Table 2.

Quotations Illustrating Key Themes

Theme	Example quotations
Advantages of Telemental Health
Increased Utilization
Access	“Advantages are that—you know—care is more accessible to certain people who have a hard time with busy schedules, with transportation, with certain types of anxiety. And I’ve seen actually a couple of patients do really well with engaging with weekly therapy…these are people who have been recommended to do CBT by many doctors in the past for years and never engaged because—you know—going to therapy weekly is a lot. And so, they were able to do that [with telehealth].” (MD)
Attendance	“The biggest one is that the no-show rates have plummeted because if I have a patient who forgets their appointment, I call them. And most of the time they’re at home and they can just log on to Zoom and we start a little late as opposed to they miss the whole appointment. That’s a huge advantage especially in psychiatry, especially for some of our underserved populations, where keeping track of appointments can be really burdensome.” (MD)
Activation Energy	“If something heavy is going on, to go to an office and kind of face that, you know, “I have to go in and talk about this thing” or trauma…I think it’s less of that if it’s over Zoom.” (LMHC)
	“Initial remote evaluation diminishes the barrier, I think, for most people to reach out and have an evaluation. The activation energy that it takes to find a clinician that accepts your insurance, and is accepting new patients, and to get the referral process done, and then to book an appointment, and then to get to downtown Boston even during the pandemic, to pay for parking, to get there on time is a huge activation energy it takes to get to treatment.” (MD)
Therapeutic Process
Self-Disclosure	“It was easier to access the really challenging things because [the patient was] alone and so during those times you see them look away from the computer …it was almost like they would be able to fully allow that emotional experience to happen and process it. Where in person, I found people to feel the need to posture or maybe try to be socially appropriate.” (PhD)
Clinical Insight	“I think actually seeing people in their own environments, sometimes there’s additional information that comes from that…I’ve seen how nice some people’s homes are. I’ve seen what they enjoy, like gardening, they’ve e showed me things that they are proud of. I think that’s a part of someone’s life that we don’t get in an office so that’s actually been really nice too and it’s a part of treatment and it helps me understand what drives this person in a way I couldn’t have understood before.” (MD)
Patient-Centered	“It’s so much easier to just do a 15-minute check on Monday and then check in again on Friday, whereas opposed to maybe a year ago, you’d do just one visit. And I think it’s kind of funny – like I have a bunch of patients…like 45 minutes/an hour away, and these days it seems kind of crazy that they would drive all the way to [clinic], park, meet with me for 15 minutes/20 minutes and then go home.” (MD)
	“I think in some ways, you could use the platform in a creative way. Like if patients are avoiding tasks, having them work through them in-session—in real time—in a way that wouldn’t be possible coming into the office. Or if there’s some type of in-home exposure work, that might be part of the therapy. … so I think that’s also an advantage that it allows for more of an in vivo environment for an intervention that you can’t really…I mean, you could emulate in the office, but not really have in the same way as being in someone’s house.” (PhD)
Provider Wellbeing
Workspace	“When I see patients at [clinic]… I actually have to walk over to a separate building for consult rooms. And, if I need a certain like material or worksheet, I really have to think about it in advance, and sometimes it becomes irrelevant during session, or I actually need something else. And now, with telemedicine, there’s a lot more flexibility. If something comes up during a session and I need a certain material or worksheet, it’s right there on my computer and I can screenshare with the patient. That’s been another huge advantage.” (PhD)
Work-Life Balance	“I also find that I myself like that I don’t have to—you know—get dressed up every day and fight traffic to get into the office to go see patients. I think it puts me in a more relaxed state in the morning.” (PsyD)
	“Working from home, I don’t get as interrupted as much, you know, ‘cause at work, people are – you know – they’ll come by, “oh, can I talk to you for a minute?” Or I’m running to and from meetings, and then you run into people… and not commuting has been good” (MD)
Disadvantages of Telemental Health
Therapeutic Process
Privacy	“I think there are sort of borderline cases where people are pretty comfortable in the room, but they’re concerned that like maybe some things they’re saying in the room can be overheard, and then there’s kind of like background unease around that…it can be hard for me to get clear on how big an impact that’s having on the work” (LICSW)
	“Many of my patients have like people walking around in the back, and I’m like ‘ah, we’re talking about like your childhood sexual abuse, like why is the kid in the room again?... I don’t think [these are] purposeful but [they] are just problematic. I think it speaks to the safety of the room.” (MD)
Distractibility - Patient	“I’m thinking of the folks… with, uh, ADD and ADHD… there are notifications popping up and …maybe someone without that diagnosis…can sort of ignore a notification and watch it go away [but it is] unbelievably challenging for some of the patients I work with. Um, and so, having the screen where they work and do all those other things being the same screen they’re trying to do therapy on can be really, really tough.” (PhD)
	“I think the other disadvantage – there’s this perception from patients that these are very casual appointments. So, there’s this attitude of like ‘oh, yeah, sure. I can talk now. That’s fine. Let me just put these brownies in the oven,’ whereas if you have an appointment on the books – and you have to travel to it – that’s not going to get in the way in the same fashion.” (MD)
Distractibility - Provider	“[My workplace] put out this suggestion for Zoom etiquette…to try to use that package as closely as possible to human interaction sitting in front of someone – keeping your camera on, trying to stay engaged, trying to not be distracted. We would normally do all of these things if we were sitting in front of a patient. Um, but I think the temptation, if we were on a videocall or even a phone call, with a patient is that you can get distracted, you don’t pay as much attention to the person or, what they’re saying. So trying to replicate what we would normally do in person via video, I think is another strategy that I’ve been trying to use.” (MD)
Limited Visual Cues	“Patients don’t really give you the full story of what’s happening, and it’s hard to see if they’re…controlling what you see on the screen and what you hear. So, I have a patient who I just realized is much more anxious and depressed than they ever let on to me. In our past visits, they’ve said that they’re fine, and I can’t get a sense of how they appear because they turn the camera off or point it up to the ceiling…If that person were in my office, I would be able to tell. It wouldn’t be as easy to hide how badly they were feeling, or how severe their symptoms were.” (MD)
	“I feel like the communication bandwidth is more restricted. You can—I feel like I can—get more emotional information from somebody’s posture or body language when I can see more of them” (LICSW)
Risk Management	“If you’re sitting with somebody and they may need to be sectioned…that’s one of the benefits of working from a hospital where, you know, it’s much easier, you know, because you’ve got security if you need them… You can literally walk them down to the ED. The logistics of sectioning somebody remotely are more complicated.” (LICSW)
	“I have one patient who is probably my most severe who I worry a little bit about suicidal ideation and it is a little strange that there’s this person I’m responsible for that I’ve never met and I’ve only seen on a screen…If something goes wrong, it’s a really big deal and that just feels different than someone I’ve sat with in my office...I think it’s just easier, it’s, um, the person just feels more real.” (PhD)
Technology Issues
Consistent connectivity	“…the technology glitches make it hard, make you miss seeing people in person because you don’t freeze when you’re seeing somebody in person and so, you can be at any point in the conversation, you know sensitive subject, and then suddenly somebody’s gone.” (PsyD)
	“Having a bad connection…is probably worse than us not meeting because we’re just like freezing, and we can’t get anything done.” (MD)
File Sharing	“So, even if I emailed them something, an application, and it was a pdf form or a word form. A lot of people printed it out but then they had no way of returning it to me..they couldn’t scan it back in.” (LCSW)
Equity	“What I also find challenging is like a lot of our patients don’t have stable internet access…since a lot of our patients are a little bit lower socioeconomic status, they have issues like, they’re either like in car next to the library trying to get Internet or people are like on their cellphone and because they don’t have a computer.” (MD)
	"I think we’re at a place where a lot of people—even if they are financially disadvantaged—might still have smartphones, but that’s not always the case, you know? Folks who have flip phones or non-smartphones or they run out of data or, um, they don’t have good WiFi.” (LICSW)
Provider Wellbeing
Provider Privacy	“When I’m in my own house and I’m Zooming with a person…I almost felt that I was being intruded upon. Like you’re Zooming into the emergency department, and somebody’s staring at you that’s really angry, that doesn’t want to be evaluated, and I’m in my bedroom.” (LMHC)
	“Being on video in each other’s homes, there’s a level of intrusiveness too, both for the provider and for patients…there’s been this loss of neutral territory, that we were afforded in like a clinic-based setting.” (MD)
Professional Connections	“I really missed my coworkers, because back when I was at the clinic—our desks were together—and we’d always kind of debrief with each other after sessions. But now, it can be hard because I’ll just go from Zoom meeting to Zoom meeting and just really kind of, by myself, sit with whatever I just processed with the patient.” (LICSW)
	“[I]t is a little bit more isolating, and it’s definitely tough to do this work exclusively from home, without sort of having that - being surrounded by that infrastructure of your colleagues and your institution…the day-to-day of doing this work from my home…it’s becoming pretty hard.” (PhD)
Separation of Work and Home	“The other thing that comes to mind is the difficulty of separating work from home...there’s literally no separation of physical space. I work and then I move a few feet and then that’s my down time so hearing about trauma for eight hours a day in my typically safe space, that was a really hard adjustment to make. …I always found the separation, like the psychological weight easier.” (PhD)
Quality of Care with Telemental Health
High Quality	“I think that for the reasons that we kind of discussed – which is like the greater flexibility, more continuity of care, having more ease with which to share materials – I actually feel that [the quality of care has] improved overall which is also something I really wasn’t expecting.” (PhD)
	“I’d say probably, on average, [the quality of care has] been pretty much the same...there may be circumstances where it’s actually better… and that may be more just ‘cause we’ve been able to see [patients] more frequently.” (MD)
Context Matters	“For example, there’s a patient that…I think would probably do better in person because she really struggles with attention. She gets really distracted by things going on in her home. But, at the same time, if I was seeing her in person, I wouldn’t be seeing her as frequently. So, I think it’s mixed. I do think that would be something to think about – like how we ensure that a patient is a good fit for telehealth and that they wouldn’t be a better fit for in-person treatment.” (PhD)
	“It’s somewhat individually based (pause), I think a broad sweep would be it’s the same…worse when someone’s in crisis…better for some, access for some has improved…we can meet more frequently.” (EdD)
New Outlook	[Regarding views on TMH in the past] “…a lot of providers having a lot of just stigma around it and them seeing that it’s so helpful. So, I think that’s the biggest thing. And I also think like patients seeing that this is a possibility, that they can do this, that therapy is easier to incorporate into their lives because they have a way of doing it. I think those are huge benefits.” (LICSW)
	“I think, going into it, I had the thought that it would be a lot different or awkward or…it just wouldn’t work as well as meeting in person…that pretty quickly faded away, and it sort of feels like very similar work or richer work in some ways. So, I think, if anything, I became much more favorability disposed to virtual care…there are a lot of advantages to it that were unknown to me prior to like diving into it head-first.” (PhD)
Preferences for Continuation
Hybrid Model	“I think that it would be best if I always had a hybrid option, for me and also for patients…if there is a patient where it’s clinically more appropriate for them to come into the office, I want to be able to offer that…and vice-versa for patients where it’s easier for them to be at home…I like the idea of [providers] having options.” (LICSW)
Barriers - Billing	“There can’t be a difference in reimbursement…because then you’re tipping the scale one way or another. Both modalities have to be able to be reimbursed equally...And that determination is up to the clinician – whether that clinician is a social worker, a doctor, a nurse, an NP, whatever. But that’s going to be up to the professional organizations and, frankly, the insurance organizations because if they tip the scale one way, people will usually go the way towards where the money is – and organizations do. So that’s my fear, is that they will tip the scale towards in-person, and we will lose the people that would’ve benefited from this. But it should be a clinical decision, just like a medication.” (MD)
Barriers - Out-of-State Restrictions	“The other challenge is that folks were practicing across state lines…their patients would be in other states and that was allowed for a while. And then, they rescinded all the emergency licenses.” (LICSW)
	“It’s a little bit complicated but we’re not really supposed to be doing virtual care with people in other states…sometimes the work around is to have them come to the clinic in person.” (MD)
Guidance	“A refresher would be nice as far as the confidentiality and those rules with liability. What if I start talking about something really intimate and someone walks in the room? And the patient – the person I’m talking to isn’t okay with it at that moment, but they were okay with it earlier—you know—before they thought that person was home?...Am I liable?…it would be nice to know I think more of the legal stuff as a clinician.” (LMHC)
	“It’s hard to anticipate what the problems are going to be until you’re in it and we know a lot more now. So for training purposes we probably could prepare people.” (EdD)

Note. Degree has been included at the end of a quote to give a sense of context