When Peter Tuerk began his new role as director of the Sheila C. Johnson Center for Clinical Services in 2018, integrating data and technology into the Center’s clinical training was a core part of his vision. Still, he never imagined telehealth would become the cornerstone of clinical operations in 2020.
The Sheila C. Johnson Center for Clinical Services at the University of Virginia’s Curry School of Education and Human Development is a multidisciplinary training center that provides a range of clinical services to local children and families – including speech and language, hearing, reading, clinical psychology, educational assessment, autism spectrum services, and more. It also provides UVA students with important clinical training.
Tuerk, for his part, is uniquely suited to lead a transition to telehealth. He’s a clinical psychologist, researcher, and educator specializing in evidence-based treatments for anxiety-spectrum disorders. Beyond his own award-winning work investigating telehealth to treat PTSD, Tuerk also serves as co-editor of a book series devoted to behavioral telehealth, and has led several funded trials investigating the augmentation of evidenced based interventions with novel telehealth technologies.
Here, Tuerk shares his thoughts on how the pandemic has shaped mental health services already – and why it may lead to lasting changes in how we treat mental health.
Q: What exactly does telehealth look like for mental health services like therapy?
A: When most people think of telehealth for mental health services, they’re thinking of clinical videoconferencing, or synchronous telehealth, where therapists and patients exchange real-time conversation. In this context, the clinical encounter facilitates a fairly similar flow and content as in-person clinical services. Communication in real time can be juxtaposed with asynchronous telehealth, such as texting or mobile app based tools, which can provide support or help to deliver key aspects of an intervention.
Before using telehealth, clinicians are often concerned about the therapeutic relationship – how can I meaningfully connect with someone through a screen, or manage a child’s behavior? These concerns often fade as clinicians gain experience with the modality. In many cases, after a while, the screen sort of melts away and you’re left with the person in front of you and the content and quality of the communication.
Q: What distinguishes evidence-based clinical videoconferencing from venting to a friend over FaceTime?
A: All good psychological interventions usually help people understand themselves better. However, lasting change most often depends on helping people to behave differently as well. Evidence-based interventions are the specific methods used to promote self-understanding and behavior change that we know we can replicate and that are based in science.
Empathy, warmth, and the ability to listen without judging or turning a conversation back on yourself – are all wonderful qualities that we want friends to possess when we vent to them. These qualities are also the cornerstone of evidence-based interventions, but that’s really just where the work begins. Those communication skills set up a positive collaboration so that clinicians can deliver or teach the core of a treatment or intervention. Specific intervention components depend on what you’re treating, of course, but they often involve behavioral assignments associated with emotional experiences or a desired outcome – facing fears, trying new skills or parenting techniques, hypothesis testing, and self-reflecting.
So one of the differences between talking to a friend for support and going to a psychologist for evidence based intervention is that the psychologist is likely going to be placing some expectations on you. If your therapist isn’t helping you to grow or challenging you, then where’s the opportunity for change?
Q: What does the current research look like on telehealth for psychotherapy?
A: Overall, there is strong evidence to support the safety, acceptability, and clinical effectiveness of interventions delivered via clinical videoconferencing. The evidence base spans six decades and includes heterogeneous populations, age ranges, and care settings.
In recent years, we’ve seen a number of positive outcomes from especially rigorous randomized control trials, called non-inferiority trials, which have validated clinical videoconferencing as non-inferior to in-person care for a variety of common problems. The positive outcomes from these special trials, combined with dozens of outcomes from standard RCTs, and decades of open trials and case reports, put us on particularly solid ground. It’s very good news for our current situation and the rapid adoption of telehealth treatments.
Q: What are some of the barriers to effective telehealth implementation?
A: On average, telehealth tends to make treatment more convenient for clients. However, it most often creates more work for providers – they have to learn a new technology, figure out how to effectively exchange materials at distance with their clients, figure out new insurance billing codes, implement new safety and emergency protocols, problem-solve creative solutions for clients who do not have stable internet connections, ensure their data is secure, and so on. Although each component by itself is not a heavy lift, it adds up quickly for busy providers.
A huge factor in the success of a clinical videoconferencing strategy is the usability of the telehealth platform. If it is easy to use and providers have confidence in it, then you’re usually off to a good start. Usability encompasses both the technology and process-related support procedures that are part of a healthy telehealth infrastructure. That infrastructure is a resource like any other resource. It needs to be activity managed, evaluated, and tweaked to set clinicians up for success.
Q: In the short term, how have you seen the current coronavirus crisis affecting telehealth for mental health services?
A: Things are changing day by day, but overall, we are witnessing unprecedented flexibility: state and federal regulations regarding telehealth practice have been temporarily expanded, enforcement of HIPAA data security rules have been temporarily flexed, private and federal insurance programs are radically expanding their coverage for telehealth services, credentialing requirements for providers have been fast-tracked or waived, and for many consumers, co-pays for mental health treatments delivered via telehealth have also been waived.
In spite of the horrible COVID-19 national emergency, this part of it has been a really wonderful thing to witness and be a part of. Right now we’re getting very positive messaging from the federal government, most states, and many insurers – they’re saying, ‘get this done for your patients.’
Q: In the long term, how do you think the virus outbreak will change the telehealth landscape?
A: Obviously, the landscape of telehealth access will be fundamentally different after this virus. Patients are going to expect access to telehealth. More importantly, the telehealth skills of a large part of our mental health workforce and their comfort with providing those services will have been fundamentally altered.
I think the virus has made it clear that prioritizing access to mental health services within health infrastructures is critical. As a culture, we have wide acceptance that mental health is an important public health priority, yet our institutions, policies, and regulations do not necessarily reflect those values, nor have they kept pace with evolving technologies and science. Mental health parity, state restrictions on telehealth implementation, and dated business processes related to HIPAA enforcement act as unintentional barriers to widespread telehealth care. Perhaps the current situation will lead to a realization that we may be able to streamline access to care and remove barriers without compromising safety, security, or ethical oversight.
Q: How have you all at the SJC been managing? What kinds of changes are you working to implement with your services?
A: We wanted to provide seamless care to as many of our clients as possible. The core steps included securing a telehealth platform, onboarding our 80-some clinicians, conducting trainings, adapting the electronic medical record and schedule to support virtual clinics, and aligning staff workflows and tools to stand up a virtual Center. We had plans to do this over the summer and fall, but it was going to be a two-month search and four-month rollout, instead of a week and a half. Thankfully, we had some things already in place to support the rapid transition –a web-based electronic medical record, asynchronous telehealth support tools, prepared telehealth training materials, and a decision tree approach based on a few guiding principles to support rapid decision making and prioritization of competing goals on the fly. Of course, the most important resources we had were our students, supervisors, and staff who worked quickly and creatively as a team, and those efforts were met with unwavering support from the Curry School operations offices.
We’re open for business, with expanded hours, and are scheduling telehealth appointments through our main website. We just reached the 400 mark of completed telehealth appointments, serving 120 clients, mostly with seamless care. We are currently adapting our summer language and reading programs to fit the telehealth model, have implemented social skills groups virtually, and are expanding parent training services to help families adeptly address homeschooling and the added stresses of parenting during the COVID-19 crisis. In the coming weeks, we are hoping to leverage leading edge mobile technologies to provide at-distance real-time support for families and individuals implementing treatment plans at home. We’re all in this together, as a University and community, and are hoping to model how technology can be used to safely and effectively convey those values and support to clients.