Opinion | Telehealth is failing Michigan’s mental health clients

Countless clients and health care providers will tell you that telehealth — using video or phone calls to conduct medical appointments — has improved health care. As someone who regularly provides outpatient mental health services to individuals, I must respectfully disagree.

It’s true that telehealth was a critical tool for many during the early days of the pandemic. As an ongoing means of delivering health care, however, it can have serious shortcomings for individuals with more significant mental health conditions.

There’s a lot happening during a mental health appointment. I’m listening to my client, yes. But I’m also taking note of things like the person’s grooming and hygiene. I’m tracking eye contact, or lack thereof. I’m observing a person’s hand movements, fidgeting or foot tapping. These subtle details allow clinicians like me to see the entirety of a patient’s condition.

Yet only a few of these nuances can be picked up through a camera lens. With telehealth, you often see clients from the waist up, so a lot of clinical information can be missed.

Virtual visits can also put clients themselves at a disadvantage. People experiencing significant delusions, hallucinations and other psychotic symptoms are a prime example. Some have trouble concentrating during virtual appointments. In extreme cases, clients with psychosis cannot participate in the virtual session in a meaningful way. The computer screen can be a barrier for many reasons, depending upon the individual’s perception.

Meanwhile, some clients are uncomfortable having a psychotherapy session from their home. They may live in unstable households and worry that a family member will overhear them through thin walls or air ducts. In these instances, clients fail to open up during the appointment or even quit it altogether, especially if it is not possible for them to participate from an alternate location. 

Some clients find another location for their virtual session, but this solution introduces new problems. Say a client appears to be overusing substances or talks about suicidal ideations. I may need to intervene, either by contacting the police or by calling for an ambulance. If a client is not participating from a location that has an address, I may not know where my client is located. This is one of the most significant considerations that is part of providing mental health treatment through telehealth, and especially through a phone call.  

Ethically speaking, clinicians are required to know where the client is located and if that individual is available by phone. We are also required to have the name and contact information for someone that can be called in an emergency.  It has been my experience that individuals may sit in their cars outside of their homes so that they can have privacy or may be going for a walk outside. There are times when the environment for providing virtual mental health services can be less than ideal. My biggest concern is focused on ensuring that the client is safe and in a location that can be easily located.

Then there are young clients with mental health conditions, who present yet another set of challenges.

Children don’t always understand the concept of a virtual therapy session. They may be distracted by the computer or tablet they’re using. They attempt to “play” at the session the way they would a video game, even turning the monitor off and on mid-conversation. These young and vulnerable clients need first-rate care. Yet clinicians can only control so much about the visit when they’re at the other end of a cell phone or iPad.

The stakes are high for many mental health clients. And, from where I sit, telehealth is simply not serving some of them well.

To do right by individuals seeking mental health services, providers need to take a close, person-by-person look at what works best. First, consider what’s right for the person. Then, take into account their diagnosis or the problem they’re experiencing. Consider how acute their symptoms are. And, where appropriate, ask for permission from the client to include the family or loved ones in the event of a crisis.

For certain clients, conditions or visits, virtual care works well. For others, in-person care continues to be the gold standard. Telehealth is not a one-size-fits-all solution. 

That’s why the national conversation about telehealth should prioritize balance. Policies should allow clinicians to make decisions based on what’s right for each individual patient.

The millions of Americans living with the burden of mental health conditions deserve no less.