The scene was maddening. But after more than a decade of reporting on the mental-health beat, I knew it was not unusual. The system is cautious, often for good reasons. But that conservative approach often means throwing up hurdles that keep vulnerable people from getting the care they need.
The coronavirus pandemic has exposed how inadequate our hospital system can be. But it has also set in motion changes that should have happened years ago: It has finally shocked the mental-health system out of its complacency. And none too soon, given the mental-health crisis that will follow the pandemic.
A fundamental change is happening, and we should never turn back. Not only have states and private insurance companies dropped burdensome rules that blocked “teletherapy,” but mental-health professionals are experimenting with new ways of caring for their patients, with exciting and gratifying results.
The mental-health system can seem designed to be as inaccessible as possible. Therapy can feel like an out-of-reach luxury for people who work long hours or have child-care issues, which is just about everybody. Federal data shows that the majority of those who could use mental-health services don’t receive them. With teletherapy, the system now has the potential capacity and flexibility to meet more people on their own time.
Becky Stoll, vice president of crisis and disaster management for Centerstone, one of the largest behavioral health nonprofits in the country, said she had been advocating for teletherapy for at least a decade. “What I think covid-19 has done is pushed us into the largest beta test that we ever could have hoped for,” Stoll explained to me.
So far, Stoll added, there are encouraging signs. No-show appointments are down even among the hardest to reach. Centerstone clients who have been identified as at risk for suicide are even more engaged in therapy since the virus shut the clinics down. For these clients, kept appointments were up an astonishing 12 percent.
These results make sense. During interviews with those who have overcome suicidal urges or endured time in psychiatric wards, I always ask what got them through their ordeals. People always remembered the moments when the therapist didn’t play by all the old-fashioned rules. They talked about the psych nurse that paid them a little more attention, the therapist who took them out of the office and bought them coffee. For some, it was the one therapist who randomly texted just to say they were thinking about them.
This new virtual-care model suddenly allows for these more off-the-cuff moments. After a client complained that he couldn’t use up his cellphone minutes with long sessions, his therapist calls him for mini-sessions. Social workers are cold-calling clients just to see how they are handling their anxiety and isolation. A Centerstone clinic manager organized a rotation of different clinicians to call one suicidal client once a day just to check on her. Her clinicians jumped at the chance to help out.
The problem with therapy is that it generally doesn’t traditionally take place in the setting where clients could be their most comfortable. In virtual sessions, therapists are finding they can be more direct in their manner than they would in an office setting. They can also see not only where their clients live but also how they are living. The context can be crucial. Therapists can encourage them to practice various coping skills in their home or complete a task they have been putting off, such as applying for a job. In this virtual setting, therapy becomes more practical.
I never understood why the mental-health system requires people who are in significant states of distress to navigate office appointments and emergency departments. It waits for people in crisis to just appear neatly with proper insurance and co-pays in hand. Suddenly, therapists and social workers are meeting people where they are. Treatment is now coming to them.
In this new system, that man with the panic attacks and suicidal thoughts wouldn’t have to wait for hours sequestered in a corner of an emergency room. He could be assessed without ever leaving home. This kind of outcome is already having a positive effect. Crisis workers are finding that people in distress are opening up more than they ever have — and their families are joining in to help. We are finally starting to learn how to get Americans the mental-health care they need when and how they need it — and just in time to treat the epidemic after the pandemic.
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