What We Got Wrong About Telehealth for Therapy

By. Bart Magee, Ph.D.

​While promising increase access, the teletherapy boom has left us with greater disparities

It’s no secret that teletherapy has radically transformed mental health care delivery. Widely viewed with skepticism by mental health professionals just a few years ago, telepsychiatry has taken over mental health care. The once-iconic image of a patient on the couch has morphed into a meme of therapy sessions through a screen.

As the telehealth tidal wave surged during the COVID-19 lockdowns, it came with lofty promises for its potential to reduce disparities in access to care. Five years later, the research is in and the results are truly disturbing. In spite of the initial hope of increased access and equity, just the opposite has occurred. 

While higher income groups have taken advantage of the technology, increasing their access to therapy, vulnerable populations – low-income families, non-white communities, older adults, the unemployed and individuals with severe mental illness have not. Rather than closing the access gap, teletherapy has widened it.
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How did we get it so wrong and what can be done to reverse the trend?  ​

Let’s start by looking at some of the key promises championed at the time: Increased Accessibility Telehealth was expected to eliminate geographic barriers, allowing individuals in rural or underserved areas to access mental health services that might not otherwise be available locally.

Convenience and Flexibility The ability to attend therapy sessions from home was seen as a way to make mental health care more accessible for people with inflexible work schedules, caregiving responsibilities, or transportation challenges.

Cost Savings By reducing the need for travel and allowing therapists to cut down on office-related expenses, telehealth was expected to lower costs for both providers and patients, making care more affordable.

Engaging Younger Generations Many believed that telehealth would appeal to younger, tech-savvy individuals who might prefer video or text-based therapy to traditional in-office sessions.

Efficiency in Care Delivery With the ability to quickly schedule and attend appointments, telehealth was expected to streamline the process of receiving care, reducing wait times for services.

Why Telehealth Falls Short
We’ll need more research to understand why these promises have not translated into real world results, but I can offer some ideas based on my experience providing care at Access Institute’s clinic. Despite telehealth’s increased availability, our clinic continues to see a rise in referrals from low-income individuals and those with severe mental illness—people teletherapy was meant to help most.

While the predicted cost savings have been realized as therapists let go of offices and save on rent, those savings have not been passed on in the form of lower fees. And while telehealth may address a lack of providers in rural areas, for low-income people in urban areas it provides little benefit. Lower-income people don’t typically work from home, so having access to a therapist on zoom provides little benefit. And the home environment of a low-income person is not easily transformed into the kind of quiet, confidential space needed for treatment. Flexibility, convenience and efficiency in care delivery are all benefits of teletherapy, but they only go so far.

What we see at the clinic is that on-line sessions are a great addition to in-person care, making it easier to maintain continuity when illness or inevitable disruptions to schedules occur. But for those grappling with profound emotional challenges, the convenience of telehealth often misses the mark. Therapy, by its very nature, is inconvenient. It’s about opening up emotionally, facing discomfort, and committing to the hard work of self-reflection. The emotional work needed to maintain that commitment forms the foundation for any productive treatment. Making therapy convenient or easy isn’t necessarily therapeutic.

And the “seamlessness” factor of telehealth may be overstated and overlooks its inherent barriers. The digital format inherently reduces interaction quality—flattening emotional nuance, distorting tone, and introducing technical glitches and distractions. Fatigue and the lack of a controlled therapeutic environment further detract from its effectiveness. When you factor these barriers in, some of the perceived advantages to teletherapy begin to fade. Moreover, in a time of increasing social isolation, where an epidemic of loneliness is a major driver of a mental health crisis, leaving your home to travel to your therapy might itself become part of the cure.

This is why, for patients experiencing more severe and complex problems and for the clinicians who work with them, there is no replacement for in-person care. Again, we see this clearly at Access Institute. Many of the people who seek our services have tried teletherapy, but couldn’t make it work. During the lockdowns when telehealth was our only option, the loudest calls for a quick return to in-person sessions came from individuals and families who had the greatest needs and whose environments not only didn’t support the work (try doing a therapy session from your closet or car) but could be detrimental to it (think about your abusive spouse being in the next room.)

What Needs to Change
The new research has not only busted the myth that telehealth will be a panacea for the monumental challenge of increasing access to mental health care, but (hopefully) will refocus our attention on the real barriers to access which are so obvious to all: the high cost of care, a chronic shortage of providers and a broken insurance and care delivery system.  Telehealth, while a useful tool, has not and cannot compensate for these systemic failures. Our focus must shift to addressing the structural barriers that prevent the most vulnerable from getting the care they need.
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At Access Institute, we’ve spent over 20 years tackling these challenges through community engagement and innovative care models, but true change requires more. As we navigate the future, I remain confident that collective action paired with a fundamental shift in our values and a rebuilding of our broken healthcare system will close the gaps in mental health care access. The telehealth story serves as an important reminder: While we may get distracted by the promise of technological fixes, real change takes time, focus and persistent effort. ​