Randall D. Ordovich Clarkson, MD
August 24, 2022
For those who grew up in the 90s such as myself, the use of remote technology like Skype, FaceTime, and Zoom is like something out of the Jetsons. Now with the rise in technology in the practice of medicine, telehealth has become a big player in providing remote treatment options to patients, whether it be due to distance from clinical sites or the prevention of communicable diseases, as was the case during the COVID-19 pandemic. To begin with, telehealth allows for the reduced need to commute potentially long distances for both the clients and, if choosing the work from their home office, the therapist as well. Considering our record-breaking gas-prices, this is becoming a more and more attractive consideration. Additionally, depending on the circumstances, telehealth can provide a degree of immediacy, being available for clients who are undergoing acute needs.
When it comes to behavioral health, rural areas tend to receive less behavioral health services than more urban communities (Talbot et al., 2020). This is mostly a factor of being in more isolated regions without adequate access to healthcare services. Because of this isolation, remote telehealth can help to fill in the gaps, as it were. Telehealth has also demonstrated a great deal of benefits, particularly to non-emergency type visits for the purpose of routine/maintenance therapy such as refilling prescriptions and monitoring for adverse side effects. Furthermore, telehealth can also play a huge role in providing important interventions for a myriad of conditions ranging from mood disorders to autistic spectrum disorder (ASD) (Lindgren et al., 2020). Throughout this paper, we will discuss some of the key considerations in the use and implementation of telehealth in the evolving landscape of modern psychotherapy.
Telehealth in Psychotherapy and Behavioral Health
In a study by Lindgren et al. (2020), the authors were seeking to test whether remote functional communication training (FCT) could be administered to patients with autistic spectrum disorder (ASD) via telehealth. In Lindgren et al. (2020), the authors conducted a randomized control trial (RCT) to test whether: (1) FCT treatment would decrease problem behavior in ASD patients, (2) that FCT would increase manding or the verbal request for something as well as task completion, and (3) that parents would accept FCT treatment modalities via telehealth. As an RCT study, the researchers compared remote FCT with “treatment as usual” or delayed treatment for children with ASD (Lindgren et al., 2020). The conclusion of the study found that remotely administered FCT resulted in reduction of problematic behavior by 98% compared to the controls.
In terms of methodology, Lindgren et al. (2020) conducted the RCT comparing immediate treatment cohorts to the “waitlist control” or delayed treatment cohort. In other words, both groups would receive treatment, though treatments were administered at two separate times—immediately and delayed. Upon receiving the intervention, FCT would be administered over a 12-week duration, allowing for comparisons between groups that received immediate vs. delayed intervention.
Both qualitative and quantitative metrics were measured in this study. For qualitative measures, the authors observed social functions such as escaping behavior and attention during observable sessions. Other qualitative metrics included the completion of tasks during tangible sessions (Lindgren et al., 2020). Some examples include the following: “Child played with preferred items for approximately 30 seconds;” “Parent instructed the child to complete a developmentally appropriate task that was identified in the FA as resulting in problem behavior;” “Parent instruction to complete the task continued until the child completed the task” (Lindgren et al., 2020). For quantitative analysis, the behaviors were placed into 50 separate 6 second intervals whereby each behavior could be uniquely coded.
The results of the study appeared to be highly successful, demonstrating an 80% reduction of problematic behaviors during the RCT. When comparing interventions vs controls, the immediate treatment group had an improvement of 100% vs. 12% in the control group (Lindgren et al., 2020). This confirms the findings of previous research which have demonstrated that parents of ASD patients can be trained and coached through telehealth in implementing FCT to reduce problematic behaviors (Lindgren et al., 2020). Furthermore, this demonstrates the overall benefits that remote telehealth can provide when working with patients in a myriad of circumstances—a finding that should be considered by all professionals in the field of behavioral health.
In the treatment of depression, telehealth has also been found to produce positive outcomes for patients. In a study by Hunkeler et al. (2000), the authors found that quantitative measurements of nurse-based telehealth increased quantitative metrics by 50% on the Hamilton Depression Rating Scale at 6 weeks and at 6 months, on the Beck Depression Inventory at 6 months, as well as symptom reduction on the Hamilton scale at 6 months. As for qualitative metrics, the authors found overall improved mental functioning at 6 weeks as well as increased treatment satisfaction at both 6 weeks and 6 months (Hunkeler et al., 2000). Another metanalysis by Osenbach et al. (2013) found similar results in terms of effectiveness when comparing telehealth with traditional in-person psychotherapy for depression. The authors concluded that there was, “no evidence to suggest that the delivery of psychotherapy via synchronous telehealth modalities is less effective than nontelehealth means in reducing depression symptoms” (Osenbach et al., 2013).
These aforementioned studies demonstrate the overall effectiveness of telehealth modalities for certain conditions. However , it is also important to consider circumstances whereby telehealth may not be a suitable modality.
Discussion on the Benefits and Drawbacks of Telehealth
For those who follow a scientist-practitioner model of counseling and psychotherapy, it is critical to be able to gather data, both qualitative and quantitative, and integrate those findings into one’s clinical practice. For example, it is critical to understand both benefits as well as drawbacks of certain practices, including the implementation of telehealth. For example, certain conditions require more face-to-face type therapeutic sessions unsuitable for the integration of telehealth. For instance, a meta-analysis of telehealth for PTSD patients found that although telehealth resulted in significant reduction in PTSD symptoms, “telehealth intervention produced an inferior outcome relative to a face-to-face intervention” (Sloan et al., 2011). Studies regarding conditions such as schizophrenia and bipolar disorder are somewhat inconclusive in the overall effectiveness of telehealth; though, telehealth as a whole allows for a greater degree of access to services than would be available otherwise (Patel et al., 2020; Santesteban-Echarri et al., 2020). Considering such limitations, telehealth is excellent for maintenance visits, particularly when discussing possible side effects or other complaints regarding prescribed medications—findings that can help to guide a therapist’s clinical practice.
For professionals considering the incorporation of telehealth, it is also important to consider other aspects of evolving technology, thereby necessitating that counselors keep up-to-date on current trends. This may involve obtaining “special certifications” or “additional course work” (ACA, 2014). Secondly, therapists must be well acquainted with local state and federal laws, particularly relating to the location of the therapist and the client’s place of residence. Thirdly, confidentiality is very important and electronic records and other client information must be maintained using secure, up-to-date encryption standards. The fourth consideration is with regards to potential limitations insofar as electronic communication may interfere with visual and non-verbal cues resulting in potential misunderstandings. Fifth, counselors must be mindful of accessibility to persons with disabilities. Also, language barriers must be taken into consideration, which involves the necessity for access to adequate translation capabilities. The final consideration is maintaining a professional digital presence. This may involve the separation of personal vs. professional social media pages and respecting client’s privacy on their social media platforms.
Conclusion
In a post-COVID-19 world, telehealth has gained a great degree of acceptance in both medical as well as behavioral health communities. As the digital landscape evolves over the years, the potential benefits and drawbacks of telehealth must be considered and integrated in modern psychotherapeutic modalities. For counselors who engage in a scientist-practitioner approach, it is crucial to keep up-to-date on research pertaining to telehealth and other digital trends in healthcare. In that, the research is clear in demonstrating positive outcomes for the treatment and maintenance of conditions such as mood disorders and ASD; however, conditions that might involve more acute treatment such as schizophrenia, bipolar disorder, and PTSD may not be suitable candidates for telehealth; though, more research must be conducted to determine what alternative approaches may be considered in the digital space.
References
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Osenbach, J. E., O'Brien, K. M., Mishkind, M., & Smolenski, D. J. (2013). Synchronous telehealth technologies in psychotherapy for depression: A meta‐analysis. Depression and Anxiety, 30(11), 1058-1067.
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Santesteban-Echarri, O., Piskulic, D., Nyman, R. K., & Addington, J. (2020). Telehealth interventions for schizophrenia-spectrum disorders and clinical high-risk for psychosis individuals: A scoping review. Journal of Telemedicine and Telecare, 26(1-2), 14-20.
Sloan, D. M., Gallagher, M. W., Feinstein, B. A., Lee, D. J., & Pruneau, G. M. (2011). Efficacy of telehealth treatments for posttraumatic stress-related symptoms: a meta-analysis. Cognitive Behaviour Therapy, 40(2), 111-125.
Talbot, J. A., Jonk, Y. C., Burgess, A. R., Thayer, D., Ziller, E., Paluso, N., & Coburn, A. F. (2020). Telebehavioral health (TBH) use among rural medicaid beneficiaries: Relationships with telehealth policies. Journal of Rural Mental Health, 44(4). https://doi.org/10.1037/rmh0000160
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