Telehealth
4:59Wellness at Work Teletherapy is
on the rise as employees try to cope with the ’24/7
workday’
Millennials, born between 1981 and 1996, are the largest generation in today’s U.S. workforce. And while they may be revolutionizing and redefining the way we work — with more than 75% of them eschewing a typical 9-to-5 workday for a more flexible and fluid environment — this flexibility comes at a cost: a harried, hurried and overworked mass who is plugged in 24/7, pushing to work harder and better. Indeed, a whopping 77% of those who responded to a 2018 study by Deloitte reported experiencing employee burnout at their current job. Burnout recently has been redefined by the World Health Organization as a “syndrome” linked to “chronic workplace stress that has not been successfully managed.” According to the Centers for Disease Control and Prevention, stress can negatively affect job performance and productivity, engagement with one’s work, communication with co-workers and physical capability and daily functioning. While WHO does not classify the problem as a medical condition and rather an “occupational phenomenon,” it does conclude that burnout is a factor that influences health status and gives motive to contact health services outside of illnesses or health conditions. “The concept of separation between work and free time doesn’t exist for a lot of us,” says one millennial Manhattan attorney who did not wish to be identified. He says he spends three-plus hours round-trip commuting to his job from a Connecticut suburb. “Thanks to technology, we’re expected to be responsive regardless of where we are or what we’re doing,” he says, adding that “disconnecting only leads to feelings of guilt and anxiety.” Using teletherapy to cope Ironically, one of the culprits behind millennial burnout — technology — can also be utilized to extinguish burnout’s flame. Teletherapy, a form of telehealth, offers online counseling with licensed therapists via phone, webcam, email or text message. Also known as telepsychology, telemental health or telepractice, this service has been around for more than 20 years, originally utilized by the military to treat veterans and serve patients in rural areas. And now the convenient way to access mental health is catching on with millennials. “Being digital natives, millennials are naturally drawn to apps and online services,” says clinical psychologist Sonya Bruner, Ph.D., former clinical director of the largest online counseling platform, BetterHelp.com, where 23- to 28-year-olds make up 60% of its total users. In addition to BetterHelp.com, more than a dozen sites and apps launched in the last several years, according to the American Psychological Association, among them TalkSpace, 7 Cups of Tea, American Well, Breakthrough and Lantern. Packages vary; some charge weekly fees starting at $32, while others bill monthly at rates ranging from $49 to $150 per month. "[Teletherapy is] the new frontier in mental health counseling. It’s amazing how it’s caught on: It’s private. It’s convenient. It’s comfortable for both the therapist and client. And it eliminates the stress of traffic and time." - Goali Saedi Bocci, Mental Health Therapist There are also a growing number of mental health therapists, like Goali Saedi Bocci, Ph.D., of Portland, Oregon, who treat their patients remotely. “I treat my patients 100% online,” she says, adding that teletherapy is emerging as the “new frontier in mental health counseling. It’s amazing how it’s caught on: It’s private. It’s convenient. It’s comfortable for both the therapist and client. And it eliminates the stress of traffic and time.” Teletherapy vs. face-to-face care According to CTel, a legal and regulatory telehealth organization, many millennials embrace the practice of teletherapy. A recent survey of more than 3,500 insured adults throughout the U.S. found that millennials were “far more likely to express an interest in telemedicine compared to prior generations.” Among its fans, some who have posted reviews of their experiences on teletherapy websites are those who say, “I’m a ten-times better version of myself;” “I feel like I can talk in a way I can’t in any other part of my life;” and “My therapist always responds quickly and provides insight and direction.” Research says that teletherapy is not only “an acceptable alternative” to traditional face-to-face care, but it can be just as effective. Because millennials are used to and comfortable with communicating via mobile device, it appears to be easier for them to open up this way, especially when sharing more personal information. Here are some of the other benefits:
Employers are catching on Millennials are not alone in embracing teletherapy; as health-care costs skyrocket and employers seek alternatives to ensuring their employees’ mental health, many companies are in favor, too. Forty-seven percent of Cisco’s workforce is comprised of employees born between 1980 and 2000. The company embraces a “conscious culture” and recognizes the importance of addressing employee stress and burnout. As Ted Kezios, vice president of human resource global benefits explains: “We want our employees to recognize that we all have mental health, and offer personalized solutions to all our employees that address the spectrum of well-being. Likewise, we encourage our managers to listen to their employees with compassion and empathy.” Weekly “check-ins” allow ongoing communication between employees and their managers in an atmosphere of safety and trust: “Employees are encouraged to reflect back on the prior week and report on what they loathed and on what they loved.” So it’s no wonder that Cisco, who is also conscious of workload’s close relation to burnout, offers teletherapy to its employees to help them deal with work-life stressors and personal issues that might stand in the way of their performance. Last year they launched a program with Vida, a digital coaching platform with one-on-one coaching, offering guidance on nutrition, exercise, sleep issues and stress management. Additionally, the company offers other mental health perks, like teletherapy via some of its onsite health centers (where employees can connect virtually with a therapist after an initial in-person consultation); an online five-session mindfulness course and countless other online mental health resources. But therapists must do their due diligence, since rules and regulations for providing teletherapy vary by state. Insurance coverage, too, differs for users of teletherapy, depending on their provider. Some online services will accept specific independent health plans as well as employee assistance programs and behavioral health benefits, while others advise potential clients to check with their individual health insurance plans. Still, some are still not sold on the concept of online therapy — among them the 34-year-old Manhattan attorney, who says that although his is a generation used to getting satisfaction from their mobile phones, he wouldn’t use a teletherapy service. “In order to really focus on a conversation, I need to be physically present; I feel like I’d be distracted by yet another function completed via technology.” Jen Rice, a 23-year-old administrative assistant for a major entertainment company, tried a few sessions through the app Teledoc but didn’t continue. “I think a huge part of therapy is the in-person interaction and ability to talk face-to-face,” she says. Still, with time being extremely
limited and a precious resource for millennials, teletherapy
remains a viable, valuable and popular way for them to
embrace and combine their flexibility and tech-savviness
with a good cause: their mental health. A growing wave of online therapy The flexible nature of these services benefit clients and providers, but the onus is on psychologists to make sure they comply with federal and state laws. It was an ad on Facebook that first prompted Los Alamitos, California, clinical psychologist Nina Barlevy, PsyD, to visit the online therapy website BetterHelp.com. The company promoted affordable online counseling, available anytime and anywhere, and Barlevy thought joining their panel of therapists might be a great way to supplement her income during slow times in her private practice. "It looked like a good way to expand my practice here and there in my free time, if I was already going to be on my computer in the evenings or on my days off anyway," Barlevy says. She went through Better Help's rigorous application process, which included verifying that she was licensed, and began communicating with users in her state via the site's secure messaging platform. The site also offers members the option to schedule live video and phone sessions with their therapists, though Barlevy worked mainly with clients via the site's unlimited asynchronous messaging service. They messaged her about many of the same issues her face-to-face therapy clients were dealing with, including stress, anxiety and relationship issues, among other concerns, and she messaged them back with questions, feedback, insights and guidance. They benefited from easier access to therapy, which particularly helps people in rural areas who may not be able to drive an hour each way to see a therapist face-to-face. "[It is] a whole lot more appealing to be able to sit at your computer and type back and forth with someone," Barlevy says. Telepsychology, be it by phone, webcam, email or text message, has been around in one form or another for more than 20 years, used most often by members of the military. But the explosion of smartphone users has created new opportunities for app-based companies to offer more accessible and affordable therapy. Still, such online therapy creates concerns over patient privacy, as well as legal and ethical issues, including interjurisdictional practice issues, for providers who contract to work for these companies, which may not share the same code of conduct and commitment to do no harm, says Deborah Baker, JD, director of legal and regulatory policy in APA's Practice Directorate. Many of these online therapy companies also are not run by psychologists. "When you're an individual provider, you can't assume that a business is going to be looking out for your best interest, so you really have to dig a little deeper and check in with your professional association and malpractice carrier to make sure you're complying with the law and with the APA Ethics Code." Benefits for patients and therapists The growth in online therapy companies—nearly a dozen have launched in the last several years—doesn't surprise Lindsay Henderson, PsyD, assistant director of psychological services at Boston-based telehealth company American Well, which offers therapy through video conferencing. The ease and convenience of scheduling a therapy appointment online and talking with a therapist from the privacy of one's own home—or wherever one may be—is a huge draw for consumers, many of whom are seeking therapy for the first time in their lives, she says. American Well's online platform helps "normalize mental health care, especially among generations now who are so accustomed to interacting with people using technology," Henderson adds. "It just eliminates so many barriers." Research studies, many of which are listed in bibliography format by the Telemental Health Institute, also indicate that telemental health is equivalent to face-to-face care in various settings and an acceptable alternative. While much of the research tests only the use of videoconferencing as the telehealth modality, a few studies, including two published in 2013, have also shown that asynchronous messaging therapy can be as effective as in-person therapy (Journal of Affective Disorders and Cyberpsychology, Behavior and Networking). Even more encouraging is that when digital interventions are positive, effective experiences for patients, they may go on to seek face-to-face therapy, says Megan Jones, PsyD, adjunct clinical assistant professor of psychiatry and behavioral sciences at Stanford University School of Medicine. A study she led found that college students who needed a higher level of care for eating disorders were more likely to seek it out after participating in a digital body-image program and working with a coach online via asynchronous messaging through the online therapy company Lantern (Journal of American College Health, 2014). "It can really be a nice first step in treatment for someone who needs more intensive therapy," says Jones, who also serves as chief science officer at Lantern. Mental health professionals can also reap benefits from joining online care teams. In addition to supplementing practitioners' incomes with new patients, providing online therapy can help them maintain a better work-life balance, Henderson says. "From the provider perspective, the flexibility of practicing telemental health fits so well into my life and allows me to better meet my patients' needs," she says. "I'm not at a point in my life where I want to be going to an office at 8:30 in the evening, but I will happily go to my home office, lock the door and see a patient at that time." Employment at online therapy companies isn't limited to providing therapy to clients, either. Opportunities abound and will continue to grow in supervisory and training roles as well as full-time research positions at these mental health technology companies, Jones says. But tread carefully Of course, online care is not for every patient or practitioner. Clients with more serious mental illnesses or addictions likely need more treatment than digital therapy can provide. And some clinicians may find certain telehealth modalities difficult, says Barlevy. "I'm such a people person, so it was tough for me to feel a real connection when I was just messaging with people," she says. "Plus a lot of people just stopped responding, and I felt like there wasn't enough time to really build a relationship. It actually turned out to be more difficult than I imagined." In addition, some online therapy companies don't have clear guidelines for handling risky situations, such as a patient who may seem suicidal in his or her messaging responses, says Lynn Bufka, PhD, associate executive director for practice research and policy at APA. While some apps do report that they use a member's IP address to determine their exact location and send police if a therapist is concerned about a member's safety, it's often more difficult to determine a patient's level of risk via a messaging app than face-to-face with them in a therapy room. "If you're using an online therapy platform and you ask someone if they're suicidal and they say no, is that it?" Bufka says. "Those kinds of clinical issues come up, which is why I think most psychologists seem to feel much more comfortable integrating technology into an ongoing face-to-face or video/teleconferencing relationship versus using only messaging." Practitioners also need to do their due diligence when it comes to making sure their decision to contract with an online therapy company doesn't run afoul of complying with the Health Insurance Portability and Accountibility Act (HIPAA), state licensing laws and other legal and ethical practices, Baker says. In addition, platforms that allow patients to connect anonymously with therapists may create legal and ethical issues for psychologists. "My concern is that some of these models are probably start-ups that are launched by people in technology, who have good intentions but haven't fully investigated all the nuances in what's involved in providing health services," she says. "Do they fully understand HIPAA/HITECH, any related state laws and patient confidentiality policies? Do they fully understand that psychologists cannot simply provide services to patients anywhere in the United States?" Psychologists interested in joining these companies should investigate those issues, and also find out exactly where patients are located if they are providing them therapy services to ensure that they are authorized to do so. Such issues were part of the reason Columbia, South Carolina, clinical psychologist Shawna Kirby, PhD, decided to part ways with an online therapy company she worked for in 2015. After several months as a contracted therapist, she terminated the agreement, due to a series of ethical concerns she had over how the company dealt with interjurisdictional practice issues, consumer privacy, informed consent and therapy termination. When she brought her concerns to the company's clinical director and owners, none of whom are psychologists, she says they brushed off her concerns, and then eventually blocked her from messaging with her clients. "It all seemed more financially driven, rather than care driven," she says. That's why it's so important that psychologists play a leadership role at mental health technology companies, Jones says. "These companies need our knowledge and competency at the heart of their decision-making process because we have a very different framework and we understand the responsibilities that we have to users in a very different way than you do if you come from a technology background," she says. "I want to have a peer at any company like ours." Resources APA's guidelines for telepsychological practice TeleMental
Health Institute
3 things mental
health professionals need to know about teletherapy Rising healthcare costs, government-mandated access to healthcare, and a shortage of mental health professionals are driving demand for teletherapy. As a result, current trends suggest that virtual home, work or school visits will be routine in a few short years. Read this eGuide and find out how you
can expand your availability and reach – regardless of
geography – making it easier to provide quality,
consistent care to your clients. Implications
of Telepsychiatry for Cost, Quality, and Equity of Mental
Health Care - 101922 In the US, the practice of psychiatry and related disciplines is primarily regulated by the states. State licensure requirements, in addition to pre–COVID-19 expectations of in-person care, have contributed to the development of multiple, separate markets for mental health care. In each market, prices are based, at least in part, on demand for services, clinician availability, and cost of living within each geographical area. Expansion of telepsychiatry has challenged the expectation of in-person care and softened the boundaries of those compartmentalized markets. Telepsychiatry expansion could help decrease the cost of mental health care. Relaxation of licensing regulations could increase availability of clinicians, stimulate market competition, and lead to lower prices as a way to compete for patients.4 Eliminating commuting times for patients and clinicians along with greater flexibility in scheduling virtual rather than in-person care could further increase the functional supply and reach of clinicians including in underserved areas. Greater office sharing could lower overhead costs. Fewer missed appointments could increase treatment adherence, which, combined with broader access to experts, may improve clinical outcomes resulting in fewer failed treatments and decreased need for hospitalization and emergency care. Although these forces should lower per-unit service costs, they might not lower aggregate treatment costs. For example, greater access could lead to increased provision of discretionary care that could offset per-unit service savings.2 Furthermore, savings might not be passed along to patients, particularly if expansion of telepsychiatry leads to highly consolidated treatment markets. Consolidation could occur because larger systems may have advantages over smaller ones in marketing their services, navigating telepsychiatry regulations, or engaging in arbitrage, the practice of buying a product in one market (in this case clinicians’ time) and selling it at a higher price elsewhere.5 Consolidation could also limit patients’ ability to choose their clinicians. Expansion of telepsychiatry can also influence quality of care. Some studies suggest that outcomes are similar in virtual and in-person care, but whether that holds across disorders, levels of symptom severity, and populations is unknown.6 For example, in accord with the Ryan-Haight Act, prescription of controlled substances requires an initial in-person visit. This requirement has been suspended during the COVID-19 public health emergency. However, if there are concerns about greater medication diversion or lower quality in virtual care than in-person care, it may be reactivated once the COVID-19 pandemic emergency is declared over. More broadly, because it is easier to monitor cost than quality,7 crude implementation and scaling up of telepsychiatry care could lead to worse overall quality of care and patient outcomes. Fortunately, small amounts of monitoring can lead to substantial increases in quality of care.7,8 Thus, even modest advances in the assessment of the quality of telepsychiatry could lead to large increases in its value. Expansions of telepsychiatry could also help generalize standards of care, reduce unjustified practice variation, and moderate legal liability risks associated with deviations from standards of care. Nevertheless, tensions may arise in balancing broadly applied care standards with justifiable and desirable experimentation and local variation in practice. To ensure patient centeredness, patient preferences in delivery modality (virtual vs in person) should be carefully assessed without constraints imposed by clinicians, health care systems, or payers. Optimal hybrid models may vary by disorder type and chronicity, stage of care, and prevailing barriers to accessing high-quality care.2 Equity is also a key consideration. Lower costs could reduce inequities, as financial barriers to care have greater influence on those with fewer economic resources. To ensure that expansion of telepsychiatry reduces rather than exacerbates inequities by expanding access primarily for those with greater resources, it will be important to address the digital divide (ie, the gap between those with and without knowledge and easy online access).9 Investing in information infrastructures necessary to provide telepsychiatry will be central to improving care across populations and achieving equity. Expansion of telepsychiatry will have implications for multiple stakeholders through a complex interplay that will involve resetting treatment costs, challenges to assessing quality of care, embracing patient centeredness, and achieving equity. For patients, telepsychiatry is likely, at least in the short term, to increase access to care and lower costs.1,2 As choices expand, a challenge for patients will be to evaluate the quality of care offered by different clinicians and health care systems7 and to appropriately balance ease of access, costs, and quality of care. For clinicians, access to larger patient populations through virtual care could offer opportunities to better match their skills to patients’ needs, which may lead to increased productivity and income.2 A challenge and opportunity for clinicians will be to reduce clinically unjustified practice variation and to converge toward delivery of evidence-based care. Health care systems may be compelled to accelerate adoption of global standards and protocol-driven care. The flexibilities afforded by virtual care may stimulate development of hybrid models of care in which experts are more accessible to consult with generalists. An important decision for health care systems will be the selection of geographical and population markets for their services.2 Increased access to clinicians and systems of care should help payers lower costs and honor patient preferences while improving the quality of care, patient centeredness, and equity. A challenge for payers will be to determine whether treatment reimbursement will vary by delivery modality (virtual vs in person).2 An additional challenge for state-based payers, such as Medicaid, will be to decide when to contract services to out-of-state providers (including clinicians, hospitals, and health care systems) that may offer lower costs, high-quality care, or value than in-state providers. Lastly, regulators will have to balance the amount of evidence necessary to ensure the safety and efficacy of telepsychiatry with societal needs to make mental health care more accessible, patient centered, and equitable. Delaying policy making because of limited evidence can constrain policy frameworks later, once the technology has been diffused and adopted (the Collingridge dilemma),3 and restrict access to mental health care for those who might need it most. Establishing explicit standards regarding which data will be used to inform decisions could help stimulate data collection and ensure that policy decisions are evidence-based. These standards may include data on patient preferences for virtual vs in-person care, treatment initiation, treatment adherence and retention, and selected patient outcomes (eg, emergency department visits or hospitalizations). In summary, expansion of telepsychiatry creates new opportunities to increase treatment access, while it poses overlapping challenges to multiple stakeholders, as outlined above. Aligning the incentives of the key stakeholders offers a rare and important opportunity with far-reaching implications to lower the cost, increase the quality, advance equity of psychiatric care, and improve patients’ outcomes and satisfaction. References 1. Lo J?, Rae M?, Krutika A?, Cox C?, Panchal N?, Miller BF?. Telehealth has played an outsized role meeting mental health needs during the COVID-19 pandemic. KFF. Published March 15, 2022. Accessed September 17, 2022. www.kff.org/coronavirus-covid-19/issue-brief/telehealth-has-played-an-outsized-role-meeting-mental-health-needs-during-the-covid-19-pandemic 2. Bestsennyy O?, Gilbert G?, Harris A?, Roast A?. Telehealth: a quarter-trillion-dollar post-COVID-19 reality? Published July 9, 2021. Accessed April 13, 2022. www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality 3. Mathews DJH?, Balatbat CA?, Dzau VJ?. Governance of emerging technologies in health and medicine: creating a new framework. ? N Engl J Med. 2022;386(23):2239-2242. doi:10.1056/NEJMms2200907 4. Mullangi S?, Agrawal M?, Schulman K?. The COVID-19 pandemic-an opportune time to update medical licensing. ? JAMA Intern Med. 2021;181(3):307-308. doi:10.1001/jamainternmed.2020.8710 5. Glied S?, D’Aunno T?. Efficiency and arbitrage in health services innovation. ? JAMA Health Forum. 2022;3(3):e220619. doi:10.1001/jamahealthforum.2022.0619 6. Jones CM?, Shoff C?, Hodges K?, et al. Receipt of telehealth services, receipt and retention of medications for opioid use disorder, and medically treated overdose among Medicare beneficiaries before and during the COVID-19 pandemic. ? JAMA Psychiatry. Published online August 31, 2022. doi:10.1001/jamapsychiatry.2022.2284 7. Rochaix L?. Information asymmetry and search in the market for physicians’ services. ? J Health Econ. 1989;8(1):53-84. doi:10.1016/0167-6296(89)90009-X 8. Blanco C?, Olfson M?, Blanco-Jerez C?. Managed care market share, fee-for-service Medicare, and information theory. ? JAMA. 1999;282(3):235-236. doi:10.1001/jama.282.3.235 9. Blanco C?, Kato EU?,
Aklin WM?, et al. Research to move policy: using evidence
to advance health equity for substance use disorders. ? N
Engl J Med. 2022;386(24):2253-2255.
doi:10.1056/NEJMp2202740
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