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TeleMental Health: Bridging Long-Term Barriers to Care.
Lindsay Scholz, LPC, NCC, BC-TMH • Jul 17, 2020
Telehealth has been around now for over 50 years, but TeleMental Health (TMH) remains, in comparison, a relatively new offshoot of this branch of healthcare. TMH has become increasingly popular over the last decade with research demonstrating time and time again its overwhelming effectiveness when working with a variety of demographic groups suffering from an equally diverse variety of mental health issues and ailments. So why has it taken until now for its widespread implementation?
Traditionally, many individuals preconceptions and ideas surrounding the effectiveness of TMH have been that which have stunted its widespread dissemination as a viable treatment approach that indefinitely holds the potential to reduce the disparities that currently continue to exist across our nation in terms of access to quality mental health care (Jameson, Farmer, Head, Fortney, & Teal, 2011; Morgan, Patrick, Magaletta, 2008). Research has sited that perceptions among both consumers as well as clinicians as to the effectiveness of mental health care treatment carried out in this manner have provided as major barriers, despite the overwhelming evidence to the contrary, again demonstrating its high levels of efficacy with diverse groups of people.
There are many, frankly, shocking statistics that serve to highlight the importance of implementing TMH practices indefinitely, even upon the remittance of the COVID-19 pandemic. There is currently a significant shortage of mental health providers relative to demand for mental health treatment services in the United States (U.S.) (Flaum, 2013; Bishop, 2017; Mental Health America [MHA], 2018; Quashie, 2016). This article reviews the current state of Mental Health in America as well as the disparities that exist in treatment accessibility across our nation. It then continues to discuss how Telemental Health (TMH) may address the large and continuously growing gap in access to mental health care across the U.S., specifically through the enactment of reciprocal TMH parity laws across all 50 states.
The National Law Review suggests that approximately one in four Americans experiences mental illness, totaling roughly 60 million individuals, each year (Quashie, 2016; MHA, 2018). Only 40% of those with mental illness however report receiving treatment for their condition(s). Additionally, across our nation it has been approximated that one mental health provider exists for every 790 individuals (Quashie, 2016). Quashie (2016) sites one report made to congress which indicated that a vast 55% of our nation’s counties had no practicing psychologists, social workers, psychiatrists, or counselors to provide needed mental health services in these areas. In 2018, 56% of American adults with a mental illness reported they had not received treatment due to a lack of accessibility to services (MHA, 2018). In addition, youth mental health continues to deteriorate while access to care remains limited. In 2018, over 1.7 million youth with major depressive episodes did not receive treatment due to these limitations as well.
The discrepancies that exist between supply and demand for mental health services are accentuated by a marked variation in the geographical distribution of existing mental health treatment providers (Flaum, 2013; Bishop, 2017; MHA, 2018; Luxton, Pruitt, O'Brien, Stanfil, Jenkins-Guarnieri, Johnson, Gahm, 2014; Quashie, 2016). The U.S. continues to experience an, ongoing, increasing demand for mental health services and, coincidingly, continues to maintain an overall maldistributed supply of qualified treatment providers (MHA, 2018; Quashie, 2015). In 2018, Mental Health America (MHA) concluded, based off national statistics examining the state of mental health across America, that there is a shortage of mental health treatment providers on a national level.
In fact, in the MHA’s 2018 publication, “The State of Mental Health in America,” it was reported that over 4.000 areas across the U.S., together containing over 110,000,000 people, were identified as “mental health professional shortage areas (p.2).” This publication from MHA (2018) additionally breaks down mental health workforce availability by state, finding that in the lowest ranking state (Alabama) there is a rate of one mental health professional per 1,260 people, while in the highest ranking state (Massachusetts) a rate of one mental health professional per 200 people exists. With this, it is suggested that the enactment of reciprocal TMH parity laws, specifically aimed at eliminating barriers which currently prevent qualified mental health practitioners from providing TMH counseling across state lines, may be able to address the widening gap among supply and demand for mental health services that exists nationally today.
In considering how to potentially decrease the disparities that currently exist in the U.S. in terms of those in need of mental health services and those with accessibility to them, one avenue certainly worth consideration may be to implore all 50 states to consider the enactment of reciprocal/mutual TMH parity laws. While we cannot simply force qualified clinicians to change geographical location in order to meet the high demand for mental health care services in various under-served areas across the country, it may be feasible to enhance the accessibility of these much needed services to those living in disadvantaged regions through the enactment of this parity law on a national level for TMH service providers. It is suggested specifically herein that those Board Certified in TMH, holding a current BC-TMH credential, who are coincidingly credentialed as Nationally Certified Counselors (NCC’s) and hold the appropriate licensure or certification required by their respective State Board to provide mental health treatment services, should be permitted to provide TMH services across the U.S. regardless of their state of residency or geographical location and, alternatively, based upon their national credentialing which denotes a prestigious level of competency in providing such services to the public.
The variation that currently exists from state to state, with little reciprocity among them, regarding the laws that govern the provision of TMH treatment services must be reconsidered. For while these laws certainly have not contributed to the mental health crisis we face as a nation today, they unequivocally may hold the key to remedying this crisis by permitting the provision of TMH services across state lines, something currently prohibited by regulation through state licensure boards across the U.S. (Huggins, 2018). As a result, the enactment of the reciprocal TMH parity laws advocated for within this article could undoubtedly lead to increased availability and accessibility to mental health treatment services for all Americans during a time when these services are needed more than ever across our country.
TMH has been shown to mitigate, and may even hold the key to potentially eradicate, some of the various barriers that have been empirically demonstrated to serve as significant hindrances to an individual’s ability to pursue mental health treatment services despite their need for such treatment (Bishop, 2017; Quashie, 2016). These barriers include, but are certainly not limited to, physical disability, financial hardship or an inability to self-fund mental health services when needed, and a lack of access to qualified mental health treatment providers actively practicing and providing services in many geographical areas as previously denoted.
TMH has been demonstrated through various empirical inquiries to enhance accessibility to treatment services for many individuals who face the greatest disadvantages and obstacles in obtaining them (Bishop, 2017; Quashie, 2016). The result of independent state legislation passed over the last decade allowing the provision of TMH services seems clear and has been repeatedly demonstrated through clinical research (Bishop, 2017; Godleski & Darkins, 2012; Luxton et al., 2014; Quashie, 2016). Multiple studies have shown that through the provision of TMH services an increased number of consumers currently battling mental illness or mental health issues who previously lacked access to treatment services are now beginning to receive services as significantly higher rates (Quashie, 2016). TMH proves to be promising in its prospect of providing treatment services to those in need who cannot access in-person services for an array of reasons and who have historically been disadvantaged as a result.
TMH counseling services have additionally been demonstrated through multiple research inquires, examining varying demographic groups as well as specific mental health conditions, to yield the same treatment outcomes among consumers and to be as equally as efficacious as in-person, face-to-face, counseling services provided (Flaum, 2013; Quashie, 2016). However, issues arise given that in the vast majority of states the laws stipulate that TMH services must be rendered only by those practicing clinicians licensed or approved by the licensure board for the state in which the client is physically located at the time in which treatment services are rendered (Huggins, 2018). This specific regulation stunts TMH service providers from currently being able to serve those in alternative states and in areas identified as “mental health professional shortage areas” where the demand for mental health care is often highest (Bishop, 2017; MHA, 2018, p.5).
Through the enactment of reciprocal TMH parity laws all consumers of mental health services will experience potential benefits (Bishop, 2017). These may include: less time spent by consumers waiting for available appointments and to receive treatment services, enhanced access to a greater pool of qualified professionals including specialists for consumers to choose from, and even potentially the an increase in the affordability of services (Bishop, 2017; Flaum, 2013; Quashie, 2016). Most quintessentially however, the enactment of such laws would provide potential consumers in great need of mental health services, yet disadvantaged due to a lack of access to treatment providers within their geographical areas as well as due to alternative barriers that may exist within their lives which hinder their ability to engage in face-to-face counseling services, with greater accessibility to treatment services.
With this, it is with urgency that state legislators in collaboration with their respective licensure boards come together to discuss the consideration of adopting a TMH parity law that is uniform across all 50 states, reciprocally, and which extends the provision of treatment services provided by the aforementioned qualified clinicians to working with those in need across our country as opposed to confining them to the state in which they reside.
References
Bishop, M. (2017, June 16). Telemental health. Retrieved from https://www.publichealthpost.org/research/telemental-health/
Flaum, M. (2013). Telemental health as a solution to the widening gap between supply and demand for mental health services. Retrieved from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.439.3440&rep=rep1&type=pdf
Godleski, L., & Darkins, A. (2012, April 1). Outcomes of 98,609 U.S. Department of Veterans Affairs patients enrolled in telemental health services, 2006-2010. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22476305
Huggins, R. (2018, November 6). Telemental health across state lines: Doing It legally. Retrieved from https://personcenteredtech.com/2018/11/06/telemental-health-across-state-lines-doing-it-legally
Jameson, P. J., Farmer, M. S., Head, K. J., Fortney, J., & Teal, C. R. (2011). VA community mental health service providers' utilization of and attitudes toward telemental health care: The gatekeeper's Perspective. Journal of Rural Health, 24, 425-432.
Luxton, D. D., Pruitt, L. D., O'Brien, K., Stanfil, K., Jenkins-Guarnieri, M. A., Johnson, K., … Gahm, G. A. (2014). Design and methodology of a randomized clinical trial of home-based telemental health treatment for U.S. military personnel and veterans with depression. Contemporary Clinical Trials, (38), 134–144. doi: 10.1016/j.cct.2014.04.002
Mental Health America [MHA]. (2018). The state of mental health in America: 2018. Retrieved from https://www.mhanational.org/sites/default/files/2018 The State of MH in America - FINAL.pdf
Morgan, R. D., Patrick, A. R., & Magaletta, P. R. (2008). Does the use of telemental health alter the treatment experience? Inmates' perceptions of telemental health versus face-to-face treatment modalities. Journal of Consulting and Clinical Psychology, 76(1), 158-162. doi:10.1037/0022-006x.76.1.158
Quashie, R. Y. (2016, August 24). Boom in telemental health . Retrieved from https://www.natlawreview.com/article/boom-telemental-health
Traditionally, many individuals preconceptions and ideas surrounding the effectiveness of TMH have been that which have stunted its widespread dissemination as a viable treatment approach that indefinitely holds the potential to reduce the disparities that currently continue to exist across our nation in terms of access to quality mental health care (Jameson, Farmer, Head, Fortney, & Teal, 2011; Morgan, Patrick, Magaletta, 2008). Research has sited that perceptions among both consumers as well as clinicians as to the effectiveness of mental health care treatment carried out in this manner have provided as major barriers, despite the overwhelming evidence to the contrary, again demonstrating its high levels of efficacy with diverse groups of people.
There are many, frankly, shocking statistics that serve to highlight the importance of implementing TMH practices indefinitely, even upon the remittance of the COVID-19 pandemic. There is currently a significant shortage of mental health providers relative to demand for mental health treatment services in the United States (U.S.) (Flaum, 2013; Bishop, 2017; Mental Health America [MHA], 2018; Quashie, 2016). This article reviews the current state of Mental Health in America as well as the disparities that exist in treatment accessibility across our nation. It then continues to discuss how Telemental Health (TMH) may address the large and continuously growing gap in access to mental health care across the U.S., specifically through the enactment of reciprocal TMH parity laws across all 50 states.
The National Law Review suggests that approximately one in four Americans experiences mental illness, totaling roughly 60 million individuals, each year (Quashie, 2016; MHA, 2018). Only 40% of those with mental illness however report receiving treatment for their condition(s). Additionally, across our nation it has been approximated that one mental health provider exists for every 790 individuals (Quashie, 2016). Quashie (2016) sites one report made to congress which indicated that a vast 55% of our nation’s counties had no practicing psychologists, social workers, psychiatrists, or counselors to provide needed mental health services in these areas. In 2018, 56% of American adults with a mental illness reported they had not received treatment due to a lack of accessibility to services (MHA, 2018). In addition, youth mental health continues to deteriorate while access to care remains limited. In 2018, over 1.7 million youth with major depressive episodes did not receive treatment due to these limitations as well.
The discrepancies that exist between supply and demand for mental health services are accentuated by a marked variation in the geographical distribution of existing mental health treatment providers (Flaum, 2013; Bishop, 2017; MHA, 2018; Luxton, Pruitt, O'Brien, Stanfil, Jenkins-Guarnieri, Johnson, Gahm, 2014; Quashie, 2016). The U.S. continues to experience an, ongoing, increasing demand for mental health services and, coincidingly, continues to maintain an overall maldistributed supply of qualified treatment providers (MHA, 2018; Quashie, 2015). In 2018, Mental Health America (MHA) concluded, based off national statistics examining the state of mental health across America, that there is a shortage of mental health treatment providers on a national level.
In fact, in the MHA’s 2018 publication, “The State of Mental Health in America,” it was reported that over 4.000 areas across the U.S., together containing over 110,000,000 people, were identified as “mental health professional shortage areas (p.2).” This publication from MHA (2018) additionally breaks down mental health workforce availability by state, finding that in the lowest ranking state (Alabama) there is a rate of one mental health professional per 1,260 people, while in the highest ranking state (Massachusetts) a rate of one mental health professional per 200 people exists. With this, it is suggested that the enactment of reciprocal TMH parity laws, specifically aimed at eliminating barriers which currently prevent qualified mental health practitioners from providing TMH counseling across state lines, may be able to address the widening gap among supply and demand for mental health services that exists nationally today.
In considering how to potentially decrease the disparities that currently exist in the U.S. in terms of those in need of mental health services and those with accessibility to them, one avenue certainly worth consideration may be to implore all 50 states to consider the enactment of reciprocal/mutual TMH parity laws. While we cannot simply force qualified clinicians to change geographical location in order to meet the high demand for mental health care services in various under-served areas across the country, it may be feasible to enhance the accessibility of these much needed services to those living in disadvantaged regions through the enactment of this parity law on a national level for TMH service providers. It is suggested specifically herein that those Board Certified in TMH, holding a current BC-TMH credential, who are coincidingly credentialed as Nationally Certified Counselors (NCC’s) and hold the appropriate licensure or certification required by their respective State Board to provide mental health treatment services, should be permitted to provide TMH services across the U.S. regardless of their state of residency or geographical location and, alternatively, based upon their national credentialing which denotes a prestigious level of competency in providing such services to the public.
The variation that currently exists from state to state, with little reciprocity among them, regarding the laws that govern the provision of TMH treatment services must be reconsidered. For while these laws certainly have not contributed to the mental health crisis we face as a nation today, they unequivocally may hold the key to remedying this crisis by permitting the provision of TMH services across state lines, something currently prohibited by regulation through state licensure boards across the U.S. (Huggins, 2018). As a result, the enactment of the reciprocal TMH parity laws advocated for within this article could undoubtedly lead to increased availability and accessibility to mental health treatment services for all Americans during a time when these services are needed more than ever across our country.
TMH has been shown to mitigate, and may even hold the key to potentially eradicate, some of the various barriers that have been empirically demonstrated to serve as significant hindrances to an individual’s ability to pursue mental health treatment services despite their need for such treatment (Bishop, 2017; Quashie, 2016). These barriers include, but are certainly not limited to, physical disability, financial hardship or an inability to self-fund mental health services when needed, and a lack of access to qualified mental health treatment providers actively practicing and providing services in many geographical areas as previously denoted.
TMH has been demonstrated through various empirical inquiries to enhance accessibility to treatment services for many individuals who face the greatest disadvantages and obstacles in obtaining them (Bishop, 2017; Quashie, 2016). The result of independent state legislation passed over the last decade allowing the provision of TMH services seems clear and has been repeatedly demonstrated through clinical research (Bishop, 2017; Godleski & Darkins, 2012; Luxton et al., 2014; Quashie, 2016). Multiple studies have shown that through the provision of TMH services an increased number of consumers currently battling mental illness or mental health issues who previously lacked access to treatment services are now beginning to receive services as significantly higher rates (Quashie, 2016). TMH proves to be promising in its prospect of providing treatment services to those in need who cannot access in-person services for an array of reasons and who have historically been disadvantaged as a result.
TMH counseling services have additionally been demonstrated through multiple research inquires, examining varying demographic groups as well as specific mental health conditions, to yield the same treatment outcomes among consumers and to be as equally as efficacious as in-person, face-to-face, counseling services provided (Flaum, 2013; Quashie, 2016). However, issues arise given that in the vast majority of states the laws stipulate that TMH services must be rendered only by those practicing clinicians licensed or approved by the licensure board for the state in which the client is physically located at the time in which treatment services are rendered (Huggins, 2018). This specific regulation stunts TMH service providers from currently being able to serve those in alternative states and in areas identified as “mental health professional shortage areas” where the demand for mental health care is often highest (Bishop, 2017; MHA, 2018, p.5).
Through the enactment of reciprocal TMH parity laws all consumers of mental health services will experience potential benefits (Bishop, 2017). These may include: less time spent by consumers waiting for available appointments and to receive treatment services, enhanced access to a greater pool of qualified professionals including specialists for consumers to choose from, and even potentially the an increase in the affordability of services (Bishop, 2017; Flaum, 2013; Quashie, 2016). Most quintessentially however, the enactment of such laws would provide potential consumers in great need of mental health services, yet disadvantaged due to a lack of access to treatment providers within their geographical areas as well as due to alternative barriers that may exist within their lives which hinder their ability to engage in face-to-face counseling services, with greater accessibility to treatment services.
With this, it is with urgency that state legislators in collaboration with their respective licensure boards come together to discuss the consideration of adopting a TMH parity law that is uniform across all 50 states, reciprocally, and which extends the provision of treatment services provided by the aforementioned qualified clinicians to working with those in need across our country as opposed to confining them to the state in which they reside.
References
Bishop, M. (2017, June 16). Telemental health. Retrieved from https://www.publichealthpost.org/research/telemental-health/
Flaum, M. (2013). Telemental health as a solution to the widening gap between supply and demand for mental health services. Retrieved from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.439.3440&rep=rep1&type=pdf
Godleski, L., & Darkins, A. (2012, April 1). Outcomes of 98,609 U.S. Department of Veterans Affairs patients enrolled in telemental health services, 2006-2010. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22476305
Huggins, R. (2018, November 6). Telemental health across state lines: Doing It legally. Retrieved from https://personcenteredtech.com/2018/11/06/telemental-health-across-state-lines-doing-it-legally
Jameson, P. J., Farmer, M. S., Head, K. J., Fortney, J., & Teal, C. R. (2011). VA community mental health service providers' utilization of and attitudes toward telemental health care: The gatekeeper's Perspective. Journal of Rural Health, 24, 425-432.
Luxton, D. D., Pruitt, L. D., O'Brien, K., Stanfil, K., Jenkins-Guarnieri, M. A., Johnson, K., … Gahm, G. A. (2014). Design and methodology of a randomized clinical trial of home-based telemental health treatment for U.S. military personnel and veterans with depression. Contemporary Clinical Trials, (38), 134–144. doi: 10.1016/j.cct.2014.04.002
Mental Health America [MHA]. (2018). The state of mental health in America: 2018. Retrieved from https://www.mhanational.org/sites/default/files/2018 The State of MH in America - FINAL.pdf
Morgan, R. D., Patrick, A. R., & Magaletta, P. R. (2008). Does the use of telemental health alter the treatment experience? Inmates' perceptions of telemental health versus face-to-face treatment modalities. Journal of Consulting and Clinical Psychology, 76(1), 158-162. doi:10.1037/0022-006x.76.1.158
Quashie, R. Y. (2016, August 24). Boom in telemental health . Retrieved from https://www.natlawreview.com/article/boom-telemental-health
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