Telehealth and the COVID-19 Pandemic: Making the Pivot from Offline to Online Therapeutic Interventions

Introduction

A wide body of literature related to advantages of telehealth therapies is now available. Factors contributing to positive outcomes generally include improved access to care, lower transportation costs, high patient satisfaction, openness to disclose personal issues, enhanced flexibility for scheduling, and increased ability for family members to participate. ¹ In addition, the benefits of general online interactions as a means of enhanced social behaviors have also been explored. A study examining Facebook usage, for example, found highly engaged users of social media were more likely to report lower rates of depression and anxiety compared with low-engaged counterparts. ² Similarly, users of a closed-group online journaling platform generally reported an enhanced sense of “family cohesiveness” after 2 months of using the service. ³ Benefits of online interactions have also been noted in support groups designed for individuals who identify as a caregiver for another family member. ⁴

Despite the plethora of research dedicated to online interactions, findings related to the use of telehealth during a Disease X event like COVID-19, are only now beginning to emerge. Disease X, where X denotes the “unexpected” is a term utilized by the World Health Organization to generically note the widespread growth of a potentially fatal pathogen. ⁵ Brief summaries of methodologies, contexts, and outcomes of telehealth interventions utilized during the most recent Disease X event are reviewed in the following sections. The “delivery of healthcare services between a provider and a patient [or client] who are physically distant from one another at the time of service” is how telehealth was operationally defined for the review. ⁶ One should note, these services are variable, and may include mediums such as the internet, phone apps, and videoconferencing.

Training and Support

The COVID-19 pandemic accelerated the need for helping professions to create and provide virtual services for their clients. Within weeks of global lockdowns, professionals met virtually through a 4-day workshop hosted by the eHealth Pediatric Summit. ⁷ Nearly 10,000 parents and health care participants from 16 countries attended the online event. While the pandemic has presented obvious challenges, families reported several benefits related to virtual therapeutic interventions. Therapy through telehealth, for example, was cited as a means to save time, effort, money, and inconvenience for parents of children with disabilities. Encouraging results, as many families with special needs live in rural areas with fewer resources and often have greater time demands than others.

Virtual technologies have also been instrumental in assisting health care workers, who were otherwise overwhelmed by the demands created by the COVID-19 pandemic. In March of 2020, all medical staff at Johns Hopkins were asked to participate in the Resilience in Stressful Events (RISE) mentorship program. ⁸ RISE support for medical staff included coordinated efforts with several established wellness programs within the institution. During the first 9 months of the pandemic, RISE serviced over 4,000. Worker support and maintenance of resilience were deemed most critical to the pandemic response.

Before COVID-19, the typical RISE intervention included in-person support with groups and individuals. While the pandemic did not eliminate these offline services, they were dramatically reduced and often replaced by virtual support. Additional peer responders with mental health backgrounds (e.g., psychiatric nurses) were trained to support employees during the early days of the health crisis. Notably, the trainings, traditionally held in-person, were conducted on virtual platforms as well. The success of the virtual support for health care providers, led to the implementation of the model in 84 additional hospitals by the end of 2020. ⁸ In addition, similar virtual training platforms have been utilized for surgical residencies and emergency psychiatric services in rural areas.^9,10

Therapists have utilized telehealth and e-therapies now for quite some time. Traditional guidelines for nonlicensed counselors, however, often involves a supervisor observing a session on the other side of a one-way mirror. Cyber supervision has been described as utilization of digital tools through a synchronous audio/video format, when the supervisor and the trainee are located in different physical locations. ¹¹ While guidelines for cyber supervision date back to 2001, since that time several concerns have been reported. ¹² Ethical concerns about confidentiality, crisis situations, and difficulty interpreting verbal and nonverbal cues in the light of physical separation were among the common pitfalls reported in a recent poll of mental health counselors. ¹³

Despite some of the concerns noted above, COVID-19 warranted an alternative to traditional face-to-face clinical supervision. A staff of clinical supervisors at the Barcai Institute in Tel Aviv, Israel, made the pivot away from face-to-face to virtual training through a new process they called PractiZoom. ¹³ During the first 2 months of the pandemic, over 100 virtual sessions were conducted between 14 clinical supervisors and 28 therapist trainees through Zoom. The process was transparent to clients, who were told about the necessary transition to cyber therapy/supervision. Supervisors communicated with trainees during counseling sessions through the WhatsApp text messaging service or phone calls.

On some occasions, supervisors actually made themselves present during the Zoom counseling sessions. The PractiZoom sessions allowed trainees to work with supervisors with specific expertise, despite different geographic locations. The program continues to garner positive feedback from all parties and will continue to be utilized as an alternative to face-to-face counseling/supervision sessions. In essence, findings suggest supervisors should not be constrained by geography and continue to explore innovative virtual technologies.

Mental Health Treatment

We have a substantial amount of literature available on the potential benefits of virtual therapies predating COVID-19. Clients who are attracted to teletherapy consistently cite the absence of barriers that are inherently linked to offline, face-to-face office visits. In particular, concerns for those who live in rural areas related to sparse provider availability and long commutes to a mental health facility, are essentially eliminated. The “convenience factor” is coupled with consistent findings of successful telehealth interventions. For example, Internet-delivered cognitive-behavioral therapy (iCBT), is among the most extensively researched telehealth therapies to date. ¹⁴ This form of telehealth has been shown to be as effective as offline/traditional CBT in reducing symptoms ranging from body dissatisfaction to depression and anxiety. ¹⁵

The fallout from COVID-19 is now serving as the catalyst for a renewed interest in the exploration of specific forms of therapy that have little to no history of deployment in an online environment. For example, virtual reality exposure therapy (VRET) has traditionally been practiced in the office of a trained clinician. The procedure typically involves the presentation of a computer-generated three-dimensional situation through head-mounted hardware. In turn, clients are allowed to face the target of a phobic reaction in a less-threatening, virtual environment. ¹⁶ Advances in technology now allow anyone with a Wi-Fi connection to partake in such virtual experiences.

Data collected just before the onset of COVID-19, suggest VRET will become more commonplace away from the clinician's office and in the comfort of one's own home. From 2017 to 2019, researchers compared VRET remotely versus in-person groups of individuals reporting a fear of flying (aviophobia). ¹⁷ Participants were asked to complete the Flight Anxiety Situations assessment, which measures anticipatory anxiety, in-flight anxiety, and fear of airplanes. Researchers also requested participants to schedule a flight at the beginning of treatment, with a departure window of 2-weeks at the end of the project. While all participants experienced a reduction in fears of flying, there were no significant differences between the in-person and remote VRET groups across all dependent measures.

A number of positive outcomes related to the “telehealth pivot” have also been reported at a Level 1 trauma center at the Boston Medical Center (BMC) in the United States. ¹ Psychological services within the BMC typically serve clients with posttraumatic stress disorder and major depressive disorder. Client therapy attendance rates improved from 71 percent to 87 percent in a few short weeks following the move to telehealth during the early stages of COVID-19. In turn, more clients were able to receive psychological treatment without the same health fears of contagion as one might face with offline office visits. Additionally, clients at BMC reported enhanced communication and social support through social media platforms and increased knowledge of online technologies in general.

Another area of offline/online treatment efficacy research has been focused on the potential success of treating eating disorders through online platforms. ¹⁸ To date, virtual interventions have been reported to provide the same efficacy as face-to-face interventions in some studies, but not others. ¹⁹ After the onset of COVID-19, investigators are now looking at the potential effectiveness of online platforms for higher level care (e.g., inpatient, residential, partial hospital, and intensive outpatient therapies). ²⁰ In the early stages of COVID-19, individuals were recruited to participate in a pilot study to evaluate a virtual intensive outpatient program (VIOP). VIOP consisted of 6 weeks of Zoom meetings, including family counseling and dietitian consultations. Client self-reported measures of feasibility and acceptability were collected at the end of the intervention phase. Results indicated significant improvements in all outcomes, including eating disorder symptoms, decreased symptoms of depression, increased self-esteem and quality of life, and overall satisfaction with the virtual treatment.

While the current review focuses on the benefits of telehealth, studies related to the transition from offline to online therapeutic services do not always produce positive results. Some individuals may be resistant, fearful, and averse to using technology in such a personal manner. For example, a large group of clinicians and trainees completed an extensive survey about their experiences during the COVID-19 telehealth transition. Many of the participants perceived a diminished sense of therapeutic skills and lower perceived efficacy for their clients' improvement. ²¹ However, a majority of these participants were young males with no prior experience with teletherapy. Nonetheless, it is important to consider a theoretical framework as the foundation for successful future online therapeutic approaches.

Telemental health measurement-based care (tMBC) is based on the premise that clients will benefit the most from services that are reliable and linked to continuous feedback from the provider. The latter will also gain competence through the same interpersonal exchange. ²² Measurement-based care in general, has been shown to be an effective practice with broad applications across a variety of conditions, settings, and populations. ²³ The process involves the systematic recording of information as the means to gauge progress and guide future interventions. Clients are likely to gain a better understanding of their problems and have a more meaningful therapeutic relationship as assessment feedback is discussed. Discrepancies between treatment goals and a client's current status may also serve as an impetus for directing the therapist toward more appropriate interventions. ²⁴

Douglas and colleagues (2020) have compiled a list of general tMBC strategies for optimizing success. For example, sending links to clients through e-mail or SMS (text-messages) allow clients to respond to questions within Health Insurance Portability and Accountability Act-compliant technology platforms (including encryption security measures). Telehealth technology also allows for multiple screen sharing to promote simultaneous viewing of feedback reports and other clinical tools. Accordingly, a wide range of screening measures and assessments can be built into the tMBC protocol. Notably, the protocol also provides a safe and efficient mechanism for online screening for contagious diseases.

Conclusion

Regardless of one's opinion about the merits of telehealth, the outbreak of COVID-19 demonstrated the need for a coordinated response between providers and governmental policies. Programs and initiatives across the globe are now focused on efficient and effective strategies for integrating digital technologies for therapeutic services during a Disease X event. However, the adoption of such strategies is often accompanied by concerns such as privacy and security. During the COVID-19 pandemic, a group of researchers proposed an “epistemological framework” to address these concerns resulting from the necessity of a pivot from offline to online services. ⁵ The framework specifically cites the need to integrate therapeutic narratives with online tools such as YouTube and social media platforms.

Questions regarding the pros and cons of telehealth will undoubtedly continue to emerge as mental health technologies continue to grow. Much of the research examines attitudes about the process and outcome. The current review is not intended to be an exhaustive review of that line of the telehealth literature. Again, the aim is not to suggest the replacement of offline office visits, but rather promote effective alternative online strategies in the presence of a Disease X outbreak. A recent survey of Israeli psychologists, therapists, and social workers illuminate the need and desire for professionals to learn the most effective ways to utilize and practice effective teletherapy. ²⁵ Of the many lessons learned from the most recent pandemic, being better prepared for making the pivot from offline to online services should be a goal for us all.