Is Telemedicine and/or Teletherapy a Good Idea? Part II | Karen Lankford, PhD, Neuroscientist at Yale University

About five weeks before the planned start of my first major backpacking trip, I briefly dislocated my knee falling off a milk cart that I had been standing on to trim a hedge. My knee bent sideways with an audible pop before snapping back into position. Nothing was broken, but the tendons and ligaments had been over stretched, and the knee was unstable, causing my leg to collapse underneath whenever I did not place my foot perfectly flat and straight. This was obviously going to be a problem for even the training hikes, let alone carrying a full backpack full of gear for two weeks. So, I went to the urgent care center for my HMO and wheedled the doctor into approving a 15-minute consultation with a physical therapist.

She was great. She told me the right kind of knee brace to use which would allow a full range of normal motion to continue my hiking training but that prevent lateral movement that could cause more damage or result in a fall. She walked me through the rehabilitation process, telling me how long I should use the brace, what additional exercises I should perform and how I needed to wrap the knee at night to prevent injuring it if I moved in my sleep or got up groggily to go to the bathroom. With her help, I was able to rehabilitate my knee in time to be able to carry a 30-pound backpack up and down the mountains of Vermont without any knee instability.

My therapist was great. She gave me exactly the information and advice I needed. But this was only a great experience because my therapist was precisely the right person for the job. Her specialty was sports injuries. She spent most of her career helping healthy student athletes get back in the game quickly and I was able to benefit from her years of training and experience. If, however, I had broken or torn something, she would not have been much help. She would not have known how to diagnose the problem, let alone set a bone or perform orthoscopic surgery to correct the problem. If my fall had actually been caused by loss of balance due to an inner ear infection or the early stages of Parkinson’s disease, physical reconditioning of the knee would have done nothing to address the underlying problem. Likewise, if she had been a respiratory therapist rather than a physical therapist, or if her physical therapy training and experience had focused on stroke and heart trauma patients, rather than those with injuries involving bone, cartilage, muscle, ligament and tendons, she would not have been very helpful.

Good cognitive therapists are like good physical therapists. They can be incredibly helpful to patients, but only if they are the right person for the job. The term “therapist” unfortunately has been applied to a wide range of professionals with very different training and expertise. Furthermore, with the exception of those who are also psychiatrists, therapists lack the kind of training to recognize when cognitive and emotional symptoms may be caused by underlying medical problems which require a different kind of treatment.

So, is telemedicine mental health therapy a good idea? It depends. If other health problems which might be a cause, or major contributor, to the symptoms have been ruled out, teletherapy may be a more convenient way to receive treatment. Telehealth allows patients to interact with their therapists in an environment where they feel most comfortable (in their favorite chair with their dog or cat on their lap and a glass of iced tea on the table beside them), which can make it easier to talk about uncomfortable things. However, telehealth also creates greater emotional distance between therapist and patient. A telehealth therapist is not going to be able to see your full body language on a screen, and you are not going to be able to see their reactions as fully. Your therapist is not going to be able to reach out and hold your hand or pat you on the back if you feel the need for human comfort. If you are a recovering alcoholic or drug addict, your therapist is not going to be able to help keep you on the straight and narrow by making you take a Breathalyzer or test a urine sample if they suspect you have been using again. Sometimes, you really need to be in the same room with your therapist to get the full benefit from a session.

The VA health care system has been conducting telehealth treatments for some veterans with PTSD for years, but only after a medical screening and an evaluation to see if this is a good fit for the individual patient’s symptoms. Telehealth can allow more people access to mental health professionals with the right skills, training, and experience to address their problems, but it has its limits, and it is not right for everyone.

Right now, teletherapy is being marketed as a panacea for the general lack of accessibility for much of the population to good mental health care. I am somewhat skeptical about a move away from making sure that hospitals have inpatient treatment beds and staff psychiatrists available to treat patients in acute psychiatric crises, and towards simply directing patients to online therapy. This saves hospitals and insurance companies money, but it does not necessarily meet the needs of those with serious mental illnesses, such as schizophrenia, bipolar disorder or even major depression.