In home-based treatment settings, access to firearms or other weapons or lethal doses of prescription medications may concern providers. When providers assess clients for telemental health treatment, as with in-person appointments, they need to evaluate the potential for risk along with access to weapons or other lethal means. For example, if a client reveals acute suicide risk and has access to firearms, other weapons, or other lethal means in the home, a clinic-based treatment may be most appropriate depending upon the situation. Because many rural areas have a culture of firearms, owning a firearm would not necessarily rule out home-based telemental health treatment. However, clinician assessment of risk in combination with access to the means by which to carry out threats to others or self is an important clinical consideration and may impact provision of services when it is not possible to have clinical staff with the client when/if they experience active suicidality/homicidality during sessions. Of note, with the necessary transition to virtual modes of treatment during the COVID-19 pandemic, research has shown comparable treatment effectiveness for diagnoses, symptoms, and treatments previously thought too risky to treat virtually such as borderline personality disorder and intensive outpatient programming. This research shows comparable levels of patient satisfaction, symptom reduction, functional improvement, and suicide attempts (Zimmerman et al., 2022). Additional safety precautions should include verifying the privacy of the client, such as asking the client in a domestic violence situation if the abuser is around the home. If the abuser is around the home, the clinician may want to see the client in a clinic-based setting or adjust the timing of the session. Clients should also be reminded that telemental health sessions are to be completed with the same expectations for sobriety, wearing appropriate clothing, and removing inappropriate paraphernalia from the video view. Nonbehavioral risk factors should also be addressed in the first telemental health session. If a patient were to be receiving services within a clinic and had a cardiac arrest, the provider would likely call a medical provider (if they were within a medical hospital) to come into the session or call 9-1-1. However, in a telemental health session, the patient and provider are not in close proximity, and therefore an emergency plan should be developed so that the patient
knows what to expect and the provider knows whom to call. For example, it is possible that there may be a family member in the room next door, and it would be the patient’s preference for the provider to call both the family member and 9-1-1. The proximity of family members likely will change from session to session; therefore, it is imperative to briefly rediscuss the plan at the onset of every session. It is also important to verify the client’s location during each session in case this impacts the emergency plan or other safety factors. Providers should ensure that safety planning is an integral part of a treatment plan. Safety plans are written safety procedures about what defines an emergency situation and what steps should be followed. Luxton, Nelson, and Maheu (2016) recommend several components that should be included in a safety plan. ● If treatment is clinic based, the provider should talk to on-site staff prior to beginning telemental health services. ● The clinician should assess for a client history of violence toward self or others. ● The clinician should discuss the presence of firearms or other weapons before beginning home-based telemental health services. ● The clinician and client should have a backup communication plan, such as a cell phone or landline, in case the connection with each other is lost. ● Identify and document local resources, such as contact information for family members and local emergency departments. ● Ensure that the clinician has the client’s physical location documented. ● Both the clinician and client should review the safety plan and the expectations of both parties prior to the beginning of treatment. Additionally, it is recommended to include review of expectations in terms of behaviors that may otherwise acceptable be in the home environment but would detract from the telemental health session, including maintaining sobriety, not driving or being in a moving vehicle during session, removing drug paraphernalia and potential weapons from where they will complete the session, and being fully clothed.
ASSESSMENT AND DIAGNOSIS
As with any assessment and diagnostic interview, clinicians must understand the concerns, symptoms, and problems that clients bring to therapy. Behavioral health practitioners assess individuals as whole and unique persons who live within an environment that affects health and well- being (Johnson, 2014; Sheafor & Horejsi, 2015). Typical assessments include evaluations of an individual’s cognition, intellect, physical and mental health, communication ability, coping styles, spiritual and religious supports, and community resources. In addition, the clinician should gather information about the client’s economic conditions, culture, legal issues, employment, and family involvement. The practitioner should also evaluate nonverbal communication, such as eye contact, gestures, personal space, body positioning, facial expressions, touch, arm and hand movements, and dress and appearance (Luxton et al., 2014; Sheafor & Horejsi, 2015). In traditional face- to-face settings, these nonverbal cues are readily seen and evaluated; however, conducting assessments through video conferencing requires additional preparation and adaptation. Guidelines for assessment and preliminary diagnosis suggest that clinicians should conduct face-to-face
assessments initially when possible (Johnson, 2014; Luxton, Nelson, & Maheu, 2016; Swenson et al., 2016). Practitioners may want to review an individual’s file prior to the first meeting to ascertain the client’s cognitive, intellectual, and psychological needs that may impair the ability to use telemental health (Johnson, 2014; Luxton, Nelson, & Maheu, 2016). One of the first issues that should be addressed is whether a remote video intervention is appropriate for service provision, as discussed later in the course. The risks and benefits of the use of video therapy should be discussed with the client. Practitioners should conduct ongoing assessments of whether remote therapy continues to be appropriate. Clients who exhibit certain symptoms, such as active psychosis or extensive self-harm behaviors, and practitioners who rely primarily on nonverbal or symptomatic client cues, such as those present with individuals who have severe developmental disorders, may need to consider the risks and limitations associated with remote assessment (Luxton et al., 2014). Practitioners may find it difficult to rely on nonverbal senses to gain information about such areas as personal hygiene, alcohol use, or substance use when delivering services using remote video services.
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