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:
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.
Issues specific to CBT for Insomnia (CBTI) and Brief Behavioral Treatment of Insomnia (BBTI)
Issues specific to Cognitive Processing Therapy (CPT)
Issues specific to Prolonged Exposure (PE)
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.
Acierno R.; Gros, DF., Ruggiero, KJ., Hernandez-Tejada, MA., Knapp, RG., Lejuez, CW., Muzzy,
W., Frueh, CB., Egede, L., & Tuerk, PW. (2016) Behavioral activation and therapeutic
exposure for posttraumatic stress disorder: A noninferiority trial of treatment delivered
in person versus home-based telehealth. Depression and Anxiety, 33; 415-423.
Acierno, R., Knapp, R., Tuerk, P., Gilmore, A. K., Lejuez, C., Ruggiero, K., Muzzy, W., Egede, L.,
Hernandez-Tejada, M.A., & 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. http://doi.org/10.1016/j.brat.2016.11.009
Gehrman, P., Bellamy, S., Medvedeva, E., Barilla, H., & Brownlow, J. (2018). Telehealth delivery
of group CBT-I is non-inferior to in-person treatment in veterans with PTSD. Sleep, 41
(Supp 1, A141-A142).https://www.doi.org/10.1093/sleep/zsy061.369
Maieritsch, K. Smith, T., Hessigner, J., Ahearn, E., Eickhoff, J., & Zhao, Q. (2016). Randomized
controlled equivalence trial comparing videoconference and in person delivery of
cognitive processing therapy for PTSD. Journal of Telemedicine and Telecare, 22(4), 238-
Morland, L., Mackintosh, M., Rosen, C., Willis, E., Resick, P., Chard, K. & Frueh, B. (2015).
Telemedicine versus in-person delivery of cognitive processing therapy for women with
posttraumatic stress disorder: A randomized noninferiority trial. Depression and Anxiety,
32(11), 811-820. https://doi.org/10.1002/da.22397