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The World of Online Therapy Explained

Virtual counseling, which grew during the pandemic, is more popular than ever. But it has its issues.

Early in the pandemic, Yelena, a 33-year-old government contractor (who asked that her last name not be used) noticed that her anxiety had begun to go through the roof and she was isolating from others—signs that her chronic depression was flaring up. Yelena had left her Columbia Heights home at the start of the pandemic to live with her parents in Virginia’s Shenandoah Valley, and the past year-plus was taking an emotional toll: She was caring for herself and her family in addition to rolling out Covid-19 vaccine communications as part of her job. “It just sort of felt like I was in a mini-war,” she says.

It was time to see a counselor. She reached out to professionals in the area, but everyone was booked. Pre–smartphone and internet, her search might have ended there. But in an already highly virtual world that’s gone even more so due to Covid, Yelena still had options. She turned to the mental-health app Cerebral, where she took a 15-minute quiz about what kind of help she was seeking and, after reading the program’s reviews of counselors, signed up to see both a therapist and a psychiatrist via the app.

Most people are already aware of the increased use of telehealth during Covid. But what started as a necessity for social distancing may continue to be popular even if people feel comfortable interacting IRL again. This is especially true for the mental-health sector, where the provider doesn’t literally have to lay hands on you—or even live in the same area.

An American Psychiatric Association study found that before Covid, 64 percent of respondents saw no clients via telehealth. In January 2021, 81 percent were seeing 75 to 100 percent of patients virtually. Additionally, the study found that patient no-shows dropped significantly when telehealth was used, and 90 percent of respondents said patients were satisfied using this type of care.

It’s not just telehealth counseling—mental-health apps such as Ginger and Talkspace are booming, too, despite consumer concerns regarding the levels of care and patient privacy. The top ten mental-health apps in the US hit 4 million first-time downloads in April 2020, up by 17.6 percent from January 2020, according to the market-intelligence group Sensor Tower. The market for this type of app is predicted to surpass $3.3 billion in five years.

 

The Ease of Mental-Health Apps

Yelena originally looked at Cerebral because she had few other options, but she eventually liked that “it takes the stress away from going to therapy.” She didn’t have to travel for her weekly 45-minute sessions—she just had to make sure her phone or laptop was charged. The $325 monthly fee for both counselor and psychiatrist access is cheaper than typical rates in DC, where many therapists don’t take insurance and can charge $200 for one session.

Cerebral offers convenient scheduling, including on weekends. If they’re working with a therapist, patients have to live in a state where the provider is licensed. However, you can opt for a cheaper plan in which you work with a care counselor—i.e., a mental-health professional who isn’t licensed—in which case your location doesn’t matter.

The flexibility that an app offers appeals to Crista Carter, a 31-year-old account manager in Wheaton. She started using the BetterHelp app during Covid to see a therapist weekly and now says she’ll never go back to fully in-person therapy.

One feature Carter says she liked is that she could tailor her search for a therapist more than she could through her insurance provider. Carter, who identifies as a pansexual Black woman, was able to specify that she was looking for a Black female therapist experienced in working with the LGBTQ community. The one she was paired with was such a good match that Carter followed her even after she left the BetterHelp platform. They likely would never have connected if not for the virtual renaissance—though licensed in Maryland, her therapist lives in Chicago.

Another benefit: Virtual platforms help democratize mental health, Carter says, due to benefits such as lower pricing and the ease of seeing a counselor from your home. “In my community—young people and people of color—there can be such a barrier to therapy,” she explains. “Apps like these can potentially be a way that we can move towards universal understanding that therapy is okay and really destigmatizing [it].”

 

Counseling Stays Virtual

Kathleen Smith, a DC counselor offering web sessions, agrees that therapy’s online pivot has lowered barriers. Virtual counseling increases access to folks who may not be able to take time out of their day to commute to see a therapist, she says, or who don’t have access to a car or an easy public-transportation route.

And, says Niya Lewis, another DC counselor who sees clients virtually, online therapy can seem more approachable to first-timers who might feel intimidated in person: “It’s like that shy child in class that doesn’t ever raise their hand, but they’ll have a good one-on-one conversation with the teacher. It’s definitely helped clients who are a bit more shy to be a bit more open.”

Case in point: Karen Onaran’s therapist moved online once the pandemic hit. Onaran, a 50-year-old DC resident who works in energy policy, found that virtual sessions at home allowed her to be more open. “Face-to-face, you kind of have to put on a certain persona that you’re very confident and put-together,” she says. “When you’re online and you’re just sitting in your house in your pajamas, you feel more relaxed. You can be yourself and be a bit more vulnerable because you’re in a safe space.”

Since Onaran no longer had to commute from her office on Pennsylvania Avenue to Chevy Chase for counseling, she found she was likelier to schedule and make it to appointments and therefore to better prioritize her mental health. She plans on sticking with all-virtual for the long haul.

Therapists we spoke with say they’ll continue to offer online sessions, however the pandemic develops.

Lewis started her therapy practice during Covid, so she has seen clients only virtually. None of them have asked about switching to in-person, and she plans to stick with operating entirely online.

Smith, on the other hand, had never offered virtual sessions. She says she didn’t lose any clients when she switched, and even though she now offers in-person appointments to vaccinated patients, three-quarters of her clients are opting to remain virtual. She plans to offer hybrid services permanently—which is also saving her money, as she no longer has to rent an office full-time.

 

The Issues With Online Therapy

Remote therapy is not perfect. The move to virtual means providers are having to consider new issues such as finding HIPAA-compliant platforms that keep patients’ data secure or making sure that people dialing into sessions reside in a state where the therapist is licensed. Plus, clients tend to be distracted at home, says Smith—dogs or family members will walk into the room, notifications may pop up on screens. Or, in the case of one client who fired up the counseling call with a glass of wine in hand, people can get a little too comfy. (No, Smith will tell you, you’re not supposed to crack open the Cab Sauv at therapy.)

The online route might not be for everyone, says Lewis. During initial consultations, she’s clear with clients that she doesn’t recommend virtual if they’re on heavy psychiatric medication or are dealing with severe trauma or crisis.

Clients can be distracted at home—dogs or family members will walk into the room, notifications may pop up on screens. Or, in the case of one client who fired up the counseling call with a glass of wine, people can get too comfy. You’re not supposed to crack open cab sauv at therapy.

What’s more, mental-health apps have had their own troubles: For instance, former Talkspace therapists and employees have alleged that the company utilized patients’ counseling transcripts for data and encouraged employees to leave fake positive reviews. Some BetterHelp users have reported terrible experiences with the app, such as excessive fees and being assigned unhelpful or untrained therapists, and there have been concerns over the patient data it shares with third parties such as Facebook.

Yelena, too, eventually had problems with Cerebral. While she believes the app helped her and she would recommend it, she says she experienced technical issues—her therapist’s mike stopped working one session and Yelena was unable to reschedule the appointment on the app. Ultimately, when her therapist was no longer available on Cerebral, she stopped using it.

All this is to say that while it looks like virtual therapy may be a permanent option for many, don’t expect everyone to sign on forever. Just ask Sam Peters. The 31-year-old restaurant general manager living in Bloomingdale switched to online sessions with his counselor at the start of Covid. He hated it: He found video calls exhausting and awkward, as it’s hard to read body language, and he realized it’s difficult for him to feel a connection with his therapist via a screen. (Plus, like Zoomers everywhere, he constantly found himself staring at his image in the right-hand corner and worrying about the lighting and angle.)

So when Peters switched counselors recently, he considered only those with DC offices, as he plans to return to in-person eventually when his provider allows.

He’s looking forward to the day when that’s possible, he says, but until then, virtual will have to do: “It is absolutely, 10,000 percent better than not doing anything.”


Comparing the Apps

Mental-health apps aren’t for everyone—especially if you’re dealing with major trauma—but their prevalence has increased significantly over the past few years. Here’s what to know about four of the biggest players.

The app: BetterHelp.

The gist: Fill out a questionnaire that will match you with a therapist, with whom you can schedule weekly 30- or 45-minute sessions via phone, video, or live chat. You also have access to unlimited 24-7 messaging with your therapist.

The cost: From $60 to $90 a week depending on preferences—with the option to apply for financial aid. Better­Help doesn’t submit medical claims to insurance.

The providers: Licensed psychologists, therapists, and social workers.

The audience: Individuals, couples, teens.

 

The app: Cerebral.

The gist: Answer a survey to be matched with either a care counselor and a prescriber, a therapist and a prescriber, or just a therapist. Therapists meet with users weekly; counselors meet monthly (but provide unlimited messaging). If you’re working with a prescriber, any medication will be delivered to your door monthly.

The cost: Care counseling and medication: $85 a month. Therapy alone: $259 a month. Therapy and medication: $325
a month. Prescriptions are billed separate­ly, and Cerebral works with certain insurance companies.

The providers: All therapists and prescribers are licensed; however, not all care counselors are.

The audience: Adults.

 

The app: Talkspace.

The gist: Complete a survey or a video consultation to be matched with a therapist or prescriber. All users get unlimited 24-7 text, audio, and video messaging access to their therapist, but a live session or psychiatry costs extra.

The cost: While pricing and monthly fees vary based on where you live and on network availability, the cost is generally $52 a week for text therapy only, $63 a week for messaging and one weekly live session, and $79 a week for messaging and four weekly live sessions. Talkspace works with certain insurance companies.

The providers: Licensed therapists, psychiatrists, and prescribers.

The audience: Adults, couples, teens.

 

The app: Amwell.

The gist: Enroll online and choose from virtual therapists and psychiatrists (as well as other professionals such as nutritionists and urgent-care providers). As opposed to Amwell urgent-care visits, which are on demand, you’ll have to book your therapy or psychiatry appointments in advance. This platform is for those who want to do video calls—it doesn’t have the chat functions that other apps offer.

The cost: Initial psychiatric consultations are $279; follow-ups are $109. Therapy appointments are $109 or $129, depend­ing on provider qualifications. Some insurers offer coverage.

The providers: Licensed psychologists, therapists, and psychiatrists.

The audience: Adults and kids—although only adults have access to psychiatry and medication; kids are therapy-only.

This article appears in the July 2022 issue of Washingtonian.

Mimi Montgomery Washingtonian
Associate Editor

Mimi Montgomery joined Washingtonian in 2018. Her work has appeared in Outside Magazine, Washington City Paper, DCist, and PoPVille. Originally from North Carolina, she now lives in Petworth.

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