© Springer International Publishing Switzerland 2015Ulrich Schnyder and Marylène Cloitre (eds.)Evidence Based Treatments for Trauma-Related Psychological Disorders10.1007/978-3-319-07109-1_25
25. Telemental Health Approaches for Trauma Survivors
Dissemination and Training Division, National Center for PTSD, Department of Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA
The past couple of decades have witnessed a veritable explosion of technology development and services with nearly ubiquitous uptake of innovative electronic products. In fact, today about 40 % of the earth’s population has access to the Internet, and there are almost as many mobile phone subscriptions as there are people on the planet (International Telecommunications Union [ITU] 2014). Virtually overnight, we have become reliant on these technologies for many of our everyday activities, such as finding information, shopping, banking, and staying connected to friends and family. Modes of communication have multiplied to include options such as no-cost web-based video calling, instant messaging at home or on the go, and asynchronous microblogging tools for connected self-reflection. The latest generation of mobile phones, called smartphones, offers capabilities and functions that only a few short years ago were unimaginable or only available on stationary computers. As these technologies continue to transform our everyday lives, their potential to address the tremendous unmet mental healthcare needs of trauma survivors is also beginning to be realized through innovative telemental health (TMH) approaches.
In this chapter, we define TMH and discuss its potential and challenges in mental healthcare for trauma survivors. Three emerging TMH approaches that have been applied to the treatment of individuals with trauma-related mental health issues are reviewed. These approaches include clinical video-teleconferencing (CVT), web-based interventions, and mobile phone interventions. We conclude this chapter with a discussion of future directions of TMH for helping those affected by trauma.
25.2 Telemental Health (TMH)
Telehealth or telemedicine has been broadly defined as using telecommunications technology for delivering medical information and services (Perednia and Allen 1995). TMH is subsumed under this rubric as it entails using this technology to deliver information and services for mental health specifically. Modes of TMH delivery include plain old telephone services (POTS), video-teleconferencing, and web-, mobile phone-, and, more recently, smartphone-based interventions.
TMH has vast potential to help address the unmet mental health needs of trauma survivors by expanding access to and increasing efficiency of care. For example, TMH approaches can extend the geographic reach of care to rural areas that have a shortage of mental health clinicians (e.g., Morland et al. 2010). Likewise, asynchronous TMH approaches (e.g., web-based interventions) are highly scalable, easily being able to accommodate increasing numbers of users, and can serve as a force multiplier increasing the capacity of existing providers (Marks et al. 2004). By utilizing TMH approaches, providers can increase efficiency by seeing more patients while spending less time per patient (e.g., with groups, shorter sessions, and brief coaching calls) without necessarily compromising the quality of services. TMH approaches that employ evidence-based treatments (EBTs) for PTSD (Foa et al. 2009) could allow less highly trained providers to deliver quality care (i.e., task and skill shifting), expanding access to services while reducing cost.
TMH approaches could also improve the effectiveness of traditional care. For example, outcomes could be improved by better generalization of skills taught in in-person psychotherapy sessions being practiced and used when needed in the patient’s natural environments (e.g., facilitated with smartphone interventions). Psychotherapy typically involves placing a tremendous responsibility on patients to learn materials during the session and then remember to apply what was learned in suitable contexts (at certain times, places, and situations) outside of session. Mobile TMH approaches can reduce this burden by providing cueing to use appropriate skills along with supportive practice materials when needed. In addition, communication between sessions is typically very limited; TMH can increase opportunities to communicate and get support through email or text messaging, which may improve outcomes.
TMH could confer other benefits as well, such as allowing clinicians to expand the range of problems they treat. For example, clinicians could attend to secondary or co-occurring problems by using web- or mobile phone-based self-management programs. They could also be employed after care has concluded to enhance relapse prevention, possibly preventing or delaying return to treatment or potentially even enhancing effects after treatment is over. Lastly, TMH approaches could improve outcomes by increasing provider and patient fidelity to EBT protocols by affording easy access to standardized materials and facilitating protocol adherence through highly structured programs.
In addition to their potential to improve effectiveness of care, TMH approaches also could increase access to care. Providers and service organizations could use TMH approaches to engage individuals with limited motivation or capacity to participate in traditional care as an initial step toward more intensive care, if needed. If care requires little or no face-to-face contact with mental health professionals, this may reduce stigma-related obstacles to help-seeking and privacy concerns of seeking care (e.g., in-home CVT).
While it is clear that TMH has great potential, various issues must be considered before it is used. Foremost among these is ensuring patient safety when practicing remotely. Before using TMH with a patient, providers should ensure that local emergency resources are known and that a plan is in place should the need arise. This plan should also include involvement of a supportive significant other (e.g., spouse, parent), if available.
Other professional and ethical issues must also be attended to, including prevention of information security problems, which could range from fairly innocuous breaches of privacy to situations that can truly endanger patients (e.g., when working in politically unstable regions or less than open societies). Thus, data must be secure when transmitted (i.e., strongly encrypted) and protected when stored (e.g., behind a firewall). Costs of the required devices and data plans must be considered as the aim is to expand access to those with fewer resources.
Providers adopting and using TMH will require guidance on ethical and legal use of TMH, as well as training to develop and maintain competence, given the rapidity at which technology changes. The American Psychological Association (2013) has created guidelines that cover everything from security of patient data to informed consent and clinical boundaries for successful and legal implementation of TMH (e.g., providing services outside of one’s professional license jurisdiction).
25.3 TMH and Trauma
TMH can help to fill gaps in trauma care services across a number of contexts. These include assisting in covering mental health needs in places where traumas have recently occurred or are ongoing and therefore may be unsafe for mental health providers to be practicing in person. These include active war zones, politically unstable countries or regions, areas acutely affected by natural and manmade disasters lacking basic necessities (potable water, shelter, food), and regions with uncontained contagious disease outbreaks (e.g., avian flu). Aside from areas that may be too risky for providers, there are many places and trauma-exposed populations that lack sufficient access to mental health services. Many stable but developing nations have inadequate mental health infrastructures. But even in the most developed countries, coverage can be insufficient in certain areas, for example, in rural areas or in underserved communities of ethnic minorities. Likewise infirm, elderly, or disabled trauma survivors may not be able to get to needed care readily. Specialty trauma services may not be available in jails and prisons where populations have high rates of PTSD and other mental health conditions (Goff et al. 2007).
TMH approaches could also be used to monitor disaster-stricken populations, allowing for identification and triage of those most affected in order to ensure that limited resources are used most efficiently. Moreover, they could help provide care in disaster-stricken regions that have compromised transportation infrastructure that is restricting or entirely prohibiting patient travel or during disasters and other mass-scale traumas in which the demand for mental healthcare services has exceeded the supply. TMH also has the potential to provide more convenient access to care for trauma survivors facing a host of post-trauma and other logistical challenges. For example, trauma may cause physical injuries that could restrict mobility.
TMH may be a more palatable or less risky modality of care delivery relative to in-person traditional care for some trauma survivors, including individuals who are concerned about the social stigma associated with having been traumatized (e.g., raped) or those fearing possible untoward repercussions of disclosing trauma (e.g., military service members or members of certain ethno-cultural groups). Likewise, many individuals perceive stigma about having and disclosing post-trauma mental health issues and seeking treatment for them (e.g., Vogt 2011). In certain ethnic groups (e.g., Asian Americans), individuals may fear that seeking services will cause them embarrassment and shame (Jimenez et al. 2013).
Some TMH approaches (e.g., web- and mobile phone-based interventions) may offer help when no other options are available or accessible. For example, individuals who are socioeconomically disadvantaged who have limited or no healthcare coverage or cannot afford traditional MH care services could benefit from TMH services. Likewise, individuals who do not have the capacity to engage in traditional care due to time constraints because of employment requirements or childcare responsibilities could benefit from TMH approaches.
When considering using TMH approaches for traumatized individuals, clinicians and other service providers should weigh potential drawbacks. For example, most EBTs for PTSD are trauma-focused requiring patients to forego maladaptive avoidant coping strategies and instead engage in exposure by actively discussing or repeatedly confronting painful trauma memories and situations that provoke trauma-related distress. For some trauma survivors, venturing out to connect in person with a mental health provider can be an initial therapeutic step in overcoming avoidance, while remaining at home exclusively using a TMH approach (e.g., a web-based program) could serve to further reinforce avoidance.
TMH approaches, such as web- and mobile phone-based programs, require little motivation to initially access them. However, a great deal of motivation may be required to fully engage and sustain meaningful use over time, especially without some amount of regular support (e.g., telephone-based coaching). Thus, there is a risk that aborted or other unsuccessful attempts to use and benefit from TMH for self-management will lead to discouragement and beliefs that treatment in general does not work or will not work for the user in particular.
25.4 Examples of TMH Approaches Applied to Trauma Populations
25.4.1 Clinical Video-Teleconferencing (CVT)
CVT involves using video equipment, including cameras and monitors (e.g., television, computer, or mobile devices such as tablets or smartphones) to deliver mental health services remotely through telecommunications infrastructures (e.g., broadband). CVT affords a close approximation of traditional face-to-face care by allowing both patient and provider to see and hear one another in real time. However, compared to traditional care, CVT’s primary advantage is that it can increase convenience by reducing or entirely eliminating travel requirements (e.g., with in-home CVT applications). CVT typically involves providers located in one healthcare setting (e.g., main hospital) and patients located at a distant healthcare facility (e.g., a rural clinic). Recent advances in and broader availability of video-teleconferencing technology (e.g., low-cost and smartphone cameras, expanded broadband access) have made CVT to patients’ homes feasible, entirely eliminating travel and further reducing inconveniences associated with receiving care. It also overcomes the stigma of having to go to a mental healthcare setting, which could engage more patients, reduce missed appointments, and prevent premature termination of treatment.
CVT is a mode of care delivery that can be used for a variety of trauma-related mental health services, including screening and diagnostic assessments (e.g., Nelson et al. 2004), medication and case management (e.g., Shore and Manson 2005), and psychotherapy, both in individual (e.g., Tuerk et al. 2010) and group (e.g., Morland et al. 2011b) formats. Despite this broad applicability, some providers may be reluctant to use CVT because of concerns that patients will not want to use it or it may compromise the therapeutic relationship or negatively impact care delivery in other important ways. In fact, CVT has been shown to be an acceptable form of treatment delivery for PTSD patients, with some patients preferring this modality over in-person care (Thorp et al. 2012). Likewise, research has shown that a strong therapeutic relationship can be developed and maintained (Germain et al. 2010), although when it is used with groups, the alliance might suffer somewhat (Greene et al. 2010). Furthermore, providers have been shown to be able to deliver the same level of care in terms of adherence to and competence with therapy protocols using CVT for PTSD patients (Frueh et al. 2007a; Morland et al. 2011a).
Considerable evidence has been amassed establishing the efficacy of CVT for a variety of mental health conditions, with outcomes generally comparable to those of in-person care (Backhaus et al. 2012). For trauma care specifically, a number of studies have been conducted, including both CVT from clinic to clinic (Morland et al. 2004, 2011a, b; Frueh et al. 2007a, b; Germain et al. 2009; Tuerk et al. 2010; Gros et al. 2011; Hassija and Gray 2011) and more recently from clinic to patient’s home (Strachan et al. 2012). Consistent with the broader CVT literature, comparable outcomes have been shown between CVT and in-person delivery of psychotherapy for PTSD patients (Gros et al. 2013). However, several studies suggest that outcomes for exposure therapy delivered by CVT, while good (and comparable to those found in the extant in-person delivery literature), may not be as good as those from in-person delivery (Gros et al. 2013).
There are a number of issues that should be attended to when using CVT. Foremost among these are equipment and technical considerations. Early applications of CVT required costly monitor and camera systems, but now inexpensive, ready-to-use off-the-shelf equipment and software that have adequate encryption capabilities are widely available. Once the hardware is in place, clinicians should be prepared for technical issues that can arise, such as unreliable or slow connections leading to dropped connections and delays in communication that disrupt the flow of the session. Having backup plans in place, such as reverting to telephones, will lessen the impact of these inevitable disruptions. Setting issues will also need to be managed when using CVT to a remote clinic. For example, patients will need a private office with video-teleconferencing equipment, and remote clinic personnel will be required to prepare the space for the patient and be available if clinical or technical issues arise. Finally, clinicians must also overcome other logistical issues when using CVT. For example, EBTs for PTSD such as prolonged exposure (PE) and cognitive processing therapy (CPT) routinely use self-report symptom measures and homework forms. Providing these to patients and having them completed and transferred back so they can be used in a timely fashion will require additional technology (e.g., scanners, fax machines). Obviously, for in-home CVT, all of these issues require additional careful forethought and contingency planning.
Specific clinical issues can also arise when using CVT with trauma patients. While CVT affords the opportunity to assess nonverbal signs, it can lack the sensitivity needed to detect or distinguish subtle emotional signs (e.g., soft crying, fidgeting) that are a routine part of trauma-focused care. Likewise, detection of other clinically relevant issues that arise in trauma care, such as recent alcohol or marijuana use and poor personal hygiene (Thorp et al. 2012), may be compromised. Depending on what can be brought into the video frame, the clinician may not be able to see the entire patient. A stark case of this is described by Thorp et al. (2012), who note a situation where the clinician did not know the patient was in a wheelchair because it was out of frame.
25.4.2 Web-Based Interventions
Web-based interventions provide a platform for reaching a huge proportion of the population. Anyone with Internet access can use web-based interventions, and once they are constructed, they can be used by large numbers of individuals with no additional costs. This makes them especially well suited for use in the aftermath of large-scale traumatic events that affect hundreds or even thousands of individuals.
But in addition to advantages of reach, web-based interventions have characteristics that may enable them to be particularly effective. EBTs typically incorporate common therapeutic components that are likely to contribute to their effectiveness. These include information and education, skills training with demonstration/modeling, individualized assessment, goal setting, behavioral task assignment, self-monitoring, and personalized feedback. Web-based interventions lend themselves to incorporation of these features, and many existing web programs have successfully included these elements (Amstadter et al. 2009). In this sense, it can be argued that many EBTs for PTSD are well suited for translation to and delivery via the Internet. Automated interactive programs essentially seek to replicate many aspects of face-to-face interventions that have been found to be effective.
In addition to preventive and treatment interventions, web-based programs can offer screening and assessment of trauma-related mental health issues. Individuals can screen themselves for problems and be offered customized feedback, in the privacy of their own homes. They can track their own progress in efforts to improve their symptoms. Their assessment information can be used to tailor the intervention by directing them to particular information, skills, or materials. This capacity for assessment means that web-based interventions can collect data, both in terms of usage and self-entered information and automatically collected site use data. Potentially, the gathering of data before, during, and after the intervention is used can help clinicians increase their ability to monitor progress and outcomes of treatment and more generally move toward evidence-based decision-making. A fundamental obstacle to routine measurement of mental health outcomes is a reliance on the use of paper and pencil questionnaires to provide information that cannot easily be integrated into electronic health records or viewed across time and treatment sessions. Web-based programs can potentially permit ongoing data entry by clients that can then be summarized in visual “dashboards” that can be reviewed by provider and client to review treatment progress and inform decision-making.
It is also possible that, if well-designed, web-based interventions may be motivating for those who might benefit from their use. The unlimited access and 24/7 availability of programs enables users to self-pace their experience getting as little or as much from the intervention as is desired at virtually any time they can access the Internet, including from the privacy of their own home. Individuals can use web-based interventions anonymously, so that perceptions of stigma or embarrassment at help-seeking are likely to be less significant impediments to care. Cost is also reduced or eliminated as a barrier, since many interventions are available at no or low cost.
Web-based interventions can vary in terms of the degree to which they are intended to include human service provider involvement. At one end of the continuum, they can be designed as entirely stand-alone self-help interventions, delivering symptom assessment and monitoring, psychoeducation, and instruction in a range of intervention tools (e.g., self-regulation skills) to be self-administered by the user. At the other end of this continuum, web-based interventions can serve as treatment augmentation tools in which care is delivered by human service providers but supplemented by the web program. It is possible that integration of web-based interventions into traditional care might serve as a force multiplier by reducing the amount of time required to treat each patient allowing more patients to be seen by a provider (Marks et al. 2004).
Between these two extremes is assisted self-help, in which individuals self-manage their problems or symptoms but are offered human support that is less intensive than that likely to occur during face-to-face mental health treatment. For example, support could include brief phone calls to provide caring support and coaching to reinforce program use, encourage persistence, and problem-solve difficulties with implementing intervention components. This contact would also increase accountability to help ensure consistent, meaningful engagement with the intervention. Support personnel could be mental health professionals, but a range of other helpers could also provide support (e.g., peer specialists, clergy).
Provider concerns about patient nonacceptance of this form of TMH and its effect on treatment may affect adoption. As with CVT, substantial research to date indicates that patients using web-based programs often find them to be acceptable and satisfying (Marks et al. 2007) and that incorporating web-based activities into therapy is not incompatible with establishing a good relationship with the therapist (Klein et al. 2009; Knaevelsrud and Maercker 2007). Evidence on effectiveness from several studies of web-based interventions for trauma survivors is promising (Lange et al. 2000, 2001; Hirai and Clum 2005; Knaevelsrud and Maercker 2007; Litz et al. 2007; Klein et al. 2009, 2010; Steinmetz et al. 2012; Wang et al. 2013). Most of the web-based programs evaluated in this literature have relied on significant provider involvement, and unfortunately, many of the programs studied have not been made widely available to the public. Fortunately, there are a number of very good, publicly available, free web-based programs that are available, which are informed by evidence-based intervention components commonly found on research sites. These include the VA National Center for PTSD’s PTSD Coach online (www.ptsd.va.gov/apps/PTSDCoachOnline) designed for the general population and DoD’s AfterDeployment.org (Ruzek et al. 2011; Bush et al. 2013) that was designed for military service members and veterans.