Teletherapy: Promise or problem?

By most estimates, rural areas like ours are vastly underserved by healthcare providers. Nowhere has this been truer than in mental health. When I moved to Salisbury and opened my therapy practice, there was only a tiny handful of mental health professionals in the area. New patients often arrived in my office exhaling with relief at having finally found a therapist within reasonable driving distance of home.

I found myself revisiting that period recently while working on a presentation on mental health services to be held on October 29 at the Scoville Memorial Library. My co-presenter and I were assembling a list of mental health services in the area and noticed that when we consulted the Psychology Today “Find a Therapist” website, a useful first stop for locating therapists in a particular geographic area, many more providers seemed to come up.

Are we witnessing a sudden flood of therapists relocating to our rural communities? More likely what we are seeing is the flowering of teletherapy – therapists who do not actually live here but treat patients here via teletherapy. During the pandemic, many therapists like me took advantage of the temporary suspension of many states’ licensing restrictions so they could practice in states that, at least temporarily, permitted therapists to practice without being licensed there. This allowed them to maintain continuity of care without violating state licensing laws when either they or their patients relocated. It also had the unintended effect of briefly creating what amounted to a national market for therapists. People needing help in underserved areas could suddenly draw from a whole new pool of therapists outside their state.

Although this leniency turned out to be short-lived, the boom in teletherapy uncovered an untapped market, sparking the development of a new breed of mental health organization focused on helping therapists obtain licensure and market themselves outside their home states. One leading company in the practice management field, Headway, explicitly identified rural communities as part of its marketing strategy, reporting that in 2023 its network completed 155,000 appointments in rural areas.

This is an undeniable benefit for communities like ours. Some care is often better than no care. Teletherapy was genuinely helpful to some of my own patients who needed more frequent sessions but could not accommodate added travel time. More frequent therapy may even have shortened their time in treatment. For others, teletherapy helped them disclose experiences, such as sexual violence, without the immediacy of being physically present with a therapist.

For all its potential benefits, telehealth also has some notable limitations. Physical observations, such as significant weight changes, can provide important clues to a patient’s emotional state but can be difficult to detect through a screen. In high-needs cases, therapists practicing far from their patients’ communities may lack knowledge of local resources, especially when emergencies arise.

Most significantly, the growth of teletherapy does little to address one of the biggest ongoing challenges to increasing mental health service access – the pivotal role of insurance companies in increasing patients’ access to care and fostering providers’ willingness to participate in insurance plans. The involvement of insurers in financing practice management groups like Headway has raised serious question about whether the investors’ incentives to control costs will ultimately conflict with the goal of expanding access to appropriate care? In a 2025 survey of 667 mental-health professionals, the Psychotherapy Action Network, a research and advocacy group, reported that 85 percent of respondents said they would not use a practice-management company if they knew an insurance company had a large ownership stake in it. Their concern, which should be taken seriously in assessing the likely impact of such groups, is that pressure to minimize costs could take precedence over clinical judgment and quality of care. How these organizations balance cost and access will help determine whether they deliver the affordable, continuous care they promise.

The good news is that we do not need to depend entirely on private companies, with incentives that can pit clinical and financial interests, to create a system that enables therapists to practice in rural areas even if they do not live there. Many states, including Connecticut, are rolling out interstate licensing “compacts” that allow approved therapists to practice legally in Connecticut even though they may live and be licensed in another state. They can play an influential role in reducing regulatory barriers to the provision of services by therapists outside rural areas even if they do not, themselves ensure affordability and insurance coverage. Although one such compact is now operational for psychologists, the state and professional groups should be doing all they can do to complete the implementation of similar compacts for other mental health professionals like social workers and counselors.

Flora E. Lazar, Ph.D., is a retired clinical social worker and historian interested in evolution of mental health services in the United States.