Why 'telehealth' for mental health patients seems to be working

What once seemed futuristic—receiving health care through a screen—has not only become common place, but preferable for certain medical visits, including mental health.

Both adult and pediatric providers say that offering care via telehealth (real-time visits through a smart phone, tablet, or computer with audio and video) has been not only crucial during the pandemic, but also often advantageous, even as many clinicians are again seeing patients in person.

Naturally, there are benefits and drawbacks—and it isn’t ideal for every patient, or every situation—but many providers and patients are happy. We talked to several Yale Medicine mental health clinicians to hear how telehealth has worked for them and their patients.

At Yale Medicine, a telehealth appointment begins by logging into the MyChart app on your device and clicking “begin video visit.” Your provider will start the session and things proceed much like they would at an in-person visit, except on a screen.

For visits with children, mental health care providers get creative to replicate traditional play therapy. Jin Ju Lee, MA, is a psychiatric nurse at the Yale Child Study Center and a provider with IICAPS (Intensive In-Home Child and Adolescent Psychiatric Services), in which care teams visit children and families in their homes. The program was completely virtual for months due to COVID-19.

“Often, kids jump on a session and show us how to do things on Zoom and feel more comfortable than we do with elements of it.”

—Paige Lembeck, PhD, Yale Child Study Center clinical psychologist

Lee says her care team would often drop off toys or specific supplies for games to a child’s home ahead of time, and then use them together over a screen.

“Another example was that many of our kids had interests in playing specific games online like Minecraft, so when engagement was particularly difficult or at the start of a session, we would have the child share their screen and walk us through how they navigated a character in that game and attempt to join with them in that way,” she says.

Another tactic was cooking lessons (again with supplies dropped off ahead of time). The child, along with a parent or guardian, would cook on screen “with” a clinician. “These were great ways to observe family interactions, dynamics, and ways in which they communicated with each other,” Lee says.

“The biggest surprise from my perspective is how easily kids have been able to adapt to telehealth,” says Paige Lembeck, PhD, a clinical child psychologist at the Yale Child Study Center. “Often, kids jump on a session and show us how to do things on Zoom and feel more comfortable than we do with elements of it.” But it’s not always the optimal choice for every child or adolescent. “A 4-year-old may be someone who works well over a screen, yet I’ve had teen patients who refuse to show their faces on a screen because they don’t want to look at themselves.”

Lee agrees that the familiarity with technology is a reason telehealth can be a good option for some kids and adolescents.

“This younger generation has grown up with technology and they are comfortable with FaceTime. Teenagers especially like to offer a curated view of their room,” she says. “The younger group has also surprised me. I worked with several children who had not engaged well in person, but they were quite savvy with technology and eager to teach me things online. I had another child recently who wanted to communicate through the Zoom chat, as there were things she felt nervous about saying out loud.”

Carolina Parrott, LCSW (licensed clinical social worker), of the Yale Child Study Center, says the addition of telehealth has been beneficial, but good results definitely depend on the child.

“In general, I think it works more smoothly for pre-teens and teenagers, but I’ve also had 8- and 9-year-olds who can sit still on camera,” she says.

Paula Zimbrean, MD, a Yale Medicine psychiatrist, notes that the switch to telehealth was abrupt, and the transition back to in-person has been more gradual.

“When the pandemic hit, the scale at which telepsychiatry was adopted was huge and we were all ‘tele’ for months. It was a no-brainer because we had no other option,” she says. “But it’s been more complicated as we slowly transition back to in-person sessions. There are some people who love telehealth, and others who prefer in-person sessions because of technical, cognitive, or medical issues. I would say now that my clinic is 50/50.”

More research is needed, Dr. Zimbrean says, to tell what works best for certain patients. “I work with organ transplant donors and there is a comprehensive evaluation I do, much of which can be done via telehealth—but this is less true for the cognitive and neurological data, which can be more complicated,” she says. “However, there have been studies showing that virtual cognitive behavioral therapy [CBT] has really good results for people with depression.”

The convenience is unprecedented, Dr. Zimbrean adds. “Patients can meet with us in their car on a lunch break, which is wonderful. This is all about expanding access, and it achieves that,” she says. “Plus, there are a lot of follow-up visits that can be done like this, and hopefully elements of telehealth will stay with us.”

Lembeck adds that for many families, transportation to and from appointments can be a burden. “Certainly, the accessibility and convenience element are important, especially for families that had trouble with attendance,” she says. “However, some patients don’t have reliable wi-fi or access to tablet devices for virtual visits.”

Overall, transportation barriers are more common than technological accessibility, says Parrott. However, as a bilingual provider, Parrott says there can be initial difficulties getting non-English-speaking families set up with all the necessary consent forms. Those have been some minor hurdles, she says. On the flip side, it is easy to add a translator to a session with the click of a button, Lembeck says.

Another benefit is scheduling, she adds. “Some of our families are fractured and living separately and getting them all in one room can be difficult, and this helps with that,” she says.

Parrott says the ability to now offer families a choice between in-person and telehealth visits is a valuable one.

“I’ve seen some families who have adjusted to it and others who were new to treatment in general and they really embraced telehealth. But other families tell me they only want to come in person,” she says. “I have one teenager I work with who told me she wanted to meet me in person at least once, even though we had worked together online. And I understood that. There is a connection that is felt in person that is different than on video.”

It’s important to note that there are certain situations in mental health—such as family crisis, suspected abuse, or suicidality—that present challenges when care is online.

Another element is masks—which patients don’t need to wear at home but do in the office.

“This can be a challenge for autism assessments, for example, as there is so much you need to see in a child’s face. So, in that sense, it can be really nice to see them on a screen,” Lembeck says.

People come to therapy to share emotion, and it can be hard to replace the feeling of being in the same room as someone, Lembeck says. “There’s something called 'therapeutic silence,' and it doesn’t feel the same way over a screen,” she says.

Also, physical cues don’t always translate to the screen. “There is body language and facial expressions and all these bits of micro data we absorb during an in-person visit,” Lee says. “With telehealth, you might have a whole family squeezing into a screen, so the computer is at a distance or it’s being passed around from person to person.”

However, clinicians also get a glimpse into a family’s home via telehealth. “It’s a rare opportunity to directly witness a child’s environment. The younger ones are excited about showing us things, but we also have to do planning if the household is chaotic and find them a place where they can talk and have privacy and not be distracted,” Lembeck says.

Parrott describes herself as a people person who would always choose live interactions over virtual, but still she says she hopes telehealth remains an option for families. “I think it’s a valuable service.”

Paul Desan, MD, PhD, director of the Psychiatric Consultation Service at Yale New Haven Hospital, agrees.

“You can do psychotherapy and mental health care very well if you have a good quality audio-visual connection,” he says. “It’s much easier for people to schedule a visit and they don’t have to drive there and then wait to be seen. I don’t think the mental health system will ever go back to all in-person sessions as long at the insurers keep paying for it.”

That doesn’t mean there aren’t some disadvantages, Dr. Desan says. “Physically being with someone is a closer connection, of course, and I also occasionally have a situation where I’ll say, ‘I think it would be better if we met in person.’”

Ultimately, telehealth allows for another means of connecting with patients, says Pamela Hoffman, MD, medical director for Telehealth Services for Yale Medicine and Yale New Haven Health System.

“Perhaps it’s patients who aren’t ready for the physical confines of an office, or patients who would otherwise not be in care at all,” Dr. Hoffman says. “Telehealth increases access to services and offers choices that, combined with the clinical judgement of the provider, can make for a very successful treatment.”

Moving forward, it will be important to continue to support training in telehealth and access to technology, broadband, and devices for all patients to have this option when they need it most, she adds.