In mid-March, Penn Medicine Princeton House Behavioral Health made the decision to transition outpatient treatment to remote services before social distancing was required. The goal: protect 600-plus patients and 200-plus staff and physicians, even if it meant a sea change in how they would operate.
“We had absolutely no telehealth plans or plans to activate telehealth,” says Jodi Pultorak, executive director of outpatient services. “By the week of March 9, everything was so rapidly changing that it became clear that we could not put patients and staff at risk by bringing people into group settings to sit in a room for hours a day with 10 to 12 people.”
In three weeks, she and her staff have developed and implemented a telehealth program. And in that short span, she has seen telehealth in a new light.
“It’s been an amazing experience, to be honest,” Pultorak says. “What has surprised me most is the overwhelming response and dedication that our staff has had to get this up and running. It doesn’t surprise me the staff care about patients, but it was great to see how everyone jumped in and took on extra roles. We tapped into people we may not have tapped into before.”
She then adds: “I don’t think we will ever go back to a non-telehealth world.”
Pultorak says she conducted telehealth sessions as a therapist to individual patients before the pandemic, but has felt a tonal shift in how people perceive its value. Patient response has been positive, and the vast majority of patients they work with have not had problems accessing technology required to attend group sessions or engage in standard medication checks remotely.
“My hope for the future, when we get out of this and we’re back to a level of normalcy, is we continue to offer amazing services in the brick-and-mortar setting, but we have another service line available to help people in this virtual setting,” she says. “This eliminates any barriers people may have to treatment, for the appropriate patient.”
The program operates in six locations across New Jersey, providing Partial Hospital and Intensive Outpatient Programs. The Partial Hospital Program operates five days a week for six hours, and the Intensive Outpatient Program is three days per week for three hours a day. Patients are generally in treatment for several weeks. As such, travel was a big component of getting patients to sessions.
Telehealth also eliminates physical space constraints; if a particular program was offered only with therapists who worked in Princeton, for instance, now patients from anywhere can attend. If more groups are needed, that’s possible no matter the size or flow of a particular building.
Melissa Hunt, associate director of clinical training in the School of Arts & Sciences, explains that counseling via telehealth has undergone more study in the past decade, triggered by a flurry of reviews in 2010 that outlined a need for more research comparing telehealth interactions with in-person ones.
“[Telehealth] was clearly effective, but there weren’t a lot of comparisons,” Hunt says. “Since then, there have been a number of trials—not a huge number—but ones that have directly compared telepsychology to face-to-face, and generally found that, except for people with the most severe disorders, telepsychology is equally or even more effective.”
Part of this reason, she explains, is that patients tend to assert more independence and take ownership over their treatment, whether on the phone or in videoconference.
There’s also a broader interpretation of telepsychology that’s less prominently considered, Hunt says, pointing to apps that have been methodically developed for people with particular challenges—ranging from depression to OCD, body dysmorphia to IBS. The best of these apps have programs that adhere closely to evidence-based, empirically supported treatment protocols and sometimes have consultants made available.
At the moment, though, she says that every therapist is trying to set up for remote video that is both secure and HIPAA compliant, noting that only a handful of video services are. (Zoom has a HIPAA-compliant platform but requires practitioners to subscribe to a paid version. Penn Medicine uses BlueJeans, which is also HIPAA compliant.)
“I think what’s going to be really interesting, and what I hope will be a result of this crisis, is one of the major impediments to doing [teletherapy] was the issue of licensure across state lines,” explains Hunt. “Psychologists have always had to be licensed in the state where the patient is located. Which means as of two months ago, it was perfectly legal for me to do a telehealth session with someone in Pittsburgh, but not Cherry Hill. Which is rather ridiculous, when you think about it, and has nothing to do with quality of therapy and patient protections and everything to do with state’s rights and guild protection.”
She’s hopeful that the crisis will spark a conversation about national licensure.
“This is the way we ought to be moving anyway,” Hunt says, pointing to rural populations in particular. “For a lot of people, teletherapy reduces burdens of transportation, of geographic limitations, and it massively opens up the availability of well-trained providers who can engage in empirically supported treatments for distress or specific disorders.”
Still, there are advantages to in-person sessions—not just the ease of HIPAA compliancy, but the security and privacy of the room.
“I’ve had two patients in my private practice who decided they do not want to do video sessions with me because they’re living in situations in which family members might overhear—they can’t guarantee sufficient privacy,” Hunt says.
There are also physical practices that are more difficult to execute in a video, such as deep breathing exercises, she says. And, she adds, exposure therapy for OCD, which might include, for example, a patient with contamination fears touching a pile of dirt or—a real example of hers—smashing raw eggs on a table.
“Would it be possible to do an intervention like that over video? Yes, but perhaps not quite as easily or compellingly in the moment,” she says.
Torrey Creed, assistant professor of psychology in psychiatry in the Perelman School of Medicine, leads an implementation program teaching providers who work in community mental health how to do cognitive behavioral therapy and adapt to real-world scenarios like the current pandemic. As such, she’s spending much of her time helping these community providers adapt to telehealth and deliver quality care.
In those communities, she says, access to technology is one of the largest barriers to making teletherapy work as well as it could.
“We have NIH-funded research studies looking specifically at tech-based interventions in community mental health, so I have a good sense of how much access to technology community providers have,” Creed says. “Although it varies across organizations, the overall sense is, ‘Not much.’”
She is sometimes able to provide these community providers with technology, she says, but the widespread nature of the moment has made the effort challenging, and she and her team have more recently been focused on guidance around telehealth and adapting evidence-based treatments to address pandemic-related stressors. Most of the communities she works with are in Philadelphia—60 community health organizations—with several global mental health partners also among those she assists.
“When we all quickly realized quarantining needed to include therapy, everyone identified telehealth as the solution, but my community mental health partners and their clients often don’t have the fundamental equipment necessary to do that,” she says. “Telehealth assumes the provider and client have access to tablets, phones, computers, internet-connected devices, and private space to talk. And clients receiving care oftentimes have limited access to WiFi or data; so, streaming a 50-minute session can be prohibitive.”
It’s also true, she says, that chronic underfunding of mental health services means that therapists may also have limited means, without access to computers, internet, or private space in their offices or homes.
“I think therapists are scrambling trying to figure out how to make this transition,” she says. “I think therapists have been so focused—understandably so—on ‘Oh my gosh, which button do I click to make this work?’ that they’re missing other key pieces [like privacy and technology access].”
To guide therapists in the process of implementing teletherapy during the pandemic and beyond, Creed offers six tips to making the most of a remote session conducted by video.
Teletherapy tips, from Torrey Creed, assistant professor of psychology in psychiatry:
- Eye contact is important in therapy but complicated when the web cam and your client’s eyes are in different spots on your monitor. Data suggests that people tend to perceive eye contact when it would normally be expected as long as you’re looking somewhere reasonably close, so just do your best.
- Make sure that neither you nor the client are multitasking during session. Agree to resist the temptation to check email, text, or even drive while in session.
- With kids, consider a room and camera angle that allows them to move around a bit. Younger kids may want assurances that you’re there in real time (rather than TV or videos), so take turns describing what you see each other doing. Teens may like to choose a virtual background to choose “where” you’ll meet next.
- If needed, consider a code word in case someone is interrupted or has someone unwanted join off-screen. (This is particularly helpful in situations with domestic violence or other risks.)
- After session, there isn’t the usual decompression time of traveling home, so make sure clients have a plan for what to do to relax or get some space before returning to their life.
- And finally, reimbursement rules are being shifted to allow telehealth, but be sure to check with your malpractice provider, too.