Tele-counseling during the pandemic: Accessibility, feasibility, and challenges for therapists

Dear Editor,

Tele-counseling/medicine is found to have both benefits and shortfalls. Tele-consultation has been instrumental in both normal and pandemic situations, aiding in identifying illnesses, reducing delay in care, improving continuity of care and follow-ups, and it also offers help to those who have physical limitations.^1,2 It enables patients to maintain continuity of care even during travel restrictions, pandemic, or extreme weather. To a person with mental illness, it provides a level of anonymity that can reduce barriers to seeking help for their mental health concerns. This ensures therapy sessions can continue uninterrupted and promotes consistency in treatment sessions. Tele-consulting allows for more flexible scheduling options since therapists can conduct sessions from anywhere. This flexibility can lead to higher patient retention rates and also allows patients to continue multiple therapy sessions with the same therapist. It can also be cost-effective and reduce the care burden, as patients and their caregivers save time by eliminating the need for travel to and from appointments, and patients or their caregivers need not take time off work for in-person sessions. In addition, the audio-visual tele-counseling allows the therapist to observe visual cues such as facial expressions, body language, and gestures than simple telephonic conversation through tele-counseling and these cues lead to better understanding and interpretation of patients’ emotions and reactions. However, according to Zhou et al. (2020)², mere conversation through tele-counseling is more effective during a pandemic like COVID-19.

The magnitude of any illness reaching a pandemic level with enormous, unprecedented psychosocial aftermath leads to various mental health–related problems.^3,4 It also increases psychological distress resulting from excessive anxiety, especially among persons with preexisting mental health conditions. Due to pandemic situations, inaccessibility to mental health settings or therapists has gradually shifted from routine man-to-man services to reliance upon tele-counselling services for non-pharmacological interventions.

Considering the magnitude of Coronavirus 2019 (COVID-19) and its impact on mental health, the Government of India initiated the Tele Mental Health Assistance and Networking Across States (Tele MANAS). It provides a 24*7 structured, accessible, affordable, and efficient framework for tele-consulting. This platform ensures accessibility to mental health services, streamlines communication between patients and healthcare providers, and integrates various health services.⁵ This program is vital in fulfilling the aforementioned benefits.

Despite having the aforementioned benefits, it is difficult for therapists to respond quickly and effectively when a crisis arises, especially during pandemic situations. Tele-counseling may not help when a person has severe or complex symptoms of mental illness. Sometimes, it is also very difficult for a therapist to understand the nonverbal responses of the patient during the tele-consultation which may impact the therapeutic relationship with a patient as well. Similarly, internet connectivity issues might result in poor audio/video quality, disrupt the conversation, hamper the continuity of the therapeutic process, or result in an incomplete session. At times, patients, especially those from a rural background, are unable to operate their Smartphones or make video calls as the video call feature may not be available on their mobile phones. Such issues limit the benefits of tele-counseling.

Furthermore, patients and their caregivers do not honor the time schedules given for therapy sessions, or are unable to comprehend the therapy instructions due to technical issues and language differences. Moreover, the burden on mental health service providers increased enormously due to the influx of cases during the uncertain times of the pandemic. Sometimes, during an ongoing tele-counseling session, frequent requests or repeated calls might be received by the therapist from many other patients. In such situations, assuming that the person calling might be in distress, the therapist has to wind up the session quickly. Similarly, many a time, therapists may receive calls from patients or caregivers during nonoffice hours. This affects the balance between the personal and professional life of therapist. Such untimely requests lead to irritation and mental exhaustion among the therapists, and it may also lead to incomplete personal tasks. Moreover, conducting six to seven sessions every day telephonically with a minimum duration of 40–60 minutes impacts the therapist’s psychological well-being, and it also increases the chance of burnout and negative countertransference.⁶ These challenges may lead to poor therapeutic relationships and poor therapy outcomes. It is a grave concern for mental health professionals to tackle these issues during pandemic situations such as COVID-19 for effective delivery of tele-mental health services.