Attention Magazine Fall 2017

 Download PDF

“ZACH” WAS BEING TREATED BY A PSYCHOLOGIST for his ADHD and anxiety on a regular basis. One day in between his weekly sessions, he was distressed to learn he didn’t get a part in the school play, and he asked to talk with his psychologist. Although an adult was home with him, no one was able to drive him to the office on short notice. While in the past, transportation difficulties may have prevented Zach from getting together with his psychologist, she offered to “see” him through a secure video system. In the comfort of his home, he was able to process the incident and develop coping strategies to deal with it that day.

“Sara” and her parents were working together with a therapist skilled in behavioral parent coaching. They made progress setting consistent limits on behavior and praising Sara’s positive behaviors. However, when they returned home from the session, they had difficulty applying the skills that they had explored. After Sara’s parents discussed these difficulties with their therapist, he suggested a morning video session during the most difficult part of their day. This allowed for the therapist to observe in the natural home setting and coach the family to help with behavioral changes.

Whether telemental health is used intermittently as the situation indicates, or for continuous services, it opens up possibilities for increased access to therapy.

What is telemental health? Also known as telebehavioral health, telemental health is the delivery of mental health services via synchronous audio and video connection, specifically video conferencing. The growing use of privacy-secured and encrypted video conferencing soft – ware by psychologists offers an alternative pathway for families who seek consultation, assessment or treatment. Research indicates good outcomes across many disorders-including ADHD and anxiety disorders.

First, let’s look at some of the advantages of telemental health services, and then we’ll discuss how to determine if you could be a good fit for these services.

• Telemental health can include more family members in treatment.

Often, one caregiver may wish to be included in treatment but may be unable to attend. For example, Zach’s mom was unable to make it to the initial appointment because she could not afford the time for the long commute to the appointment. Zach’s father attended the appointment with Zach, and his mother joined via secure video conference. She was relieved that she was able to participate and provide valuable information without missing a meeting at work. Telemental health can also allow for the inclusion of interpreters to assist with family members who are not fluent in English or who require sign language.

• Telemental health can allow for continuity of care.

Zach could attend a last-minute session with his psychologist despite not having transportation. Sara was able to have a videoconference session during a particularly difficult week when she had strep throat and was contagious to others. Telemental health can help when weather conditions prohibit safe driving. Or, perhaps a provider who specializes in your child’s specific condition lives on the other side of the state, too far away for you to realistically meet with her each week.

• Telemental health can promote the generalization of skills.

Sara’s parents understood the parenting skills discussed in session, but when they returned home they felt swept up in the chaos of their home and found them difficult to enforce. Joining by video, their therapist was able to provide specific prompts to the parents in the moment. Another important application of telemental health is exposure-based cognitive behavior therapy (CBT), which helps clients overcome their anxiety by gradually facing feared situations. Clients get the opportunity to face a wide array of fears with the support of their therapist outside the office. For instance, a child with dog phobia can go to the dog park with her parent and, using a videoconferencing app on her cell phone, respond to prompts from her therapist to gradually approach and eventually pet a friendly dog nearby.

• Telemental health can allow for a therapist to effectively conduct PCIT.

Parent-child interactive therapy is an evidence-based treatment for young children with behavioral disorders focused on improving parent-child interactions. Historically, PCIT has involved the parent and child meeting in one room. The clinician sits in an adjacent room with a one-way mirror using a pair of headsets. The clinician coaches and provides feedback to the parent through the headset. However, most provider offices do not have rooms with one-way mirrors. A practical solution might be to carry out the procedure using a computer. equipped with webcams in separate offices, and providing the parent with a Bluetooth earbud to communicate with the clinician. In addition to conducting PCIT in the office using videoconferencing, exciting research has shown promising results for internet-delivered PCIT with the clinician coaching the parent while the parent and child are at home. This allows the clinician to generalize the skills to a real-life setting while simultaneously reducing barriers to coming into the physical office.

Factors to consider in advance

Telemental health is not without its potential pitfalls. We suggest that you discuss each of these questions with your therapist prior to scheduling a session.

1. Is my child/family a good fit for telemental health?

Telemental health is not recommended for all clients. Some children with particularly impairing attention problems may be prone to distractions and may require therapy sessions within the context of a controlled office setting. Some children are too young to sustain attention during a session via video. We suggest that appropriateness be evaluated on an individual level.

In the case of extremely anxious individuals, meeting via telemental health may allow them to successfully avoid in-person interactions, which is not ideal to overcoming this anxiety! Some individuals benefit from in-person sessions that require them to get ready for the day and leave the house. In situations when a therapist may be concerned for the safety of a client (for example, when the risk of suicide is an issue), telemental health is not preferred unless, in some cases, an emergency plan is discussed. It is not recommended that the first session be conducted remotely, because it’s difficult for a therapist to assess the appropriateness of telehealth and establish a thorough plan without meeting a new client at least once in person.

Research suggests that therapeutic alliance, or a strong relationship between therapist and patient, can be developed within a videoconferencing setting. However, some may prefer in-person sessions. Discussion of the benefits and risks of telemental health with your provider is mandatory.

2. What type of technology do I need?

Telemental health sessions require access to a privacy protected, encrypted, HIPAA-secure video conferencing platform to protect the confidentiality and privacy of patients. A link to the videoconferencing platform is typically provided by the therapist at no cost to the client. Programs such as Skype or Facetime do not have adequate HIPAA protections and are not recommended.

Whenever a healthcare provider contracts with an individual or a company for a service that has the potential to expose confidential information, a Business Associate Agreement is required by HIPAA. It is a signed document that indicates that the contractor understands and complies with all the relevant HIPAA requirements related to the privacy of clients. Current HIPAA-secure platforms include V-See, Zoom.us, Doxy.me, Vidyo, and Secure Video.

You will also need access to high-speed internet, a webcam, speakers and a microphone. Alternatively, a smartphone can be used. We recommend that you download the necessary program in advance of your first session, to practice and ensure that the sound and video work. While clients report high satisfaction with using the videoconferencing technology, there is a risk of glitches, including insufficient internet speed, dropped calls, logon complications, or audio or visual problems. You and your therapist should discuss what will happen in these situations.

3. Will my insurance company cover telemental health sessions?

You will need to check this out with your insurance company. Your therapist can provide the modifier code for your inquiry. Many states are now mandating reimbursement for telemental health in parity with in person services; not all, however.

4. Where should I conduct the session?

We recommend that you be in a setting that minimizes both visual and auditory distractions. You should be in a well-lit room and comfortable with your therapist seeing your surroundings. It is recommended that you are in a private place where others cannot overhear the session.

5. What happens if I travel to another state and want to do a session?

Many clients will ask to do sessions while away on vacation or when they begin college. Currently, the psychologist needs to be licensed in the state where both s/he and the client are located. A therapist can contact a state licensing board and sometimes temporary arrangements can be made, but it is important to discuss these issues in advance.

When provided thoughtfully and prudently, taking into account technological, safety, and confidentiality concerns, telemental health can supplement or replace in-person sessions and enhance treatment effectiveness, while overcoming barriers to care. Psychologists look forward to additional ways technologies can benefit their clients.

 

 

Mary Alvord, PhD, is the director of Alvord, Baker & Associates, LLC. She has been involved in telemental health for the past eleven years and served as past president of the American Psychological Association Society for Media Psychology and Technology. A practicing psychologist for more than 35 years, she co-authored Conquer Negative Thinking for Teens (New Harbinger), and Resilience Builder Program for Children and Teens (Research Press).

Nina Shiffrin, PhD, is the associate director of research at Alvord, Baker & Associates, LLC. In addition to researching the effectiveness of a group treatment program, she is a practicing psychologist treating youth and their families. Dr. Shiffrin regularly uses telemental health as part of her treatment.

Colleen Cummings, PhD, is a licensed psychologist who sees children, adolescents, and young adults at Alvord, Baker, & Associates, LLC. She is also the director of research and has a strong interest in the dissemination of effective treatments to the community. Her clinical approach emphasizes evidence-based, cognitive-behavioral therapy and the use of telemental health to improve the accessibility and generalizability of CBT.