Deby Williamson used to take note of her clients’ body language and the vibe that filled the room when they came to see her for mental health therapy. That’s not happening now, since she meets them via computer.
Williamson, a licensed clinical social worker in private practice in Colorado Springs, is one of thousands of mental health professionals in Colorado who have switched to telemental health in the current age of isolation because of the new coronavirus. “When they are in the office, I can feel, gut-feeling how they are doing,” she said. “I don’t get all that now. I’m not used to it and neither are they.”
Williamson’s practice, called Safe Haven in the Springs, has moved entirely online in the past two weeks. While crisis walk-in mental health centers and mobile response teams across Colorado remain open during the coronavirus pandemic, most clinical therapy sessions have gone virtual.
The switch comes as the fear of catching the virus and the loneliness of isolation are amplifying anxiety and depression in people who already were seeking treatment, and triggering those issues in many who had not experienced — or addressed — them before.
While therapists say virtual sessions don’t provide the same level of human connection, they do have other benefits, including making it easier for clients to get to their appointments and allowing people with certain conditions — such as agoraphobia, the fear of going outside — ease into therapy from home.
The nearly overnight evolution of mental health care because of the pandemic could change therapy forever, and many professionals are hoping it will.
Psychiatrists, psychologists, clinical social workers and others are now operating under temporary guidance approved by federal and state government agencies that will allow them to bill Medicaid, Medicare and other insurance providers the same amount for a telemental health appointment as they could for an in-person session. The changes were announced last week by the state Department of Health Care Policy and Financing, the state Office of Behavioral Health and the federal government in response to the new coronavirus that already has killed at least 48 Coloradans.
They were a long time coming, according to Dr. Carl Clark, president and CEO of the Mental Health Center of Denver.
The center set up virtual, privacy-compliant therapy for its 600 clinicians in about one day. It’s keeping its 24/7 walk-in clinic, pharmacy and mobile crisis teams operating during the pandemic, and its co-responders are still accompanying Denver Police on mental health-related calls, but therapists moved one-on-one therapy sessions to the virtual world on March 16.
MHCD is using Microsoft Teams for the therapy appointments, a program that’s compliant with federal patient privacy laws. The sessions are not recorded, and no outside party can join. The therapist emails an invitation to their client, who downloads the Microsoft Teams app on their phone or computer. The therapist initiates the call, and so far, therapists are reporting that there are fewer missed appointments than there were with in-person meetings.
“My last clinic this week, I saw 100% of people on my schedule,” Clark said. “That has never happened in my career. No one missed a bus. No one didn’t have transportation.”
The pandemic has forced changes in government policy that he hopes will stick permanently. “I think there will be enough people who are receiving this service who will say, ‘Why will I get on a bus and go across town for an appointment when this works for me?’ They will not be able to put this horse back in the barn.”
Still, connecting remotely isn’t easier for everyone. Of the mental health center’s 12,000 clients, about 1,200 do not have a computer or a smartphone. Some don’t have a phone at all that they could use to call a therapist.
The center is asking companies in Colorado for iPads or laptops they are no longer using so they can give them to clients. They’re also giving people mobile hotspot devices so they can connect to the Internet, and taking advantage of pandemic-related promotions from companies, including Xfinity, which is allowing free access to hotspots.
That won’t resolve every situation, however, Clark said. “Some families have a device, but they only have one, and mom and dad are working from home and the kids are trying to do school from home, and now we are adding therapy.”
MHCD already had a long-term plan to roll out telemental health and Microsoft Teams for all of its 850 employees, but rushed to implement the plan in one day instead of six months.
The center is also ramping up a program to provide cognitive behavioral therapy for depression via a 12-week program that patients can do using an app. Clients can log in and follow prompts to help change their way of thinking — such as to replace a mantra of “nothing ever goes right for me” with a list of things they are grateful to have. They can ask on the app’s dashboard to connect with a therapist at any time.
The program allows a therapist to connect with 700 patients suffering from depression each year, compared with the typical caseload of about 70. But, so far, insurance companies do not reimburse therapists for the remote therapy, something Clark hopes will change if they can show it helped clients during this pandemic.
Telehealth rules have evolved slowly, until now
Rules regarding telemental health have gone through several iterations during the past several years, making it challenging for therapists to keep up.
At one point in Colorado, therapists could only use telemental health if the client lived in a town with a population under 50,000. Another rule stipulated that the client had to live at least 30 miles from their therapist. And another said that a person receiving telehealth behavioral health could not do it from home, but had to drive to a nearby medical clinic and use a computer there.
Despite the federal and state guidance this month that says therapists can bill for telehealth at the same rate as face-to-face therapy, those interviewed by The Colorado Sun said they had not yet received any payments so it was too soon to know how well the billing system will work.
“They needed to make these changes back in January,” said Williamson in Colorado Springs, who treats several veterans with traumatic brain injury. “I think they waited too long.”
Others are concerned about the supply of personal protective equipment — masks and gloves, etc. — for mental health staff still working in walk-in clinics and in mobile crisis teams. The Mental Health Center of Denver has enough for about two more weeks.
“These are urgent times”
For Erin Kremer, a licensed clinical social worker who counsels preteens and teenagers, the switch to virtual therapy has been particularly challenging for that age group.
“I feel like I’m pulling teeth, honestly,” said Kremer, who works for AspenPointe in Colorado Springs. She’s been doing some of her therapy appointments via phone because of technology issues with the video system. Also, some of her clients don’t have a computer and only have access to a parent’s cell phone.
Kremer asks a teenage girl how she’s feeling and gets, “Meh.” She asks what’s going on and gets, “Nothing.”
“It’s hard to engage,” she said, on a day last week after a taxing round of virtual sessions. “I am just kind of humbled by how much of my work is accomplished through watching the client and through the energy in the room. With teens, I feel like it’s harder to draw them out. They are not as glib as grownups with their facade.”
In other words, they don’t talk just to fill the space.
Kremer expected to see heightened anxiety in her clients the past two weeks, probably because, she acknowledged, she is anxious these days. But in fact her teenage clients are more likely to have depression right now, likely due to the isolation they feel.
“Social isolation is especially damaging to the young folks,” she said. “At first, they were happy they didn’t have to go to school. Now they are, ‘Enough of that. We’re bored.’”
Teens are used to spending time alone in their rooms, watching movies and social media. “But not being able to see friends and go to school has been very disruptive,” Kremer said.
Similarly, Williamson is looking forward to returning to in-person therapy with most of her clients. But a few current and former patients would benefit from a permanent rule change for telemental health — including one man who quit because the drive down a steep, Teller County mountain road to get to an appointment exacerbated his anxiety.
Williamson said her clients, adults and many veterans, are experiencing anxiety. “They’re anxious and afraid,” she said. “It’s fear. They had trouble sleeping before, but now it’s, ‘I have to go to the grocery store and what if somebody coughs?’”
They’re struggling without the usual stress-relieving outlets of meeting friends or going to a restaurant, she said.
For many people, the hardest part of the pandemic, mental health-wise, is that its duration is uncertain, said Vincent Atchity, president and CEO of Mental Health Colorado. It’s not like a looming hurricane that we know we have to weather for a few days before sunshine returns.
“We are all in a state of anxiety,” he said. Humans are used to living with some uncertainty — like the fear of losing their job or getting cancer, but this is a collective uncertainty, he said.
“When we tie it to a real event that is taking place at the same time for everybody, that intensifies concern.”
Atchity encouraged Coloradans to watch out for loved ones who are prone to mental health issues and urged them not to wait out the pandemic before making a call. Mental health treatment — in person on virtual — is available.
“These are urgent times,” he said. “The greatest urgency is with somebody who is seriously mentally ill and requires that ongoing continuity of therapy and medication to remain stable. It should be the same level of urgency you would have if you don’t want a diabetic to run out of insulin.”
Colorado’s 17 community mental health centers, in all regions of the state, are open for in-person services and telehealth appointments. Outreach workers are checking on families who were receiving mental health care through now-closed school-based clinics and going to COVID-19 testing lines to talk to people who are anxious, said Doyle Forrestal with the Colorado Behavioral Health Council, the membership organization for Colorado’s community mental health centers.
“They are taking new clients,” she said. “They want people to reach out.”
Many of the centers are already experiencing an uptick in new patients. Clark, with the Mental Health Center of Denver, said the center is “as busy as it always is” and that clinicians are prepared to help people through the coronavirus outbreak.
“No matter where they are,” he said, “we are connected.”