Colleagues, acquaintances, e-patients, media and others often ask me, “What’s the state of online therapy? Does it have a future?” My answer hasn’t changed significantly in the past decade, for good reason — very little has changed in the field.
For folks who may be unawares, I’ve been a part of the mental health landscape and online therapy since the early 1990s, and e-therapy specifically when it started to hit the scene hard in the late 1990s. In fact, I coined the term “e-therapy” to describe online psychotherapy — a specific modality of psychotherapy that utilizes many techniques and features of traditional face-to-face psychotherapy. In 1999, I joined an e-therapy startup — HelpHorizons.com — as the industry’s youngest COO and led that company to a successful acquisition years later.
There’s no dearth of professionals willing to give e-therapy a try. In fact, when we ran HelpHorizons in the early 2000s, we had over 1,000 professionals at one point who signed up for the service.
What we lacked were people who actually utilized or wanted to utilize the service. And that’s the key problem with online psychotherapy: It’s a great modality that few consumers actually want to use.
One way around this problem, from a business perspective, is to simply get health or employee insurance plans to sign up for an e-therapy service based upon offering this as an “added benefit” for employees or covered lives in the plan. The idea is simple — if X% of insured lives use online therapy over face-to-face therapy, it’ll save the insurance company some money (because typically e-therapy is a little less expensive than traditional psychotherapy — but not significantly so when practiced via live chat or video conferencing services like Skype).
The problem comes when the rubber meets the road. If you look at utilization rates of people who actually use e-therapy services, they’re frightening. Nobody uses it. Nobody cares for it. Okay, that’s an exaggeration, because obviously e-therapy is right for some small percentage of people who need or want psychotherapy services. But the important thing is that it’s neither right nor used by the vast majority of people who have access to it. Once insurance companies review the utilization rates, they cancel the contract. If nobody is using the service, what’s the point of offering it?
Over the years, I’ve talked with dozens of people who’ve tried out e-therapy. I always ask them the same question, “Why did you stop?” Two factors have emerged — cost and face-to-face is more authentic a therapy experience.
People don’t like to pay for services online, unless it is helping them in a game (think Farmville, Cityville or Second Life), or to buy a subscription to an established information source. Even that bastion of pay-for-service model — porn — has given way to free porn. Nobody pays for porn any more, which has devastated the porn industry (or so I hear!). Nobody pays for advice either (since there are hundreds of places you can get free advice online, including our own Ask the Therapist service, and Psych Central Answers).
So all that leaves is paying for a real therapy interaction.
Well, that’s cool — there are some people willing to do that. And many therapists willing to provide that. But when you look at things like cost, you find out that you can see a real therapist face-to-face for either less (because your insurance covers the majority of the cost of care) or just a little more (if you choose to pay out of your own pocket). And trust me, when it comes time for mental health treatment, there is something definitely reassuring in talking to another human being in the same room with you.
Which is the other reason that people stopped with e-therapy service. They used it for a short-term problem, and didn’t need it any longer. Or it showed them that what they really needed was to see a real therapist, face-to-face. The feedback I’ve gotten is that while online therapy can be rewarding and reassuring, it doesn’t compare with the authenticity (at this point, anyway) of a face-to-face therapy interaction.
Additionally, many of the benefits of e-therapy quickly lose their status when you move e-therapy from asynchronous communications (two people are logged on at different times) — secure email, for instance — to synchronous communications (two people must be logged on at the same time). Once you require a therapist to spend the same amount of time talking to you online (whether it’s through Skype, chat room, or text messaging), the therapist is going to charge similar amounts of money as they do for face-to-face sessions. So one of the primary benefits of online therapy in the past — reduced cost, whenever-I-want convenience — flies out the door.
“If I have to schedule my online session just as I schedule a face-to-face session with a real-life therapist, I might as well see the real-life therapist,” is what I often hear. Which is what the vast majority of folks do when confronted with the actual costs and inconvenience of real-time, synchronous online therapy. Add to that that most insurance companies still do not cover the cost of online sessions, then it’s a no brainer. Face-to-face, traditional psychotherapy is often less expensive and more emotionally fulfilling than a comparable online therapy session.
Sometimes it’s hard for a businessperson who doesn’t have a deep background in mental health reimbursement to see the realities and complexities of behavioral healthcare in the U.S. Some appear to have the naive belief they can change a marketplace overnight that’s been formed through decades’ worth of existing treatment, mental health policy and administration, politics, budgets and reimbursement schedules. That a TV commercial and a mention in the The New York Times is all it takes.
Mental health professionals who’ve spent any time actually working and getting reimbursed within the current system know how difficult and convoluted the system really is. Billionaire and AOL founder Steve Case thought it would just take some technology and gumption to change healthcare in the U.S. when he launched Revolution Health in 2004. A few years later, disillusioned, he sold the remnants of his company to Everyday Health.
Healthcare in the U.S. isn’t going to change quickly — or overnight. The ObamaCare bill and Mental Health Parity Act don’t really do much to change the playing field when it comes to online therapy. And there still has been little demand for online therapy from consumers, because they don’t see a cost-benefit ratio that makes sense to them. Media hype notwithstanding, this particular application of telehealth makes the most sense for people who live in rural areas and can’t get to see a therapist locally. That’s a good market, but a small one.
I have a lot of hope for the future of e-therapy making small inroads into the mental health treatment space over time. But this part of telehealth is the least interesting right now from a business perspective because the consumer demand remains extremely limited.