Online Therapy Services

We all have busy schedules and in a state like Colorado, due to extreme weather, it's not always possible to make it to a clinician's office. Tele-Mental Health (Teletherapy, Distance Counseling, etc.) has received a lot of attention over the past few years. Improvements in technology plus a need for clients to receive treatment in their homes or when they're traveling have spurred interest in this modality, and consumers now enjoy access to a variety of vendors offering online therapy. My recent experience as a therapist on BetterHelp and with the on-boarding process for TalkSpace has made me aware of some limitations of these services that clients often underestimate.

Cost

Subscription-based services like TalkSpace and BetterHelp tend to run around $200+/month. In order to be on a plan with them and use the service, you have to pay that chunk of money monthly. They break it down by week and compare it with some (highly inflated) copay examples, but keep in mind that you pay that times four.

Counselor Training on Online Therapy

Boundaries

Is it really healthy to have the expectation that your counselor will respond to messages 5 days per week? I can tell you from experience that this is an onerous task for counselors, and unfortunately, that is bound to affect client care. These sites generally do not compensate counselors adequately to have work on the site as a sole source of income. Consequently, most counselors work at least one in-person practice job, and see online clients in their off-hours.

This is not a commentary on telementalhealth in general. If you see a counselor in her own practice who offers telementalhealth as a service or have an EAP provider who does this, typically, you have a one hour session per week (or on a less frequent schedule) and it's essentially like any other therapy session just over the phone or video chat. Contact between sessions tends to be limited to administrative questions that the provider may or may not address before your next session. This is very different from the way TalkSpace and BetterHelp operate.

I happen to believe that the time between sessions and between contact with the therapist is just as valuable as the time we spend engaging with the therapist because that is the time we spend practicing skills on our own and receiving authentic feedback in the world. While a security blanket sounds nice, people rarely need one as much as they believe they do and it's important to learn that.

Also, burnout is a real problem. Counselors have personal lives and other jobs. Have you ever had a week where your car broke down, you got the flu, and someone dumped you within three days? Yes? So have we. Add that to a situation we were never professionally prepared for---clients texting us at all hours of the day and being entitled by subscription to a response within 12 hours--you get a very stressed out person.

Speaking for myself, I genuinely love helping people. My work fills my cup. It truly does. Still, I have bad days. I have bad moments. A normal professional schedule allows me to plan around those. I know that I just need to keep it together for someone else for a few minutes, then I can watch a sad movie. These subscription services open us up to an endless bombardment of notifications and deadlines. Also, the thing about counselors choosing clients on BetterHelp and TalkSpace is a lie. They assign people, even if the counselor thinks it's a bad fit.

I once tried to have a client removed from my caseload on BetterHelp. The whole exchange was documented, and the owner recently tried to fib to me and tell me, "Oh no, you can always ask support to do that." When I followed up and told her that I had the documented exchange of support telling me they specifically couldn't do that, I stopped hearing from her.

Methods

The subscription platforms offer their own form of training. TalkSpace has a set of training videos for therapists. BetterHelp has sample transcripts for various situations.

I received training for a Distance Counselor Certificate (DCC) several years ago, and probably should renew the cert for giggles, but that training focused primarily on ensuring security and confidentiality (as much as possible) and ways to troubleshoot working with someone when you don't have cues like posture, fidgeting, etc.

The DCC training never suggested that it was in any way beneficial to alter your schedule or the way you handled client sessions (timing/access to clinician between sessions) just because it was distance counseling.

TalkSpace and BetterHelp train counselors to do one thing: obtain and retain clients to make money. Why do you build rapport? To keep the client so they can make money. They also give bonuses for client retention even if the client is rarely (if ever) using the service. So, if you have a client who just forgets that their membership to TalkSpace or BetterHelp is on automatic like a gym membership or video subscription, you get a bonus because for them, that's a good counselor.

Efficacy and Access

Telemental health is a great option to consider if you generally feel like you have good social skills and just need some help troubleshooting something specific like insomnia, problems in a romantic relationship (like bad patterns you keep getting into), anxiety, and negative thoughts that perpetuate a mood disorder like depression.

You have to be able to remember to check-in with your counselor regularly with minimal prompting. You need to be able to express yourself well orally and in writing, and you need to be able to regulate yourself enough to not read "tone" into written messages.

If you're doing phone or video, make sure you have the internet bandwidth and privacy to do those things. It's hard to have a session that breaks up or freezes every few minutes. Plus, the counselor can't prevent your toddler or spouse from walking in at inopportune times. That's on you.

For a lot of clients I've worked with over the years, this just doesn't work most of the time. I'm not saying this service doesn't have its place, but it's currently marketed as if it's a fit for everyone when it really isn't. It's great if you have agoraphobia or if you live alone and just need some extra support now and then, but unless one or both apply to you, seeing a therapist in-person is usually better.

Value of In-Person Therapy

In contemporary in-person psychotherapy, the client and therapist meet in a neutral space--the office--for a set amount of time (usually an hour) and work on a mutually agreed upon part of the client's treatment plan.

This situation often gives the client a safe space to practice important skills for the first time, and receive instructions on how to apply those skills in his/her/their life. They receive verbal and nonverbal feedback.

Additionally, clients pay only for sessions attended and, yes, sometimes the copay is $75+ if they're using insurance because deductibles can be ridiculous. However, that often can be covered by an FSA or HSA. Also, in most cases, a copay is closer to $35/session. In some cases, clients have access to a number of free sessions through their EAP.