Virtual Therapy: the ‘New Normal’ After COVID-19

The expansion of telepsychiatry may outlast the COVID-19 pandemic that caused it. When the stay-at-home order took effect in West Virginia, James Berry–a clinician with the WVU School of Medicine–was part of the team that moved the Chestnut Ridge Center’s therapy sessions online. Just 10% to 15% of patients had connectivity problems. That’s fewer than clinicians expected. And–anecdotally–clinicians found that many patients were more forthcoming during virtual sessions than in-person ones.

Once the COVID-19 pandemic is over, a lot of things will go back to normal. We’ll stop wearing masks. We’ll crowd into restaurants. We’ll walk whatever direction we want to down grocery store aisles. But some changes that the pandemic spurred might be here to stay. Among them: the expansion of telepsychiatry.

“This will be part of the new normal,” said James Berry, a clinician with the West Virginia University School of Medicine. “The genie is now out of the bottle, and it isn’t going back in.”

After West Virginia’s stay-at-home order took effect in March, Berry was part of the team that transitioned outpatient behavioral-health visits to telepsychiatry at WVU’s Chestnut Ridge Center. These visits included group therapy sessions for people with opioid use disorder.

“Behavioral health issues are very treatable and manageable problems,” said Berry, who chairs the Department of Behavioral Medicine and Psychiatry and directs addiction services at CRC. “Whatever we can do to create access for people who need help is something that we need to prioritize. People don’t have to suffer.”

In a new letter published in the Journal of Addiction Medicine, Berry and his colleagues explain how large-scale deployment of telepsychiatry is possible for both individual- and group-based visits.

His team of School of Medicine researchers and WVU Medicine clinicians includes Erin Winstanley, Laura Lander, Wanhong Zheng, Kari-Beth Law and Ashley Six-Workman.

Before the stay-at-home order, virtual care and therapy was offered for rural clinics only; however, during the week that the stay-at-home order began, CRC moved 75% of its on-site therapy sessions to Zoom. Soon after, 98% of the sessions had gone virtual.

Prior to the pandemic, the department was conducting pioneering telepsychiatry services to rural areas across West Virginia through funding from the Health Resources and Services Administration, as overseen by Law. With this experience, Law was able to lead the transition at CRC to virtual care.

Bad internet connections don’t preclude good emotional connections

Even though West Virginia has the fourth-lowest rate of household broadband access in the nation, only 10% to 15% of the patients in CRC’s virtual therapy sessions had connectivity problems–a percentage that was lower than Berry expected.

“Over time, people became very creative in making the connectivity work,” he said. “For instance, several patients didn’t have broadband access in their home, but many had access to a smartphone. It’s just that not everybody had service. People used public Wi-Fi options in restaurant parking lots to conduct their visits. While this does not mean that access to quality broadband services is not a priority, it does speak to people’s resilience and need for access.

Looking at a screen–instead of directly into someone’s face in the same room–didn’t make patients more reticent to participate in therapy sessions. If anything, the opposite was true.

“I don’t know if it’s because they were in the comfort of their own home or because they didn’t feel like all eyes were on them, but one of the things I noticed early on is that people seemed more comfortable sharing details than they would have been in person,” Berry said.

The best laid plans

Even before the pandemic, CRC had been planning to expand its telepsychiatry options. They just didn’t expect to do it so quickly.

“Our five- to 10-year plan was to allow access for much of our care into the virtual world, but there were many barriers,” Berry said.

One of those barriers was patients’ and clinicians’ unfamiliarity with telepsychiatry. Another was some insurers’ unwillingness to pay for virtual therapy–or therapy in a patient’s home–even when they would cover comparable in-person therapy.

Regulations and legislation have hindered the adoption of telepsychiatry, too. “As a physician, for instance, you’re licensed to practice in a particular state,” Berry said. “I’m licensed to practice medicine in West Virginia. Pre-pandemic, that meant that in order to treat somebody who was in a state that doesn’t participate in the Interstate Medical Licensure Compact–for example, Ohio–I would have to have an Ohio license, or there would have to be an arrangement made between our two states that would allow me to do that. You can imagine the difficulty that would have presented when it comes to treating patients across state lines.”

But the pandemic swept many of those obstacles away. “Now we’re seeing patients from all over the country,” Berry said.

Coming together while staying apart

Wherever they live, many of the patients that Berry and his colleagues are seeing may need more emotional support than usual right now. The feelings of isolation that can accompany staying at home–and seeing friends and family less frequently–can trigger new mental health problems and worsen old ones.

Social distancing has been linked to declines in mental health outcomes, increases in substance use and upticks in crises such as suicidal ideation.

For these reasons, telepsychiatry can be crucial during the pandemic.

Berry said, “When we saw the pandemic coming in early March, I said, ‘Listen, everybody. We are already facing a behavioral health epidemic, an overdose epidemic and a suicide epidemic. Now we’ve got this COVID viral epidemic. Once people are isolated and don’t have their personal connections anymore, we are going to be facing a huge increase in the number of people who are experiencing severe psychological distress and disorders. We need to be prepared for this.'”

If Berry could go back to the early days of those preparations–knowing what he knows now–he would give himself one piece of advice: be patient.

“Early on, it was really easy to get frustrated when you’re talking to somebody and their connection is going in and out,” he said. “But it’s just a growing pain. Take a step back. If somebody connects at all, that’s a victory.”

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