Psychiatric Help: The Doctor Is...Online

You’ve likely seen the commercials that advertise getting some small sliver of healthcare through an online company that specializes in just erectile dysfunction treatment, birth control, etc. Most of these upstarts seem to identify some small but profitable niche in medicine where they can skim off their piece and leave the rest of the patient to someone else. Lately, however, the big thing seems to be online mental health treatment—a segment of healthcare that can be notoriously hard to make profitable, especially for clinicians willing to open their doors to everyone needing help, regardless of income or insurance.

The model for many of these larger companies is that, for a monthly fee, you can have regular videoconference therapy sessions or, if you prefer, a supportive text message exchange. Some sites even have access to a psychiatrist and the ability to receive medication. And if you happen not to like your therapist or feel like they aren’t a good fit, the companies often promise a rapid switch to someone else. Independent clinicians and smaller-scale operations also can provide contracted mental health services to places that struggle to find their own in-house professionals or to sites that need services episodically, like emergency departments in rural areas.

The ability to get mental health treatment online has been with us for many years, but the COVID pandemic gave the effort a jumpstart after nearly all clinicians were forced to suspend regular in-person operations at least temporarily and learn how to deliver care through videoconferencing platforms. Now, as both clinicians and consumers are more comfortable with therapy being done by looking at a screen, these opportunities seem to be everywhere, and just in time to meet the surge in demand for mental health treatment traditional services don’t seem able to meet. Reassuringly, research generally finds that online mental health treatment is as effective as that delivered in person, although the data on therapy by text is much thinner.

Yet despite the need and encouraging research, the reception to this new frontier of mental health care by the “establishment” has remained tepid. Even mental health organizations desperately searching to find staff have been slow to turn to online clinicians. A few of the major concerns include:

• Cost. Most online groups, especially the big national companies, don’t interact directly with insurance companies, leaving the client to pay out-of-pocket or needing to do all the insurance work themselves.
• Exclusion of higher-need patients. Most of these companies want people who need care, but not too much care. Folks struggling with milder levels of depression, anxiety disorders, or ADHD are actively recruited, but people who are suicidal, have psychotic symptoms, or actively use substances are encouraged to go elsewhere. This "skimming" works well for the company but creates additional burdens on the rest of the mental health system that doesn't turn people away based on acuity.
• Care fragmentation. Good mental health care often requires a team of people working together. If someone’s primary care doctor would like to coordinate care, how receptive is an online therapist halfway across the country going to be, and will they have any knowledge of local resources?
• The corporate model in mental health care. While it may sound awesome to be able to shop for a therapist like you would a pillow, there are many times when a person may need to be supportively confronted by their therapist or told no when asking about things like certain medications. The “customer is always right” principle often does not apply to mental health treatment.
• Lack of boundaries. Traditional therapy often emphasizes “the frame,” meaning the fairly firm boundaries in which therapy proceeds. Online treatment and the ability to text 24/7 throws new elements in the mix that need to be considered.
• Depth of treatment. It is probably fair to say that most online therapy could be described as supportive psychotherapy. This type of treatment is helpful for many but may lack depth or specific techniques that some people need. Some very effective types of treatment — like a variant of cognitive behavioral therapy (CBT) called exposure and response prevention which is used for obsessive-compulsive disorder — are hard to pull off online, let alone by text.
• Emergencies. While many online companies offer round-the-clock support for paying customers, they can quickly punt to “call 911” if there is a real mental health crisis, leaving clients to work with a totally different system in their times of greatest need.

In weighing online therapy, here are a few questions to consider (and ask) before signing a long-term contract with an online therapy company:

• Will my clinician have any knowledge of my community? If not, how much might that matter? In some cases, it may not matter that much for people who don’t need other resources or who already know how to get them. For others, this could be a very big deal that really hinders the ability of therapy to be effective.
• What happens in an emergency? Would my actual therapist be available to help me through a crisis or would it be someone different on call or even a shift back to local community resources?
• Privacy. How well would my mental health information be protected? Conversely, how easy is it to share it with people who may need to know this information, like a primary care doctor?
• Contracts. How long would I need to keep paying even if I decide to no longer to use the service? What do I really get for each level of subscription? Like fitness centers, these companies are banking on individuals who sign up but then don’t really use the benefits.
• Qualifications. What kind of training does the therapist at the site have? Is it possible to receive specific types of therapy, like CBT or parent training?

Overall, mental health treatment delivered by telehealth is here to stay, whether we like it or not. For some, it is likely to provide new access to services not easily obtainable locally; for others it could end up being a costly service that falls short on its promises. The trick is finding a way to bring online therapy into someone’s coordinated system of healthcare rather than it sitting out on its own disconnected from someone’s life and the greater community.

To find a therapist, visit the Psychology Today Therapy Directory