Future Tense

Why You Shouldn’t Just Skype Your Therapist

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It’s time to abandon the couch in your therapist’s office—at least for the time being—in favor of remote therapy. This isn’t just about moving existing sessions online, either. Over the weekend, the Lancet published a rapid review of the psychological effects of quarantine, which range from boredom and frustration to anxiety and even PTSD. The evidence is clear: Social distancing, while necessary, can be severely detrimental to mental health. These conditions naturally translate to a higher demand for therapy. And since that’s not an option in many places right now, there’s a new spotlight on teletherapy.

But your therapist shouldn’t just Skype (or FaceTime, or Google Hangouts) you from afar. That’s because video calls come with greater privacy risks. Usually, therapists have to use platforms that comply with the Health Insurance Portability and Accountability Act to mitigate those risks. “Hackers go for valuable data,” said John Torous, the director of the digital psychiatry division at Beth Israel Deaconess Medical Center. “Health data is very valuable, and insecure health systems are always primary targets for hackers.”

On Tuesday, however, the U.S. Department of Health and Human Services announced that it will waive penalties for potential HIPAA violations during the pandemic, effectively lowering the barriers to teletherapy. While Skyping your therapist won’t technically be penalized now, it’s still best to use a secure platform if possible. “Many video platforms today do already offer end-to-end encryption, so finding a secure platform is still good clinical practice,” Torous said. Fortunately, he explained, HIPAA is “not a hard standard to meet, given the options that are out there on the marketplace.”

HIPAA-compliant platforms, such as Zoom, Doxy, and TheraNest, not only meet technical privacy criteria but also usually use a business associate agreement to certify that there will be administrative and human safeguards in place to avoid data breaches. Torous used the metaphor of a castle sans guards to explain why technical precautions aren’t enough: “You can have the best castle, the biggest moat, and biggest door, but if you leave the door open, it doesn’t matter.”

While questions about HIPAA compliance may be more relevant now, as people become more aware of data privacy, teletherapy itself is nothing new. Research on video-based therapy started in the late 1980s and ’90s, and teletherapy visits have been mainstream for over a decade, said Torous. “There’s a legacy of very strong evidence that teletherapy can work well, [for] every condition, for both old and young people,” he told me. Teletherapy already broadens access to care and is often a better option, for instance, for patients in rural communities or patients with disabilities.

Still, teletherapy has its idiosyncrasies. As Torous explained, mental health professionals have to learn what they sometimes call a “web-side manner” (as opposed to bedside manner): When you’re conducting sessions through a screen, you have to discern how to “establish a therapeutic alliance, therapeutic rapport, [and] a professional setting and demeanor,” Torous said. Retaining that professionalism—even from what may be a home environment—is key. “Remember that hilarious video of that poor person doing a TV report for BBC and his kid ran in the background?” said Torous. “It’s kind of along those lines.”

Importantly, said Torous, therapists have to connect with the patient, retain cultural awareness, and be attuned to nonverbal cues—all of which can still be done via teletherapy, but may require an additional level of awareness and consideration.

One potential problem with teletherapy is the same thing that plagues any activity that relies on a strong internet connection. “I think across all the literature,” said Torous, “the one thing that makes patients upset or kind of destroys the alliance or outcome of video visits, is poor internet quality.” Just as it’s hard to follow a show that’s pixelated, or that skips and sputters, the quality of a therapeutic session deteriorates without solid audio and video.

The most serious concern with teletherapy today pertains not to data security or efficacy, but to insurance. Thirty-seven states have telehealth parity laws, which require private health insurance companies to cover telehealth services to the same extent as in-person service; 21 states mandate Medicaid coverage of telehealth. This leaves room for certain insurance plans not to cover teletherapy, which many Americans are discovering as their therapists transition to video-based sessions mid-pandemic. And not all teletherapy platforms are covered by insurance. Some patients have been barred from sessions because their therapists don’t use their insurance company’s “preferred platform.” Hopefully this is one instance where the HHS decision to waive penalties for potential HIPAA violations will ensure more people can access care.

In response to COVID-19, more insurance providers are beginning to make exceptions for telehealth and virtual therapy sessions, and coronavirus emergency supplemental legislation is expanding Medicare coverage of telehealth. But some people are still falling through the cracks and aren’t getting the care they now need—or even the care they’ve become used to—from the confines of their homes.

Delivered through teletherapy, this care would be “equivalent to in-person care in diagnostic accuracy, treatment effectiveness, quality of care and patient satisfaction,” according to the American Psychiatric Association. And it is—at least for those who have access to it.

Future Tense is a partnership of Slate, New America, and Arizona State University that examines emerging technologies, public policy, and society.