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Teletherapy and the promise of access

Reviewed by Robert Bogenberger, PhD

A woman video chats on her laptop while taking notes

On a cold, blustery morning in Northern Ontario, Canada, a community mental health case manager named Megan begins her day.

Megan is driving to her client Joe’s house (name has been changed) in the outskirts of the city. After their session, she hops back in her car and heads to her next appointment. Because her role includes medication observation, Megan or someone from her team will return to Joe’s house before noon and possibly again this evening before racing the setting sun home.

Therapy delivered online or by phone, commonly known as “teletherapy,” has been heralded for years as a way to connect mental health professionals with communities like the one Megan serves. During the COVID-19 pandemic, when demand for therapy skyrocketed, teletherapy was widely celebrated for helping make care more accessible to those who need it most.

Except none of Megan’s clients use teletherapy.

“They just don’t have the money for phones or internet,” she says. “And those who do often have more severe diagnoses that can’t be treated virtually.”

Megan’s clients aren’t alone. Even as many clinicians and patients sing the praises of teletherapy, a significant number of people around the globe remain disconnected.

Once positioned as the magic bullet for accessible mental health care, has teletherapy really lived up to its promise?

Convenience and appeal

Tuera Holland, LMSW, began her studies in social work at the University of Pennsylvania right before the pandemic. By the time she was ready to start practicing, everything had gone online.

“At first, I was disappointed,” Holland says. “That was not the way I envisioned my practice. I really loved the atmosphere of the therapist’s office, and I wanted to give that to my clients.”

Forced to offer teletherapy by circumstance, Holland quickly embraced the autonomy it gave her. She believes her clients feel similarly about its benefits.

Teletherapy is easier for some working families. Many of Holland’s clients have young kids, as does she. Finding childcare isn’t always possible, especially in the evening. Teletherapy gives parents the ability to take care of their mental health from the comfort of home—no commute required.

Teletherapy works in most clinical scenarios. Overall, teletherapy has proven effective.1 While more research is needed, studies show that teletherapy can help people with a variety of diagnoses, including depression.2 It has also shown positive results for clinicians in treating serious mental illnesses like bipolar disorder and posttraumatic stress disorder.3

Teletherapy appeals to a younger crowd. In a recent YouGov study for Forbes Health, Millennials reported using remote therapy more often than Baby Boomers and Gen X combined.4 Then there’s Gen Z, who live much of their lives online already, making them the ideal candidates for teletherapy.5 My own Gen Z daughter loves being able to lie in bed talking to her therapist. Holland says a lot of her teletherapy clients show up in similar settings.

Teletherapy may be more affordable for some. If you have insurance and switch from in-person meetings to teletherapy with your current clinician, you may still be covered. However, Mental Health America reports that more than five million adults with a mental illness are uninsured, and 42% of adults with a mental illness have been unable to receive necessary care because they couldn’t afford it.6 Teletherapy apps like BetterHelp and Talkspace are trying to close this gap by charging less and offering payment plans. But at $60 to $90 per weekly session, they’re still out of reach for a lot of people, and they have other possible downsides (learn more below).

Barriers to access

Teletherapy is often more convenient and accessible for those who were already receiving mental health services. But potential new clients face a number of roadblocks, especially if they live in underserved communities.

Teletherapy comes with extra costs. Even if you have free or discounted access to teletherapy sessions, as some of Megan’s clients do, you still need to pay for internet access at home or a data plan on your phone in order to connect. Overall the world may seem very online, but there are almost three billion people globally who have no access to the internet.7

Teletherapy requires technological literacy. The year my grandmother got cable, I spent at least two full days teaching her the difference between the TV remote and the cable remote. I can’t imagine how she’d react to the internet, let alone video calls—and she’s just the demographic teletherapy already has trouble reaching. A quarter of adults age 65 and over report they never go online, and the same age group is less likely to use smartphones.8, 9

Teletherapy doesn’t fix the shortage of clinicians. As more people seek out mental health support, the clinician deficit becomes more urgent. The American Psychological Association reports that 6 in 10 practitioners say they no longer have openings for new patients, 46% have been unable to meet demand, and 72% have longer waitlists than before the pandemic.10 So even if teletherapy is an option for you, finding a professional to work with isn’t guaranteed.

Teletherapy doesn’t address inequity in the field. The scarcity of clinicians particularly impacts clients who are looking for therapists of color. According to a Bureau of Labor Statistics study from 2021, 76% of mental health counselors identify as White.11 Holland says it’s impossible to overstate how meaningful it is for young people of color to see clinicians of color. “When you’re part of any marginalized group, a lot of what we take with us in our day-to-day is the isolation that comes with it,” she says. “Having someone who understands your experience without your having to spell it out is important.”

The slow march of progress

Movement is underway toward alleviating some of these issues. The 2022 Affordable Connectivity Program has provided financial assistance to help broaden access to internet service and smart devices. During the pandemic, the US government changed its rules to allow Medicaid recipients to receive teletherapy.12 In Canada, the government has partnered with more than a dozen internet service providers for the Connecting Families initiative, which offers subsidized high-speed internet to eligible low-income households.13

To help address the lack of diversity in behavioral health, US states are looking at both the clinician side and the client side.14 Training initiatives are addressing trauma around structural racism and creating paths to bring more people of color into the mental health field.

Considerations for therapy apps

Direct-to-consumer platforms that connect people with clinicians were already gaining popularity before the pandemic. In the years since, some of these companies have become major players in teletherapy: BetterHelp, for example, now serves more than 2.5 million people.15 But these platforms face some challenges.

Anytime access vs. boundaries

One problem, says Holland, is the promise of constant access to your therapist. BetterHelp and Talkspace both offer private “rooms” in which to send your therapist a message any time you want, day or night. Your therapist will see the message and reply, although both sites make it clear that may not happen right away.

Holland worries this level of access is unhealthy for patients and clinicians. “For the most part, therapists are not crisis workers. There is a difference,” she says. As a former crisis worker, Holland appreciates the value of teaching clients to rely on natural supports, such as trusted friends and family, along with helplines and other community resources.

“So much of our work as clinicians is creating and maintaining professional boundaries and teaching clients to rely on natural supports when possible,” she says. “I feel like these companies chip away at that.”

A matter of privacy

With any app comes the question of data privacy. Along with collecting vital stats such as your age, gender, and location, mental health apps ask very personal questions like the last time you felt suicidal or how depressed you’ve been this week. This information is collected by the app before you’re even considered a client—at which point you’ll be covered by more protections. But in the meantime, reporters at Jezebel found, some of your private information is passed on to social media and research companies.16

If you’re worried about sharing your data with a mental health app, the American Civil Liberties Union (ACLU) has created a website with tips for navigating this concern.17

Teletherapy can’t succeed in a vacuum

Megan loves her job but is frustrated by the inequity she sees every day. Although many people were able to move online and enjoy the convenience of teletherapy during the pandemic and beyond, her clients didn’t have that option.

As demand for mental health care continues to grow, bigger and better social nets are a necessary piece of the puzzle, Megan argues. Otherwise we risk leaving a large slice of our communities behind.

“My clients’ circumstances didn’t change during the pandemic,” she says. “They still needed help, but they still didn’t have internet or phones.”

This month, is exploring the future of digital mental health. What’s next for therapy, now that tech has truly entered the room? The first piece in this series takes a close look at virtual reality and its evolving role in mental health treatment, especially exposure therapy; and the second piece explores whether AI chatbots are useful enough as a mental health care tool to overcome their flaws.

About the author

Amye Archer, MFA, is the author of “Fat Girl, Skinny” and the coeditor of “If I Don’t Make It, I Love You: Survivors in the Aftermath of School Shootings,” and her work has appeared in Creative Nonfiction magazine, Longreads, Brevity, and more. Her podcast, “Gen X, This Is Why,” reexamines media from the ’70s and ’80s. She holds a Master of Fine Arts in creative nonfiction and lives with her husband, twin daughters, and various pets in Pennsylvania.