of remote technologies. In situations where clients take online assessments, clinical control over the environment is reduced (Luxton et al., 2014). For example, a client who takes a depression inventory while attending a social function may enter different responses than one who
completes an instrument in the office. When providing telemental health services to a client, the clinician should inquire about the circumstances under which the assessment was completed.
TREATMENT
Before implementing treatment using telebehavioral health, practitioners should know the different technologies that are available and their strengths and limitations (Johnson, 2014). The clinician and client must discuss and agree on the best strategy for treatment within the current context. Some clients may have broadband Internet with adequate speed for live videoconferencing. Others may not have the speed and broadband width necessary for video but may be able to use asynchronous methods, such as email or text messages, to communicate short-term needs. Both practitioners and clients will need to have a basic set of technical skills or training before embarking on a treatment regimen. Providers will likely need to tailor interventions to fit within a telemental health framework. The basic necessities include having the necessary equipment, such as a computer, camera, and microphone. Clinicians may also provide supplemental materials along with their video interventions, such as follow-up emails or texts, an online forum, and/or homework (Johnson, 2014). Therapeutic Presence Therapeutic rapport emerges as the provider and client get to know one another and develop a relationship (Sheafor & Horejsi, 2015). As the client develops trust, an alliance emerges, which helps to create an environment where change can happen. Inside the office, the provider can convey a nonjudgmental attitude, acceptance, and unconditional regard by communicating cues with body language, such as eye contact, body posture, and touch. The physical environment can welcome the client through the use of soft lighting, pleasant aromas, and pleasing aesthetics. When engaging a client in telemental health services, therapeutic presence must be carefully considered. The physical environments, both where the client is and where the practitioner is, must be consciously arranged to maximize visibility over video, yet still convey a sense of comfort. The physical space where the services are delivered must be large enough for the client to feel comfortable (Johnson, 2014; Luxton, Nelson, & Maheu, 2016; Luxton et al., 2014). If families or groups meet for services, the room must be large enough to accommodate them while allowing the therapist to be able to see each of the members. Multiple cameras may be needed during large family or other group sessions (Luxton, Nelson, & Maheu, 2016). The area where services are delivered should be in a quiet area of the building where there are minimal disruptions to the sessions. If teletherapy is delivered to the client in the home, distractions, such as the presence of roommates, family members, pets, or phone calls, should be minimized. If the provider would like to review a written document or report, the provider should send it to the client ahead of time. Telepresence allows for the provider and client to establish a supportive and engaging relationship despite the physical distance between them (Johnson, 2014). Beginning sessions may include a brief check-in with the client to allow time to adjust to the technical restraints of the session. The clinician may want to allow the client time to make adjustments to the physical space and computer setup before beginning a session. Cameras should be adjusted, usually in the
Many research studies document the effectiveness of telemental health services in treating individuals with a variety of behavioral health problems (Lauckner & Whitten, 2016; Lustgarten, 2017). Studies reveal that mental health outcomes from telemental health services are as effective as those for face-to- face treatments for individuals who have the following conditions: Panic disorder (Lauckner & Whitten, 2016; Lustgarten, 2017), anxiety (Bischoff et al., 2017), depression (Bischoff et al., 2017; Lauckner & Whitten, 2016; Lustgarten, 2017; Luxton, Pruitt, et al., 2016), PTSD (Lauckner & Whitten, 2016; Lustgarten, 2017), military combat–related PTSD (Acierno et al., 2016; Wierwille et al., 2016; Yuen et al., 2015), substance use (Lustgarten, 2017), chronic pain (Lustgarten, 2017), acquired brain injury (Bergquist et al., 2014), and obsessive-compulsive disorder (Stubbings et al., 2015). There is also initial research to suggest this modality can be effectively implemented for diagnoses seen as too complex for this format before virtual implementation during the COVID-19 pandemic, such as borderline personality disorder (Zimmerman et al., 2022) and psychosis (Chaudry et al., 2021). center of the line of sight, so that eye contact is maximized (Luxton et al., 2014). Further, there are several things to consider about the provider’s physical space that is visible to the patient within the telemental health session. Small patterns and small stripes can appear blurry on video, so it can be helpful for providers to wear solid colors or larger patterns to ensure that the patient is not distracted by the appearance of blurry clothing because it can strain the patient’s eyes. Additionally, brightness should be tested to ensure that the lighting is not straining to the patient’s eyes. The background can also be important and should be simple, not distracting, and should portray a professional space, just as a provider would do in a traditional office space. Technical failures are an occasional annoyance in telemental health service provision and should be expected to occur at some point in time. The provider and client should discuss what will happen if there is a disruption to the service (Johnson, 2014). A provider may inform the client that they will send the client an email about what to do next, such as wait a few minutes for the system to reboot or reschedule in the case of an Internet failure. Clients should not feel that technical failures are a rejection by the clinician, which is why communication ahead of time is important. Similar to in-office sessions, increased compliance and positive outcomes are related to the quality of the teletherapeutic relationship (Johnson, 2014). A clinician who tends to be more reserved with body language will need to practice and improve those skills to establish a therapeutic presence. Because body language is constrained in telemental health sessions, the provider may want to pay close attention to their own body language and make conscious choices about communicating understanding. A provider may want to nod frequently or exaggerate typically minimal movements of the head or arms or other gestures to demonstrate understanding and convey empathy and concern.
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