Shirah Vollmer MD

The Musings of Dr. Vollmer

Tele-Psychiatry: Obtaining Mental Health Online

Posted by Dr. Vollmer on April 10, 2020

How can providers or patients access mental health in the time of Covid-19? Telemental health is behavioral health services provided through technology. It allows psychiatrists, therapists and other mental health professionals to reach their clients despite long distance, the client’s inability to come to the office, or more recently during a pandemic. The hope is that with greater access, there will be less barriers to mental health care. Having said that, there is still a nationwide shortage of psychiatrists, and so tele-mental health for psychiatry could still be in short supply.

Now, during the pandemic, tele-mental health is the option for mental health care, but as the pandemic recedes, tele-mental health, for some, will be a supplement to in-person treatment or it may replace in-person treatment. As with all aspects of the pandemic, we will need to wait and see which changes in our world will stick, which will revert to our old ways of doing things, and which will become a hybrid of both.

Let’s start with a little history. Although it seems like tele-mental health is a new concept, the timeline begins in 1959.

In 1959, the Nebraska Psychiatric Institute used videoconferencing to provide group therapy, long-term therapy, consultation-liaison psychiatry and medical student training. This goes back a long way but it was not mainstream at that point.

Tele-psychiatry was slow to be adopted because one of the major concerns is privacy. Even with privacy protections, there is still a large concern that the conversation can be hacked, and can be used for unwanted purposes. As such, there can be tension in the patient about what they can and cannot say. Privacy is the bedrock of mental health services, and as such, video-conferencing tools, even with protection, are still quite vulnerable to hacking, and so the patient and the provider must understand the risk of losing privacy and what that might mean to the trust in the dyad. In addition, there are significant limitations when it comes to aggressive patients. In an office setting, long-acting injectable and/or restraints can be used to treat aggression, and when the patient is at home, our only option is to call for emergency services, which are in short-supply in some areas of the country. Further, we are only just beginning to learn the appropriate scope of practice with tele-psychiatry and the limits with regards to both diagnosis and treatment.

In the past, all tele-psychiatry guidelines have strongly suggested that there also needs to be boots on the ground, and that means that there is an in-person available if the therapist/psychiatrist feels that the person is unstable and needs to be evaluated in person. This may not mean that the patient needs to go to urgent care or an emergency room, but only that online treatment may not be appropriate for all patients. With more limited resources, and the fear of going to a physician’s office, an urgent care or an emergency room, the options for “boots on the ground” are limited. In this case, the provider is encouraged to learn better assessment tools online. It may also be important to get consent to talk to loved ones who can help us evaluate what is going on with the patient. Online therapy may have to expand to family support therapy, with patient consent, as the family has eyeballs on the patient, whereas the therapist only sees the patient from the neck up.

The other major limitation to tele-psychiatry is that although there is a history of tele-psychiatry which precedes this pandemic, the studies are very limited as to what are the potential pitfalls. With the absence of studies, we can anticipate that the screen might disguise or cover up information that would have been apparent with an in-office visit. For example, if the patient does not shower for ten days, there is no way an online provider would suspect that, unless the patient confessed. Not being able to smell the patient is an example of how tele-psychiatry is not the same as in-person treatment. Future studies will illuminate other examples of the limitations, but for now, both patient and practitioner need to be mindful of the differences between in-person and on-line assessment and treatment.

Clinical experience tells us that switching a patient from the office to video therapy is fairly straight-forward. The challenge is in working with new patients. With new patients, a rapport must be developed and this is usually facilitated by sharing physical space together. In the absence of sharing physical space, the patient and the provider are left to a verbal interchange, which, when building a relationship online may seem superficial or mechanical. This is a bad outcome which providers need to learn how to avoid. Transmitting warmth and concern to a new patient is one of the challenges of online treatment. In other words, seeking online treatment is convenient, and necessary during this pandemic, but the downside might be retention. Will patients stay in treatment while doing online therapy? Does the ease to “connect” to a therapist make it also easy to disconnect? With time, we need to monitor the strength of the provider/patient relationship for those who started treatment online. Further, we need to develop new relationship building tools to apply to online treatment.

Perhaps these new tools come in the form of having patients text message between sessions, or having them share essays that they have written or songs they have written and/or sung during this period. Adding on exchanges outside of the therapy hour may be critical to developing deeper and hence more trusting relationships online.

In the past, all tele-psychiatry guidelines have strongly suggested that there also needs to be boots on the ground, and that means that there is an in-person available if the therapist/psychiatrist feels that the person is unstable and needs to be evaluated in person. This may not mean that the patient needs to go to urgent care or an emergency room, but only that online treatment may not be appropriate for all patients. With more limited resources, and the fear of going to a physician’s office, an urgent care or an emergency room, then once again, the online provider is encouraged to learn better online assessment tools. In this situation, it may also be important to get consent to talk to loved ones who can help us evaluate what is going on with the patient. Online therapy may have to expand to family support therapy, with consent, as the family has eyeballs on the patient, whereas the therapist only sees the patient from the neck up.

Having outlined some concerns, the advantages, especially in the days of COVID 19 are numerous. The accessibility is great, not only because all that is necessary is two computers capable of video chat, treatment can be done when the patient wants to take a break during their work-day, thereby minimizing the time taken away from their demanding job and also providing immediate on the job relief.

Since the major tool in a psychiatric visit is listening, tele-psychiatry lends itself to this modality since listening is intensified, given that other senses, such as smell and touch are out of the question. This forces both the patient and the provider to focus on a narrative, which is a key component to working through the stresses and strains trauma in general and this pandemic in particular. In other words, on the positive side, tele-psychiatry is an exciting option for those verbally-inclined individuals who are overwhelmed or internally disrupted in general, and/or specifically internally disrupted by this pandemic.

As a psychiatrist myself, I am living through an era of great transition in medical practice. This pandemic has forced us to rapidly shift our practices from office work to online evaluation and treatment. We had little time to prepare for this transition, and as such, we are learning as we go. We know we will make mistakes. We know we will make both diagnostic and therapeutic errors. We know that these errors can cause human suffering to our patients and their families. And yet, we have no choice. We must adapt to a new delivery method of care. We must be humble and learn new skills which suit our new technology. We must be mindful that although we have trained for many years, some of our old skills might not transfer over to our new demands. Knowing all of the above, and knowing that our patients need our services, however clumsy we may feel, we need to learn as we go, and be open and curious to how we are both succeeding and failing with online communication tools.

Psychiatry brings to medicine a deep humility. We must listen to our patients because only they know their experience. This pandemic must deepen our humility further, because patients want to be heard and we want to listen, but now we must rely on machines, with internet connections, which can be unreliable and thereby limit our understanding of the patient and their concerns.

In summary, tele-mental health is the major option today for obtaining behavioral health care during COVID-19. This is a new frontier for both providers and patients. With new frontiers brings a steep learning curve to providers, mandating that we stay curious and humble in the face of many unknowns. Patients are given easier access which might decrease stigma and increase demand, but might also decrease retention if a bond is not formed. History is yet to be written. I will be particularly curious about the history of psychiatry during COVID 19.

References

Learning Objectives:

1. The practitioner will learn the advantages and disadvantages of telepsychiatry

2. The practitioner will learn the concern about privacy and aggression with online mental health evaluation and treatment.

3. The practitioner will learn the ease of setting up online therapy, if there are enough providers available.

Summary: This podcast reviews how a referral to online psychiatry is not the same as a referral to in-person psychiatric assessment. There is a discussion of the potential advantages and disadvantages of mental health moving to an online platform.

2 Responses to “Tele-Psychiatry: Obtaining Mental Health Online”

  1. Shelly Tannenbaum said

    Awesome, Shirah. I am also curious about how the psychiatrist perceives self-reporting by the patient, especially if the patient has a known psychiatric disorder. Does the psychiatrist believe everything the patient says, like if the patient says, “I feel great! I sleep 3-4 hours a night but I don’t need any more…I think clearer than ever and get so many projects done that I didn’t used to get done! My wife says that there is something wrong, but don’t listen to her.” Does the psychiatrist take that at face value because the patient is the patient after all? How does the psychiatrist support the patients’ families, who are bearing the brunt out of control spouses, fathers, brothers and significant others? If the patients don’t give consent for psychiatrists to be in contact with families, then I suppose you cannot do so?

    • Absolutely not. The job of the psychiatrist is to listen with love, no judgment, but also with skepticism. That is why listening is so very complicated. Collateral information is vital to psychiatric assessment and treatment, and most of the time that requires consent of the patient, but consent can be strongly encouraged and most patients comply with a plea for obtaining collateral information. Supporting the families can be very important, but sometimes this is a two-person job, meaning one person treats the patient and one person supports the family. The concept is that a treatment alliance is formed and with a good treatment alliance there is then an extension into family work. Of course, when this is not possible, the treatment suffers, and the psychiatrist understands that there could be a lot that is hidden from them, just like we know that with video chats, we are missing a lot of vital clinical information. Thank you, as always.

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