Question: What is the telebehavioral health evidence base?*
I have taken your initial 4 hr course and would like to take more courses. But I need to know if you will cover more about evidence-based research in one of your other training programs. If yes, which training? (My administrator says there is no telebehavioral health evidence-base. She insists on my doing EMDR practice in the office during COVID.).
Most state law regulating health care professionals in the United States require the use of an evidence-base when practicing. Telebehavioral health is no exception. For that reason, the US federal government funded the development of the evidence base since the 1950s. The Telebehavioral Health Institute houses more than 4,500 such articles in its training. In short, the telehealth evidence-base not only exists but is quite robust.
Let’s start with a bit of history. The first US-based psychiatric telehealth connection was in 1959, launching what is now known as telebehavioral health. In 1988, the US federal government started addressing this issue by assigning the task of looking into telehealth to the Deputy Director of the Department of Rural Health, Dr. Dena Puskin. When she saw the potential of telehealth to serve the millions of people who did not have access to healthcare, she asked Congress for funding and thereby helped to launch the telehealth evidence-base in a much well-funded, systematic way.
Today, the evidence-base for telebehavioral health is remarkably robust. The military did the early work to develop and deploy its use on a broad scale. Recognizing the many advantages, some programs in Medicare (CMS) started paying for telebehavioral health 15-20 years ago, but only in rural areas. Many third-party payors have been reviewed the evidence-base and have been paying for over a decade. As you probably know, without evidence-based treatment protocols to be followed by the average practitioner, none of the insurance companies would have paid. The state governments had to get involved to pass laws to force the payers to cover. The first such law was passed in California in 1996.
One of the difficulties in looking at the telebehavioral evidence-base is that many people have coined different terms for it. US state licensing boards have been documented as using 27 different terms to regulate telebehavioral health alone. Decision-makers range from using other terms such as telemental health, behavioral telehealth, electronic service delivery, connected health, ehealth, e-therapy, distance counseling, telepsychology, telepsychiatry, telemedicine, etc. If the decision-makers can’t agree to use a single term, those of us who follow their rules, guidelines, and ethical codes are certain to be confused, and more importantly, be at a loss when looking at the scientific literature to find the telebehavioral health evidence-base.
The telebehavioral health evidence-base started building in 1959. Today, TBHI carries citations for references more than 4,500 peer-reviewed documents, most of which have been published by US researchers. More than a thousand of those references are visible here in our public bibliography. (Be sure to look for the link to part II in the opening paragraph.) The rest is reflected in our various training courses, as relevant to the topic at hand. We introduce the evidence-based through three meta-analyses detailed in our 101 intro course and then go into more specifics in every course thereafter. See links to all these individual courses and packages.
As for EMDR, adaptations are needed, obviously. Similar to the telehealth adaptations needed for most other services in our field, once you learn the fundamentals (which we teach in our Micro Certification Level II training), you will have learned enough to consult with others in your workplace to make adaptions that help you meet with requirements for legal and ethical compliance for your state and profession, as well as the current protocols that you are using. Special adaptations for EMDR is something that you can research using the lists identified above, or by searching with the help of a librarian or online resources such as Google Scholar, PubMed, ResearchGate. (We invite you to post any of your findings below in the comment box so that our community can augment and learn from each other.)
Authority during COVID?
The second issue that may need to be addressed is whether your administrator is in the right when requiring you to deliver in-person care during a national emergency that involves a highly contagious disease such as COVID. To get clear answers without endangering your employment status as you gather information, I encourage you to:
- Write to your licensing board to see what your legal obligations are. They are the best resource for you to help educate your supervisor because they can often give you a detailed list of ethical codes to consider when making your decisions. Discussing that list of issues with your administrator will get you further than just expressing your reluctance if your judgment pulls you toward avoiding in-person care at this time.
- Next, send the same letter outlining your situation to your professional association, both at the state level and at the national levels.
- Send that same letter to your malpractice carrier.
I encourage you to at least get informed from them all, then decide what to do. Each of these groups will have very detailed responses, but it may take a few weeks to hear back from them. Put your inquiries into writing and ask for a written response for all these people. Laws and ethical codes are in place to protect you. Knowledge is power, even if you choose to comply with your administrator’s requirements for you to help others by putting yourself at risk to keep your job.
Whatever you choose to do about researching the telebehavioral health evidence-base or challenging your administrator’s authority over you during COVID-19, I applaud you for having the courage to seek more information. That one choice on your part will make you a much better clinician.
Marlene M. Maheu, Ph.D.
- Executive Director
- TBH Consultation, Staffing & Credentialing
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