  3. Know the qualifications of the provider, including license number and status (active, inactive, revoked, conditional, under supervision).

  4. Understand the fees that you are expected to pay.

  5. If insurance coverage applies, know who is expected to bill the insurer.

  6. Discuss with your therapist the suggested duration and course of treatment.  

  7. Ask who has access to your treatment records.

  8. Ask how records are protected, stored, and when or if they are deleted. 

  9. Determine what happens in the event of an emergency. 

  10. Ask about options if you are unsatisfied with your experience.  

  11. Obtain and read an informed consent document that provides full disclosure about the risks and benefits of treatment. Don't sign it until you understand what it means.

Carol Povenmire, Ph.D. is a licensed psychologist in Pasadena and Manhattan Beach, California.

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