Online Therapy, Booming During the Coronavirus Pandemic, May Be Here to Stay

Telemedicine finds a niche

Online Therapy, Booming During the Coronavirus Pandemic, May Be Here to Stay

Mental health flows from the ceramic jug psychotherapist Lori Gottlieb keeps on her desk. There’s nothing special about the jug—a minor accessory in an office designed with the sort of tidy impersonality common to her field. And there’s no special elixir in it—just water. But all the same, the jug provides a certain kind of healing. When patients are struggling, crying, overcome in some way, Gottlieb, a Los Angeles based practitioner and author of the book Maybe You Should Talk to someone, will offer up a cup of water, pour it for them and hand it across.

In that small gesture is a whole constellation of meaning: concern, care, protectiveness, generosity. It’s a little grace note that’s possible only in person—only when two people are in the same room, sharing the same space, face to face across just a small physical gap. Ever since March, however, when much of the U.S. went into lockdown as a result of the COVID-19 pandemic, such in-office intimacy became impossible across nearly all professional disciplines. Psychotherapy sessions—like so very much else—have become virtual, conducted on-screen, at a remove, riding the electrons of Zoom or Skype or Google Meet. And that comes at a price.

“There’s the ritual of coming in every week, sitting in that room on the same spot on the same couch in the same office,” says Gottlieb. “It feels incredibly comforting and safe. I think the environment part of it is very important for people.”

That’s not true just of mental health, of course. Most of us aren’t getting a fraction of the person-to-person interaction we’re accustomed to, and most of us are pretty well fed up with it. Virtual birthday parties are no party at all. Virtual happy hours have everything but the happy. Call it Zoom fatigue, cabin fever, flat-out loneliness—many today are suffering from isolation to one degree or another and long for the moment that the virtual lives we’ve been forced to live can be tossed aside.

But telepsychology (or telepsychiatry or tele-mental-health, as it’s been variously called) may have a stickiness to it that other aspects of virtual living lack. In recent years there’s been more and more talk in the health care professions about the potential for telemedicine. For some kinds of care, it’s easy to see how routine “office visits” that allow doctors and patients to meet without the need for an actual office could work: the orthopedic surgeon checking a patient’s range of motion and inquiring about pain after knee replacement surgery, say. But too many other visits require hands-on contact—palpating, blood draws, suturing—to make telehealth a universal practice.

Tele-psych, though—with its talk-and-listen simplicity—is a different matter. If ever there was a caring discipline that was poised to jump aboard the telemedicine train, it’s mental health.

“In February of 2020, before COVID-19 really hit our country, telepsychiatry was beginning to be widely available but only sporadically adopted,” says Dr. Jay Shore, a professor at the University of Colorado Anschutz Medical Campus and the chair of the American Psychiatric Association’s Telepsychiatry Committee. “Now it’s been a tsunami. At the University of Colorado maybe 10% to 20% of [mental health] visits were over video before. Now, outside of inpatient stuff, we’re at like 100%.”

That has been true pretty much everywhere else in the country, where therapy sessions have been happening either online or not at all. In mid-May, the American Psychiatric Association surveyed its members on how frequently they held tele-psych sessions both before and after the onset of the pandemic. The results were striking: Prior to COVID-19, 63.6% of respondents did not use virtual sessions at all. After the onset of the pandemic that figure plunged to just 1.9%. Conversely, before COVID-19 hit, only 2.1% reported using tele-psych 76-100% of the time. During the pandemic that figure has soared to 84.7%.

It was a change made by necessity, not by choice, but there are plenty of people who like what they’re experiencing. There’s convenience for one thing: a 50-minute session is a 50-minute session, not two or three times that as the patient wastes part of the day just getting to and from the appointment. That’s especially important in rural communities that might have been mental health deserts before—with the nearest caregivers requiring a long drive to the closest big city.

Patients are able to have their appointments pretty much anywhere. “If you were going to go drop your kids off at soccer practice, you could sit in the car and have a relatively private session with your therapist while you’re waiting for the soccer match to be over,” says psychologist Jared Skillings, chief of professional practice for the American Psychological Association. “This provides a significant increase in access and quality of life.”

Tele-psych also allows for more enduring doctor-patient relationships. If your job transfers you to another city, you can always find another doctor to tend to your physical ills, but you didn’t spend years confiding your most intimate secrets to your cardiologist or ophthalmologist and now have to start over with an entirely different person. Your psychologist is another matter entirely. “The advantage is clearly that you get to have continuity of care,” says Gottlieb.

All of those plusses have some in the community convinced that not only are tele-sessions the future of mental health, but that that future is now. “I think that anyone who tries to prognosticate comes across as a fool,” says Shore. “But what I can say is that we will never be the same, we won’t go back to where we were.”

And yet, what about that water jug? What about the sense that a therapist’s office is a third place, a safe space, neither work nor home but a place that, for those 50 minutes at least, feels like the patient’s own? Not every patient is the same and for many there is a comforting ritual in the opening of the doctor’s door and the gathering in that follows. Shore may indeed be right that the forced experiment with tele-psych that the quarantine months have necessitated has dramatically changed the game. Just how much and how enduringly it’s been changed is the real question.

Teletherapy may seem very much of the moment, but it’s not a new idea. As long ago as 1959, the University of Nebraska began a pilot project using mid-century video technology to allow patients and doctors to meet remotely. But the system was expensive and impractical and it lent itself poorly to the Freudian era of lying on couches and free-associating to a silent therapist whose face you didn’t even see. It wasn’t until the late 1990s, with the Internet fully entrenched and two-way video platforms coming online that the telehealth gained any traction. Even then though, it was used in a limited way.

“We started to see big systems like the Department of Defense and the Veteran’s Administration and jails develop sustainable larger scale telepsychology services to serve their populations,” Shore says.

Still, that was enough to prove the technology’s potential—if not its immediate appeal—and practitioners adopted it unevenly. While Shore reports that well before the pandemic he already had patients he’d worked with for 12 to 15 years and had never met in person, Gottlieb wanted no part—or at least very little part—of telehealth.

“I didn’t do telehealth at all unless there was a circumstance like I already had an established patient and that person was going to be on a work assignment for a few months,” she says. “But I would never meet somebody doing telehealth.”

Then the pandemic forced the profession’s hand and even doubters like Gottlieb have seen some of its advantages. She concedes that she likes the leveling effect of both patient and doctor getting background glimpses into each other’s homes—a sort of intimate equality of behind-the-scenes access. She likes the insight she gets when a patient Zooms from a bedroom and she catches sight of what’s on the nightstand.

“Usually what people keep on their nightstand tends to be the most personal of things, what means the most to them,” she says.

And she likes, too, the spontaneity and humor that a tele-session can provide. A surprising number of people, Gottlieb says, will have a session in the bathroom, sitting on a closed toilet—looking for a private spot in their homes. During one session, a patient was crying because her mother was in a nursing home where COVID-19 had been detected, and she was worried. She sat back and accidentally hit the handle of the toilet causing it to flush loudly.

“She was embarrassed and said, ‘Am I the only person who does therapy from the toilet?’ And I said, ‘No, actually the toilet has become the new couch.’” They both laughed—which the patient later said was the best and most helpful moment in the session.

Whether all sessions will be so effective depends at least in part on the kinds of issues the patient is struggling with. Obsessive-compulsive disorder, for example, lends itself comparatively well to tele-psych sessions because the standard of care for it is what’s known as skill-based therapy—learning behavioral tools that help break the OCD cycle—which may require less intimacy than other kinds of therapy, and instead calls for rigorous practice and discipline. Post-traumatic stress disorder patients may similarly benefit from online therapy, at least at first, since the home might feel like a safer space than a doctor’s office.

But there are downsides in treating these and other disorders online—in the form of cues missed due to the limited frame of a computer screen. The jiggling foot, the knotted hands, the subtle shifting in the chair that telegraphs unease with a topic of conversation are all lost to the doctor in tele-sessions. For patients battling substance abuse it’s hard to get away with the telltale gait of intoxication or the smell of alcohol on the breath in an in-person session. Not so hard on Zoom.

Group therapy can present its own challenges. A key part of the dynamic of the group involves eye contact—who’s listening, who’s not, who’s offering an affirming nod or shifting uncomfortably at someone else’s story that may hit a raw nerve in the listener. On a Zoom screen with a dozen faces arranged in Brady Bunch tiles, all of that is missing.

Even when the group is just two people, things get lost. Gottlieb recalls counseling a couple in a telehealth session and suddenly noticing their mood going from comparatively detached to warm and compassionate. “I was trying to figure out what had shifted there and then one of them said they were holding hands,” she says. “But I didn’t see it. They were holding hands under where I could see.”

If tele-psych is going to have a wide, post-pandemic future, it depends on more than just the acceptance of patients and providers. As with so much else in the U.S. health-care system, things come down to who will pay. During the pandemic, Medicare, many state Medicaid programs and commercial insurers have loosened rules or allowed waivers to cover telehealth sessions. When the pandemic ends, however, so could the payments.

Those in the field want to stop that from happening, making sure we don’t lose the lessons we’ve learned from the experience. “We are advocating for Medicaid, Medicare, and private payers to keep telehealth turned on at least for 12 more months after the coronavirus pandemic is officially declared to be over so that we can better evaluate the impact that has had on patients,” says Skillings. In a live June 9 event with STAT News, Seema Verma, the Administrator for the Centers for Medicare and Medicaid Services (CMS), offered support for that kind of sentiment, arguing that coverage for most forms of telemedicine, including tele-psych, should indeed continue after the pandemic ends. The dramatic increase in overall access to care—with telemedicine visits increasing 40-fold in some parts of the country during the pandemic—is, all by itself, an argument for maintaining the system, she said. In August, the CMS issued new guidelines that provide physicians nine new billing codes to cover telemedicine going forward.

The portability issue is another unsettled question that will endure beyond the pandemic. It’s true that one of the advantages of tele-psych is that patients who move from state to state can continue to work with their original doctor—but that’s only if each state’s licensing rules permit that kind of cross-border practice, and so far most don’t.

In 2011, the Association of State and Provincial Psychology Boards—one of the profession’s governing bodies—created a task force to promulgate tele-psych guidelines for practitioners. From that came a proposal for what became known as PSYPACT, a national reciprocity system under which states would accord tele-psych privileges to practitioners living in other states. Joining the group requires action by state legislatures, and currently 15 have passed the necessary laws, with approval pending in 12 more states and the District of Columbia.

“At the end of the day,” says Skillings, a vocal PSYPACT advocate, “this is actually about providing care to our community, to improve their health.”

Improving community health is, of course, what all medicine, virtual or otherwise, is about. Mental health, which lacks the clarity of other medical disciplines—the blood tests and CT scans and MRIs that can make diagnosing illnesses and prescribing treatments so straightforward—has always needed more options in its therapeutic toolkit. Tele-psych, even with its doubters and its drawbacks, is easily one of the newest. In time, it may also prove to be one of the best.

Source : Time More   

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Mercury Use in Dentistry Is on Its Way Out

This Mercury-Free Dentistry Week, we celebrate the 20th anniversary of Consumers for Dental Choice, the nonprofit advocates moving mercury-free dentistry from dream to reality. From protecting dentists' right to practice without mercury-laden dental amalgam fillings to obtaining mandated fact sheets to inform patients about amalgam's mercury content, to bans and restrictions on amalgam use around the world, Consumers for Dental Choice and its leader, former state Attorney General Charlie Brown, are making mercury-free dentistry more widely available than ever before. And, that progress is starting to sway the U.S. Food and Drug Administration (FDA), the chief regulator of dental amalgam, at the federal level. Thanks to your donations, Consumers for Dental Choice has reopened the door for FDA action against amalgam. I ask that you continue your support by donating at, and I will match all donations during Mercury-Free Dentistry Week (August 23 to 29, 2020) up to $150,000. So, double your impact today. Together, we can win the campaign for mercury-free dentistry at FDA that has come so far. >>>>> Click Here

Mercury Use in Dentistry Is on Its Way Out

This Mercury-Free Dentistry Week, we celebrate the 20th anniversary of Consumers for Dental Choice, the nonprofit advocates moving mercury-free dentistry from dream to reality.

From protecting dentists' right to practice without mercury-laden dental amalgam fillings to obtaining mandated fact sheets to inform patients about amalgam's mercury content, to bans and restrictions on amalgam use around the world, Consumers for Dental Choice and its leader, former state Attorney General Charlie Brown, are making mercury-free dentistry more widely available than ever before.

And, that progress is starting to sway the U.S. Food and Drug Administration (FDA), the chief regulator of dental amalgam, at the federal level. Thanks to your donations, Consumers for Dental Choice has reopened the door for FDA action against amalgam.

I ask that you continue your support by donating at, and I will match all donations during Mercury-Free Dentistry Week (August 23 to 29, 2020) up to $150,000. So, double your impact today. Together, we can win the campaign for mercury-free dentistry at FDA that has come so far.

>>>>> Click Here <<<<<

Consumers for Dental Choice Sues the FDA — and Wins

The FDA is legally required to classify — that is, issue a rule for — all medical devices, including dental amalgam. But for 30 years, FDA dodged its legal duty to classify amalgam.

Consumers for Dental Choice put an end to FDA's negligence. In 2008, this dynamic nonprofit organization assembled plaintiffs and sued FDA, demanding that amalgam be classified. The judge agreed and told FDA to sit down with Consumers for Dental Choice to determine a deadline. FDA was compelled to commit to classifying amalgam by July 2009.

But when July 2009 came around it was clear the FDA had not considered the science — especially the evidence of harm amalgam can cause vulnerable populations like children, pregnant women and breastfeeding mothers. Its abysmal rule reflected it, posing no restrictions on amalgam use to protect the public — or even requiring that patients be told that amalgam is made of mercury.

Nonetheless, FDA's rule acknowledged that amalgam could be harmful and that there was no proof of safety for the populations most susceptible to this toxin:

"The developing neurological systems in fetuses and young children may be more sensitive to the neurotoxic effects of mercury vapor. Very limited to no clinical information is available regarding long-term health outcomes in pregnant women and their developing fetuses, and children under the age of six, including infants who are breastfed."

Fortunately, Consumers for Dental Choice never puts all its eggs in one basket. So, Charlie and his team challenged FDA's rule while pursuing other opportunities to advance mercury-free dentistry, like defeating pro-mercury state dental boards, fighting for amalgam fact sheet laws for patients at the state level and getting amalgam into the Minamata Convention on Mercury.

And as Consumers for Dental Choice racked up win after win — regaining licenses for mercury-free dentists persecuted by state boards, gaining fact sheets to protect dental patients, achieving an amalgam reduction requirement in the Minamata Convention — the FDA's rule became more and more outdated and the U.S. slipped further and further behind.

Consumers for Dental Choice's Game-Changing Return to FDA

Almost a decade after the FDA issued its flawed amalgam rule, Consumers for Dental Choice launched a nonstop campaign focused on getting FDA moving again on amalgam. And that campaign is starting to bear fruit. To succeed, Consumers for Dental Choice brought a whole new ball game to the FDA, giving the agency even more reasons to act.

First, Consumers for Dental Choice assembled an accomplished team of experts to approach the FDA. In 2018, they unveiled the Chicago Declaration to End Mercury Use in the Dental Industry at the University of Illinois School of Public Health.

This declaration, signed by 50-plus heavy-hitter environmental groups, called on the FDA "to bring its policies in line with the Federal Government as a whole and with its responsibilities under the Minamata Convention and to publicly advise a phase down of the use of mercury amalgams with the goal of phasing out entirely."

Furthermore, it recommended immediately ceasing amalgam use in children, pregnant women and breastfeeding mothers. Working with some key signatories to the Chicago Declaration, Consumers for Dental Choice sent the declaration to FDA — and their team got meetings with the top of the agency.

Second, Consumers for Dental Choice organized a strong showing of public support from you. Do you remember its online petition that almost 50,000 of you signed? Consumers for Dental Choice presented it to the FDA in person at its first meeting with the agency and has continued to make sure your voice is heard via such means as the public comments on patient preferences it asked you to submit to the FDA last spring.

As one article's headline described the result, "FDA Gets Mouthful on Mercury Dental Fillings After Requesting Public Comment on Device Regulation."1 Third, Consumers for Dental Choice presented the FDA with new science showing amalgam's harmful effects.

FDA Flips Their Position on Amalgam

Having reached the top of the agency, Consumers for Dental Choice could submit scientific studies that someone at the FDA would read. As a result, FDA's most recent scientific review of amalgam flips FDA's position on a major issue.

FDA now recognizes evidence that shows once dental amalgam is implanted in the human body, its elemental mercury can convert to toxic methylmercury — the same type of mercury that the FDA warns about in fish.

Furthermore, FDA is starting to recognize the bioaccumulative effect of amalgam's mercury. With patients exposed to so many sources of mercury — from high-mercury fish in their diets, occupational exposures in their workplaces and waste incinerators emitting mercury in their neighborhoods — the mercury from amalgam could very well be the straw that breaks the camel's back.

Consumers for Dental Choice laid a track record of victories on the table at the FDA. Working with strong local partners, Consumers for Dental Choice has won amalgam phase-out set dates in the Philippines, Ireland, Slovakia, Finland, Nepal, Moldova, Czech Republic and New Caledonia.

Consumers for Dental Choice has also won — again partnering with a local partner — bans on amalgam use in children in the European Union, Vietnam and Tanzania, and public warnings about amalgam's mercury in Nigeria.

And, it let the FDA know about these victories because if other countries can do it, so can the U.S. Armed with this new support, Consumers for Dental Choice succeeded in persuading the FDA to reopen the amalgam issue, starting with a new FDA review and scientific advisory committee meeting.

Consumers for Dental Choice Convinces the FDA

In November 2019, the promised FDA scientific advisory committee met to discuss metal implants and specifically dental amalgam. First, the committee heard from the public, primarily Consumers for Dental Choice's team of 16 experts.

Consumers for Dental Choice executive director Charlie Brown testified alongside 15 heavy hitters from the Children's Environmental Health Network, Tuskegee University, International Indian Treaty Council, Organic & Natural Health Association and Connecticut Coalition for Environmental Justice, as well as city and county commissioners, a physician expert in environmental justice, a pharmacist specializing in toxicology and several attorneys — all speaking out for mercury-free dentistry.

You can see Consumers for Dental Choice's team and their colleagues in action in the video at the top of this article, which shares highlights of the advisory panel meeting. The FDA advisory committee members discussed amalgam among themselves. They recommended that the agency provide information to patients about the risks of dental amalgam, especially for vulnerable populations.

Committee members expressed particular concern about the disproportionate use of amalgam in disadvantaged populations, including communities of color and low-income communities that are already exposed to higher levels of toxins. And many committee members even called for an end to amalgam use:

Dr. McDiarmid — "I'll speak for myself and say I think that the evidence is there because we can show an exposure and we know the behavior of these neurotoxicants in the developing brain of children. We really need to think about continuing to just bless this because the evidence isn't quite there."

Dr. Connor — "But it seems like if a product came on the market today that said it's 50% made with a material we know is highly toxic and we're only going to use it predominantly in disadvantaged populations, we wouldn't be having a meeting, you know? FDA would not approve it without a meeting.

So, I mean, I'll leave that right there in terms of our discussion, but if this were coming on the market today saying it's 50% highly toxic material and we're predominantly going to use it in disadvantaged populations, it wouldn't even be a question."

Dr. Weisman — "So given all that, my feeling is that mercury-containing amalgam should probably be on its way out."

Mr. Lison — "I think everybody would agree that mercury in the body isn't a good thing. I see no reason why it shouldn't be phased out as quickly as possible."

Even the FDA advisory committee chair, Dr. Rao, agreed as he summed up the committee's conclusions to the FDA:

"And I think, generally, the Panel feels in response to Question Number 6 that the evidence that was presented and is available currently confirms what was previously known and tends to move the needle a little bit further along in the direction that there is some recognition and understanding of the risks associated with mercury-containing amalgams.

These risks are to the environment and also to the patient, and potentially, to the — and to the dental professionals involved in the insertion of these. I don't think there's been any clear understanding of a quantified increase in risk that is available currently.

But the trend seems to be that when there are alternatives available to the use of mercury, the general direction should be to move away from using mercury-containing amalgams and towards non-mercury-containing products to help with dental restorations."

So, the consensus of its own advisory committee is that FDA's silence on amalgam must end. But as executive director Charlie Brown explains:

"FDA has a history of not acting on advisory committee recommendations, so Consumers for Dental Choice is keeping them on the agency's plate. We've been following up with meetings, letters from experts and multiple memos answering specific questions raised at the committee meeting."

Now It's Your Turn to Act

Consumers for Dental Choice has brought a whole new ball game to FDA, and this time it looks like the FDA is ready to play ball. But you don't have to wait on the government; you can go to a mercury-free dentist now by checking out Consumers for Dental Choice's listing of mercury-free dentists.

With your continuing support, this effective advocacy organization can make the dream of mercury-free dentistry a reality at the FDA. Will you consider a donation to this 501(c)(3) nonprofit organization dedicated to advocating mercury-free dentistry?

If you donate during Mercury Awareness Week (August 23 to 29, 2020), I will double your money. I'll match you, dollar for dollar (up to $150,000). Donations are tax-deductible and can be made online at Checks can be mailed to:

Consumers for Dental Choice
316 F St., N.E., Suite 210
Washington DC 20002

Thank you for helping make the dream of mercury-free dentistry into reality for all patients, everywhere.

donate today

>>>>> Click Here <<<<<

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