More than a month into COVID-related stay-at-home orders, and therapists and their clients have mostly found a routine to stay connected. Videoconferences can be a reliable substitute for face-to-face meetings, either one-on-one or for groups. But their effectiveness depends on the ability of providers and clients to access Zoom conferences, and that’s not a given. Whether trying to provide continuity of therapy for people with HIV, those struggling with addiction, those suffering domestic violence—or all the above—counselors worry that interruption in face-to-face sessions will cause some of the most vulnerable clients to slip away.
Mike Discepola, M.A., vice president of behavioral and substance use health with San Francisco AIDS Foundation, said SFAF was able to offer same-day, drop-in counseling, via Zoom, to those in need the day after stay-at-home orders were in place.
But, he admits, some clients haven’t been able to make the transition to telehealth, and tragically, they’re often the ones who need the support most.
“Participants without the means from an equipment or financial perspective, such as lack of phones, computers, housing stability, have been more heavily impacted by the inability for us to provide on-site services.” In addition, he said, those with more complex issues, such as people experiencing psychosis or other psychological and emotional challenges, have not been able to access care as easily—or in some cases, to access care at all.
Still, SFAF hopes some workarounds may help reach those who are harder to contact and engage in services. “We are developing strategies to put the word out that we are open for care through substance-using networks, social media, ads, stories, and our website,” Discepola said.
Samantha Arsenault, M.A., vice president of national treatment quality initiatives at Shatterproof, an addiction advocacy organization, says the COVID-19 shutdowns are a “perfect storm” for people receiving counseling, especially for those struggling with addictions.
“The transition [to video counseling] is not by choice,” she said. “It’s forced on patients. And when you have a vulnerable population, some with limited resources, limited data plans, there are challenges with the technology. And then you add maybe losing their income, maybe losing their parents [to COVID-19], this is the worst time to be scaling back any elements of a treatment plan.”
Getting people in distress into care by whatever means is especially critical now, during a unique pandemic with an uncertain end. It’s too early to find national data quantifying the toll COVID-19 has taken on Americans’ mental health. However, a projection released last week by The Meadows Mental Health Policy Institute of the toll COVID-related mental issues could take on Texans paints a dire picture.
Without adequate preparedness to detect and treat depression and addiction, every five-percentage-point annual increase in the unemployment rate could result in 300 additional Texans’ lives lost to suicide and 425 additional lives lost to drug overdoses, per year, the study concluded.
Diane Kubrin, M.A., director of behavioral health services with the Los Angeles LGBT Center, said they’ve seen a dip in attendance in addiction-recovery groups after moving to video meetings, but an increase in attendance in victims’ groups.
“We think there’s a lot more people trapped in abusive relationships that are triggered now [by the shelter-in-place orders],” Kubrin said. As for those reluctant to do Zoom, “We tell them to do it now and not wait until shelter-in-place is over. Because we really don’t know how long the order will last.” To make sure that vulnerable people don’t disappear for good, Kubrin and her team are using “everything we have to get them back: phone calls, emails, texting.”
Challenges for Providers
Gabriel Lopez, M.S., director of health information systems with the Los Angeles LGBT Center, said that preparation for what was coming helped the organization transfer to videoconferencing on March 16. “We had no interruption to access to care for groups, partly because we already had a good relationship with the vendor that provides the patient portal.”
But switching all patients to Zoom conferencing takes more than setting up the technology and telling patients to use it. All of the providers contacted for this story said that older patients were more reluctant to use technology as a replacement for in-person sessions. And if they are able and willing to use videoconferencing, there’s the issue of where to go for the session. For a person in an abusive relationship, or who simply wants some privacy, finding a safe place in a crowded apartment to do an hour of telehealth can be challenging.
Arsenault said she’s seen some successful privacy workarounds, however. “Some people have [teleconferences] in their parked cars, or even while going on a walk if they can do it safely,” she said.
Other counselors experience glitches not just in getting their clients to use technology, but also in billing. In many cases, Medicaid requires an actual teleconference in order to pay the provider, but sometimes, because of technical issues, a counselor has to rely on only an audio call.
Several counselors contacted for this story said in some cases—because of either the patients’ lack of videoconferencing technology or unwillingness to use it—they’ve relied on phone calls as a last resort. Prior to the COVID-related public health emergency declared on Jan. 31, every Medicaid patient needed to be within four actual walls of an office in order for the therapist to be reimbursed. A waiver relaxed that rule to allow payment for videoconferences, but not for simple audio therapy sessions.
Sean Boileau, Ph.D., behavioral health services director at APLA Health, was accustomed to telehealth before he had to start using it when the organization went online in mid-March.
“With private sessions, I suggested it when a patient maybe had a cold and didn’t want to cancel the session, and then I found it worked well for patients who were out of town,” Boileau said.
APLA Health transferred all patients to video therapy on March 17, a week before Los Angeles issued its stay-at-home order. Boileau said that, while videoconferences can be great when a patient is on board with the idea or even initiates it, having video as the only option has been a “mixed bag.”
“Some people are more relaxed at home; for example, people who deal with social anxiety. For some, though, it puts them too much in their comfort zone. For an agoraphobic, or someone who needs to confront their boss or family members, [video sessions] make it too easy for them to avoid those issues and not apply their new skills in the real world. It can be too much of an intellectual exercise.”
Boileau notes that boundaries are lost when both parties are on screen, which can be fine for a patient with an established relationship. “But when I’m doing an intake, there’s a lack of three-dimensionality. It’s like flying a plane just looking at the instruments, but not the landscape.”
Fortunately, Boileau hasn’t seen a significant drop-off in clients after moving online. APLA Health, though, estimated that group sessions have dropped off by about 25% after a month. Jeff Bailey, director of HIV access and community-based services at APLA Health, said he’s seeing people start to return, possibly spurred by the understanding that stay-at-home orders could last many more weeks.
Discepola said SFAF also saw a dip in group participation after shifting them online, but that aggressively working social media and telling the community that they’re open for [online] care has helped them actually expand group offerings in the past two weeks. And he said SFAF will continue offering telehealth services after the shelter-in-place order is lifted.
“The COVID-19 crisis will therefore have a lasting impact on how we deliver care—and conceptualize reasonable access for populations in need. When we resume on-site services, even if significantly reduced for some time, we will focus services for those who for whatever reasons are not served well [or at all] through remote or telehealth.”