Jan./Feb. 2007

Country Comfort — Mental Health Telemedicine in Rural America
By David Surface
Social Work Today
Vol. 7 No. 1 P. 28

Video psychiatric service delivery isn’t perfect, but it is providing mental health care to rural areas where there may have been none.

In the foothills of northeastern Arizona’s White Mountains in a small town nestled on the banks of the Little Colorado River, a woman enters a darkened room and sits before a large TV monitor. The face that appears on the monitor smiles, looks into her eyes, and calls her by name. “Good morning, Linda. How are you feeling today?”

The World of Telemental Health
Telemental health utilizes a variety of technologies, but the one most often used is video teleconferencing (VTC) technology, in which a patient or group of patients in one location and a clinician in a different location look at a computer monitor or television screen to see and hear each other in real time.

While some people may think of Internet VTC as a tool for CEOs in corporate boardrooms, it’s now being used as a means of bringing basic mental health services to underserved people in the most remote areas of the country. In places such as Springerville, AZ, and Big Stone Gap, VA, with small populations, mental health services arrive through a network of broadband telephone lines.

“We’ve been doing telemedicine since 1998,” explains Michael Downs, MSW, ACSW, LCSW, CEO at Little Colorado Behavioral Health Centers. “We’re about 150 miles from Flagstaff, AZ, where our managed care organization is.”

Flagstaff is the home of the Northern Arizona Regional Behavioral Health Authority (NARBHA), which provides telemedicine for a network of small behavioral health clinics throughout the region. “For all the patients in Springerville and St. Johns, every single psychiatric service they receive is over video,” says Nancy Rowe, telemedicine program manager for the NARBHA. “Those were the first two clinics we provided telepsychiatry to. They’re so tiny and remote, it was the only way to give them access to those services.”

When a nurse practitioner who was providing telemedicine services from Flagstaff moved to Colorado, Downs decided to use technology to keep from severing the link. “We partnered with her because we liked the service she provided,” says Downs. “So she set up a DSL line, and now she’s providing 21/2 days of telemedicine a week from her home.”

While many people speak of mental health telemedicine in terms of improved access, equally important issues are continuity and longevity.

“Before we instituted telemedicine, the patients in those small towns were seeing psychiatrists come and go,” says Rowe. “Now they’ve had the same psychiatrist for 10 years, so they have that continuity that’s so important for the development of the therapeutic relationship.”

Another long-running rural telemental health network is The Appal-Link network that serves nine sites throughout rural Virginia. With support from the Appal-Link project, the Blue Ridge Community Services Board in Roanoke began in spring 1997 to provide specialized interpreting, counseling, case management, and support services to deaf individuals with mental health conditions.

“Our entire mental healthcare system in Virginia has become more integrated since the implementation of the Appal-Link Network more than three years ago,” says Henry A. Smith, LCSW, project director of Appal-Link. “Patients leave the psychiatric hospital sooner and stay out longer as a result of advances in continuity of care.”

Needed Support
Luckily for its practitioners and recipients, this new form of mental health delivery receives financial support from the federal government.

“If you look at rural areas,” says Downs, “there’s a lot of videoconferencing for psychotherapy and a lot of third-party reimbursement, particularly from Medicare.”

Rowe cites the high expense of rural telecommunications as a factor driving federal support. According to a study by the Telemedicine Alliance of Healthcare Organizations project of the Office of Rural Health Policy, service connection costs for rural telecommunications lines needed for telemedicine were approximately $7,543 per month after installation costs and equipment purchases. In contrast, the monthly service connection costs of an identical system contained entirely in the Denver metro area would be $805.26 per month, or roughly 10% of the fee charged in the rural areas.

“Any telemedicine network in the U.S. that has rural clinic locations are eligible to receive a federal rebate on their telecommunications lines because rural services are 10 times more expensive,” says Rowe.

What to Call It?
One of the most basic initial challenges for any discussion of this relatively new practice is what to name it. Telepsychiatry, telemental health, video counseling, and online therapy are all terms that probably should not be used interchangeably, but often are.

According to Downs, the most appropriate term is telemedicine. If counseling or psychiatric services are involved, Downs admits that the term should probably be modified to psychiatric telemedicine.

For Downs, telemedicine is not a sweeping term that obliterates the specialties involved—it’s used precisely because these many kinds of health services, both medical and behavioral, are not offered in isolation, but in concert with one another. And it’s often rural isolation, with its limited opportunities for observing and interacting with the patient or client, that prompts this kind of holistic team approach.

The Growth of Mental Health Applications
Telemedicine itself has been in use for more than 30 years, primarily for teleradiology and special medical consultations. However, according to Jon Linkous, executive director of the American Telemedicine Association, there’s been a recent surge of growth in its use as a tool for providing mental health services.

“Mental health is now one of the four or five biggest uses of telemedicine technology in this country,” says Linkous. “It’s a growing area with a lot of interesting applications.” As a result of this growth, the American Telemedicine Association has developed its own special interest group focused on mental health.

One factor driving the growth of telemedicine technology in mental health is the rapid advancement of computer technology, including the use of enhanced telephone lines to upgrade data transmission networks. The better the equipment works, the more people want to use it.

“The technology has really improved,” says Downs. “When we first started using this equipment, it was patchy. The voice was delayed, some of the video would get that digital checkerboard break-up—now, it’s all live. You talk, and it’s almost instantaneous. There’s still a slight delay, but it’s only a half second.”

Patient Satisfaction
As with any new technology, there were some initial reservations about the quality of mental health services delivered via videoconferencing. A primary concern for mental health providers was how their patients would react to the unfamiliar technology.

“Our policy is that every patient is given a choice; they have to sign an informed consent form—if you don’t wish to receive services in this way, you can travel to a location where a psychiatrist can see you in person,” says Rowe. “I had no idea how they felt about it at first, but their comments in the initial satisfaction survey were positive.”

While Downs reports some initial reservations on the part of patients, they were temporary. “One small drawback is that the first session is sometimes a little intimidating for people who’ve never participated in it before because they don’t know what to expect,” says Downs. “Most people are used to being a passive observer of television as opposed to having live interaction with it. So it takes a little time for people to adjust to that.”

But after that brief initial period of adjustment, Downs reports that patients’ experiences are extremely positive. “After the first session, our patients tell us that they sense no feelings of separation or estrangement. In fact, most people’s reaction to it is that it’s just like having the therapist in the room with you. I’ve only known two clients out of thousands who said they really didn’t like it. But it didn’t stop them from coming in.”
For mental health professionals, adjusting to the new technology and evaluating its usefulness is an ongoing process.

“If you look at online therapy, there’s a lot of debate about whether that’s actually therapy because some people feel you can’t do traditional therapy online,” says Miream Coleman, MSW, senior policy associate for clinical social work at the National Association of Social Workers (NASW). “The best psychotherapy treatment is face to face.” However, Coleman concedes that telemedicine does have its uses. “It does help people who can’t get to an office or who have to travel for hours to get the help they need. It’s beneficial for helping people have access to care they couldn’t otherwise.”

But while some tend to view mental health telemedicine as the lesser of two evils—it is better than no help at all. Mental health professionals who actively work with the technology are beginning to speak of what they see as its unique benefits.

Many mental health professionals point to an increased openness from their patients participating in telemental health sessions; some go so far as to say they believe they actually get better information from their patients through telemedicine than they do face-to-face.

“Some patients have said that they actually prefer not being in the same room with the psychiatrist,” Rowe says. “Some patients feel more comfortable opening up and sharing more that way.”

“We’ve also noticed that for some psychiatric patients who have a lot of anxiety, especially social anxiety, and issues with intimacy, they like it a lot better,” Downs says. “They’ve told us they’re a lot more comfortable than seeing the doctor face to face. It’s actually a better situation for them, and they’re often able to make more progress that way.”

Developing Professional Standards
As in many other areas of modern life, the development of technology (particularly Internet-based technologies) tends to move at a faster pace than society’s ability to consider the effects and create safeguards. Mental health professionals are working to stay ahead of that curve. Several professional organizations for both psychology and psychiatry, including the American Psychiatric Association and the American Psychological Association, have established ethics committees to develop guidelines for behavioral telehealth. Linkous says the American Telemedicine Association is currently developing overall standards for telemental health. “We hope to develop them in cooperation with mental health organizations,” says Linkous. “And our next annual meeting will contain a special focus on mental health.”

Although the NASW does not have an official policy about mental health telemedicine, there are a set of guidelines, or what Coleman calls technology standards, on the NASW Web site. The guidelines were developed in 2005 in partnership with the Association of Social Work Boards.

“We were getting a lot of questions about the use of technology in practice,” recalls Coleman. “It seems as if technology was really becoming integrated into the work, and people needed some guidelines to help them decide how to go about it properly.”

While we were working on these technological standards, Coleman and her coworkers considered every aspect of communications technology that social workers may use in their practice, including the fax machine, answering machine, and even the cell phone.

“They provide guidelines and an overview of things you should caution yourself on,” says Coleman. “For social workers doing online therapy, using e-mail and chat rooms, you must have encryption software to prevent hacking, firewalls, etc. You have to be very careful about making sure you have certain security measures in place to ensure confidentiality.”

A New Kind of Team Approach
Perhaps one of the most common misconceptions about mental health telemedicine is that it takes place between two persons who are miles apart, and that both patient and provider have only the video image before them, with which to interact. In fact, many provider networks require the presence of a third party in the room with the patient during the session to provide the patient and provider with needed information and support.
“One of the protocols of our network is that we generally require a case manager or nurse in the room with the patient at the remote location,” explains Rowe.

“We always have a behavioral health professional or a registered nurse in the room with the client during the session,” says Downs. “They can make any physical observations that need to be made. They’re trained to do blood pressure, and they weigh the patient in. If there are any physical problems that need to be investigated, we have a very tight coordination of care with the patient’s primary care physician.”

In addition to providing basic medical information, the third party can provide the therapist with subtle physical observations that the therapist may not be able to make from a distance.

“One of our psychiatrists says that sometimes she has difficulty telling on video if the patient is crying, so now the nurse in the room can point out to the doctor, ‘Mary is crying now,’” says Rowe. “That’s actually created an improvement in our team care because the patient realizes that there’s a team approach to their care. They see two people working together in the same visit; that minor drawback in not being able to see every little thing is more than made up for by the patient experiencing the team approach. I’ve actually heard patients say, ‘I’m really glad to see how all these people are working together to help me.’”

— David Surface is a freelance writer and editor based in Brooklyn, NY.