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Despite the substantial growth in evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), such as cognitive processing therapy (CPT; Resick, Monson, & Chard, 2017), and prolonged exposure (PE; Foa, Hembree, & Rothbaum, 2007) therapy, and the high demand for such services (Kilpatrick et al., 2013), critical barriers continue to prevent patients from accessing and engaging in these interventions (Maguen et al., 2019; Sripada et al., 2018). Barriers can include distance, travel time, lack of afterhours access to care, privacy, limited specialty providers, perceived stigma, and PTSD avoidance symptoms. Although not the only reasons, these barriers certainly contribute to gaps in access to care for patients with PTSD. 
One promising solution to bridge some of these gaps is the advent of telemental health (TMH) technology.  TMH refers specifically to the use of telehealth technology to provide virtual psychological or psychiatric health services. Several types of telehealth exist, however the most widely utilized and studied TMH modality is clinical videoteleconferencing (CVT), which allows a therapist and patient in separate locations to see each other and interact in two-way real time. With the increase in demand for mental health services, the lack of available specialty services, and the rapid growth in technology, TMH modalities, such as CVT, are dramatically altering the mental health landscape in general and specifically for trauma survivors seeking PTSD services.

The provision of PTSD care through CVT has rapidly evolved over the past decade. Originally, TMH providers delivered PTSD treatments via CVT through the traditional “hub and spoke model,”, whereby a provider physically located in a large health care facility would meet remotely through CVT with a patient physically located in a smaller clinic or health care facility office (office-based CVT). This was initially implemented to support individuals residing in rural areas or due to limited specialty providers located at smaller, more remote clinics. This “hub and spoke” model increases access to specialty providers, and, in many cases reduces travel time and cost, but does not necessarily address other barriers, such as lack of mobility, parking and office space difficulties, perceived stigma while in waiting rooms, afterhours access, and trauma reminders when at the facility (e.g., seeing individuals who may share features with the perpetrator). 

In the past few years, technology has further evolved, and with the dramatic growth of broadband internet access, providers and health care systems have adopted home-based CVT. Home-based CVT allows providers to meet virtually through CVT with patients located in their homes or another private location (e.g., library, a hotel during work-related travel, their car during a lunch break) often using their personal tablet or smartphone. There has been substantial uptake in the use of home-based CVT because it increases flexibility and overcomes more barriers than office-based CVT (e.g., perceived stigma, travel time).  In addition, in many cases this home-based model allows for providers to also be in their homes, further broadening the playing field for specialty care and afterhours access.  

Feasibility and Efficacy of Office-Based and Home-Based TMH for PTSD

Research has found that both office-based and home-based CVT are feasible and clinically effective to deliver individual and group PTSD treatments. Most of the research examining the efficacy of PTSD treatments delivered via CVT has been conducted with veteran populations. Two non-inferiority randomized clinical trials (RCTs) conducted with female and male veterans found that individual and group CPT delivered via office-based CVT were non-inferior (i.e., equivalent) to in-person CPT (Morland et al., 2014; Morland et al., 2015). This means that providers can deliver CPT through office-based CVT without compromising its efficacy. Acierno and colleagues (2017) found that individual PE delivered through home-based PTSD was equivalent to PE delivered face-to-face in the office. Most recently, we also found that individual PE significantly reduces PTSD symptoms in male and female veterans when delivered via office-based and home-based CVT, as well as in-home, in-person therapy (Morland et al., 2019). This is consistent with findings from Peterson and Morland (2019) using home-based CVT to deliver CPT into the home. These findings are promising and force the health care system to rethink where, how and when we deliver care, ultimately affording more options for providers and more choices for individuals with PTSD.

Some PTSD providers have expressed concerns that the use of CVT would negatively impact the therapeutic alliance and therapists’ adherence to the protocol or treatment dropout. Overall, the existing research indicates that the therapeutic alliance is not negatively impacted using CVT and that therapists do adhere to manualized protocols even when delivered through CVT. Additionally, the dropout rates between CVT and traditional office-based care are comparable. Recent studies (Morland et al., 2019; Peterson et al, 2019) found that delivering PTSD EBPs into the home, either through home-based CVT or in person within veterans’ homes, had less dropout than traveling to the clinic. Clinicians can feel confident that if they choose to use CVT, they can still form a strong therapeutic alliance and provide effective therapy to patients virtually.

Patient-centered care emphasizes the importance of considering patients’ preferences when providing care. Studies have also found that most individuals are willing to use CVT and, even when they do not originally prefer it, they often grow to like it throughout therapy. Additionally, U.S. veterans with PTSD are not only willing to engage in care through CVT, but two of our recent projects (Morland et al., 2019; Wells et al., 2018) have found that about half prefer to receive individual or couples-based PTSD treatments through home-based CVT. Thus, if providers decide to implement home-based CVT within their clinical practice, they may be able to fulfill more individuals’ preferences for how they receive their care.

Clinical Implications and Lessons Learned

The use of CVT can increase the reach of PTSD EBPs and thereby improve the lives of individuals with PTSD. Clinicians can increase their clientele base by utilizing CVT to reach individuals who live in rural areas or in farther away locations that would prohibit office-based face-to-face visits. Additionally, providers can consider using home-based CVT to provide more flexible scheduling opportunities for clients. For example, if a client is sick, physically immobilized or traveling for work and unable to attend therapy in person, providers can meet with an individual through home-based CVT and literally “meet them where they are at.” Depending on the work setting, providers may also consider setting up a private office within their own homes to provide home-based CVT. This may allow them to expand the number of hours when they can see clients, such as offering early evening appointments that may otherwise not be possible. Overall, CVT provides flexibility for clients, providers and health care systems for how and where therapy is conducted.

We have learned many lessons through our work conducting CVT during RCTs and within clinics, particularly for the use of home-based CVT, and will highlight a few of these for those who may be new to or considering the use of CVT in their practice. The use of home-based CVT lends itself to unique safety considerations. Firstly, providers should do an initial assessment to determine psychiatric acuity and risk level (e.g., suicidality) to ensure that home-based CVT is appropriate. However, to date there are no absolute contraindications to patients being assessed or treated using CVT. Once home-based CVT is implemented, providers should establish clinical emergency procedures. For example, when possible providers should identify an emergency contact and confirm the individual’s location at the beginning of each appointment so that the provider can contact local emergency personnel if needed during the session.

Secondly, providers should orient clients to their expectations and boundaries for meeting though home-based CVT, such as to remind clients that appointments should be treated similarly as office-based appointments including wearing appropriate attire and having a private area in the home to meet. This is often referred to as creating the “virtual therapeutic environment.” Thirdly, it is beneficial to identify an alternative means of communication, typically telephone, in case the CVT is disconnected and unable to resume for any reason. Fourthly, it can at times be difficult for the provider to observe important behaviors or environmental factors, such as the use of safety behaviors or presence of physical disabilities, because the visual field may be limited due to the camera’s location and field of view. For example, an individual may be petting their animal on their lap during an imaginal exposure as a safety behavior, but the therapist may be unable to see the animal. To help minimize these safety behaviors, therapists can address this when discussing boundaries of conducting home-based therapy and assessing for safety behaviors during session, if appropriate such as during PE.

We have also seen cases where for several sessions the therapist was unaware that the client was in a wheelchair because the wheelchair was not easily visible through the camera. Therefore, the provider may need to conduct additional assessments to address these issues. Finally, some individuals’ comfort with technology is varied and some individuals may require additional support to orient themselves to the CVT technology prior to the first session. Similarly, providers’ comfort with the technology is critical to successful implementation of TMH.

In summary, the current state of the literature demonstrates that CVT is highly effective for delivering PTSD treatment, is preferred by many individuals and does not compromise the therapeutic process or the clinical integrity of the provision of EBP for PTSD. With a solid research base to draw from and the clear benefits afforded by TMH care, many best practice guidelines and standards have been developed to inform clinical consideration when providing TMH. For example, the American Psychiatric Association’s Telepsychiatry Toolkit (APA, 2016) and the most recent version of Best Practices in Videoconferencing-Based Telemental Health was adopted by both the APA and the American Telemedicine Association (ATA) in the spring of 2018 and have been developed to standardize and ensure safe and clinically effective implementation. We encourage providers to review these for more information about how to implement TMH. We are in an exciting time for mental health delivery when trauma providers can increase their impact by adopting and implementing CVT in their practices to increase the number of individuals who can access effective PTSD treatments. Through these efforts, we can make a substantial impact on the lives of those living with PTSD.

References

Acierno, R., Knapp, R., Tuerk, P., Gilmore, A. K., Lejuez, C., Ruggiero, K., … Foa, E. B. (2017). A non-inferiority trial of Prolonged Exposure for posttraumatic stress disorder: In person versus home-based telehealth. Behaviour Research and Therapy, 89, 57–65. doi:10.1016/j.brat.2016.11.009

APA Web-based Telepsychiatry Telemental health Toolkit (2016). Retrieved from https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit 

Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for   PTSD: Therapist guide: Emotional processing of traumatic experiences. New York, NY: Oxford University Press.

Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM‐IV and DSM‐5 criteria. Journal of Traumatic Stress, 26, 537-547.

Maguen, S., Li, Y., Madden, E., Seal, K. H., Neylan, T. C., Patterson, O. V., ... & Shiner, B. (2019). Factors associated with completing evidence-based psychotherapy for PTSD among veterans in a national healthcare system. Psychiatry Research274, 112-128.

Morland, L. A., Mackintosh, M. A., Glassman, L. H., Wells, S. Y., Thorp, S. R., Rauch, S. A., ... & Sohn, M. J. (2019). Home‐based delivery of variable length prolonged exposure therapy: A comparison of clinical efficacy between service modalities. Depression and Anxiety. Advance online publication.

Morland, L.A., Mackintosh, M.A., Greene, C.J., Rosen, C.S., Chard, K.M., Resick, P., & Frueh B.C. (2014). Cognitive processing therapy for posttraumatic stress disorder delivered to rural veterans via telemental health: A randomized noninferiority clinical trial. Journal of Clinical Psychiatry75, 470-476.

Morland, L. A., Mackintosh, M. A., Rosen, C. S., Willis, E., Resick, P., Chard, K., & Frueh, B. C. (2015). Telemedicine versus in‐person delivery of cognitive processing therapy for women with posttraumatic stress disorder: A randomized noninferiority trial. Depression and Anxiety32, 811-820.

Peterson, A.L. & Morland, L. A. (2019, October). In-home CPT and PE for combat-related PTSD: Preliminary results of two randomized clinical trials. Presented for the Combat PTSD Conference, San Antonio, TX.

Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cognitive processing therapy for PTSD: A comprehensive manual. New York, NY: The Guilford Press.

Wells, S.Y., Jaime, K., Schnitzer, J., Grubbs, K., & Morland, L.A. (2018). Examining veterans’ preferences for family-based posttraumatic stress disorder services. Poster presented at   the 34th annual meeting of the International Society for Traumatic Stress Studies, Washington, DC.

About the Authors:

Dr. Leslie Morland is the director of the San Diego VA Telemental Health Center, a clinical psychologist at the U.S. Department of Veterans Affairs (VA) San Diego Healthcare System, an associate professor of psychiatry at UCSD and a health research scientist at VA’s National Center for PTSD Pacific Island Division. Dr. Morland devotes time to local, regional and national leadership roles focused on the strategic planning and implementation of the use of technology to increase access to PTSD specialty care in the Veterans Health Administration, university settings and in the community sector. As a researcher, Dr. Morland continues to conduct multiple federally funded research projects examining the clinical and cost aspects of using technology to improve access to evidence-based PTSD services for rural or remote populations.

Dr. Stephanie Wells is a research psychologist at the Durham VA Health Care System and VISN 6 Mid-Atlantic MIRECC, and research interventionist at Duke University. Her research examines the impact of evidence-based PTSD treatments on PTSD symptoms and comorbidities. Additionally, her work focuses on how to increase engagement in and access to evidence-based treatments.