PTSD and Telemental Health

Leslie Morland, PsyD, Carolyn Greene, PhD, Josef Ruzek, PhD, & Linda Godleski, MD

Many individuals in need of specialized posttraumatic stress disorder (PTSD) services live in geographically remote regions, such as on tribal reservations or in rural areas. Since people with PTSD often use self-isolation to reduce stimulation, hyperarousal, and interpersonal conflict, people with PTSD are more likely to settle in remote areas with low population densities. Mental health care in these remote areas is generally only available on a limited basis - especially mental health care for PTSD.

Traditionally, the individuals that need treatment do not get the services they need. Sometimes an individual will travel a great distance to a larger city, or the clinicians based in the larger medical centers will travel a great distance to visit rural communities. As a result, providing PTSD care to these individuals can impose a tremendous financial, travel, or personnel burden. Telemental health technology is increasingly easing these burdens by making PTSD clinical and educational services available in remote areas.

What is telemental health?

Telemedicine, also known as telehealth, uses electronic communications and information technology to provide and support healthcare when distance separates patients from the clinician (1). Telemedicine uses various communication methods to connect clinicians and patients in lieu of their meeting in person.

The term "telemental health services" typically refers to behavioral health services that are provided using communication technology. These services include clinical assessment, individual and group psychotherapy, psycho-educational interventions, cognitive testing, and general psychiatry. The term telemental health describes the overall situation in which a clinician uses various technologies to deliver mental health care to a patient who is miles away.

The major benefit of telemental health is that it eliminates travel that may be disruptive or costly. In addition, telemental health is a useful tool in situations, such as in correctional and forensic settings, where it is difficult to transport the patient to a clinician. Telemental health also allows mental health providers to consult with or provide supervision to one another.

Telemental health technology and services

Although telemental health may utilize a variety of technologies, it is closely associated with video teleconferencing (VTC) technology. In VTC, a patient (or group of patients) in one location and a clinician in a different location each look at a computer monitor or television screen in order to see and hear each other in real time. Although many psychiatrists are employing telemental health technology, it is still considered an untapped opportunity for psychologists, social workers, and counselors (2).

In addition to VTC, telemental health also utilizes other technologies. Telemental health can make use of electronic mail (e-mail), electronic administration of psychological tests, online self-help groups, chat rooms, blogs, and websites. Mental health information on websites is available to anyone with Internet access.

Some applications of telemental health, such as psychotherapy through e-mail, have been quite controversial and have not undergone scientific evaluation. In response to such controversies, professional organizations for both psychology and psychiatry have established committees to develop guidelines for behavioral telehealth (i.e., American Psychological Association Ethics Committee, 1997; American Psychiatric Association Ethics Committee, 1997).

Plain old telephone service (POTS) is often not included in discussions of telehealth. However, telephones may be very useful; they provide a way for clinicians and patients to conduct simple program evaluations and the necessary aftercare. Most recently, virtual reality has been used to augment treatment for a variety of anxiety disorders and pain-management conditions. Virtual reality is a revolutionary computer technology that enables clinicians to immerse their patients in a highly interactive, three-dimensional, computer-generated world. This technology has already demonstrated clinical effectiveness for a variety of psychotherapeutic purposes including the treatment of PTSD (3).

Telemental health applications for PTSD

While preliminary research has clearly established that a variety of telemental health modalities are feasible, reliable, and satisfactory for general clinical assessments and care (4-5), less is known about the clinical application and general effectiveness of telemental health modalities employed in the assessment or treatment of PTSD.

For individuals with a history of trauma exposure, the first step in getting the necessary treatment is to have an accurate assessment of psychiatric or psychological symptoms, related problems, and factors influencing functioning. The accuracy of a PTSD diagnosis is important for both treatment and benefit claims. Research comparing VTC and face-to-face methods for assessment of PTSD has found the methods to yield comparable results, and patients expressed satisfaction with the VTC method (6).

Researchers at sites, such as the VA Pacific Island Healthcare System and the South Carolina VA Medical Center, are examining the efficacy of VTC group treatment for Veterans with PTSD. The VA Pacific Island Healthcare System's Traumatic Stress Recovery Program has successfully provided a variety of telemental health PTSD clinical therapy groups to the neighboring Hawaiian Island Community Based Outpatient Clinics (CBOCs). Findings from pilot data of a PTSD psychoeducation and coping skills group suggest that the Veterans, the clinic staff, and the remote clinician all viewed the VTC treatment as helpful. A comparison of the VTC group to an in-person control group in this study revealed no significant difference between the two groups on measures of satisfaction and information retention (7).

The clinical effectiveness of a 12-session anger management group delivered via VTC was evidenced in a randomized clinical trial (RCT) that examined the noninferiority of treatment delivered via VTC compared to in-person treatment (8). Secondary analyses of the outcomes of this trial indicated that the use of VTC does not affect group therapy process (9) or therapist adherence to a manualized cognitive behavioral therapy (CBT) protocol (10). Preliminary findings from another RCT comparing in-person and VTC delivery of a group CBT for PTSD with Veterans suggests the clinical effectiveness of delivering a trauma-focused intervention over VTC (11).

Therapy provided over the Internet has been among the most controversial applications of telemental health services. However, Alfred Lange, et al. (12), recently published the results of a controlled trial in which they provided psychoeducation, screening, and a protocol-driven treatment for people suffering from PTSD and grief via the Internet. More than 50 percent of the treated participants in this study showed reliable change and clinically significant improvement. The largest changes were seen in measures of depression and avoidance. Although it is too early to recommend web-based delivery of services, it is likely that the Internet will be increasingly used to supplement face-to-face care.

Most would agree that telemental health presents a more convenient and economical way to provide or supplement specialty care services to patients living remotely. However, research is still needed to determine the quality and clinical effectiveness of these services. There is still a great deal we need to know about how, when, and with what patient populations we can effectively apply this new technology. Based on early pilot studies, telemental health appears to be a promising way to offer skills-training and assessment from a distance to individuals with PTSD.

Clinical considerations

Using telemental health for clinical work requires planning and preparation. It is important to consider logistics, such as preparation of the room and equipment, and to be sure there is technological and clinical backup support. It is also important to consider the patient's convenience and privacy. In the case of VTC services, the quality of the video images can be optimized by providing appropriate lighting and using stationary chairs.

One essential key to working with PTSD patients is to establish a sense of safety, comfort, and trust. This may seem like an added challenge when the clinician is not physically in the room; however, there are tools and techniques that can be used to achieve these goals. Some helpful tips:

• Administering evidence-based treatments for PTSD via telemental health is not much different from face-to-face therapy. Very few modifications to treatment protocols are necessary.
• Pre-treatment orientation sessions allow for gauging patient understanding of the treatment, introducing the technology, and increasing client motivation.
• Both cognitive processing therapy (CPT) and Prolonged Exposure (PE) require an established electronic exchange protocol for written materials, homework, and questionnaires. Fax machines are preferable.
• For CPT, therapists should have copies of patient materials during the session to assist when reviewing or explaining worksheets and handouts.
• For group CPT sessions, a brief, structured check-in at the start of the session assists with containment of the group and orients the therapist to the emotional state of the clients.
• For PE, the client must know how to record the session in the office he or she is in. Having a backup recorder in your office is helpful.
• In-session avoidance and hypervigilance can be more difficult to manage via telemental health, but telehealth appears to pose additional clinical difficulties only for patients with very severe presentations.

Since telemental health is offered (in most cases) because there is not adequate or specialized services at the patient's site, it is not appropriate to open up an individual's traumatic experiences without having the necessary clinical backup available. However, telemental health can be used successfully to provide clinically significant interventions such as basic PTSD education, symptom management, coping-skills training, and stress management. Trauma-focused telemental health interventions may be recommended in the future, following closer clinical and empirical evaluation.

Pros and cons of telemental health for patients with PTSD

Before deciding to provide a clinical intervention utilizing telemental health, it is important to carefully consider the patient's clinical needs and the potential benefits and costs. As with other remote services, these considerations include what clinical support is available at the patient's site and what availability there may be for follow-up care. A thorough evaluation of needs at a particular site is the first step.

Using telemental health to provide PTSD treatment can significantly reduce the costs, both in time and money, of having patients or clinicians travel to in-person sessions. Telemental health allows a small community clinic to offer access to specialized interventions and specialists in PTSD, which the clinic would normally not be able to provide. Home-based telemental health has become a way for housebound patients to get the help that they need.

However, telemental health is not without its drawbacks. The equipment, maintenance, and fees for VTC, for example, can be costly. The quality of the equipment ranges widely, with lower-end equipment being quite unreliable. Clinicians need to be properly trained so that they can maximize the benefits of the technology and minimize technical malfunctions. Some technical malfunctions will inevitably occur, so it is recommended that the clinician have a backup technician available.

There are significant clinical challenges when using telemental health for PTSD. Perhaps the biggest clinical challenge is that the clinician is not physically present to address crises such as suicidal thoughts and aggression, which are commonly associated with chronic PTSD. Having a backup clinician on-site with the patient is strongly suggested. Although quality VTC equipment and connections can render extremely clear images, clinicians may find it somewhat challenging to pick up on nonverbal cues such as psychomotor agitation or poor hygiene. There is also a risk that the patient will not pick up on the clinician's warmth and empathy and will perceive the interaction as impersonal.

Since telemental health is still a relatively new phenomenon, it has not been thoroughly empirically validated. Ethical, clinical, and insurance-reimbursement guidelines are still in development. Clinicians must also be careful to follow interstate licensing rules when applicable.

References

1. Field, M. (1996). Telemedicine: A guide to assessing telecommunications in health care. Washington, DC: National Academies Press.
2. Maheu, M., Whitten, P., & Allen, A. (2001). E-Health, Telehealth, and Telemedicine: A guide to start-up and success (Jossey-Bass Health Series). New York: Jossey-Bass/John Wiley & Sons, Inc.
3. Rothbaum, B. O., Hodges, L., Ready, D., Graap, K., & Alarcon, R. D. (2001). Virtual reality exposure therapy for Vietnam Veterans with posttraumatic stress disorder. Journal of Clinical Psychiatry, 62, 617-622.
4. Frueh, B. C., Deitsch, S. E., Santos, A. B., Gold, P. B., Johnson, M. R., Meisler, N., et al. (2000). Procedural and methodological issues in telepsychiatry research and program development. Psychiatric Services, 51, 1522-1527.
5. Hilty, D.M., Marks, S.L., Urness, D., Yellowlees, P.M., & Nesbitt, T.S. (2004). Clinical and educational telepsychiatry applications: A review. Canadian Journal of Psychiatry, 49, 12-23.
6. Porcari, C.E., Amdur, R.L., Koch, E.I., Richard, D.C., Favorite, T., Bartis, B., & Liberzon, I. (2009). Assessment of post-traumatic stress disorder in veterans by videoconferencing and by face-to-face methods. Journal of Telemedicine and Telecare, 15, 89-94.
7. Morland, L. A, Pierce, K., & Wong, M. (2004). Telemedicine and coping skills groups for Pacific Island veterans with post-trauamtic stress disorder: A pilot study. Journal of Telemedicine and Telecare, 10, 286-289.
8. Morland, L. A., Greene, C., J., Rosen, C., Foy, D., Reilly, P., Shore, J., He, Q., & Frueh, B. C. (2010). Telemedicine for anger management therapy in a rural population of combat veterans with posttraumatic stress disorder: A randomized noninferiority trial. Journal of Clinical Psychiatry, 71, 855-863.
9. Greene, C. J., Morland, L. A., Macdonald, A., Frueh, B. C., Grubbs, K. M., & Rosen, C. S. (2010). How does tele-mental health affect the group therapy process? Secondary analyses of a noninferiority trial. Journal of Consulting and Clinical Psychology, 78, 746-750.
10. Morland, L. A., Greene, C. J., Grubbs, K. M., Kloezeman, K., Mackintosh, M., Rosen, C., & Frueh, B. C. (2011). Therapist adherence to manualized cognitive-behavioral therapy for anger management delivered to veterans with PTSD via videoteleconferencing. Journal of Clinical Psychology, 67, 629-638.
11. Morland, L. A., Hynes, A. K., Mackintosh, M., Resick, P. A., & Chard, K. (2011). Group Cognitive Processing Therapy for PTSD delivered to rural combat veterans via telemental health: Lessons learned from a pilot cohort. Journal of Traumatic Stress, 2, 465-469.
12. Lange, A., Rietdijk, D., Hudcovicova, M., Van de Ven, J, Schrieken, B., & Emmelkamp, P. (2003). Interapy: A controlled randomized trial of the standardized treatment of posttraumatic stress through the Internet. Journal of Consulting and Clinical Psychology, 71(5), 901-909.