Telehealth is Transforming the Therapeutic Landscape

Mental health care is undergoing a transformation, with telehealth becoming an essential part of the therapeutic toolkit. The Monitor on Psychology (October 2024) highlights this shift, noting that while the use of audio-only telehealth services has declined since its peak during the COVID-19 pandemic, nearly 50% of psychologists continue to use it as a tool in their practice (American Psychological Association [APA], 2024), especially as a supplement for other modalities. Patient preference drives much of this trend, alongside the flexibility and accessibility telehealth provides.

While we don't (yet) do audio-only therapy at our university clinic, many of our clients prefer the benefits of video therapy sessions over in-person which wasn't even something we offered prior to COVID. This reflects a broader movement in mental health care that prioritizes meeting clients where they are - in their world, not bringing them into ours. In this sense, I am very optimistic as it helps make therapy and mental health care part of the client's everyday life rather than something artificial in a therapy office 50 minutes every Wednesday morning (for example).

Telehealth’s Proven Effectiveness

Empirical research, including recent meta analyses, continues to show that telehealth is not only effective in the treatment of mental health disorders related to depression and anxiety, but be just as effective as in-person care. As an important side note, research is often only published if results are significant, meaning that we don't know how many studies did not find significance because they rarely get published. However, large sample sizes, solid research methods, control groups, and objective measures create a strong indicator that the results are generalizable to the general public.

For example, a study published in the Journal of Psychiatric Research compared outcomes for 1,192 patients who received in-person therapy before the COVID-19 pandemic and another 1,192 who received telehealth therapy during the pandemic. They used standardized tools like the Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR) and the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), and found no significant differences in outcomes between the two groups. This suggests that telehealth does not significantly differ in outcome from traditional in-person therapy (Zhang et al., 2021). As a positive psychologist, I was thrilled to see they measured both the reduction of negatives as well as the addition of positives.

Similarly, a systematic review published in the Journal of Telemedicine and Telecare evaluated meta-analyses from 2010 to 2019, covering mental health, cardiovascular care, and rehabilitation. The review concluded that telehealth interventions often match or exceed the effectiveness of traditional care. Specifically, in mental health, modalities such as video conferencing and telephone-based therapy yielded outcomes comparable to in-person sessions in reducing symptoms of depression and anxiety (Kruse et al., 2021).

As the Monitor on Psychology notes, the use of telehealth continues to evolve, with psychologists employing it to address various client needs, from logistical challenges to preferences for remote care (APA, 2024). These findings reinforce telehealth’s role as a cornerstone of modern mental health care but also our increasing willingness to engage and build relationships through technology. But does technology change our relationships?

The nuances of Telehealth and Telephone-Only Therapy

Despite its promise, telehealth faces several challenges that can impact its effectiveness. One major issue is the potential for a weaker therapeutic connection. In-person therapy allows therapists to pick up on non-verbal cues such as body language and facial expressions, which are essential for understanding clients’ emotions and building rapport. While video sessions capture some of these cues, telephone-only sessions lack them entirely, making it harder to fully assess and respond to a client’s needs.

Technical issues, such as unstable internet connections or poor phone reception, can disrupt the therapeutic flow and frustrate both clients and therapists. Privacy is another significant concern, as many clients struggle to find confidential spaces for therapy, particularly in shared living environments. These barriers can create added stress for clients and may limit their ability to engage fully in the therapeutic process.

But as therapists lose some of these cues to a client's' inner psychology, we gain a new perspective that, from my experience, adds a lot of depth to understanding clients - a unique understanding that we don't get sitting in a fake living room with a desk in the corner. I have watched clients do therapy from their kitchen as they are making lunch for their kids and parents at soccer practice sitting in their parked car. I get to see how they interact with the important people in their lives, how they engage in the safety and comfort of their own home, and how they engage with the world and their kids' soccer practice. Before this, all I got was how they engage in my office and while I worked hard to make it comfortable, it was still my office, not their home.

Strategies to Enhance Telehealth Services

To overcome these challenges, therapists can employ several strategies to ensure telehealth, especially telephone- or audio-only therapy, is effective and client-centered:

1. Start with an In-Person Session. When possible, initiating therapy with an in-person session can help establish rapport and build trust. This creates a strong foundation for the therapeutic relationship, making future virtual or telephone sessions more effective. It may be a good idea to haven in-person session everyone once in awhile just to remind each other that we are real humans.

2. Collaborate and Pre-Plan. Therapists can work with clients to create a quiet, private place for therapy and to integrate therapy into their daily life. Suggestions include a discussion of how teletherapy works and collaboration on how to work toward goals using technology. Ideas for privacy and quiet space include noise-canceling headphones, turning off notifications, or scheduling sessions during quieter times. For clients struggling to find privacy, unconventional spaces such as a parked car can sometimes be effective solutions.

3. Use Verbal Techniques to Enhance Connection. For telephone-only therapy, therapists can use intentional verbal strategies to bridge the gap created by the lack of visual cues. Techniques such as reflecting on the client’s statements, summarizing key points, and explicitly acknowledging emotions can help deepen the therapeutic connection. Asking open-ended questions may be key as well - this way therapists can 'check-in' on the client to make up for some of the cues that are missing.

4. Incorporate Regular Feedback. Along with checkin-in, I I teach my students that regularly seeking feedback from clients is critical to both client engagement and therapeutic outcomes. These four questions include:

   1. How is our relationship? This fosters transparency and helps to address any disconnects that may arise in telehealth settings. It demonstrates the importance of the relationship and the focus of the therapist on fostering and maintaining a safe therapeutic alliance.
   2. Are we making progress toward your goals? This ensures the focus remains on the client’s objectives, validating their experience and highlighting growth. It also provides a space for the client to say no, especially if the relationship is positive, which not only corrects the course of therapy for the better, it also builds confidence and agency in the client - two things many of us could use more of.
   3. What would you like more of? This question empowers clients to voice preferences, such as wanting more coping strategies or opportunities for reflection and demonstrates that the therapist and client both bring unique knowledge to the process and to the relationship.
   4. What would you like less of? This invites clients to share any frustrations or aspects of therapy that might feel less helpful or effective and, like the other questions, helps ensure agency for the client regarding the process of therapy.

   These questions foster a collaborative approach, allowing clients to voice their preferences and ensuring therapy remains aligned with their needs.

5. Address Privacy Concerns. Therapists should proactively discuss privacy with clients and help them identify confidential spaces. It’s also important to reassure clients about the confidentiality of telehealth platforms and troubleshoot any concerns about interruptions during sessions. For therapists, make sure any technology you use is HIPAA Compliant and that everything you do adheres to the ethics, standards, and laws associated with your profession and license.

6. Provide Technology and Telehealth Support. Offering guidance on how to use telehealth platforms can help clients feel more comfortable and confident. Simple steps, like sending clear instructions and troubleshooting tips, can reduce technical barriers and improve the overall experience. Some psychologists and therapists are creating telehealth info sheets to their new clients, sharing technology support as well as information about how to get the most out of telehealth.

Telehealth as a Tool for Expanding Access to Mental Health Care

One of telehealth’s most significant benefits is its ability to expand access to mental health care. It eliminates logistical barriers such as transportation, childcare, and long commutes, making therapy more accessible for individuals with demanding schedules or limited resources. For clients in rural or underserved areas, telehealth can provide a lifeline to services that might otherwise be unavailable.

However, ensuring equity in telehealth requires systemic efforts. Expanding broadband access, providing affordable technology, and advocating for comprehensive insurance coverage of telehealth services are critical steps toward making telehealth a viable option for all clients. One fantastic initiative for expanding mental health care is PSYPACT (psypact.gov) - an interstate compact designed to facilitate the practice of telepsychology and the temporary in-person, face-to-face practice of psychology across state boundaries. This agreement between 42 states allows for telehealth services by licensed psychologists across state lines.

Conclusion: Embracing Telehealth’s Potential

The Monitor on Psychology underscores the importance of telehealth as a tool for modern mental health care, and research continues to validate its efficacy. As therapists, we must embrace this evolution, addressing its challenges while leveraging its strengths. Telehealth is not just a stopgap solution during a pandemic, it is a sustainable and effective modality that will likely continue to grow.

By adopting client-centered strategies, regularly seeking feedback, doing good research, and addressing barriers to access, we can help bring out the best in our use of technology. Telehealth continues to be a powerful tool for enhancing mental health care. It allow us to see our clients in a more natural setting - truly joining them in their world rather than bringing them into ours.

References

American Psychological Association. (2024). Audio-only telehealth services remain a key part of professional practice. Monitor on Psychology. Retrieved from https://www.apa.org/monitor/2024/10/datapoint-audio-only-telehealth

Kruse, C. S., Krowski, N., Rodriguez, B., Tran, L., Vela, J., & Brooks, M. (2021). The clinical effectiveness of telehealth: A systematic review of meta-analyses from 2010 to 2019. Journal of Telemedicine and Telecare. https://journals.sagepub.com/doi/10.1177/1357633X211022907

PSYPACT (n.d.). The Psychology Interjurisdictional Compact). Website. Retrieved from https://psypact.gov/.

Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR) Retrieved from https://med-fom-ubcsad.sites.olt.ubc.ca/files/2013/11/QIDS-SR.pdf.

Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q). Retrieved from https://www.med.upenn.edu/mfc/assets/user-content/documents/Q-LES-Q-SF.PDF.

Zhang, W., Dulai, J., & Smith, R. (2021). Effectiveness of intensive telehealth mental health treatment: Evidence from a comparative study. Journal of Psychiatric Research. https://doi.org/10.1016/j.jpsychires.2021.07.009