Why Your Shrink Wasn’t Offering Virtual Therapy Until Now

Did it need to take a pandemic to let us Zoom with our therapist in our PJs?

Arsh Raziuddin / The Atlantic

There was a moment a couple of years ago when I realized it was time for an intervention. While on a particularly stressful reporting trip, I picked at my cuticle so intensely that my thumb got infected.

I signed up for an app called Joyable, which is meant to help with social anxiety—the closest approximation of what I thought I was struggling with. The app had me set goals and do activities that were likely to provoke anxiety, so that I could practice managing the anxiety in the Joyable-approved way.

The app came with a counselor who, she was quick to note, was not a licensed therapist. (In my book, when I talk about using the app, I call her “Chloe” for confidentiality purposes.) Over regular phone calls, Chloe’s role was to cheer me on, help me through the activities, and, broadly, “check in with me,” whatever that was supposed to mean.

I quickly learned it meant a lot. Even though my calls with Chloe were prescheduled, they kept happening at unexpectedly opportune times. Once, for example, she called me right after a source yelled at me for attempting to get the other side of a story from someone she didn’t like. I vented to Chloe that my job sometimes made me feel terrible. When I was done, Chloe paused, then said, “You’re personalizing this.” I was taking a standard part of any journalist’s job and making it about me. She had a good point, and a lot of other pithy tips. Ultimately, she became the best part of using Joyable.

My foray into teletherapy was accidental, but tens of thousands of Americans have shifted to the practice since the start of the coronavirus pandemic. With most offices closed down, many psychologists and counselors are treating their clients remotely, using tools such as phone calls, Zoom, and Skype. Suddenly, a therapy appointment that took two hours, including travel time, can be over in the actual 50 minutes it was scheduled for. Employees who are working from home don’t even have to give their boss the “doctor’s appointment” excuse. Quarantine-induced Zoom fatigue is real, but many patients and therapists likely hope that virtual therapy will continue—at least as an option—after the pandemic ends.

But in a 2018 survey, fewer than than half of psychologists reported delivering some therapy digitally, and the most common technology used was the phone and email, not videoconferencing. If teletherapy is so convenient, why wasn’t it a more popular option before it became the only one? There are two reasons, experts told me: Therapists weren’t paid enough to do it, and the government was worried about patient privacy. Out of necessity, these obstacles were quickly cleared once the pandemic broke out—and they’ll quite possibly stay that way even after it’s no longer necessary for patients to call their shrinks from their bathrooms. That could mean a future in which lots of people have their own Chloe—a helpful phone-a-friend you can talk to in your PJs.

Historically, teletherapy hasn’t been treated the same way as traditional therapy. Before all of this, not all teletherapy was reimbursed by insurers, and if it was, it wasn’t always reimbursed at the same level as in-person therapy. It varied based on the insurer and the state, Lynn Bufka, the associate executive director for policy at the American Psychological Association, the trade group for therapists, told me. Some insurers would pay for clients who were in rural areas, where therapists are rarer, but not in cities. Others would pay for video calls, but not phone calls. Some would make patients come to a nearby clinic for teletherapy—thus negating the point of it in the first place. Without guaranteed payments from insurers, therapists were reluctant to offer virtual appointments. “We want to help people and help people change their lives,” Bufka said. “But you also have to pay the rent.”

But in March, the Centers for Medicare & Medicaid Services—the main government insurer—said it would begin to pay for telehealth visits on a much broader and consistent basis “for the duration of the COVID-19 Public Health Emergency.” Medicare and Medicaid, which together cover about a third of all Americans, would consider these virtual visits to be on par with traditional doctor’s appointments, and would reimburse doctors accordingly. And as goes Medicare, so go many private health insurers, such as Cigna and Blue Cross Blue Shield.

As is usually the case in American health care, there have been some pitfalls to this new system, in which patients get stuck with the full bill for their telehealth visits. But to therapists, even a moderate reassurance that they’ll be paid for their time is enough to get them to fire up Skype. “If you’re in a situation where all of your regular treatment models have been shut down, you’ve got to find a revenue source,” Nicolas Terry, the executive director of the Hall Center for Law and Health at Indiana University, told me. “So suddenly getting some money from telehealth doesn’t seem so bad.”

The other thing shrinks worried about prior to the pandemic was running afoul of a government medical-privacy rule called HIPAA. Because apps such as Skype and Zoom have some security vulnerabilities, they weren’t previously considered suitable for something as sensitive as psychotherapy. (Zoom also has a HIPAA-compliant platform, Zoom for Healthcare, though unlike the regular version, it is not free.)

But the federal government released another memo in March essentially saying it would turn a blind eye to medical providers who want to use popular videoconferencing apps for telehealth during the pandemic. Doctors should feel free, the government said, to use everything from FaceTime to Skype to treat patients. It specified, however, that they may not use TikTok. Seriously.

Suddenly, therapists didn’t have to scour obscure corners of the internet for a videochatting software that complied with arcane rules about patient records. And rather than download some clunky telehealth software, patients could now simply toggle between their work Zoom meetings and Zoom therapy. “Prior to COVID-19, if you were going to be providing telehealth, the expectation was you were going to really do your research; you were going to make sure that you have a product that meets the type of requirements to ensure privacy and security,” Bufka said. But with the start of the pandemic, “it was clear that requiring that level of vetting … was really going to slow down the transition and really disrupt continuity of care.”

But the rapid transition to telehealth hasn’t been entirely seamless. For patients who are cooped up with their family members, finding a quiet place to Zoom with a therapist—and potentially complain about those same family members—can be hard. Therapists may have trouble reading emotions over the phone, so they may risk not picking up on important cues about imminent crises. For some disorders, being in the same room as the therapist is part of the treatment. And some cybersecurity experts warned me that there’s a small but real risk that virtual-therapy sessions could be hacked and personal medical data could get stolen.

It’s not clear whether the relaxation in payment and HIPAA rules for teletherapy will continue after the pandemic ends. Still, while it’s unlikely that all therapists will go fully remote once meeting face-to-face is safe again, there are a few signs that virtual therapy is here to stay. Like working from home, Zoom therapy is a perk that might be hard to claw back from people who have been enjoying it. And there might be more coronavirus-related shutdowns to come, so if the federal government rescinds the new telehealth rules, it might be forced to simply re-implement them. Some experts even envision a future in which telehealth “clinics” spring up that would let you see a therapist or any other doctor with just a few clicks. The explosion in virtual therapy could be “a beacon for what we could do post-pandemic, if we ever get there,” Terry told me.

Bufka says therapy delivered through videochat or even over the phone can be just as effective as the kind delivered in person. Some people even attend more therapy sessions remotely than they would otherwise, because of the convenience. After the pandemic, what will make a big difference in mental-health treatment is whether patients get their choice of therapy. In general, treatment works better if it’s what the patient wants. Medication works better for people who want medication. Therapy works better for those who want to talk with someone. And the same will likely hold true for our post-pandemic future. Those who want to continue Zooming with their therapist will see an upside to not having to go into their office. Those who can’t wait to cry it out in front of a person, rather than a screen, will probably want that instead.

For me, a quick phone call with Joyable’s counselor hit that therapeutic sweet spot. At the time, I was too busy for standard therapy sessions. Having an unusually wise, calm—though, yes, unlicensed—person I could call was exactly what I felt I needed. And the best kind of therapy is just that.