Health Letter, October 2021
By Michael T. Abrams, M.P.H., Ph.D.
Thanks to the COVID-19 pandemic and well-established computer and internet technologies, the use of telemedicine has exploded in the last 18 months. Estimates from the U.S. Agency for Healthcare Research and Quality show that within the private insurance market, telemedical visits increased from well under 1 million to around 8 million per month between February and December 2020. The surge has been especially large in behavioral health, so much so that experts in the field have written the following:
COVID-19 has changed the field of psychotherapy overnight from in-person to “virtual,” remote teletherapy. This shift will likely have lasting effects on psychotherapy practice.
But what does this mean for patients seeking therapy for behavioral health issues such as depression, anxiety and alcohol or opioid use disorders? This article discusses the emergence of e-counseling with some basic suggestions for existing and potential clients.
E-counseling, also referred to as digital modality (for example, video, text and chat) therapy, existed before COVID-19 and remains an area of growth for profit-seeking firms.
A 2019 study authored by psychology, psychiatry and social-work researchers in California provided a preliminary analysis of client experiences with the online therapy firm BetterHelp. That study observed that three months into therapy for overwhelming sadness, grief or depression, 38% of 318 adult clients demonstrated “clinically significant” improvement on a standardized depression survey. This result led the researchers to conclude that such e-counseling approaches have promise. However, the study had numerous limitations, including that it was not randomized, lacked a control group, enrolled a relatively small number of subjects who were 80% female, and excluded patients with serious mental health issues, including thoughts of self-harm. Accordingly, the effectiveness of this approach was unconfirmed compared with other therapeutic approaches (or no therapy at all) as was its relevance across the spectrum of mental-health populations and issues.
Despite such a limited evidence base for effectiveness of its services, BetterHelp claims to be the largest online e-counseling platform in the world with accumulated enrollment of over 2 million clients who have paid $60-$90 per week for online therapy only (no in-person contact). Moreover, BetterHelp — acquired six years ago by the New York Stock Exchange-listed firm Teladoc — is said to have expanded its mental-health business by 500% in 2020, which enabled Teladoc to outperform Wall Street analyst expectations.
BetterHelp has many competitors. The commercial website Top10.com promotes the following other online behavioral therapy firms:
- ReGain (couples therapy)
- Faithful Counseling (for Christians)
- Teen Counseling
- Pride (LGBT counseling)
- Online-Therapy.com (cognitive behavioral therapy)
Talkspace is clearly a direct and expanding competitor of BetterHelp for general e-counseling services. Talkspace further offers psychiatric care, including diagnostic evaluations and medication management (except for controlled substances like buprenorphine for opioid dependence). Talkspace saw its revenue grow by 73% in the second quarter of this year versus the prior year and grew their active membership rolls by 40% over that same 12 months. Their second quarter profits in 2021 were $31 million, and they claimed over 61,000 active clients.
As evidence that their methods are “proven effective at scale,” Talkspace cites a recent study that observed, across 10,718 volunteers using text therapy for 12 weeks, 4- to 5-point average improvements on 21-point anxiety and 24-point depression scales. These are suggestive results but, given the lack of randomization and a control group, not proof of clinically meaningful effects attributable to the Talkspace approach specifically, nor are they informative about Talkspace’s ability to cope with other behavioral health issues.
Mental health practitioners view e-counseling favorably
A recent anonymous survey of 819 mental health professionals — including psychiatrists, psychologists, nurses, social workers, counselors (including peers) and behavioral health trainees — conducted during the COVID-19 pandemic at 18 health care facilities in 11 states in the U.S. revealed wide acceptance of telepsychiatry but with limits on its use. Specifically, the study published in Psychiatric Services in June 2021 found 73% of surveyed professionals using videoconferencing and 66% of those using the telephone for therapy rated such experiences as excellent or good. Moreover, 64% of these respondents planned to continue such e-counseling sessions for at least a quarter of their caseload after the pandemic resolves.
There were no response differences across the various categories of behavioral health professionals who participated in the survey. The survey further revealed that psychotic disorders were considered least appropriate for telehealth management, whereas anxiety disorders were considered the most appropriate. The authors of this study advocated for the use of videoconferencing over telephonic therapy to afford sensitivity to nonverbal body language, and they further cautioned that patients with sensory and cognitive limitations may need additional supports to make e-counseling feasible.
Benefits and drawbacks of e-counseling
The National Institute of Mental Health specifically offers the following list of benefits and drawbacks associated with “telemental health”:
The first three benefits are self-evident and related because e-counseling services, if deployed properly, naturally reduce travel time to the provider’s office and thus further ease related challenges like missing work or family time. Such technology also provides access to mental health care to people living in areas where in-person mental health care services are not available. “Advances technology use” in this context means that as more telehealth services are used, providers become more adept with such enabling technologies, including those that enhance medical records.
As is evident from the drawbacks list, technology has downsides — especially the costs of acquiring and maintaining computers and internet connectivity, including hardware and software approaches to safeguard personal health data.
The nonprofit organization Consumers Union in its March 2021 issue of Consumer Reports published an assessment of privacy issues associated with mental health computer “apps” (applications), including those of BetterHelp and Talkspace. Consumers Union researchers found that existing privacy policies of these apps often “blur the lines between medical research and marketing” and concluded that users of these apps should be informed of how their data is being used and what privacy protections apply to their health data. At a minimum, patients should review their prospective providers’ procedures for handling and sharing protected health information to judge whether they are clearly stated and acceptable. One way to do that is to review Health Insurance Portability and Accountability Act (HIPAA) documents that providers typically ask you to sign before your therapy begins, though the Consumers Union cautions that mental health apps often do not apply HIPAA protections to all the information they collect from their users.
A preeminent drawback to e-counseling is potentially lower quality of the therapist–client interaction, especially for some mental health conditions, which is likely why the aforementioned Psychiatric Services survey found that the majority of health care professionals aim to return to mostly in-office care after COVID-19 recedes. Here are some suggestions for optimizing the quality of your e-counseling visits (inspired by a March 2021 American Journal of Psychiatry publication directed towards behavioral health professionals):
- Silence email and turn off other computer or cell-phone applications, and refrain from use/checking
- Position yourself in front of the camera to allow a head and shoulders view so your therapist can perceive your facial expressions and body language
- Use a comfortable chair and a quiet room
- Make sure your wi-fi signal is sufficient by closing other applications or purchasing a booster
- Tell your therapist if you are having suicidal thoughts* or other violent feelings towards yourself or others
*If you are in immediate distress or are thinking about hurting yourself, call the National Suicide Prevention Lifeline toll-free at 1-800-273-TALK (8255). You also can text “HELLO”: to the Crisis Text Line (741741).
Tips for identifying a good online therapist
If you believe e-counseling may work for you, finding an online therapist should be similar to identifying a good in-person mental health care professional. First, if you already have an in-person therapist, see whether they can offer you some sessions online or refer you to someone with whom they can coordinate your care. Your primary care physician may also be a source of referrals to therapists who can provide some online services. There are many other sources of referrals for online therapy including, but not limited to, behemoth providers like BetterHelp and Talkspace. For example, the Psychology Today website has a searchable database of licensed therapists available online by region.
Finally, once you have identified some candidate e-counselors, plan to interview and evaluate them with the following questions:
- Are you a licensed behavioral health practitioner in my state?*
- What are your degrees/credentials?
- Are you fully HIPAA-compliant and equipped to protect my health information?*
- Do you have experience treating my problems?*
- Please estimate how many sessions I will need.
- How often will we interact each week, and how?
- What is the cost of your therapy sessions?
- How much will be covered by my insurance?
*if not, then move on to other candidates
Only settle on a therapist who gives you satisfactory answers and know that you may end your counseling anytime or find a new therapist if you are not making satisfactory progress towards your therapeutic goals.
Online behavioral health counseling is certainly here to stay and likely will prove to be a useful complement to in-person care; but such remote modalities have limits, may not be appropriate for more serious forms of illness, and must be held to cost, quality and access standards that rival in-person office visits.
 Markowitz JC, Milrod B, Heckman TG, et al. Psychotherapy at a distance. Am J Psychiatry. March 2021;178(3):240-246.
 Marcelle ET, Nolting L, Hinshaw SP, Aguilera A. Effectiveness of a multimodal digital psychotherapy platform for adult depression: A naturalistic feasibility study. JMIR Mhealth Uhealth. 2019;7(1):e10948.
 Renauer C. A big quarter from BetterHelp is just what Teladoc needed. The Motley Fool. May 1, 2021. https://www.fool.com/investing/2021/05/01/a-big-quarter-from-betterhelp-is-just-what-teladoc/. Accessed September 4, 2021.
 Talkspace. Press release: Talkspace reports second quarter 2021 results. August 9, 2021. https://investors.talkspace.com/news-releases/news-release-details/talkspace-reports-second-quarter-2021-results. Accessed September 5, 2021.
 Hull TD, Malgaroli M, Connolly PS, et al. Two-way messaging therapy for depression and anxiety: longitudinal response trajectories. BMC Psychiatry. 2020;20(1):297.
 Guinart D, Marcy P, Hauser M, et al. Mental health care providers’ attitudes toward telepsychiatry: A systemwide, multisite survey during the COVID-19 pandemic. Psychiatr Serv. 2021;72(6):704-707.
 National Institute of Mental Health. What is telemental health? https://www.nimh.nih.gov/health/publications/what-is-telemental-health/. Accessed September 5, 2021.
 Germain T. Mental health apps aren’t all as private as you may think. Consumer Reports. March 2, 2021. https://www.consumerreports.org/health-privacy/mental-health-apps-and-user-privacy-a7415198244/. Accessed September 5, 2021.
 Markowitz JC, Milrod B, Heckman TG, et al. Psychotherapy at a Distance. Am J Psychiatry. 2021;178(3):240-246.
 Mental Health America. Get professional help if you need it. https://mhanational.org/get-professional-help-if-you-need-it. Accessed September 6, 2021.