Psychotherapy after the pandemic will likely be a hybrid — part office, part telemedicine

The pandemic poses an unprecedented danger to mental health, but it’s also sparking new approaches to patient care that promise to revamp the field.

Teletherapy — through video, often Zoom, and audio — is not new, but during the pandemic, it has come to nearly replace face-to-face sessions. “I haven’t seen a patient in person for more than a year,” said Stanford Steinberg, a longtime Philadelphia psychiatrist.

So will traditional, on-the-couch therapy ever return?

Not likely. As in other fields, the pandemic has produced new approaches and accelerated changes that were already occurring. What is emerging is a hybrid model, part office, part teletherapy, aided by shifting regulatory and professional norms, and aiming to make mental health treatment more accessible — whether online, via an app or at the corner drugstore. The trends are also bolstering the prospects of mental health providers — psychiatrists, psychologists, or social workers — who face a growing demand for their skills.

“We’re going to see the impact of the pandemic on the human psyche for years,” said Jeffrey M. Cohen, an assistant professor of medical psychology in the department of psychiatry at Columbia University.

The growth in teletherapy depends more on insurance coverage and state licensing regulations than the desires of patients and practitioners.

Typically, a psychiatrist licensed in Pennsylvania cannot treat a patient unless both are in the same room. However, many hope that Gov. Tom Wolf’s administrative waiver, which permits teletherapy but ends Sept. 30, will be extended. Meanwhile, the American Medical Association is urging Congress to enact legislation that would make telehealth permanent.

“Numerous studies indicate it [teletherapy] can be just as effective as seeing a practitioner in the office,” said Jared L. Skillings, chief of professional practice for the American Psychological Association. “There is no question that teletherapy is here to stay.”

Even initially skeptical patients and practitioners see an upside to teletherapy. For many patients, therapy without leaving home is appealing: less time consuming and less disruptive of daily routines.

And practitioners get to observe a patient’s environment. “Sometimes, I even have the chance to involve family members in the therapy,” said Vivian Pender, president of the American Psychiatric Association and clinical psychiatry professor at the Weill Cornell Medical College in New York.

Most practitioners say they are seeing fewer latenesses and cancellations and are free to be more flexible with their hours. “If someone wants to see me at 8:30 at night, I can easily do that,” said New York psychoanalyst Miriam Schacter. “If I do have a cancellation, I can go upstairs and make a salad.” She thinks more than half her patients will want to remain remote.

During the pandemic, licensed practitioners in other states can treat Pennsylvania and New Jersey residents through telemedicine. Other governors, too, granted temporary licenses to allow for teletherapy, which in some cases permitted a patient in one state to be treated by a practitioner in another.

At the same time, the American Psychological Association has developed the Psychology Interjurisdictional Compact, or PSYPACT, state-enacted legislation that allows a licensed psychologist to use teletherapy to treat a patient in another state that has also joined the compact. So far, 26 states, including Pennsylvania and Delaware, have signed up. New Jersey will come on board early next year.

It remains to be seen, however, which state licensing boards will resume requiring that practitioners be licensed in the state where their patient is located. There is already a move in several states to resume this restriction.

During the pandemic, the Centers for Medicare & Medicaid Services (CMS) paid for a “temporary expansion of “telehealth” benefits; now it is proposing to allow certain services to be paid for through Dec. 31, 2023. CMS is the powerful federal agency that administers Medicare.

Will insurers, many of which have covered teletherapy during the pandemic, keep doing so? Richard Snyder, chief medical officer at Independence Blue Cross, is hopeful. As part of a five-year strategy, his company has included virtual visits, which he says are ideal for behavioral health. In 2020, there were 420,000 claims for behavioral telemedicine, up from 2,900 in 2019. While his company has been especially aggressive in covering teletherapy, he believes that most insurers will follow suit.

The Kaiser Family Foundation reports that overall during the pandemic, four of every 10 adults in this country complained of anxiety or depression, up from one in ten in 2019. More than 30% reported difficulty sleeping and eating. Alcohol consumption and substance abuse worsened.

The Pew Research Center’s surveys earlier this year, which measured loneliness, anxiety, depression, and sleeplessness, found that those between 18 and 29 were more than twice as likely as those in other age groups to fall into the “high stress” category.

Other age groups are suffering too. “Parents report,” said Skillings, “that children have become more fearful, are having troubling mood swings, difficulty sleeping and complaining of headaches and stomachaches.” The elderly are prone to loneliness and loss of connection.

Charlotte Zacker, of Ventnor, N.J., whose children and grandchildren live in Florida, said, “I haven’t seen them in 18 months and I’ve missed critical years of watching my grandsons grow and develop. I can’t make up for that.”

Mental and behavioral health specialists acknowledge that their practices are strained beyond capacity. “There used to be a time when there was a shortage of patients,” said Skillings. “Nowadays, people are waiting for weeks, even months, to get an appointment.”

Statistics from the U.S. Department of Labor indicate that the mental health profession will grow dramatically in the next decade. Psychiatrists, the only practitioners with a medical degree and who can prescribe medication, are projected to grow 12.5% between 2020 and 2030. Their median annual wage in 2020 was $208,000 or more depending on where they practice.

Employment of psychologists is projected to grow 7.6% and social workers, the nation’s largest group of mental health providers, are projected for 12.5% growth in the same time period. Psychologists’ growth is slower than the other two specialties because so many are self-employed, which brings the estimate down. Excluding self-employment, these workers are projected to grow 10.1%. All are close to or exceed average job growth of 7.7%.

The median annual wage for psychologists in 2020 was $82,180. For social workers it was $51,760.

“There is a huge, unresolved gender pay gap,” said Sarah Butts, director of public policy for the National Association of Social Workers. “Historically‚ social workers, like teachers and nurses, tended to be women and were undervalued.” Moreover, Medicare’s reimbursement rate is 100% of the cost of the visit for psychiatrists and psychologists and only 75% for social workers even when they and psychologists often provide similar services.

No matter the practitioner, mental health care in the future will probably be a hybrid — perhaps beginning with an office visit where a therapist can get a full picture of a patient. Subsequent visits would be remote, and those conducted via computer would still allow the therapist and patient to see each other, if only from the waist up.

At the same time, tech-savvy entrepreneurs and future-thinking experts are creating tools to expand the ways patients can jump-start and maintain self-directed therapy.

According to the American Psychiatric Association, digital mental health already is a multibillion-dollar industry and includes more than 10,000 apps, easily downloadable on smartphones and other devices.

But John Torous, director of digital psychiatry at Beth Israel Deaconess Medical Center and assistant professor at Harvard Medical School, warns that “this new reality is worrisome. The apps have not been thoroughly investigated through clinical science or overseen through regulatory control,” he says. “Moreover, they often do not respect the privacy of personal health information.”

Woebot, which debuted in 2017, does not purport to replace a therapist, but has the advantage of 24-hour access. It uses artificial intelligence and the principles of cognitive behavioral therapy to treat anxiety and depression. Like other mental health apps, Woebot is not subject to strict oversight from the Food and Drug Administration because it falls under the category of a “general wellness” product.

La Salle University is going in another direction. Using Kognito, a program that features simulation with avatars, it is training teachers and students to recognize those with mental health problems.

“We have been trying to create a campus around awareness of mental illness,” said Serita Reels, La Salle’s director of student support and equity. “Initially we used Kognito to train undergrad and graduate students; this year we are expanding it to faculty,” she said. “Those who have taken the training say it has increased their knowledge of behavioral and verbal cues that could be signs of mental unrest, and steer those students toward treatment.”

Getting young children to talk about their mental health is a challenge, but Kim Wieland, a former teacher and Kognito spokesperson, said that Kognito users learn the skills that can identify those who are struggling. A teacher, for example, may ask a child, “Which cat are you today? The happy cat or the sad cat?” This opens up conversation in a way children can relate.

It’s not just psychologists, psychiatrists, and social workers who will be needed to create treatments that will be effective in the digital space. A team will have to include software engineers, graphic designers, marketers, artists, and content providers, opening up new job options.

Already, in California, Matthew Smith, a professor of humanities at Azusa Pacific University in Los Angeles County, has assembled a team of scientists and therapists to study how mental health treatment can be customized to each patient’s needs. He says that the rollout of this “one size doesn’t fit all‘’ program is just around the corner.

Of course, digital mental health care or even teletherapy won’t work for everyone. “When I was so depressed I couldn’t get out of bed, I needed to be seen and sent to a hospital, said Barbara Full, who has an underlying mental condition — obsessive compulsive disorder.

After several years of cognitive behavioral therapy with psychologist Allen Miller, daily doses of a prescribed medication and 13 years of mental stability, she was toppled by the pandemic. Last March, she reached out to Miller who she says is her lifeline, but communicating by phone or Zoom at that point wasn’t working. “I know how important it is for me to get in front of my illness,” Full said. “By the time I talked to him, my house was on fire. I was too far gone.”

During the pandemic, Full was hospitalized three times. The day she was discharged from the first hospital, she tried to take her life. It was her 60th birthday.

Since last November, Full has been treated via Zoom by Miller, director of cognitive behavior therapy programs at Bala Cynwyd’s Beck Institute for Cognitive Behavior Therapy. “Now I was stable enough that teletherapy worked for me.”

Psychologist Judith S. Beck, president of the Beck Institute, says cognitive therapy transfers easily to teletherapy because it is highly collaborative. The Institute trained twice as many therapists in 2020 as it did in previous years.

Meanwhile, a new service offered by CVS Health, which accepts multiple payment types — Medicare, Medicaid, employee assistance programs and many insurances — is taking mental health care right to the patient’s neighborhood. CVS Minute Clinics, each staffed by a licensed clinical social worker or master’s level mental health practitioner, offers mental health screening, clinical counseling and, if necessary, referral to a resource in the community.

The clinics debuted early this year with centers in four communities including Philadelphia and South Jersey where research revealed a need. If a person is paying on his own, cost is $129 for the initial evaluation and $69 to $119 for subsequent sessions depending on length and frequency.

“CVS wanted to increase access to care by being just around the corner,” said Ashley Karpinski, CVS senior director of behavioral health. Following an initial evaluation, weekly sessions can be scheduled with the same counselor, and care coordinated with the patient’s primary physician.

After several frustrating weeks trying to get an appointment with a therapist for depression and anxiety exacerbated by the pandemic, Shakira Teagle heard about the CVS program. “I called early in the week,” she says, “and I got an appointment the same day. I was shocked.”

“The every-other-week — therapy sessions have reshaped her, said Teagle, who is a marketing assistant at Lincoln Financial Group. “The pandemic was hard … and isolating, and there was so much change in world dynamics,” she said. ”I needed to talk to someone beside family and friends.”

Teagle is coming up on her last appointment, but says her therapist has encouraged her to contact her when she needs a pick-me-up. “My therapist gave me techniques to help myself, and I feel so much more confident now. In the Black community, we tend to suffer in silence, but my mom was so impressed with how much therapy made a difference for me that she’s going now too. "

The Future of Work is produced with support from the William Penn Foundation and the Lenfest Institute for Journalism. Editorial content is created independently of the project’s donors.