The Effectiveness and Feasibility of Videoconferencing Technology to Provide Evidence-Based Treatment to Rural Domestic Violence and Sexual Assault Populations

Abstract

Objective: Although evidence-based treatments for post-traumatic stress disorder (PTSD) have been available for some time, many treatment-seeking trauma survivors are unable to access such services. This is especially the case in remote and rural areas where access to specialists is an exception rather than a rule. Advances in videoconferencing-based technologies are improving rural residents' access to specialized psychological services. However, at present, little is known about the viability and efficacy of providing psychological interventions via distal technologies to individuals who present at rural domestic violence and rape crisis centers. The present study attempts to partially address this void by evaluating, in the context of an uncontrolled trial, the effectiveness and feasibility of providing evidence-based, trauma-focused treatment via videoconferencing to rural survivors of domestic violence and sexual assault. Materials and Methods: Participants in the present study were clients referred to the Wyoming Trauma Telehealth Treatment Clinic (WTTTC) for psychological services via videoconferencing from distal domestic violence and rape crisis centers located in the state of Wyoming. Fifteen female victims of assaultive violence who received at least four sessions of trauma-focused treatment via videoconferencing-based technology at distal rape and domestic violence crisis centers were included in the present study. Participants completed measures of PTSD and depression symptom severity and client satisfaction. Results: Participants evidenced large reductions on measures of PTSD (d = 1.17) and depression (d = 1.24) symptom severity following treatment via videoconferencing. Additionally, participants reported a high degree of satisfaction with videoconferencing-administered services. Conclusions: Results provide evidence in support of videoconferencing as an effective means to provide psychological services to rural domestic violence and sexual assault populations. Clinical implications and avenues for future research are discussed.

Introduction

Sexual assault and domestic violence are quite prevalent within the general population and can have significant implications for an individuals' mental health. Results from the National Violence Against Women Survey indicate that ∼52% of women report a history of assaultive violence at some point in their lives.¹ Prevalence reports for intimate partner violence have been estimated at 25%,² and information regarding the frequency of sexual assault is more difficult to determine, as most instances go unreported.³ Regardless, assaultive violence is clearly a significant societal concern with an unfortunately high rate of occurrence. Further, despite common misconceptions that rural environments are free from high rates of violent crime, prevalence rates of interpersonal violence, such as sexual assault and domestic violence, are comparable in rural contexts.⁴

A common consequence of domestic violence and sexual assault is post-traumatic stress disorder (PTSD).^5
–7 As outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV),⁸ PTSD is the collection of persistent symptoms of re-experiencing (e.g., intrusive recollections or nightmares of the event), avoidance and numbing of general responsiveness (e.g., avoidance of thoughts, feelings, or conversations associated with the trauma, feelings of detachment from others), and hyperarousal (e.g., exaggerated startle response, hypervigilance) following exposure to a traumatic event. Also, there are a number of secondary psychological difficulties that often emanate from assaultive violence aside from or in addition to PTSD. For instance, high rates of comorbidity between PTSD and depression have been documented among intimate partner violence (43%)⁹ and interpersonal assault (52%)¹⁰ populations. Further, as a consequence of pervasive avoidance behaviors to trauma-related cues and reminders, individuals with PTSD often abuse substances and may withdraw socially, thereby increasing the likelihood of developing substance dependence disorders and secondary depression.¹¹

Fortunately, a number of empirically supported treatments (ESTs) exist to alleviate PTSD and associated forms of psychological distress following assaultive violence. Prolonged exposure,¹² a cognitive-behavioral treatment, has garnered substantial empirical support and is often regarded as one of the most effective interventions for PTSD.^13
–15 The primary objective of PE is to facilitate the gradual confrontation of typically avoided memories, images, objects, and situations associated with the traumatic experience through exposure exercises. Additionally, cognitive processing therapy (CPT),¹⁶ a cognitive-behavioral treatment originally designed for rape populations, has received strong empirical support and is also recognized as a highly effective treatment for PTSD.^17,18 The goal of CPT is to target and modify distorted beliefs and cognitions about the meaning and implications of the traumatic event through in-session dialog and between-session written exercises. Also, motivational interviewing (MI)¹⁹ can be useful when attempting to facilitate behavior change during treatment, such as when a client is reluctant to engage treatment, has co-occurring substance dependence issues, or is experiencing ambivalence about terminating an abusive relationship.

Rural Residents’ Barriers to Evidence-Based Trauma Treatment

Although a number of evidence-based treatments exist to address emotional and psychological difficulties emanating from sexual and physical violence, rural populations experience considerable difficulty accessing such services. In recent years, rural residents' inequitable access to quality mental health services has become a growing concern. A number of logistical barriers, such as geographic obstacles and transportation difficulties, as well as individual and social factors (i.e., poverty, high rates of unemployment, poor health, and reduced social and health services),^20,21 have been cited as possible reasons for disparate access to psychological services. In fact, most rural residents with a psychiatric diagnosis fail to receive any mental health treatment, and those who do are typically seen by their primary care physician rather than a mental health specialist.²² Further, stigma associated with seeking mental health services and concerns about anonymity and confidentiality when receiving psychological services are more pronounced in rural settings.^23,24 Accordingly, a number of characteristics, inherent to rural populations, significantly limit trauma victims' ability to access psychological services.

Also contributing to the disparity of quality mental health treatment in rural communities is individuals' and providers' access to evidence-based treatments. Although rural providers have been found to generally espouse favorable attitudes toward ESTs for trauma, they report significant obstacles to procuring specialized training in trauma treatment (i.e., geographical barriers, insufficient time to learn ESTs, lack of access to relevant information resources, and prohibitive expense of training).²⁵ Moreover, rural communities have greater difficulty securing qualified mental health professionals.²⁰ Typically, mental health facilities specializing in the provision of evidence-based treatments are located in urban centers or university-based clinics, which are often inaccessible to rural residents. Hence, despite the existence of a number of effective, evidence-based interventions for post-traumatic distress, rural providers and trauma victims are often unable to access and benefit from them.

Efficacy of Videoconferencing-Based Psychological Treatment

An obvious means of connecting mental health specialists with rural clientele who may not have access to evidence-based, trauma-focused treatment is telemental health. Telemental health can refer to a broad range of technologies, including telephone, Internet and e-mail, virtual reality simulators, and videoconferencing.²⁶ One current means of connecting rural trauma survivors with specialized care is via secure, encrypted videoconferencing-based technology. Videoconferencing is an innovative technological medium that allows individuals to communicate securely, with access to both visual and auditory information, through a computer monitor or video screen in real time. Accordingly, videoconference technology provides a suitable proxy for traditional in-person service delivery—especially in very rural areas where services would otherwise be unavailable altogether.

Initial empirical evaluations have garnered encouraging support of videoconference technology as a viable medium to provide specialized evidence-based psychological services to previously underserved, remote client populations. Although there have been few controlled investigations of psychotherapy delivered using telemental health technology, evidence suggests that the efficacy of this medium is equivalent to that of traditional in-person care (for a recent review, see ref.²⁶). In addition, a number of studies have documented provider and client satisfaction with general psychotherapy services provided through this medium.^27
–29 Telemental health appears to be a successful solution to the plight of rural residents, whose standard of care in many instances is no services at all.

Although studies have documented the efficacy and high rate of provider and client satisfaction with general psychological treatment provided via videoconferencing-based technology, little is known about the feasibility of using this medium to deliver trauma-focused therapy. For example, Thomas et al.³⁰ found evidence supporting the viability of using telemedicine for psychiatric screening, evaluation, treatment, and referral among rural domestic violence victims with diagnoses of primarily PTSD and major depression. Results revealed high client satisfaction with the quality of services provided and successful rates of evaluation completion and treatment initiation. However, participants received psychopharmalogical treatment and were monitored via telehealth by a psychiatrist until stabilized and then transferred to a community health center. Additionally, rates of symptom improvement were not assessed. Accordingly, the results of this investigation do not speak to the effectiveness or feasibility of utilizing telehealth as a medium for delivering psychological services.

To date, few investigations have monitored symptom improvement in an effort to evaluate the utility of videoconferencing-administered treatment for PTSD. Hassija and Gray³¹ published a case report that demonstrated the effectiveness of PE provided via videoconferencing for a rural motor-vehicle accident survivor with PTSD. Results were encouraging, as they documented a high level of client satisfaction with the delivery of services and marked improvement in PTSD symptoms at post-treatment and follow-up periods. Additionally, Frueh et al.³² compared the efficacy of telehealth-administered and traditional in-person cognitive-behavioral group treatment for combat-related PTSD in a randomized investigation. No significant differences were evidenced between groups on PTSD and depression clinical outcomes at a 3-month follow-up period or on measures of patient satisfaction. Further, Germain et al.³³ investigated the effectiveness of cognitive-behavioral therapy delivered via videoconference versus in-person among a sample of adult clients with a primary diagnosis of PTSD. Results failed to demonstrate any significant differences between mode of treatment delivery, as participants who received treatment from either medium improved significantly on measures of PTSD and depression. However, it is unknown how generalizable the results are to domestic violence and sexual assault populations, as their participants were a mixed trauma sample. In addition, as reviewed below, there are a number of unique, complicating features of assaultive violence that may render a telehealth-based approach unsuitable for satisfactorily addressing the mental health needs of this population.

The Present Study

There is initial support to suggest that videoconferencing is an efficacious means of connecting rural clients with specialized, evidence-based services for PTSD. However, the viability of connectivity with rural domestic violence and rape crisis centers is still unknown. Specifically, victims of domestic violence and sexual assault presenting for services at community crisis agencies may be more likely to present with more acute needs, which may hinder their ability to commit to receiving ongoing psychological services. Additionally, because of commonly co-occurring feelings of self-blame, guilt, and shame, concerns with confidentiality may be more pronounced among rural domestic violence and sexual assault survivors and negatively interfere with treatment. Similarly, because of the interpersonal nature of victims' traumatic experiences, treatment is likely to require a tremendous degree of trust and rapport. Accordingly, it has not yet been empirically established whether this requirement can be met to the degree necessary via distance technology. The present investigation attempted to evaluate the feasibility and effectiveness of videoconferencing-administered, trauma-focused treatment among rural domestic violence and sexual assault survivors presenting to community sexual assault and domestic violence crisis centers.

Videoconferencing-based services were provided through the Wyoming Trauma Telehealth Treatment Clinic (WTTTC), an established partnership between a university-based mental healthcare clinic and three rural domestic violence/rape crisis centers several hours away. The distal crisis centers are nonprofit organizations that provide prevention and awareness education to the public regarding assaultive violence and immediate and practical support (e.g., temporary housing, food, clothing, monetary assistance) to survivors of sexual assault and domestic violence. However, none of these centers have mental health professionals on staff and, instead, have historically provided referrals to general counseling centers in the community, which typically do not specialize in evidence-based trauma interventions. Although generic supportive counseling can be helpful for victims, interventions focusing specifically on trauma-related distress have been shown to promote optimal post-traumatic symptom reductions (e.g., see ref.¹⁵). Accordingly, the present research utilizes videoconferencing as a means to bridge this service delivery gap and connect rural sexual assault and domestic violence victims with our university-based trauma treatment clinic.

Materials and Methods

Participants

Participants in the present study were clients referred to the WTTTC for psychological services via videoconferencing from distal domestic violence and rape crisis centers located in the state of Wyoming. Since the WTTTC's inception, 37 clients have been referred. However, because of the acute needs of individuals generally presenting at crisis centers, many clients are unable to commit to an extended course of therapy by virtue of relocation, unyielding work schedules, etc. Accordingly, many referrals are one-time consults and receive, among other services, treatment referral recommendations for clients relocating to shelters or residences in other states. Therefore, all clients who began formal treatment and had received at least four sessions of trauma-focused individual therapy were considered eligible for inclusion in the present analysis. Based on these criteria, 15 participants aged 19–52 were included in the present sample.

Measures

PTSD symptom severity

The Post-traumatic Stress Disorder Checklist (PCL),³⁴ a brief, self-report questionnaire, was administered to assess the presence and severity of PTSD symptoms. The PCL contains 17 items that correspond to diagnostic criteria outlined in the DSM-IV for PTSD. Respondents are asked to rate on a 5-point scale (1 = not at all, 5 = extremely) the degree of distress experienced within the past 30 days as a result of PTSD symptoms. Total scores range from 17 to 85, with 44 being the recommended cutoff for PTSD for community samples.^35,36 The PCL has demonstrated good psychometric properties and has been found to correlate well with other well-established measures of PTSD.^35,36

Depression symptoms

Symptoms of depression were measured by the Center for Epidemiological Studies Depression Scale (CES-D),³⁷ a brief self-report instrument that assesses severity of depression symptoms. Respondents are asked to rate how often they have experienced 20 depressive symptoms in the past week using a 4-point scale (1 = rarely or none of the time [<1 day], 4 = most or all of the time [5–7 days]). Total scores range from 0 to 60, with scores above 16 indicating the possible presence of clinically significant depression. The CES-D is frequently used in depression studies and has demonstrated both exceptional validity and reliability.^37,38

Client satisfaction

The Wyoming Telehealth Trauma Clinic Client Satisfaction Scale (WTTCCSS) was created by the second author to assess client opinions and reactions regarding videoconferencing-based treatment delivery. The measure consists of 11 items and asks respondents to rate on a 5-point scale (1 = poor, 5 = excellent) their telehealth-based treatment experience. Items included assess sound and video quality, ease of equipment use, confidentiality of services, helpfulness and sensitivity of therapist, scheduling of sessions, matching of treatment to individual needs, and overall service quality. Total scores can range from 55 (indicating a high satisfaction) to 11 (indicating poor satisfaction).

Treatment

Psychological services were provided by master's level therapists working toward a doctoral degree in clinical psychology. All therapists had received extensive training in trauma intervention theory and techniques and were supervised weekly by a licensed doctoral level psychologist. Videoconferencing-based psychological services provided through the WTTTC were delivered at the domestic violence/rape crisis centers themselves, using secure, encrypted videoconferencing technology. Specifically, Polycom VSX3000 videoconferencing units were used to establish the connection between therapists at the university psychology clinic and the three distal crisis centers.

Participants were provided with free, trauma-focused psychotherapy services. Typically, sessions 1–2 were devoted to information gathering and rapport building. Then, participants received individual sessions of trauma-focused, evidence-based therapy. Treatment for all participants was based on the treatment manuals for PE¹² or CPT.¹⁶ Additionally, in instances where there were additional concerns regarding separation from an abusive partner, MI¹⁹ techniques were supplemented to facilitate decision making regarding relationship termination. Treatment components were applied flexibly, depending on the needs of the client. For instance, in cases of psychological distress emanating from domestic violence, treatment may have included PE techniques to combat PTSD symptoms and MI procedures to address ambivalence regarding the client's decision to stay or leave their current relationship. Typically, sessions took place weekly and lasted 60–90 min depending on the specific treatment being implemented. Assessment measures were administered every four sessions.

Results

Participants included in the present investigation were all female primarily identified as Caucasian (n = 13, 86.7%). The sample had a mean age of 30.20 (standard deviation [SD] = 9.25). At the start of treatment, the majority of all participants reported being either single (n = 7, 46.7%) or married (n = 7, 46.7%), and one individual indicated she was divorced (6.7%). With respect to reason for referral, the majority of participants were referred for distress emanating from a domestically violent relationship (n = 12, 80%), followed by distress related to a sexual assault experience (n = 3, 20%). Participants' self-reported symptom levels at the beginning of treatment were 50.07 (SD = 17.77) on the PCL and 27.47 (SD = 14.12) on the CES-D. The mean number of videoconferencing sessions received was 13.33 (SD = 13.89).

Treatment Outcome and Client Satisfaction

At post-treatment, participants' mean PCL score was 32.20 (SD = 12.68). Using Cohen's d ³⁹ to calculate treatment effect size, participants exhibited large reductions on PTSD symptoms (d = 1.17). On the CES-D, participants' post-treatment score was 13.07 (SD = 9.07), also indicating a large reduction in depressive symptoms (d = 1.24). Further, when separated by trauma type, effect sizes were large for each group on PTSD and depression outcomes (domestic violence: d = 1.00, d = 1.33; sexual assault: d = 2.18, d = 1.05, respectively). Accordingly, participants evidenced large symptom improvements on measures of PTSD and depression symptom severity (see Fig. 1). Additionally, clients' reports of satisfaction with the provision of psychological services via videoconferencing on the WTTCCSS revealed very high levels satisfaction (M = 52.93, SD = 2.43; see Table 1).

Fig. 1.

Participant's reductions on measures of post-traumatic stress disorder (PTSD) and depression symptom severity.

Table 1.

Means and Standard Deviations for Individual Items of the Wyoming Telehealth Trauma Clinic Client Satisfaction Scale ^a

ITEM	M (SD)
1. Sound quality	4.67 (0.49)
2. Video quality	4.60 (0.51)
3. Ease of equipment use	4.53 (0.64)
4. Confidentiality of services	4.93 (0.26)
5. Helpfulness of therapist	4.80 (0.56)
6. Sensitivity of therapist	4.93 (0.26)
7. Scheduling of sessions	4.93 (0.26)
8. Timeliness of scheduling first appointment	4.87 (0.35)
9. Matching of treatment to your individual needs	4.87 (0.35)
10. Respect shown for your opinions about treatment	4.93 (0.26)
11. Overall quality of services	4.87 (0.35)

Participants were asked to rate each item on the following scale: 5 = excellent, 4 = very good, 3 = good, 2 = fair, 1 = poor.

M, mean; SD, standard deviation.

Discussion

Results from the present study provide support for the effectiveness of videoconferencing as a medium for providing evidence-based trauma-focused treatment to trauma victims presenting at distal rural domestic violence and rape crisis centers. Specifically, participants evidenced large treatment gains on measures of PTSD and depression symptom severity after receiving psychological services via videoconferencing. In fact, rates of symptom improvement are comparable to effect sizes previously documented for cognitive-behavioral interventions for PTSD in the Practice Guidelines from the International Society for Traumatic Stress Studies (i.e., 0.62–1.91 for PE and CPT) for PTSD.⁴⁰ Additionally, participants reported a high degree of satisfaction with videoconferencing-administered services. Accordingly, there is some support to suggest that videoconferencing provides an effective means to deliver services to underserved rural domestic violence and sexual assault populations.

Videoconferencing appears to be a viable medium for implementing trauma-focused treatment, including approaches that utilize exposure techniques. Similarly, providing mental health services distally to underserved domestic violence and sexual assault populations appears feasible. Although telehealth has been used to treat a number of mental health concerns, the unique features of domestic violence and sexual assault, especially in acute/crisis contexts, make generalizations of previous findings regarding the efficacy of videoconferencing-based treatment unclear. For instance, victims may have been reticent to receive, and subsequently benefit from, treatment delivered via distance technology because of stigma associated with seeking services. Additionally, it was unclear whether clients would perceive the therapist to be distant or the treatment to be less personal than traditional in-person therapy and, further, whether these perceptions could compromise the quality of services delivered. However, the results of this investigation suggest that such concerns, though understandable, are inaccurate. Rather, evidence indicates that treatment provided via videoconferencing is capable of achieving comparable gains that accrue during traditional in-person services. Further, it is worth noting that when videoconferencing technology is utilized to connect rural clients with distant specialists, the relevant comparison is not in-person services—but rather, no psychological services at all. Thus, the ability to mitigate any degree of symptoms of emotional distress is a valuable improvement to the standard level of care.

Results from the present study have a number of valuable implications for practicing psychologists, particularly those in rural areas. Most notably, clinicians should consider the possibility of utilizing videoconferencing technology to meet the mental health needs of rural communities and facilitate such populations in overcoming the numerous logistical barriers to accessing evidence-based psychological services. However, there are some important considerations when attempting to deliver services via videoconferencing. Of paramount importance is client safety. In some instances, clients, particularly those who are victims of assaultive violence, may be so severely distressed that they are at risk for self-harm. Because of the pre-eminence of this particular safety concern and unclear ability to manage such crises distally, acutely suicidal or homicidal individuals are not eligible for telehealth services through our clinic. Rather, emergency resources in the community are the appropriate referral until this emergent need is adequately addressed. Ethically, it would be difficult to manage acutely suicidal individuals from afar, especially because the WTTTC is comprised of master's level therapists who are still working toward their terminal degrees. Although safety concerns are not insurmountable in the event that no other services exist, they do require careful consideration and planning by the therapist.

Also, technical difficulties, although rare, are a realistic possibility when providing services electronically. Accordingly, a back-up plan for service provision should be discussed with the client to avoid interruption with service delivery. For instance, therapists from the WTTTC inform their clients that if the videoconferencing connection fails during session and cannot be corrected promptly, the session will be conducted over the telephone. Accordingly, clients and therapists should know how to contact one another via telephone during session in the event of a technology failure. Lastly, despite the fact that a number of clients have been successfully treated with videoconferencing and have reported high satisfaction, some clients may find this method of service delivery unappealing, which can contribute to higher rates of attrition. Thus, it is beneficial for clinicians to inquire about and discuss with their client any concerns regarding this method of service delivery.

Results from the present study are subject to several limitations. Most importantly, there was no comparison group. We realize that this limits our ability to draw firm conclusions about the efficacy of trauma-focused treatment provided via videoconferencing, as we are unable to rule out a number of potential confounds, such as spontaneous remission. However, it is worth noting that some of our clients' traumatic experience occurred several years earlier, based on information contained in intake reports. Based on encouraging results of this initial, feasibility study, we will be conducting a 2-year controlled trial of telehealth versus conventional in-person services for domestic violence and sexual assault survivors. Specifically, we expect to evaluate outcome data obtained from clients who received psychological services in-person at a university psychology clinic in comparison to those seen via videoconferencing. Also, we do not have follow-up data on our participants, which limits our ability to make conclusions regarding the maintenance of treatment gains.

Additionally, results are based on a small sample of females who were referred from rural domestic violence and rape crisis centers and were willing to receive psychological services. Accordingly, because of our select sample, generalizability of results may be limited to other assaultive violence or trauma populations. Also, we chose to only include participants who had received at least four sessions of individual therapy, which poses difficulties with potential selection bias. However, many of our clients, at the time of referral, are not seeking even brief ongoing therapy from the outset, as they are often in a state of crisis, in the process of relocating to different towns and states to seek safety and/or separation from their perpetrator, or have more pressing practical needs (e.g., shelter, transportation) to attend to. Rather, a number of our client referrals seek and receive just a couple of sessions of supportive therapy to aid them in coping with their immediate crisis situation. In these instances, we do not collect “post-treatment” data because it is known from the outset that services rendered are consultations rather than psychotherapy and there is no a priori expectation that substantive psychopathology or distress could be remedied given the time constraints.

Conclusions

In summary, these results suggest that videoconferencing can be an effective medium to provide specialized, evidence-based psychological services to rural domestic violence and sexual assault populations. These initial findings are promising, as it is now possible to improve rural trauma survivors' access to evidence-based psychological services. Future investigations should continue to evaluate the efficacy of psychological interventions delivered via videoconferencing using controlled investigations with diverse trauma populations. In addition, variables that may impact the efficacy of videoconferencing technology or contribute to client attrition should also be investigated.

Footnotes

Acknowledgments

The authors thank Dr. Rex Gantenbein, Robert Wolverton, Thomas James, and Barbara Robinson from the University of Wyoming's Center for Rural Health Research and Education for their assistance in procuring funding and establishing connectivity to make this project possible.

Disclosure Statement

No competing financial interests exist.

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