Online therapy taking off, using virtual visits, email and texts

After two decades of administering mental health services, Toronto psychotherapist Jennifer Heintzman is discovering a new way to listen, attend and respond to clients – deepening her active listening skills and challenging herself to clearly communicate her empathy, understanding and concern. At the same time she’s accessing more people, including a new generation of 20- and 30-somethings.

And it’s all due to her enthusiasm to embrace a new form of e-therapy for those struggling with mental health and substance abuse issues.

“I love what it’s given me as a therapist,” said Heintzman, who joined Hasu Behavioural Health Inc.’s network of online therapists in 2017. “It’s required me to grow in ways I didn’t even know were possible. It’s like learning a new language and suddenly becoming proficient at it – realizing this feels really good and that I needed these words all along.”

Hasu eCounselling™ is a PHIPA- and PIPEDA-compliant online healthcare platform and mobile app that provides therapeutic services through secure video, phone and text. Launched in 2015, the company started out as a business-to-consumer (B2C) service. Recently, it is finding a new avenue of growth by providing a business-to-business (B2B) model for employers who are looking to include mental health services as part of their employee benefit programs.

As a member of the Hasu team of online therapists, Heintzman augments her face-to-face practice at a busy Toronto office – where she’s available three days a week for in-person counselling sessions – by providing online therapy from the convenience of her own home. The majority of her online clients have been with her for more than a year. Many access her services from different time zones across North America and Asia; some travel a lot for work, some are housebound due to chronic illness and others are pregnant mothers on bed rest. All of them are benefitting from the flexibility that the online platform provides.

“I have clients who find an office at lunch time, shut the door and do therapy,” said Heintzman, who primarily works with people who are dealing with issues resulting from trauma, stress, anxiety, chronic illness or loneliness. “I’ve also worked with clients in remote areas where they don’t have access to the right services,” she added.

Most of Heintzman’s therapy is conversation-based. When she prescribes a cognitive behavioural therapy (CBT) exercise, she generally works through it with the client during their scheduled online session, whether they choose video, phone or text. She also blocks time in her calendar for real-time texting. “You meet your clients where they’re at,” she said, noting that when she makes herself available, they show up.

Over the last year, Hasu has been expanding its reach by working with employers who want to add online therapy to their existing employee assistance programs, or create new benefit programs to address mental health. According to Hasu COO Marion Adams, a range of businesses are interested, including first responder agencies where the need is obvious, due to the nature of the work. Other employers at the forefront of addressing employee mental health issues are newer, smaller start-ups led by millennials.

“If you want to be in the business of supporting people, you have to meet them on their terms and that’s exactly why our text therapy business is our largest source of revenue at this point,” said Adams. “People who are using these services are already on their phone anyway, so it’s like texting a friend.”

Unlimited text therapy starts at $29 a week, plus HST. Video and phone counselling starts at $95 for one hour, plus HST. Hasu therapists are registered and carefully vetted by Hasu CEO and founder Greg Rennie, who also serves as clinical director. To start the intake process, clients can call a toll-free number, chat online or be referred by a physician. Because Hasu therapists work in a tightly knit online community, they often refer clients among themselves as well, depending on their areas of expertise.

“It’s common that there is an underlying issue that can be discovered in the initial session,” said Rennie. “If there’s a need for additional work or treatment, the therapist works on a referral or steers them in the direction to seek additional help.”

Under the new B2B model, clients are enrolled through their employer and then use an employer-specific booking page to access services. Businesses are then invoiced monthly for services rendered by Hasu e-therapists.

The technology supporting Hasu eCounselling is supplied by OnCall Health Inc. of Toronto, a company founded by Nicholas Chepesiuk in 2016 to bring virtual healthcare services to Canada’s existing healthcare system. Early on, the company found that mental health was “arguably the best fit” for virtual care and went on to engineer a platform from the ground up that could deliver a high level of encryption and security, yet require low bandwidth, he said.

“There are a lot of really big mental health clinics and organizations across Canada that are doing amazing work and they have really thoughtful workflow and treatment programs,” said Chepesiuk. “We’re not trying to replace those. We’re trying to help them bring their existing team and address their existing patient base in a more accessible, convenient way when appropriate.”

OnCall Health licenses its technology as a software-as-a-service to both clinics and clinicians who are looking to augment in-person therapy with virtual appointments.
Chepesiuk estimates there are 1,000 mental health clinicians currently using the platform across Canada, mostly for video and texting.

The technology is designed to automate day-to-day administrative tasks like scheduling, and can also be used by clinicians to track patient progress using clinically validated assessments like the Patient Health Questionnaire-9 (PHQ-9), a self-reported instrument that scores nine criteria on a scale from “0” (not at all) to “3” (nearly every day).

“Our system makes it really easy for clinicians to assign and digitize those forms, which are traditionally done on paper, through a secure online portal,” he explained. “Patients fill them out on their phone or computer, and we can score them and track their progress over time.”

Chepesiuk claims there is evidence to show that video counselling can be as effective as in-person counselling, and in some cases more effective. Patients often feel more comfortable opening up about issues when they’re in the comfort of their own home. There’s also a growing number of younger people who prefer to communicate online, he said.

“It’s pretty cool knowing that right now in Canada about 15,000 patients are doing video appointments on this system every month,” said Chepesiuk. “We like to think we’re helping to accelerate the adoption of virtual healthcare in Canada.”

The advancement of e-therapy in Canada is also being fuelled by a growing need to meet demand for mental health services. The Canadian Mental Health Association estimates that one in five people in Canada will personally experience a mental health problem or illness in any given year, and that by age 40, about half of the population will have or have had a mental illness.

At the same time, nearly one-half of those who feel they’ve suffered from depression or anxiety have never gone to see a doctor. Proponents of online therapy believe the ability to connect with people over the Internet is starting to change that. At Hasu, for example, Adams said she is encouraged by the large percentage of men who are now signing on for e-therapy through the company’s new B2B model.

“It’s a fascinating and exciting finding for us because typically men are much less likely to reach out,” she said.

Dr. Philip Klassen, VP medical services at the Ontario Shores Centre for Mental Health Services in Whitby, Ontario, said his organization has seen a doubling of requests for services in the last two years, resulting in long wait lists for treatment. Online therapy is seen as one way to effectively deal with that demand.

“The dual imperative is first, we need to improve access to psychological therapies and second, we need to improve access to evidence-based therapies, which means we need to minimize variability and try to control the product so that the product itself has a strong evidence base,” said Dr. Klassen. “One of the possible solutions is Internet-based psychotherapy.”

In May of this year, Ontario Shores introduced SilverCloud, an evidence-based platform for delivering online mental health services. Headquartered in the U.K., SilverCloud is an industry leader in Internet-delivered CBT (e-CBT) solutions, a form of psychotherapy that Health Quality Ontario recommended for public funding in February. The company’s growing online library includes programs to treat anxiety, depression, phobias, stress and OCD among others.

Clinicians in Ontario Shore’s Anxiety and Mood Disorder Clinic are currently using SilverCloud to treat outpatients, people living independently in their communities who are suffering from a variety of anxiety-related or depressive disorders. After an initial assessment to determine that e-CBT is an appropriate course of treatment, patients are scheduled for a brief intake meeting to establish a baseline of their symptoms in person. After that, everything related to their treatment happens online.

Patients are emailed an invitation to join SilverCloud and establish a secure login to access their online program materials. The Anxiety and Depression program, for example, has eight modules which patients work through at their own pace, typically completing one per week, with each module estimated to take 40 minutes. Online learning incorporates reading materials, audio and video clips, and a variety of tools such as an activity scheduler, a mood tracker and a “thinking, feeling, behaving cycle tool” that promotes emotional awareness.

“As they move through the course, every time they’re introduced to a new tool, there’s some opportunity within the module to do some practice with it right then and there. There’s also an option to add it to their home page so that the next time they log in, it’s right there in front of them,” explained Ontario Shores clinician Kristen Moore, a registered nurse who works within the Anxiety and Mood Disorder Clinic. One of the advantages, she added, is that patients who might be feeling overwhelmed with anxiety in a public place can quickly access the tools they need to work through their anxiety right from their phone.

Patients who qualify for e-CBT are also scheduled for a series of 10 30-minute meetings with a clinician who serves as their personal coach. The majority of meetings are conducted using the Ontario Telemedicine Network (OTN) videoconference platform, but in-person meetings can also be scheduled if required.

As a coach, Moore logs in to SilverCloud to manage her e-CBT clients and monitor their online activity. She sees how many pages they’ve read, what tools they’ve used and any messages they’ve left for her. Clients may also choose to share entries from their online journals. Once she’s reviewed their weekly progress, she writes a response.

“We’re only interacting with clients and reviewing their work on the day they’re scheduled, so it needs to be a very focused 30 minutes,” added Moore, noting that she typically holds a video conversation for half of the allotted time and spends the other half on review. “Having that coach connection is motivating, it holds them accountable each week.”

Moore estimates she is able to treat an additional 10 to 12 patients over and above her normal workflow because of SilverCloud. The online platform is also helping to reduce wait times since patients referred to e-CBT typically begin treatment within 30 to 60 days whereas the wait time for individual face-to-face therapy is typically a year or longer.

Dr. Klassen called online psychotherapy the “choice of the service future.” SilverCloud embeds measurements like the PHQ-9 and Generalized Anxiety Disorder (GAD) seven-item scale directly into its platform. “One of the huge gaps in mental healthcare in many places is that it’s not measurement-based,” said Dr. Klassen. “But with SilverCloud, measurement is built in, so clinicians can look both at individual and group data to see what their outcomes are like.”