Practitioners' Pivot: Creating Effective Online/Offline Therapy Systems

By Brian Belko posted 22 Apr, 2021 17:52


By: Andrea LaMarre

“Pivot” might be one of the most popular words of 2020—and one of the most maligned. When the COVID-19 pandemic hit, multi-disciplinary healthcare providers around the world had to pivot their services online in an effort to continue delivering much-needed services to people with eating disorders. Healthcare providers have found themselves innovating and navigating healthcare systems to deliver high quality care. 

While some things are lost in the move online, many healthcare providers have found that providing online services has enhanced the accessibility of treatment and met the needs of clientele that had previously not been engaged in treatment.

Undoubtedly, the COVID-19 pandemic has also brought with it an array of new challenges for people with eating disorders and their supporters. Healthcare providers have faced rising demands for services while themselves navigating personal and professional challenges in relation to this global health risk. 

In order for gains to be retained and hiccups to be smoothed out, there is a need for clear policy direction and advocacy efforts that enable flexible and responsive approaches to treating eating disorders in a pandemic and post-pandemic world. The Advocacy and Communications Committee sought out perspectives from providers around the world to better understand what eating disorders professionals saw as the good, the bad, and the ugly of pivoting online. We anchored our conversations in a focus on what the future of eating disorders service provision might look like.

We spoke with practitioners from the US, Canada, Australia, Finland, and Israel providing support to people with eating disorders to explore how they’ve navigated the move online, some of the benefits and drawbacks to the move, and what might be retained in a post-COVID world. These countries have vastly different healthcare systems, but practitioners reported several common themes around the pros and cons of online therapy.


Providing therapy online means reaching people quite literally where they are and minimizes physical access barriers. 

Kaley Roosen, a psychologist in Toronto, Ontario (Canada) is a disabled woman who started up a group for disabled people with eating distress during the pandemic. She shared that the group would not have been possible prior to the move online because of the physically inaccessible buildings in which groups typically take place. Not only does the group enable people to show up in ways that suit them, but it minimizes the need to book in Wheel-Trans (a public transit service for people with disabilities) and navigate often-inaccessible sidewalks, particularly in winter. Further, it may be easier for those who are unsure about whether or not they want to try out therapy to give it a chance. Roosen noted that the success of the group also speaks to the need to dismantle the ableist idea that therapy must be in person to be effective.

In terms of geographic accessibility, being able to easily reach clients living in rural areas was noted to be a boon of online therapy. In the Australian context, online therapy had already been available for rural and remote clients, as Janet Lowndes, a private practice therapist in Victoria (Australia), noted. However, moving services fully online meant greater accessibility for clients who might find it challenging to present to services in person even when they live in urban settings. 

In some healthcare systems, providing therapy across geographic boundaries is complicated by the need for therapists to be licensed in the State, Province, or Territory in which their client resides. Lauren Muhlheim, a private practice psychotherapist in Los Angeles (USA), shared that she needed to become licensed in multiple states in order to provide therapy for clients who moved home from college or away during the pandemic. While at times this was a relatively simple process, several delays along the way complicated the process. Moving forward, clarity of requirements might help streamline processes – further, Lauren noted a need for greater awareness about the need for a client/therapist match based on state licensure. 

Existing Structures and Upgrades

In Finland, structures for telehealth existed prior to the pandemic, making the shift online relatively straightforward, reported Monica Ålgars, a clinical psychologist in Helsinki. Similarly, Rachel Bachner-Melman, a clinical psychologist in Jerusalem, noted increased interest in the delivery of therapy via online methods in Israel prior to the pandemic. However, moving online has involved navigating layers of bureaucracy and sometimes-inconsistent funding barriers. Israel’s health system includes four major health funds, each with their own funding guidelines around telemedicine. 

In the United States, different insurance plans have differing allowances for therapy delivered online. Often, insurance providers have a different list of providers who are in-network (within the list of providers approved by an insurance company) for telehealth than face-to-face. While the COVID-19 pandemic enabled broader networks of care online, Lauren Muhlheim reported, there has been little guidance on what will happen after the acute phase of the pandemic has ended, leading to significant uncertainty about what comes next.

In Australia, many clients with eating disorders use Medicare to access psychological and dietetic services; under Medicare, those on eating disorder plans receive funding for part of their session fees. As Janet Lowndes noted, there was major fear amongst clients and providers alike around the potential loss of Medicare funding when therapy went online. However, after a month of being unable to access Medicare for online therapy, governmental changes enabled this access. Currently this funding only extends to the end of June 2021, but there have been discussions about further extensions. Many providers are still operating 100% online and lacking clear guidance about what to expect in the future.

Across contexts, there is a notable need for clear lines of communication and pathways to follow to enable most clients to reach the services they need. The financial access to quality online therapy with trusted clinicians remains top of the priority list for many when it comes to considering the future. 

Support for Therapists

One of the hidden challenges of the pandemic has been the impact that isolation and increased service demand has had on providers themselves. During the COVID-19 pandemic, there have been notable increases in people seeking support for eating disorders. Meanwhile, clinicians, often used to working in office settings with others doing similar work and ideally with access to face-to-face supervision, find themselves working long hours in their own homes.

Providers who spoke with us for this piece shared that wait lists had increased up to 300% in some locations. This has put pressure on already pressurized systems to see more clients, but this is not necessarily a long term or sustainable solution. While it may be possible, in the context of COVID-19, to create new groups for clients who might not otherwise engage in therapy, as Kaley Roosen’s group demonstrates, simply increasing the number of clients seen on a one-on-one basis does not necessarily bode well for provider wellbeing. 

Janet Lowndes noted that there is a strong need to upskill practitioners working in general mental health to be able to do eating disorders work. Without additional support, there is a real risk of therapist burnout. One potential avenue for decreasing isolation that Janet shared was bringing practitioners back into the office before being able to pursue in person therapy; this helps to manage gathering sizes while also enabling mutual peer support for practitioners. 

It may also be possible to build teams in virtual spaces and in so doing enable peer support and a wider reach for the therapy practice. Over the course of the past year, Lauren Muhlheim’s team has expanded to include practitioners who do not live nearby but who can become an instrumental part of the team and provide care to those out of state.

What’s Next for Online Therapy in the Post-COVID World?

As clients and practitioners continue to navigate global uncertainties in general, there are also a number of uncertainties related to the continuation of online therapy. All of the practitioners we spoke with shared a desire to continue a mix of online and in person therapy. Practitioners indicated some optimism about what could be gained when moving online, including increasing access to rural, disabled, and potentially ambivalent clients, and being able to join people where they are. At the same time, some were hesitant to continue solely online provision, pointing to the difficulties in assessing all aspects of eating disorders in this forum, including some of the intangibles and affect that emerge in in-person therapy settings.

In order to ensure a strong hybrid online/offline therapy system is realized, there is a strong need for adaptive, flexible, transparent, and clear systems to be in place. Part of our work moving forward as eating disorders professionals might include advocating for such systems - ones that work for practitioners, clients, and families.