My very first memories are stained with anxiety. As a child, I would cry for days when my mother went on business trips, and struggled to foster friendships with other kids. As I became older, my anxiety evolved into an obsession with getting straight As mixed with an intense fear of loss. However, through extensive therapy (and eventually, Zoloft), my mental health journey has generally been one of progress. And yet, when I started college last fall, I hit a roadblock. I‘d moved out of state for school and was abruptly cut off from my online therapy routine.
Ever since my therapist moved away from my home state of Maryland, we’d conducted our sessions through teletherapy — mental health therapy that’s facilitated through technology (usually video-chatting). Because my therapist had gotten her license in Maryland, where teletherapy is permitted, she could continue to treat me online even when she moved elsewhere. She had been an integral part of my healing, so it was important to me that our sessions continued.
But when I moved to Massachusetts — a state where my therapist is not licensed to practice — she could no longer treat me, even if she video-chatted from a state where she was licensed. Because regulations vary state-by-state, and obtaining a license is a long and difficult procedure, counselors are limited as to where they can practice teletherapy, and patients are limited as to where they can receive it. As a result of all this petty red tape — comprised of what I believe to be outdated licensing laws — patients like me are often left without crucial emotional support.
While I could have tried to find a different therapist, continuity of care is largely what makes therapy effective. “A big piece of the process is building trust. And also for the therapist, to get to know the client takes some time,” says Tara Ryan, a Florida-based clinical social worker who utilizes teletherapy in the four states where she’s licensed. When that process is disrupted, Ryan adds, “you have to start over.”
This emotional reset button can rob both parties of the time and work they’ve invested in their sessions. For example, my therapist knew every intimate detail about my obsession with grades (which was about so much more than just being a good student), and what techniques calmed me down when I did poorly on a test. Broaching this topic with someone new seemed daunting and emotionally exhausting, especially when I knew that somebody who already knew how to help me was only a call away.
For some people in therapy — those with addiction issues, for example — any gap in continuity of care can pose a threat. “If you're doing maintenance work with a client ... my worry is that something would re-emerge and they don't have someone to check in with,” says Nicole Issa, a Rhode Island-based therapist who also uses teletherapy.
One 31-year-old therapy patient, Michael, who preferred to go by only his first name for the sake of privacy, experienced an interruption of care when he relocated to different city. He’d seen his therapist for close to two years, and says it’s been draining to recreate such an intimate relationship with another therapist.
Retaining his therapist through teletherapy, Michael says, would’ve been incredibly helpful to him, even in the short-term. “I at least would have someone while I was in the process of trying to find someone else — not basically quitting cold turkey.”
A loosening of restrictions could allow therapists to "see" clients across state lines. It would also mean a far greater number of mental health professionals to go around; patients would be able to find a therapist they feel is a good fit for them anywhere in the country. For some individuals, traditional in-person talk therapy isn’t even an option, because of stigma, physical disability, distance, or cost of transportation. And in the U.S. alone, 112 million people live in areas with mental-health professional shortages — otherwise known and mental health deserts — would be all but eradicated with universal licensure combined with teletherapy technology.
For some individuals, traditional in-person talk therapy isn’t even an option, because of stigma, physical disability, distance, or cost of transportation.
Although some worry about its legitimacy, research on teletherapy is optimistic. A 2013 study indicated that psychological treatment via video-conferencing to rural military veterans with PTSD had benefits comparable to those from in-person treatment. A 2017 review of literature suggested that teletherapy leads to lower costs, more interactive sessions, and “efficient and adaptable” care. Although there are still kinks to work out — initial start-up costs, insurance coverage, privacy concerns — teletherapy holds enormous potential for the American mental-health-care system.
Still, teletherapy might not be the right fit for every patient, or every therapist. Therapists would need special training, Ryan says, particularly on how to protect patients who need in-person interventions in a crisis. Ryan requires her teletherapy patients to fill out a form naming emergency contacts, nearby hospitals, and local mental-health services, which protects these patients in the event that they need help from someone in their own area.
Given its upsides, though, why is teletherapy still choked by licensing laws? The primary reason is to ensure that state psychology boards can properly regulate all therapists who interact with patients within their state borders, says Deborah Baker, director of legal and regulatory policy for the APA. Since states vary on certain therapy protocols, Baker argues that state psychology boards are wary of teletherapists who may not be familiar with the policies of their individual state.
For instance, states differ on definitions of abuse or neglect, as well as when it is necessary for a therapist to report these instances. “With that variability, the question is, which state law applies?” Baker says. “That creates additional legal ethical dilemmas for the psychologist.”
Issues with insurance may also inhibit the expansion of teletherapy, says Danielle Louder, program director for the Northeast Telehealth Resource Center. Many insurance companies don’t cover teletherapy to the same extent as in-person therapy. As a result, states may be reluctant to change licensure laws until the insurance companies expand coverage. “It’s like putting the cart before the horse,” she says.
Basically, current licensure laws are rooted in systemic obstacles originally intended to protect patients. But it’s possible that reform of this system is on the horizon.
PSYPACT, a legal agreement between multiple states devised in 2015 by the Association of State and Provincial Psychology Boards, allows therapists with the right certification in participating states to conduct teletherapy in any other participating state — without the need to have individual state licenses. PSYPACT requires all teletherapists to follow the state protocol of their patient’s state, allowing for regulation. Although 12 states have already approved the legislation, PSYPACT must set up a commission to oversee their operations before it becomes active. However, it has the potential to be a much easier, cheaper, and quicker process than getting a separate state license — and thus increase nationwide access to teletherapy.
So why have only 12 states adopted PSYPACT legislation? It can be difficult to advocate for change in rural states with so few licensed psychologists, says PSYPACT’s executive director Janet Orwig, even though those areas would benefit the most from PSYPACT. “We are working really hard to get the word out,” she says. “Just letting them realize that this is here, this is what it does, and this is why it’s important.”
Although PSYPACT will likely make headway on the issue of licensure laws, the damage is already done for patients like me. Although I found a great Boston-area therapist, I don’t have a time machine to reverse the harm that resulted from my lapse in care. The only way to bridge the gap between those who need teletherapy and those who can provide it, Louder argues, is action.
“You’ve got to talk with [lawmakers] and provide input wherever possible to say, ‘Guys, this is a really old policy,’” she says. “There is this movement; there certainly is movement. It’s promising — but we’re still not quite there.”