Please enjoy this excerpt from Optimizing Telehealth
Episode 2: Strengthening the Telehealth Therapeutic Relationship
Dr. Maheu: Let's talk a little bit about which client or patient specific factors contribute to telehealth success in the literature.
Dr. Crawford: We have very good research in the field to show that telehealth is working across different diagnoses. Early on in this field, we used to have to say if a person is psychotic, or if they have this or they have that. Now, it's widely recognized that telehealth can be appropriate for any patient. It depends on that specific patient and on your own skills and scope of practice. Having said that, there are some things that can make it easier or more challenging, and patient comfort or familiarity with using technology is definitely a factor. I recommend just being very transparent with patients and ask how comfortable are you in this setting? Is there anything I can do to make this more comfortable for you or do you feel you have the skills to do this? We're all learning in this environment cognitively. I do a fair bit of work with clients who have intellectual impairments and also with very young clients. I wouldn't say there are any absolute barriers, it's about preparing an individual to be able to meet the needs of their assessment. Sometimes that involves bringing in other care providers to help them at their local site. Sometimes it's not seeing them in their home, but seeing them in another clinical setting.
Looking at current psychological status, we need to consider is it appropriate at this particular time?
We are often thinking about safety. Can we meet the safety needs of the client? I would say substance abuse raises a flag for me. We don't want to present barriers to care. So, if we can see evidence of substance use or abuse, I think it is important to recognize our limitations. It’s much more challenging to tell if someone is intoxicated or withdrawing from substances as an example. That's one of the limitations that's often cited in the literature.
Dr. Maheu: Shawna, did you want to add anything?
Dr. Wright: I agree with Dr. Crawford. Many issues that we experience when we transition to telehealth from in-person care we need to find adaptations for. If someone has a sensory issue, such as being hard of hearing, we might offer a headset. We might use a whiteboard that we can share through our screen. Even with physical disabilities, I've worked with individuals who aren't able to sit up for a long period of time. Yet, we can position the equipment so that they can participate even from a hospital bed. It's thinking about how we assess the individual personal needs of our clients and patients. And, can we still reach that standard of care as we adapt to their specific needs. I agree so much with what Allison said in terms of the substance use and abuse issues, because we know that there is a strong uptick in my state, in fact nationally, in terms of access to treatment for substance abuse and substance use disorders. However, we also need to guide that treatment with ensuring that our clients and patients know that we can't treat them if they are under the influence of a substance while we are connected through telehealth.
Dr. Maheu: Now we're getting to clinical conditions of populations where telehealth is indicated or contraindicated. Let’s talk about this. Alison, would you please get us started?
Dr. Crawford: Yes, no absolute contraindications. You get to decide with the patient and client whether this is appropriate for them. And part of that will be what can be done, what should be done, and what is patient choice. Over the last year, patients and providers haven't had as much choice because we've had to use telehealth. As our systems mature, and we start to go back to normal, we'll need to think about whether this will work for this patient at this time? Can I do my appropriate assessment? What is their choice? In our institution, we did about 9,000 consultations per month before the pandemic. We had decided from the beginning that the first visit with a patient cannot be in their home. Then the pandemic hits, and we're seeing 9,000 patients a month in their homes. So much of this landscape is changing. A colleague of mine pointed out, it's better to see someone than not ... he works with clients who are acutely suicidal. I think anything goes. I would make the session as safe as you can, making sure you have a contact phone number for the person and making sure that you know what their address is in case you have to call emergency medical services. Again, thinking of contingencies, but in general, no absolute contraindications, including in terms of diagnosis.
Dr. Maheu: One of the things here is safety planning with regards to the setting. I think that is pretty important. The patient might be at home, but it’s different if they're other people in the home. Knowing who's there? Who's accessible? Will you allow them into the session or will you not? Will you be really clear about your policies ahead of time? And not just winging it as you go, If somebody is in a jail cell, or a locked Ward, then telehealth is very different. You can work with people that are floridly psychotic or actively suicidal. But, if they're at home alone, and they're actively suicidal, now there's another problem. Diagnosis is a big issue. But having a regular setting is just as big an issue. And if you stop and think about telehealth, all telehealth is about changing the setting. I haven't seen enough literature addressing the setting. Without some direct conversation about this, I think we're missing the point about safety planning.
Dr. Crawford: I’m seeing a question from Marjorie who is sharing that she had a patient who was 10-years-old and one of his diagnoses was internet addiction. Marjorie is wondering about the appropriateness of telebehavioral health for that person?
I think it depends. For someone who's 10-years-old I would be thinking what are their triggers for using the internet? Can that be separated out from a session? Can we find a device that's only used for the telehealth session? Could a parent help manage that? And does the person have impulse control? Certainly, lots of 10-year-olds don't have great impulse control. But, for even older clients, do they have impulse control? Can they separate their addictive behavior and the triggers for that and the settings for that? Can they delineate that from your appointment? That might be a case where I would also think about a more supervised site, like a clinical site. If that's a possibility in your practice. Again, it's so individual.
Dr. Maheu: I agree. Let's look at the AA model, an absolute no alcohol model versus moderation training. There's two different ways to think about it. People in moderation training learn how and when to do moderate drinking, That may be a model that you can look at, Marjorie. It’s tough to deny a 10-year-old any internet contact.
Dr. Wright: Marlene, I've had questions come in regarding patients who experience psychosis and believe that they speak or interact with people on their TV. Is telehealth appropriate? Again, we assess that individual by individual, and how much insight do they have into their symptoms? I've provided treatment to individuals who suffer from psychosis with that exact symptom. But if they have insight into when they are hallucinating, and when they are in contact with someone, treatment can still be appropriate.
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