The Doctor Is Online: Talking Teletherapy
Remote services can make it easier for those who need to talk with mental health providers
Daniel Plotkin, M.D., has been treating older adults for mental health for almost four decades. Sometimes he meets patients in his west Los Angeles office. Sometimes he'll meet them in their own homes. And sometimes, they won't meet in person at all.
For about as long as Plotkin has been practicing geriatric psychiatry, he's offered patients the option to have sessions remotely. Those appointments used to be conducted over the telephone. These days, he'll often meet with patients by video via computer or smartphone.
Teletherapy was already a growing field before the pandemic, but COVID-19's extended lockdowns prompted a rapid expansion on remote services. And tele mental health services are proving their value well beyond the pandemic. Mental health treatment can be difficult to access for many Americans. Most U.S. counties have a shortage of mental health professionals, and providers with expertise in treating older adults are even harder to come by.
Remote services can make it easier for people who need support to get it — especially people who live in rural areas or have mobility or health issues that make it hard for them to get to an office.
"It's particularly suited for those where there's some kind of difficulty or barriers to coming in person," Plotkin says.
So is teletherapy a good fit for you? We asked providers some of the basics of getting remote mental health treatment.
What is Teletherapy?
Essentially, teletherapy involves a mental health provider meeting with a patient via some form of technology, rather than in person.
"They can be at a distance from one another and conducting the therapy, whether that's psychiatry or psychotherapy," says psychiatrist Mimi Winsberg, M.D., chief medical officer and co-founder of the online therapy service Brightside Health.
In most teletherapy appointments, patients meet with mental health clinicians through video call. These face-to-face sessions can help providers have a better sense of how their patient is doing through cues, like body language and facial expressions, than an audio-only call.
As teletherapy technology has developed, some platforms offer more bells and whistles than just regularly scheduled appointments. For instance, patients can log their symptoms and their progress online, and therapists can check in by message.
"There can be multiple touchpoints that happen in between appointments," says Winsberg, who has been exploring the possibilities of telehealth for mental health services for more than a decade.
Who Benefits?
Experts say teletherapy can work for almost anybody.
"For older adults who have transportation issues or geographic issues, it can be particularly helpful," Plotkin says.
For Plotkin, meeting remotely with patients allows him to treat people who aren't able to travel across sprawling Los Angeles to his office. He also has patients who are part-time L.A. residents. With telehealth, they can continue treatment even while they're in other places.
The ability to meet from long distances opens treatment options for people who live in regions with a dearth of mental health providers, or without providers who accept certain forms of insurance or Medicare.
"Most folks over 65 are quite comfortable using an iPhone or using a piece of technology and can navigate a simple platform with clear instructions quite easily."
However, some conditions are not as well-suited to remote treatment. In-person appointments are better for any type of condition that requires a physical exam. More serious mental health conditions, like psychosis, can also be hard to treat from a distance.
Remote mental health appointments have a lot in common with in-person sessions.
"It feels very similar," says Winsberg. "It's just happening through the aid of technology."
Still, there are some ways that remote appointments differ from in-person treatment.
"You don't have the same kind of feel for the person and connection with the person and body language," Plotkin says. Those cues can be important for mental health providers to understand how a patient is doing, he adds. But the flexibility and ability to accommodate patients' needs or restrictions outweighs the limitations.
"It's still so much better than nothing that it's a good option," Plotkin says.
Ease of Use
Many online mental health platforms are developed to be as easy to use as possible.
"Most folks over 65 are quite comfortable using an iPhone or using a piece of technology and can navigate a simple platform with clear instructions quite easily," Winsberg says.
A study of users of Brightside Health's online platform found that adults over age 65 had similar outcomes for treatment of depression symptoms as younger people.
In practice, though, technology is a barrier for some. Plotkin says some of his older patients, in their 80s and 90s, aren't comfortable with computers or smart phones. A family member or caregiver often helps them get set up for an appointment. He also talks with some patients over the phone.
"Some people actually prefer phone because they feel like they don't have to be quite as prepared."
"Some people actually prefer phone because they feel like they don't have to be quite as prepared," Plotkin says. "It doesn't matter what they're wearing. They can be in their bathrobe."
For a successful session, patients simply need to find a quiet, calm place, and get set up to use whatever form of technology they'll use for the appointment, Winsberg says.
Treatment typically starts with a session where the provider will ask questions and put together a treatment plan. The conversations during online sessions between mental health providers and patients generally mirror the process in person.
Finding a Teletherapy Provider
Primary care providers are a good first step, according to Plotkin. Because older people may have health conditions or medications that are interconnected with mental wellbeing, primary care providers are well-positioned to understand the full context of someone's symptoms and refer them to therapists or psychiatrists.
"If everyone has this bias that older adults are too old and too rigid ... then of course, you're going to find that most people don't avail themselves of the services."
For many older adults, the biggest hurdle is initiating mental health treatment, Plotkin says.
Ageism is a pervasive barrier to mental health treatment for older adults; health providers are not well-trained to recognize signs of depression, anxiety and other conditions in older people, according to Plotkin. There are also societal assumptions that older people won't benefit from mental health treatment.
"If everyone has this bias that older adults are too old and too rigid, 'you can't teach an old dog new tricks', that sort of thing, then of course, you're going to find that most people don't avail themselves of the services," Plotkin says.
Telehealth may not be a good fit for everyone. Particularly for people in their 80s and 90s, many of whom have complex health needs and who often have stigma around mental health, remote therapy sessions can fall short. But for those who are more familiar with technology, it can help reach important mental health supports.
"It's not going to be some kind of magic cure," Plotkin says. "Potentially it's very helpful to have an alternative pathway."