Telemental Health: Improving Access to Veterans’ Mental Healthcare

By Brian Neese

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Photo Credit: Dublin VA

Military members comprise less than 1 percent of the U.S. population, yet veterans represent 20 percent of suicides nationally, according to the National Alliance on Mental Illness. Each day, about 22 veterans die from suicide.

An issue affecting mental healthcare for veterans is accessibility. In the spring of 2014, the U.S. Department of Veterans Affairs (VA) wait time scandal emerged when allegations surfaced of veterans dying while waiting for care at the Phoenix VA Health Care System, according to Military Times. Wait time issues and manipulated appointment scheduling highlighted a nationwide problem and resulted in several top officials resigning or retiring.

Months later, Congress passed a $15 billion bill allowing more veterans to seek care in the private sector through the VA Choice program. Meanwhile, the VA continued focusing efforts on telemental health, or the use of telecommunications technology to provide behavioral health services, to try to improve veterans’ access to mental health services, National Psychologist reports.

Accessibility

Nearly one in four active duty military members show signs of a mental health condition, based on a study in JAMA Psychiatry. With 44 percent of veterans returning home from Iraq and Afghanistan to rural zip codes, accessibility becomes an important topic for veterans’ mental healthcare. This is a natural strength of telemental health services, which can include clinical assessment, individual and group therapy, educational intervention, cognitive testing and general psychiatric treatment.

The first telemental health program funded by the VA’s Office of Rural Health is at the Portland VA Center in Oregon. Through telemental health sessions, veterans saved 826,290 miles driven and $161,126 worth of gasoline in 2013, program director Mark Ward said. Some veterans who live far from Portland and lack high-speed internet are given electronic tablets and notebooks for videoconferencing.

Telemental health can increase veterans’ access to services and eliminate travel. Another benefit is that telemental health can help veterans overcome the perceived stigma sometimes associated with seeking mental health treatment. Veterans who might feel embarrassed or ashamed to get help in person can receive care in their home.

The VA delivered a total of more than 650,000 telemental health sessions nationally from the program’s inception in 2004 through 2014. The VA anticipated delivering 300,000 telemental health visits for 115,000 veterans in 2014, an increase from more than 200,000 telemental health visits for 80,000 veterans the previous year. Additionally, the VA has created free smartphone apps that veterans can use to help with post-traumatic stress disorder (PTSD), such as the PTSD Coach application developed by the VA and the Department of Defense.

Telemental health has made progress in improving accessibility for veterans’ healthcare, and it will be needed to make further ground. The Government Accountability Office found that 18 months after the wait time scandal, the VA still struggled with wait times and patients’ schedules.

Effectiveness

The first large-scale assessment of telemental health services was published in Psychiatric Services. This study assessed clinical outcomes of 98,609 mental health patients before and after enrollment in telemental health services of the VA between 2006 and 2010. During this time, psychiatric admissions of telemental health patients decreased by an average of about 24 percent, and patients’ hospitalization lengths decreased by an average of nearly 27 percent.

A survey of veterans found high levels of satisfaction and perceived safety with home-based telemental health provided by the VA pilot program in Portland, according to the International Journal of Psychiatry in Medicine. Findings support the feasibility and safety of using technology in the home for the delivery of mental health services. Additionally, results suggest fewer no-show appointments in home-based telemental health compared to clinic-based telemental health.

Currently, telemental health is regarded as appropriate for general clinical use. Yet, the VA cautions that more needs to be known about using telemental health services for conditions such as PTSD, which Jama Psychiatry says is 15 times higher for those in the military than civilians. “While preliminary research has clearly established that a variety of telemental health modalities are feasible, reliable, and satisfactory for general clinical assessments and care, less is known about the clinical application and general effectiveness of telemental health modalities employed in the assessment or treatment of PTSD,” the VA says.

The Need for Behavioral Health Professionals

Approaches such as telemental health can support better access to behavioral healthcare and are expected to grow as a result. Yet, more professionals are needed for rising populations of veterans, children and others in need of services.

The online B.A. in Behavioral Health from Alvernia University enables students to meet this need. Some graduates enter fields such as addiction counseling, long-term care and child welfare, while others enter graduate studies. The program takes place in a convenient online format to accommodate students’ work and personal schedules.

Should Social Workers Get on the Telemental Health Wagon?

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Photo Credit: La Clínica del Pueblo

There was a huge smile awaiting me at the other end of the screen. I had been anticipating this moment with some degree of anxiety. I had been to trainings, conducted several dry runs, and attended scores of meetings to prepare for what was about to unfold. “This is weird,” she said. I validated her feelings and laughed along with her. There she was, my first telemental health client.

When I first interviewed for a mental health job and I discovered the position was for a telemental health therapist who will provide therapy through video, my first thought was: therapy through this mode couldn’t possibly work. So many questions came up: “how can you build solid rapport and trust through a camera”?  Is this HIPAA compliant? How could I deal with a client in crisis?

I went home and I was surprised by my strong reactions to the interview. I thought: why was I so certain that this could not work when I have not even tested it?

After some self-reflection and checking in on my assumptions, I discovered that my skepticism and fears emerged from the “not knowing stance.” I had heard about telemental health loosely, mainly through Facebook ads that bombard my account promoting e-therapy through texting and right before that interview I had done some research on using smart phone apps as complement to therapy, where I came across a few articles about telemental health but I had not given this topic too much thought until that interview.

I turned to research and discovered that telehealth, health services provided by a form of technology, has been around for at least 40 years, some say even longer. I learned that telemental health is not just text therapy as we have seen in some ads. It was not this “new shiny thing” I thought was emerging but there has been substantial research on the use of telehealth and telemental health effectiveness with some communities, particularly in rural areas.  I also discovered the answers for many of my initial questions—there are HIPPA secure platforms to provide telemental health services and the evidence shows that it is possible to build a therapeutic alliance through video.

After a year of providing telemental health services through a pilot program supported by CareFirst and led by La Clínica del Pueblo, a federally qualified community based health clinic that has been impacting the Latino and immigrant community in the Washington, DC metro area since 1983, I can say I’m truly glad that I looked deeper than my initial fears.

Our experience providing telemental health to some clients validates other research which shows client’s functioning improve to a comparable rate as in “traditional in person therapy.” We are able to reach many clients in distress who otherwise would not be served due to a current shortage of bilingual mental health providers, which results in long waiting for access.  I have also dealt with several crisis, which initially I thought would be impossible to do via video.

Currently, the Latino community experiences high rates of mental health disorders and face significant barriers in obtaining services due to stigma, lack of bilingual and multicultural mental health providers, lack of health insurance, among other obstacles. According to the American Psychiatric Association (APA), the lack of access to mental health services is one of the most serious health problems in the Hispanic community.

As the Latino and immigrant community grow, agencies working with this population face challenges and opportunities to meet the demand of mental health services the community needs to thrive.

At La Clínica, we saw an opportunity to better serve our population and through a partner to partner model, we are expanding our services to clients who face a significant barrier in accessing services. Barriers exist because they either can’t get to us due to transportation challenges, which for many of our clients means taking several modes of public transportation and traveling from far distances or because finding a bilingual mental health provider has been difficult due to the shortage of them. Clients conveniently continue to attend their base organization for services and in a private therapy ready room receive services while I provide therapy from a counseling room at La Clínica’s DC based office.

The need to expand services and come up with alternative solutions to meet the demand is true for many of the communities social workers serve. As the primary providers of mental health services, social workers have a unique opportunity to leverage technology to respond to our community needs. To guide social workers in this endeavor, NASW and ASWB have already created standards for technology and social work practice. In addition, ASWB recently approved the Telemental Health Institute telemental health online training program. “And Star Telehealth and the Center for Credentialing Education will launch their training program in the near future.  I am currently a beta tester for the initial modules.

Our times are changing. Our client’s needs are changing. Our NASW calls us to become culturally competent, and becoming culturally competent with the use of technology is essential in today’s times.  Our communities are more connected than ever before and are turning to technology at records numbers.

Join the dialogue. My colleagues from La Clínica del Pueblo and I will present our findings and insights from our pilot program through our presentation TeleMental Health for Latinos: Expanding Access through Technology at two social work conferences: Sí Se Puede®: Social Workers United for Latino Advancement conference organized by the Latino Social Workers Organization and the Center for Latino Adolescent and Family Health at the New York University of Silver School of Social Work in New York, April 25-27 and later in Washington, DC at the National Association of Social Workers national conference in June 22-25.

We will address:

  • Demystifying Telehealth: Fears, Barriers, Limitations and How We Overcame Them Planning, Building Protocols, and Training
  • Program Preparation and Implementation: The Importance of Research,
  • Technical, Clinical, and Administrative Implications
  • Cultural Considerations for Implementation with the Latino Community
  • Ethical Considerations for Social Workers Using TeleHealth
  • Program Evaluation and Outcomes
  • The Future of TeleMental Health

Having recently attended the Mid Atlantic Telehealth Resource Center Annual Summit, where I was one of very few social workers providing direct services, I am reenergized to empower more of us to learn about telemental health, get trained, certified and practice, when appropriate and while considering cultural, ethical and clinical implications. And I hope that next year, there will be a lot more social workers at the telehealth table.

What’s the Deal with Online Therapy?

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Marlene M. Maheu, a therapist, uses video conferencing to communicate remotely with patients. She has served on task forces to address issues of online therapy. Credit Sandy Huffaker for The New York Times

Online counseling or “web therapy” is an emerging practice in the world of social services.  Although online counseling is not a substitute for traditional psychotherapy, it has many benefits, including flexibility, anonymity, comfort, and convenience.  Perhaps you are nervous about going to therapy—with online counseling you can test it out for as little or as long as you’d like in many different modalities.

Many services are offering “Skype” or video counseling using secure software, or voice phone calls directly with a therapist, or even text message/email therapy that is not offered in “real time”—giving you and the therapist both a chance to respond when most convenient for you.  Whichever modality you choose, the world of online counseling can introduce you to therapy in a non-invasive, comfortable manner at your own pace.

However, online counseling is not appropriate for everyone.  Online counseling likely does not include prescribing medications, which can be essential to the recovery of severe mental illnesses.  It is also not appropriate for anyone who is currently suicidal or homicidal, or anyone who is currently experiencing psychotic symptoms. If this is the case, you should immediately call 911 or your local emergency authority.

Another draw and danger of online therapy: anonymity. Many people avoid treatment for reasons of shame or privacy. Some online therapists do not require patients to fully identify themselves. What if those patients have breakdowns? How can the therapist get emergency help to an anonymous patient? Read More

Most importantly, anyone who needs intensive support or hospitalization is not a good fit for online counseling. Online counseling should be used as additional support and not a replacement for those needing intensive treatment.  Another limitation of online counseling is the difficulty in interpreting voice tone, body language, and other forms of non-verbal communication in traditional therapy methods.

Although online counseling is not appropriate for everyone and some professionals are still skeptical about it, there are studies showing online counseling can be just as effective as face-to-face in person therapy with a better attendance rate.

The Journal of Affective Disorders reported a University of Zurich study divided a group of 62 patients in half and found that depression was eased in 53 percent of those given online therapy, compared to 50 percent who had in-person counseling. Three months after completing the study, 57 percent of online patients showed no signs of depression compared to 42 percent with conventional therapy.

In an April 2012 edition of Psychiatric Services, it was reported that in a four-year Johns Hopkins study that included close to 100,000 veterans, the number of days that patients were hospitalized dropped by 25 percent if they chose online counseling. This is slightly higher than the number of hospital visits experienced by patients who used face-to-face counseling.

Lastly, according to the American Psychiatric Association in 2007, patients in Ontario, Canada were assigned to face-to-face or live video counseling and experienced statistically the same clinical outcome and level of patient satisfaction. The only difference was that the cost of providing the online service was 10% less per patient.

Overall, online counseling permits the client to access therapy when it’s convenient for them and without having to leave the comfort of their home.  It could be a type of counseling that can reach more people in need which is necessary and important.  What do you think?

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