Even though mental health concerns such as depression or anxiety impact around one in four Americans each year, only 43.1 percent receive treatment for their condition. In an effort to both extend the mental health treatment radius and destigmatize access to care, many employers are considering alternatives outside of the traditional therapeutic model, such as virtual therapy or telebehavioral counseling.

Telebehavioral counseling, be it by phone, video, email or text message, has been around in one form or another for more than 20 years. More recently, the explosion of smartphone users has created opportunities for health care providers to offer a variety of accessible and affordable virtual behavioral health resources. However, even as telebehavioral counseling draws greater attention, many clinicians (including those most qualified to provide telebehavioral counseling) continue to have concerns about its suitability for a significant portion of the population—especially when marketed as a 'one-size-fits-all' replacement for in-person counseling.

That said, a growing body of evidence does support telebehavioral counseling as an avenue to address some common mental health concerns—for certain people, in specific situations. For example, when someone has limited mobility, lacks reliable transportation, has scheduling challenges, lives and works in a remote area or prefers technology-based interactions, telebehavioral counseling is probably the most effective option, and is certainly preferable to no treatment at all.

But, much like the technology, the research is still new—and there is a lot science doesn't yet know. In a systematic review of the research regarding the effectiveness of online counseling published in the Journal of Technology in Human Services, the authors concluded that the overall quality of the studies is poor and stressed the need for further research to support the widespread implementation of this form of mental health service delivery. Even less is known about the effectiveness of text-based therapy, even when it's positioned as "coaching" rather than "counseling."

According to the American Psychological Association's most recent practice update regarding text-only platforms, "There is no research suggesting that texting alone is an effective modality for psychotherapy." Additionally, based on five years' worth of health and productivity outcomes data from EAP participants, CuraLinc Healthcare has observed that virtual counseling, while effective, is less impactful than in-person counseling.

Similarly, many mental health experts have noted significant limitations to telebehavioral counseling. The Telehealth Certification Institute, the only organization authorized by the National Board of Certified Counselors to provide the training required for a licensed clinician to become a Board Certified Telemental Health Provider (BC-TMF), cautions clinicians of the following drawbacks of distance counseling:

The difficulty of completing an accurate risk assessment
The challenge of intervening during a crisis
The contraindication of distance counseling for clients with (or at risk for) suicidal thoughts, homicidal thoughts or psychosis
The difficulty of verifying a client's identity
The tendency of some clients to present differently online than in person
The challenge of establishing rapport
The effect of disinhibition on counselor listening and attending skills with certain clients
The problem of clients changing therapists too soon, or seeing multiple counselors at a time
Technical problems or limitations that distract or interfere with the effectiveness of counseling
The limitations of written language (text, chat or email) that can be easily misinterpreted, especially when asynchronous

The final drawback is particularly concerning, since the design models of many new entrants into the mental health ecosystem are based on communicating through asynchronous chat. Consider the case of a program participant who experiences a mental health crisis such as suicidal thinking. After sending a message to a counselor or coach within the program, the individual may need to wait several hours to receive a response, and even after the message has been received, there may not be an avenue for the counselor or coach to evaluate the client in "real time."

Fortunately, it's possible to assess whether telebehavioral counseling is an appropriate avenue for care prior to the first session, and, more importantly, to provide guidance and navigation to a more suitable care option, when appropriate. While this is an ongoing challenge for many technology-based behavioral health providers, an employee assistance program (EAP) that offers technology-based access to clinical resources—in addition to providing mental health advocacy and in-person counseling—can ensure that all participants are connected to the right type of care, the first time they use the program.

When an employee or family member reaches out for help with a mental health issue, an EAP with the proper clinical construct will always start with a comprehensive clinical assessment. If the participant is considering counseling by video, phone or live chat, a licensed clinician can first assess the participant for fit—and then provide education regarding the advantages and drawbacks of each option. In this manner, an EAP can ensure that only individuals who are appropriate for telebehavioral counseling—and who understand the potential risks—are referred to these services. Others can be steered to more clinically-appropriate treatment options, such as in-person counseling.

Virtual counseling is a widely accepted form of treatment for common mental health concerns, and is also an important design element of an employee assistance program. With over 123 million Americans living in Mental Health Professional Shortage Areas, providers must make care accessible through a variety of channels. That said, an EAP that offers technology-based counseling as an integrated component of its suite of services expands the footprint of mental health and has the highest likelihood of engaging participants in a manner that is both personally and clinically relevant.

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David Pawlowski joined CuraLinc Healthcare as the director of clinical operations in 2014 and was promoted to vice president of administration in 2016. He is a licensed clinical professional counselor (LCPC) in the state of Illinois with 19 years of experience in the mental health field, including over 15 years in employee assistance. He is also a certified employee assistance professional (CEAP), whose expertise is the in the creation and delivery of advocacy-based employee assistance program (EAP) models. In his role as vice president of administration, he oversees the delivery of all clinical and organizational services for CuraLinc's EAP and integrated behavioral health clients.

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Expanding the footprint of care with telebehavioral counseling

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