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Staff Perspective: Can EBPs Be Delivered by Videoconferencing or Telephone?

Staff Perspective: Can EBPs Be Delivered by Videoconferencing or Telephone?

Carin Lefkowitz, Psy.D.

Over the past two weeks, CDP Subject Matter Experts have been receiving many questions about delivering evidence-based psychotherapy (EBP) via telemental health. As providers struggle to continue to deliver treatment without face-to-face contact, questions arise about adaptations for videoconferencing and even telephone-only delivery of services. I’ve summarized recommendations from our consultants on how to quickly adapt services in light of the coronavirus outbreak.

Treatment delivery via videoconferencing
The good news is that there is research data supporting the delivery of several EBPs – CBT for insomnia (CBTI), Cognitive Processing Therapy (CPT), and Prolonged Exposure (PE) – via videoconferencing. When compared to face-to-face delivery, delivery of these EBPs via video teleconferencing produces similar treatment gains, therapeutic alliance ratings, and patient satisfaction. More specific data can be accessed in the articles referenced at the end of this blog. We will soon publish a collection of protocol-specific resources as well.

What do you need to know right now if you’re transitioning to virtual sessions?
The first step is to assess whether it is appropriate to continue the protocol that you’ve started. Have the patient’s needs and priorities been impacted by the outbreak? Thinking back to Maslow’s Hierarchy of Needs, physiological and safety needs take precedence over higher order needs, and these are the exact needs that are likely to be impacted by the outbreak. Even your most motivated and high-functioning patients might suddenly be struggling to meet their basic needs, such as grocery shopping, maintaining employment, and managing childcare. It is important to have an honest discussion about the patient’s priorities and to continually reassess them in these rapidly changing circumstances.

If you and your patient agree that it makes sense to continue with an EBP, a discussion about logistics will be important. What platform will you utilize and how will you protect patient confidentiality? When and where can your patient have privacy when family members and roommates are also self-isolating? Do you have backup communication options if a connection is lost? You can listen to two of our consultants discuss these logistics here.

Another logistical concern is how to obtain and review worksheets and other assignments used in EBPs. Given that many providers have had to implement telehealth delivery literally overnight, there may not have been opportunity to physically hand materials to patients before the transition. We have identified a few workarounds:

  • Use mobile apps. Free companion apps exist for CBTI (CBTI Coach), CPT (CPT Coach) and PE (PE Coach). These apps have assessment tools, homework assignments, and worksheets built in. While the ability to export these materials to the therapist varies by app, platform, and individual clinic policies, patients will be able to access and complete the material at a minimum. A summary of the most popular companion apps is available here: https://deploymentpsych.org/resources/apps
  • Rules regarding email communication with patients vary across states and individual practice settings. If you have the capability to email your patients, of course you can send them blank copies of relevant worksheets and assignments. However, a good rule of thumb is to NOT exchange completed worksheets or any other document that includes identifiable information through unsecure email. Some telemental health platforms include more secure options for document exchange.
  • Some materials, such as blank sleep diaries, may be available publicly, while other material (such as CPT worksheets) are copyrighted. CDP is in the process of collecting open-source materials and publishing them on our website for easy access. 

Perhaps most important in this process is patience. You will inevitably experience some hiccups as you quickly transition to virtual sessions, whether that’s awkwardness in handling the treatment materials or technology glitches. The stress during this transition is universal, so expect and accept some imperfection in your sessions.

Treatment delivery via telephone
While research supports the delivery of several EBPs via videoconferencing, there is no data on delivering protocol-driven psychotherapy exclusively via telephone. Nonetheless, we’ve heard from several Military Treatment Facilities in the past two weeks where providers have urgently transitioned to telephone-based care as a response to COVID-19. The patients whom they have been treating are in various phases of treatment and it is unclear how long treatment will be delivered this way. Typically, CDP would not endorse treatment modalities that are not supported by high-quality research. But these are unprecedented times and we, like everyone else, are thinking creatively about how we can best meet the needs of our patients in these circumstances.

Given lack of research to guide us, we rely on our personal experiences and clinical judgment. In the wake of Hurricane Sandy in 2012, my colleagues and I faced the challenge of providing outpatient psychotherapy in the absence of basic infrastructure. With no electricity in my clinic (nor in my patients’ homes), there was a short period of time in which telephone-based sessions were the only option. I am basing my suggestions below on my experiences during that time, as well as input from my trusted CDP colleagues.

First, everything discussed under the heading of videoconferencing applies here. You must first assess the patient’s current needs, as well as the availability of privacy and secure communication. The issue of transmitting documents and assessment measures must also be considered. Ultimately, continuing the EBP by phone may not be feasible or appropriate for many patients. Under those circumstances it could be beneficial to switch to more supportive treatment sessions for the duration of the crisis and encourage ongoing practice of skills that the patient has already learned. Of course, this plan should be agreed upon through shared decision making.

Despite the multitude of challenges, you and your patient may decide together that it makes sense to continue with the EBP. Some challenges will apply to all telephone sessions, while others are specific to a particular EBP.

General tips:

  • You may wish to allot extra time for your EBP sessions. In my phone sessions, I found that it took longer to review worksheets and track symptoms as we were doing so verbally. Allotting an extra 10-15 minutes to each session was helpful and enabled us to complete the necessary tasks of the session without feeling rushed. If your patient can score their own assessment measures, that will save you some time, but you will still need to discuss which individual symptoms continue to cause distress.
  • Discuss ahead of time a plan for checking in without the benefit of visual cues. As therapists we track confusion and discomfort by observing our patients’ facial expressions. Without that data, we lose useful information about the patient’s needs and emotional experience. I found it necessary to ask frequently “How are you feeling right now?” or acknowledge changes in tone of voice (“It sounds like your voice is shaking. What are you experiencing?”). Letting the patient know that I would be doing more of this seemed to reassure them that I was attending to their emotional experience and also allowed me to be direct in my questions. I also found it helpful to give the patient permission to interrupt me if they did not understand something or couldn’t hear me, again noting that I could not read their facial expressions as I typically would.
  • Find a balance between maintaining fidelity to the protocol and adapting to meet your patient’s needs. Given that we are already deviating from the protocol by delivering it by phone, we’d like to avoid straying further from the protocol so as to not “water down” the treatment further. With that goal in mind, avoid making any unnecessary modifications to the EBP at this time. That said, expect that some modifications may be necessary, such as adjusting your agenda, adding sessions, or incorporating additional tools.
  • If possible, avoid beginning an EBP via telephone. While telephone-only sessions may be warranted for patients who are in the middle of a protocol, it is not advisable to begin an EBP protocol until a video option becomes available to you. This does not preclude you from offering other supportive or skill-based telephone sessions.

Issues specific to CBT for Insomnia (CBTI) and Brief Behavioral Treatment of Insomnia (BBTI)

  • Working with a sleep diary may be more challenging without being able to see it. Most likely you will ask your patient to summarize the main variables for treatment (WASO and SOL for BBTI; WASO, SOL, TIB, TST, and SE for CBTI) and then share it with you by phone. If you have been teaching your patient to score sleep logs during your sessions up to this point, the transition may be less cumbersome.
  • If you are delivering CBTI and using the CBTI Coach app, the sleep diary will automatically be scored for the patient. Keep in mind that TIB is not included in the SE calculation in the app, which may provide an overestimation of sleep efficiency if your patient is spending significant time in bed awake. You will want to specifically ask about TIB during the session for that reason.

Issues specific to Cognitive Processing Therapy (CPT)

  • Ensuring that your patient has access to the worksheets may be your biggest challenge. As mentioned previously, the CPT Coach app enables patients to access the PCL-5 and worksheets. Many patients find it easier to access on a tablet versus smartphone due to screen size. If your patient does not have access to the CPT Coach, you might share a copy of the worksheets with your patient if you can communicate via email or fax. The patient handouts are downloadable in a PDF file for therapists who own the manual. Instructions for accessing those handouts are available at the end of the Table of Contents in the manual.
  • Emotional processing remains a cornerstone of CPT, but may be challenging to assess due to lack of visual cues. As noted above, the therapist may need to ask more directly about the patient’s emotional experience during sessions. Especially in the earlier phases of treatment, you’ll need to allow space for therapeutic silence so that emotions can be processed. You may wish to let the patient know directly that you may stay silent or offer minimal encouragement as you sit with their emotions.

Issues specific to Prolonged Exposure (PE)

  • In vivo exposures might continue in phone sessions. Refer to the patient’s in vivo hierarchy to determine which items can be practiced (or adapted to practice) during self-isolation. Set a plan for assignments and monitor SUDs as you typically would.
  • It is not recommended to conduct imaginal exposure via telephone, as it would be difficult to assess engagement and encourage the patient without interrupting the exercise. However, the patient may maintain gains by continuing to listen to the most recent imaginal exposure recording and track SUDs. Phone sessions can be used to process reactions to the recording. Imaginal exposure can resume when a video connection is established.

Given the lack of data, I consider delivery of EBPs via telephone to be an urgent response in exceptional circumstances. It is an untested approach that may enable our patients to progress in their treatment when clinical judgment and shared decision making suggest that continuing the EBP is in the best interests of the patient. At the risk of stating the obvious, I recommend returning to an established approach (telehealth with video or face-to-face sessions) as soon as is feasible.

CDP remains operational and open for consultation. You can access our consultation resources here: https://deploymentpsych.org/resources/consultation-services

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Carin Lefkowitz, Psy.D., is a clinical psychologist and Senior Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.

References:

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Gehrman, P., Bellamy, S., Medvedeva, E., Barilla, H., & Brownlow, J. (2018). Telehealth delivery
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Maieritsch, K. Smith, T., Hessigner, J., Ahearn, E., Eickhoff, J., & Zhao, Q. (2016). Randomized
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Morland, L., Mackintosh, M., Rosen, C., Willis, E., Resick, P., Chard, K. & Frueh, B. (2015).
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Staff Perspective: Can EBPs Be Delivered by Videoconferencing or Telephone? | Center for Deployment Psychology

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