Welcome to Tele-Mental Health

Thinking through some curious aspects of online appointments.

Posted Apr 12, 2020

The shutdown associated with COVD-19 has pushed a huge proportion of mental health appointments by psychiatrists, psychologists, and other mental health professionals to be delivered using videoconferencing technology. 

To be sure, telehealth has been with us for quite a long time (I was involved in a pilot project well over a decade ago). Its growth until now, however, has been modest due to a myriad of issues including security and confidentiality, ability to bill for the service, and general apprehension that the format just isn’t as effective in establishing that critical alliance between clinician and patient/client. 

The pandemic, of course, changed all that, and seemingly everyone involved in the delivery of mental health care suddenly was pushed to use this technology…or else.  To help, states have been rushing to modify existing laws and regulations in an effort to make the service available to as many people as possible during this increased time of need.

Now several weeks into this new “experiment,” we are starting to get a sense of how this is working.  Not unexpectedly, the response from both clients and clinicians has been mixed. Some find the new technology distracting and difficult to learn, and some find the interactions more stale and impersonal. Others, however, love the format and are finding some unexpected benefits to telehealth within the realm of mental health treatment. In my own practice, several families have announced to me that even when in-person appointments become available, they would prefer to keep at least most of the visits online.

As more and more of these appointments take place, a number of important and interesting considerations have also arisen that have sparked debate and discussion. Many have come up before, but with the massive number of new people now using telehealth there is now a much wider audience.  Here are some examples.

Confidentiality. This issue has always been a concern for telemedicine, especially since some platforms are more secure than others. Since the coronavirus, there has been some loosening of which programs are allowable to use for telemedicine appointments but some recent incidents with Zoom and others have demonstrated why it remains a concern. With the ballooning of new telemedicine users, other types of confidentiality issues have also become apparent on both sides of the interaction. Clinicians need to make sure they are talking to patients in areas that can’t be overheard. Patients and clients, at the same time, may also be having these appointments in more public areas of their home where others can be listening, intentionally or otherwise.  In many cases, a quiet and private space in one’s home can be hard to find.

Boundaries. Telemedicine often brings the level of formality down a notch or two, with both clinicians and patients being more casual in dress and tone. This can often be a good thing, but it raises some questions about boundaries. Is it okay to talk to a client in their PJs?  How about if they are talking on their bed? With telemedicine both the clinician and the client get to see some glimpses into each other’s personal life that might otherwise not occur.  One child patient of mine asked for a tour of my house. These new dimensions can be both useful and distracting and speak to the need to think these things through carefully.

Vital Signs. Especially for those taking certain medications, it is generally recommended that vital signs are collected regularly particularly when changing doses.  Not being able to do them ourselves or in a clinic, questions arise about how much we can put off doing them or rely on patients themselves to report them.

Exposure. Individuals struggling with things like severe anxiety and their families may really like the new telemedicine format and not want to change back to in-person appointments in part because the process of getting to an appointment is quite challenging.  In many instances, this might make perfect sense by providing one fewer battle people have to fight.  At the same time, a switch to telemedicine appointments can mean fewer opportunities for people to be exposed to their fears which we know is often a necessary component to recovery.  Clinicians may need to think of more creative methods of gradual exposure during these times.

Recording. While clients have always had the technology to record treatment sessions, it now is a lot easier to do with telemedicine and can more easily be done without the clinician’s knowledge.  Like the other issues we’ve discussed, this may not universally be a good or bad thing but has both clinical and legal consequences that need to be considered and discussed.

What other issues have come up in your own interactions with telemedicine appointments? As it seems quite likely that one of the consequences of the coronavirus is a fast forward expansion of the amount of health care that get delivered by telemedicine permanently, it is good to get ahead of these issues as much as we can.