Madeline J. Bruce, Antonio F. Pagán, & Ron Acierno

We hope our state-of-the-science review can ease the unfortunate, yet common, concern that telehealth-delivered psychotherapy is less effective or ineffective when helping patients with posttraumatic stress disorder (PTSD). Telehealth-delivery refers using telecommunication technologies, usually videoconferencing, to provide the same therapy seen in-person. Through a review of the literature and our own experience at a telehealth-only PTSD specialty clinic, it seems that after a few minutes, the screen “fades away.” Strong therapeutic relationships can be developed, and the patient’s therapy goals can be achieved in our virtual offices. Evidence-based treatments (EBTs) for PTSD can be safely and effectively delivered via videoconferencing. Moreover, these modalities can help meet our patients, quite literally, “where they are at” (Shore et al., 2014).

Basic Guidance for Telehealth

Therapists new to telehealth have described several concerns when starting to practice via videoconferencing. Our review provides suggestions to ease such worries.

• Patient safety is at the forefront. Emergencies can be effectively handled by confirming where the patient is and crafting a plan early in treatment detailing what will happen during a medical or psychiatric emergency. Have the direct number to emergencies services in your patient’s location: calling 911 connects you to services to your
• Emulate the same rapport-building behaviors seen in-person while on camera. Center yourself in the camera frame, ensure your microphone can catch your voice clearly, and position your gaze to meet the patient’s.
• Momentary delays in the video signal are typically not disruptive. However, if you find difficulty volleying a conversation due to poor signal, have your patient’s phone number ready to call them and continue the session with at least a clear audio signal.
• Some therapists are concerned they will “lose touch” with patient progress if they cannot have the same in-person interactions with them. While therapists still will be able to see their patients throughout the session (and may see more of their patient’s home life than what can be seen in the office!), measurement-based care becomes all the more important to keep track of patient progress.

EBTs for PTSD Delivered via Videoconferencing

Our review of the literature included EBTs for PTSD for adults and children and treatments that address common comorbidities. There is strong evidence that these treatments are comparable to in-person delivery:

• Prolonged Exposure Therapy (PE)
• Cognitive Processing Therapy (CPT)
• Behavioral Activation and Therapeutic Exposure (BATE)

There is budding yet promising evidence that these treatments are comparable to in-person delivery:

• Written Exposure Therapy (WET)
• Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

The following treatments need further research before they can be considered comparable to in-person delivery:

• Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE)
• Cognitive Behavioral Therapy for Insomnia (CBT-I)

Increasing Uptake

PTSD treatment is difficult, especially exposure-based therapies. We detail a recent program, the PE+Peers program (Hernandez-Tejada et al., 2024), that was highly successful in helping veterans who had previously dropped out of PE treatment return and find significant improvement in their symptoms. This program was also successfully conducted via telehealth.

The trial compared added instrumental support (i.e., a peer attending in-vivo exposures) verses added emotional support (i.e., a peer calling to give encouragement). 87% of those completing at least one peer-supported in-vivo finished treatment compared to 56% of those who had no help with in-vivo homework. 97% of those attending three or more peer-aided exposures completed treatment. Bringing PE+Peers to additional populations will be promising, especially those entering PE for the first time.

Ideas to Bring Telehealth to All

Telehealth is convenient, effective, and cost-efficient, making providing this modality a socially-just action. We end our review with ideas to bring telehealth to all.

• Since most of the treatments reviewed show equal efficacy for telehealth and in-person, and because the basic requirements of a therapist office and computer with high-speed internet indicate the same facilities costs, we assert that insurance reimbursement rates should be equal for both modalities.
• Telehealth can be conducted safely. Providers practiced telehealth across state lines safely during the COVID-19 pandemic. We assert that a return to state-specific licensure barriers will be at the detriment of patient access, even if only one session of in-person care is required.
• Having high-speed internet and the devices to use it requires a certain level of economic privilege. Our clinic has used service grant funding to provide tablets with mobile data loaded to provide our services in rural Texas. Mental health professionals are in a unique position to advocate for improving our country’s internet infrastructure to increase access to all forms of healthcare.

Discussion Questions

• How can therapists and patients new to telehealth overcome their initial concerns and effectively build rapport with patients through videoconferencing?

• What are the main benefits and potential challenges of delivering PTSD treatments via telehealth compared to in-person sessions?

• How can telehealth be leveraged to improve access to PTSD treatment for underserved populations, and what role can mental health professionals play in advocating for better internet infrastructure?

• What are the key findings from the PE+Peers program, and how can similar peer-supported interventions be implemented in other populations undergoing PTSD treatment via telehealth?

About the Authors

Madeline J. Bruce, Ph.D., is a postdoctoral research fellow at the UTHealth Houston – Trauma and Resilience Center and an incoming Assistant Professor at Webster University - St. Louis. Dr. Bruce researches posttraumatic adjustment and identity, especially for traumatic events that occur in institutional contexts. Valuing evidence-based practice in her clinical work, research, and teaching, her work on trigger warnings was some of the first to subject this controversial topic to empirical scrutiny. Dr. Bruce can be followed on social media at @madsbrucephd.       

Antonio F. Pagán, Ph.D., is a clinical psychology postdoctoral fellow at UTHealth Houston. Dr.  Pagán conducts research on neurodevelopmental disorders across the lifespan with a focus on how these disorders create difficulties during key life stage transitions.  

Ron Acierno, Ph.D., is Professor and Vice Chair for Veterans Affairs and Executive Director of the Trauma and Resilience Center, Faillace Department of Psychiatry, UTHealth Houston, and a VA Senior Research Scientist at the Ralph H. Johnson VA Healthcare System, in Charleston, SC. Dr. Acierno has published over 200 research articles and has received funding from the Department of Defense, Department of Veterans Affairs, National Institute of Justice, National Institute on Aging, National Institute of Mental Health, The Retirement Research Foundation, The Archstone Foundation, and the Offices of the Attorney General of South Carolina and Texas, among others.  His diverse areas of research include telemedicine, PTSD, Elder Abuse, and Disaster Affected populations. In addition to his academic and administrative work, he offers consultation to Military, VA, Police, Fire, and Chaplaincy services, as well as primary care clinics and other agencies that serve victims of violence and abuse.

Reference Article

Bruce, M. J., Pagán, A. F., & Acierno, R. (2024). State of the Science: Evidence‐based treatments for posttraumatic stress                  disorder delivered via telehealth. Journal of Traumatic Stress. https://onlinelibrary.wiley.com/doi/10.1002/jts.23074

References Cited

Hernandez-Tejada, M. A., Bruce, M. J., Muzzy, W., Birks, A., Macedo e Cordeiro, G., Hart, S. M., Hamski, S., & Acierno, R.                  (2024). Peer support during in vivo exposure homework increases likelihood of prolonged exposure therapy                          completion. Military Psychology. Advance online publication. https://doi.org/10.1080/08995605.2024.2352601

Shore, P., Goranson, A., Ward, M. F., & Lu, M. W. (2014). Meeting veterans where they're@: A VA Home-Based Telemental               Health (HBTMH) pilot program. The International Journal of Psychiatry in Medicine, 48(1), 5-17.                                                      https://doi.org/10.2190/pm.48.1.b