Behavioral Telehealth Faces Growth Barriers

At the beginning of the pandemic, remote meetings with doctors were temporarily legalized only for those who had tested positive for COVID-19.

The increasing need for therapy and pandemic restrictions have spurred the growth of remote counseling. In Taiwan, clinicians and entrepreneurs battle bureaucratic barriers to reach those in need of care.

When Taiwan went into a Level 3 pandemic alert that initiated a near-lockdown in the spring of 2021, counselors at schools and colleges were abruptly cut off from the students they had been meeting regularly. Many tried to turn to telecounseling to maintain contact with their students.  

Telecounseling, or counseling via phone or video, has been legal since 2019, when an amendment to Taiwan’s Psychologists Act established guidelines for the practice. But counselors at schools and colleges fell under the indistinct regulatory sphere of both the Ministry of Health and Welfare’s (MOHW) Psychologists Act and the Ministry of Education, of which the latter had not yet clarified rules on remote counseling, says Lo Ming-Jung, a counseling psychologist in Taipei.  

“We were kind of working in between and using limited ways to link with the students to confirm they are safe,” she says. “Our relationship was impacted by the limited resources we can use. It’s really hard if the student cannot pick up the phone. And then how can I reach him?” 

In July 2021, the Ministry of Education released new guidelines for telecounseling under the Student Guidance Law, a move that has confused licensed counselors and clinical psychologists who work in academic settings and abide by the Psychologists Act. The debacle shines a light on the complicated bureaucratic and legal web surrounding behavioral telehealth, which counselors say have prevented them from reaching people who need services the most and hindered the industry from developing to its full potential. 

Before the pandemic, telemedicine in Taiwan was restricted to communities on outlying islands or in remote areas. But as patients were put in quarantine at home or in state facilities, remote meetings with doctors were temporarily legalized for those who had tested positive for COVID-19. 

The behavioral health sector had no guidelines on the books for remote telecommunications care before 2019, when MOHW implemented telecounseling reference principles. The new attention to telecounseling seemed like a victory for psychologists and counselors, who had been advocating for Taiwan to jump on the teletherapy bandwagon for years. Of course, the laws came with restrictions, which were tightened even further in 2020. 

Today, the laws around remote counseling vary in each of Taiwan’s 20 counties and municipalities. But some restrictions under the national guidelines apply to all regions. For example, patients under the age of 18 and those with certain neurological conditions – including severe anxiety and depression – are ineligible for remote counseling. Clinics are also required to partner with a medical institution to ensure that patients can quickly be referred to medical care if needed. All clinics that wish to offer telecounseling must apply for approval with a detailed implementation plan to their county or municipality health authority, which counselors in Taiwan say is a complicated and lengthy process with inconsistent results. Finally, counselors must perform remote sessions from their offices rather than at home, which some say has put them at risk during COVID surges. 

“I think the authorities’ mindset is that they would like to restrict things that require more medical services because telemedicine has [different] restrictions,” says Jill Niu, an attorney who heads healthcare and life science practice at Lee & Li Attorneys at Law. “And for neurotic disorder patients, and people under certain conditions, authorities believe they should receive so-called ‘medical treatment’ – diagnosis or prescription – from a psychiatrist rather than a psychologist.” 

Although many patients are children, remote counseling is only legal for those aged
18 and above.

Clinical and counseling psychologists argue that these laws are unnecessary bureaucratic obstacles to helping patients who need their services most, despite rising demand for services during the pandemic. 

For the Yuanpin Psychological Clinic in Tainan, one of the biggest setbacks has been the age limit of 18 years and older. “A lot of patients here are children or adolescents, so that makes it very difficult for us to do the service for them,” says Huang Ya-ling, the clinic’s director and chairperson of the Taiwan Counseling Psychologists Union (TCPU). 

“[Having a contract with a certain hospital] is really not good for the patients because they have the right […] to choose which hospital they want to go to,” she says. “And for the maintenance of the information security, we’re not an expert in information security, so that’s also very difficult for us to maintain and develop.”  

According to local reports, only 14 clinics in Taiwan had been approved to provide remote counseling services in 2021, two years after the telecounseling law went into effect. That number increased to 201 this year, likely because of pressure from TCPU and the growing need for remote counseling during the pandemic. The approved clinics are mainly concentrated in major cities like Taipei and Taichung. Meanwhile, Nantou, Taitung, and Kinmen only have one clinic offering remote behavioral health services each, and Lienchiang and Penghu counties have none, according to government statistics.  

Local regulations have resulted in inconsistency between services in various municipalities, practitioners say. For example, some municipalities require a first-time in-person consultation before teletherapy can begin. Lo says that she and her colleagues tend to refer clients from rural areas to Tainan since it is the only municipality that does not require an in-person consultation before initiating telecounseling. 

Filling the care gap 

In countries like China and the U.S., teletherapy has been expanding for decades, and the industry grew exponentially as the pandemic not only drove patients and providers into their homes, but also increased the need for care. The prevalence of depression and anxiety increased by 25% globally in the first year of the pandemic, according to the World Health Organization (WHO).  

Taiwan is no exception. According to the Control Yuan, the number of psychiatric clinic visits in 2021 rose by nearly 11%, from 1.31 million in 2019 to more than 1.45 million in 2020. Around 13% of the population sought medical treatment for mental, behavioral, or neurodevelopmental diseases in 2020, according to National Health Insurance statistics.  

In addition to the legal barriers to remote services, practitioners say Taiwan lacks technology-related training and best practices. The latter two, however, could be addressed by private companies and apps that connect users with therapists. 

Cary Hsieh is one innovator in Taiwan who believes he has found a way to make counseling more accessible and reduce stigma associated with therapy. Hsieh’s platform – called FarHugs (遠距抱抱) – allows users to connect with counselors from 14 medical institutions across Taiwan, as well as and hundreds of life coaches, all of whom are certified counseling or clinical psychologists. 

“There are still a lot of restrictions, especially for people who need help – they don’t want to have a negative tag on them,” Hsieh says. “They don’t want to be labeled as a patient.” Hsieh adds that this is one of the reasons life coaching has been more popular than traditional psychotherapy among the platform’s 5,000 monthly users. 

These types of apps have been criticized in the U.S. Experts have said that teletherapy platforms like BetterHelp – which claims to serve two million clients – are unproperly regulated. Some have called the apps “a privacy nightmare” as they are not required to follow the Health Insurance Portability and Accountability Act’s (HIPAA) requirements, nor do they need to protect user data privacy.  

In an attempt to the public’s data safe, Taiwan introduced the Personal Data Protection Act (PDPA) which states in Article 6 that medical records and healthcare data “shall not be collected, processed or used” except where it is expressly required by law or if the data is necessary for a government agency or non-government party to carry out its duties or research. Though the National Health Insurance Administration’s (NHIA) use of health data remains a subject of debate. In August, Taiwan’s Constitutional Court ruled that allowing certain government agencies and researchers to access health data is unconstitutional. The court found that the PDPA lacks an appropriate independent governing mechanism, and that the National Health Insurance Act does not stipulate how the NHIA uses and stores data. It asked the NHIA to changes its rules within three years to give people the option to decline third-party use of their personal data. 

Hsieh notes that FarHugs voluntarily complies with HIPAA standards and does not share specified user data since privacy remains a major concern among Taiwanese users. “We care a lot about privacy,” he says. “We don’t want to increase the risk in the future just to get very small profits.” 

Although platforms like Hsieh’s are steps in the right direction, they are still constrained by regulations and the industry’s infancy. Most other remote counseling apps active in Taiwan today remain exclusive to a specific clinic or institution. Additionally, some doctors and therapists still prefer face-to-face consultations because they believe the system is still lacking the proper tools, says Katherine Juang of Lee & Li Attorneys at Law. 

“I think the issue is that the authority is not relaxing a lot of the regulations,” says Juang. “Hence, there’s not much motive for companies to develop these kinds of tools. From the industry’s view, they will only have the motivation to [invest in telecounseling] after they can ensure that they are legally allowed to provide these kinds of services.” 

But some platforms have thrived in the regulatory gray areas, adds Niu. For example, some services that advertise meetings with lifestyle coaches or basic consultations – like a doctor looking at a rash to determine if medical care is necessary – fall outside of the existing regulatory sphere. Niu says that in these cases, the regulator’s assessment of the situation will decide whether the service should be shuttered. 

Practitioners say expanding teletherapy will only improve their ability to do their job by making it more accessible and allowing telehealth callers to obtain a sense of a patient’s home environment. But for the industry to be expanded, greater cooperation between government agencies, mental health professionals, and private companies is needed.  

“The people who made the decision [on how to regulate teletherapy] – they’re doctors, they’re not psychotherapists,” says Chiao Hung, committee chair of TCPU’s international section and faculty member at National Taiwan Normal University’s Psychology and Counseling department. “TCPU was not fully informed and [did not] have full power in participating in that discussion. And they think making more regulations can protect clients’ rights but that actually limits the services that we can provide.” 

TCPU has advocated for adjustments to teletherapy regulations since they were first implemented in 2019. Its efforts have reaped small gains so far, including the rapid growth in approval of clinics for teletherapy. But the union wants to see more progress.  

In June, the Control Yuan urged a comprehensive review of the regulations after consulting mental health practitioners across Taiwan and concluded that the guidelines “caused major controversy and impact on the professional judgment of psychologists’ practice and the protection of people’s rights and interests.” TCPU members hope the review will lead to further amendments to the psychologist law, like a relaxed application process and more uniform, nationwide regulations. 

“I think it’s time to look from the bottom up and see the creativity that has been developed in that area,” says Chiao. “And I think the government should trust our professional voices more, our energy and our suggestions more, to push the process forward.” 

MOHW did not respond to questions in time for publication.