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People with mental health concerns now have more options than ever for how they receive treatment. The COVID-19 pandemic has prompted psychotherapists to open new avenues for care, from video sessions to text-based counseling. And in 2023, many therapists have returned to their offices to see clients who prefer in-person sessions.
Anyone who is experiencing psychological challenges has plenty of company. As the COVID-19 pandemic continued to wane in February, some 32.3% of American adults were experiencing symptoms of anxiety or depression, according to health policy nonprofit KFF's analysis of federal data. These ills are even more common among young people, including about half (49.9%) of those ages 18 to 24.
The expansion of therapy settings does complicate your decision about how to get therapy. So here’s a briefing to help you or a loved one find the optimal path to improved mental health.
Online therapy is as effective as in person for many issues
The first thing to know is that numerous scientific studies have found that online therapy and in-person treatment are, by and large, equally effective.
“There is ample clinical evidence that videoconferencing therapy is as good as face-to-face treatment,” says Heleen Riper, professor of e-mental health and clinical psychology at Vrije Universiteit Amsterdam, in the Netherlands.
One 2018 meta-analysis in the journal Cognitive Behaviour Therapy, statistically combining 20 research studies, found that online cognitive behavioral therapy is just as effective as in-person cognitive behavioral therapy for a diverse array of psychological diagnoses, including social anxiety disorder, panic disorder, depressive symptoms and body dissatisfaction.
“Videoconferencing works quite well for anxiety, depression and PTSD [post-traumatic stress disorder],” says Ephrem Fernandez, a professor of psychology at the University of Texas at San Antonio. Efficacy was noticeably less for eating disorders in a meta-analysis conducted by Fernandez and fellow researchers.
One caveat: Research to date is more robust for live video therapy sessions than for text-based therapy. “We don’t have a lot of data on whether asynchronous texting or messaging is effective,” says Vaile Wright, a senior director of health care innovation at the American Psychological Association.
Online therapy: Pros and cons
Online psychotherapy is convenient and often effective, but the setting also has potential disadvantages.
Multiple ways to find a therapist. You can identify a professional qualified to help you either by seeking a referral from another health care professional or through an app or website that offers the services of therapists across the United States.
Convenience. Going online typically makes therapy more convenient and opens up more scheduling options with more mental health providers. Online therapy often enables people to avoid the need to take time off work, travel to and from the therapist’s, arrange and pay for child care and so on.
Availability of specialists. With online therapy, “you have access to more specialists who might have the expertise you need,” Wright says. Some licensed providers specialize in substance use disorders or child and family psychology, for example.
Access from underserved areas. For people in rural areas and other places where mental health professionals are scarce, online offers better access to therapy.
You miss what’s outside the screen. Some psychologists believe that online therapy limits the development of the therapeutic relationship. Body language, for example, may not be fully communicated in a video call. The privacy challenge. It’s difficult for some people to find a private place for a video call. “There are patients who have online sessions from their car or a closet,” says Jeffrey Seitelman, a psychiatrist in Seal Beach, California.
The technology challenge. If you lack consistent access to broadband internet, or you don’t have a private device, or you simply aren’t comfortable with the technology, in-person therapy may be a better choice.
If online skirts your therapeutic challenge. "Let’s take someone who has agoraphobia," Fernandez says. “It’s inherently a disorder which requires treatment that gets you out of your house." If someone who with the condition opts to stay online for their therapy, "they may not improve because they’re not being challenged to face the real-life environment.”
In-person therapy: Pros and cons
Sessions in a psychotherapist’s office make sense for some patients in some situations.
Neutral territory. Your therapist’s office is a neutral location, away from your everyday life. This may enable you to better focus on the process of dealing with your issues, getting better and getting on with your life.
Most kids do better in person. “My experience is that most adults do equally well in online sessions as in in-person, but a few people do much better in person,” said Carla Leone, of North Suburban Family Psychologists in Lincolnwood, Illinois, in an email interview. “It's the other way around for kids and teens; most do much better in person, but some — especially older teens — do fine online. Kids often need to play as part of their therapy, and it’s a lot easier to play in person.”
The power of physical presence: “Therapy does feel different in the office,” says Seitelman. Without face-to-face interaction, therapy “is less intensive, less connected.”
Inconvenience: Compared with online, in-person therapy comes with greater costs in terms of travel time and expense, and the potential need to take time off work, pay for child care and so on.
So how do you make the choice?
Experts say that as you set out to choose the setting for therapy — in person or online — it’s wise to consider how your state of mind could affect your decision.
“Patients now believe they ought to feel empowered about their decision-making,” Wright says. “But you have to balance that out with a natural tendency to want to avoid therapy and talk about the things that are really hard. That’s where shared decision-making is beneficial.”
It may make sense to have a preliminary conversation with a potential therapist to assess whether online or in person suits you and your situation. “Most providers will give a free phone consultation to discuss what may be the best options,” Wright says.
Fernandez says that “our research shows no reason why people should hold back from making the first contact with a provider via videoconferencing” unless they’re experiencing a psychiatric emergency.
Do note that your choice of a specific therapist is probably at least as important as the setting of therapy. “The research has shown repeatedly that so much depends on the credentials and the credibility of the provider,” Fernandez says. You can check a psychotherapist’s licensure and certification in your state through the American Counseling Association's database.
Hybrid therapy can offer some of the benefits of both videoconferencing and in person, plus learning opportunities. “With blended treatment, patients can monitor their own progress with their smartphone apps so they gain much more knowledge in the dynamics of their moods or fears,” Riper says.
Insurance for therapy: It’s complicated
The extent of your insurance coverage for psychotherapy — online or in person — depends on the individual therapist, your state’s regulations and your health plan. So when you’re choosing a medium of therapy and a mental health professional, note that:
Many health plans require substantial copays for psychotherapy sessions.
Some states don’t require insurers to reimburse psychotherapists equally for online and in-person sessions.
Some psychotherapists don’t take insurance for online therapy, or for in-person sessions, or for either.
To make matters even more complex, your benefits for mental health care might change with the scheduled expiration of federally mandated COVID-19 emergency coverage on May 11, 2023.
“I think there’s a lot of confusion among insurers about what’s going to happen when the public health emergency ends,” Wright says. “I do encourage people to think about eliminating possible future barriers.”
Learn more by contacting your health plan and your state’s department of health.