A study published in the Journal of the American Medical Association focused on telehealth use among the low-income population in California. The study included data from outpatient primary care and behavioral health visits from February 2019 to August 2020 at forty-one federally qualified health centers representing 534 locations in California. The study showed that 48.5% of visits occurred via telephone, 48.3% occurred in person, and 3.4% occurred via video with regards to primary care visits. For behavioral health visits, 63.3% via telephone, 22.8% in person, and 13.9% via video. The study’s key finding was that most appointments were conducted through telephone telehealth during the pandemic period. “Eliminating telehealth coverage for audio-only telemedicine visits would disproportionately impact underserved communities,” according to Lori Uscher-Pines, the study’s lead author.
“Lower-income patients may face unique barriers to accessing video visits, while federally qualified health centers may lack resources to develop the necessary infrastructure to conduct video telehealth,” she said. “These are important considerations for policymakers if telehealth continues to be widely embraced in the future.”
Since telehealth expanded due to COVID, few studies have examined differences in the use of telehealth modalities. One federal agency estimated that 30% of visits are telephone telehealth alone during the pandemic. According to the study, telephone telehealth visits peaked in April 2020, comprising 65.4% of primary care visits and 71.6% of behavioral health visits.
Before the pandemic, many definitions of telehealth excluded phone therapy visits, and private insurers or the government rarely reimbursed them, the study authors noted. Some payers, including the Centers for Medicare and Medicaid Services, have indicated they may stop telehealth coverage reimbursement for phone therapy sessions when the pandemic ends. Read more about previous rulings for COVID-19 Telephone Telehealth Reimbursement.
“There are some concerns that telephone visits could result in fraud, abuse, and unnecessary and lower-quality care. Although these concerns are important to assess, eliminating telehealth coverage for telephone visits could disproportionately affect underserved populations and threaten the ability of the clinics to meet patient needs,” stated Dr. Uscher-Pines.
The Reality of Professionalism and Telephone Therapy
It seems a bit dramatic to point out that telephone therapy can be more subject to fraud and abuse when it actually is often the only lifeline for many people in distress during the pandemic and beyond. However, fraud and abuse can potentially exist everywhere. The real question is whether the professional has bothered to learn how to use the telephone for clinical interventions properly – or if they are making it up on the fly.
Unfortunately, although a clear evidence base exists for telephone-based interventions, very few professionals have received adequate training. More likely, there is no professional training to use only the telephone to deliver services to a patient or client. As a result, they may not have yet realized that a good in-person clinician is not the same as a good telephone therapist, regardless of intention or need.
This point can be clarified quite readily by looking at the case of the alcoholic therapist-in-recovery who now decides to offer therapy for alcohol use. Assuming, of course, that the therapist has excellent therapy skills to start, the therapist’s history with alcohol can actually interfere with their functioning as an addictions therapist, narrowing perspective with unchallenged assumptions related to etiology, treatment options, and/or prognosis. This is why the professional standard for qualifying alcohol therapists is not one’s prior experience with alcohol but rather a course completion certificate or certification in alcohol interventions.
Even a good (or great) in-person therapist approaching telephone telehealth without training is likely to overestimate the quality and/or effectiveness of their communications. If one does read the literature about telehealth in general and telephone therapy, it is evident that professional training is in order. In fact, most published studies directly call for clinicians to get such training for telehealth and telephone therapy.
The Telephone Telehealth Evidence-Base
The research in telephone telehealth, in general, has also been quite clear that therapists who have received training are more likely to use the medium correctly to deliver outcomes that are not only comparable to in-person care but also to minimize frustration in both themselves and their clients/patients and feel more confident about how to protect the privacy of the exchange. In 2018, after conducting a systematic search for articles published over a 25-year period (January 1991–May 2016), Coughtrey & Pistrang published a study of 14 studies that concluded that “telephone-delivered interventions show promise in reducing symptoms of depression and anxiety.” This conclusion is warranted, given that much of the Similarly, in 2020, Castro and colleagues published a meta-analysis looking at 10 studies looking at treatment adherence to telephone therapy for depression. In general, they showed beneficial effects on depression severity when compared to control conditions. However, in these and other published reports showing the effectiveness or adherence rates of telephone telehealth, treatment models are typically highly manualized. That is, they do not consist of free-form, open discussion common to many psychotherapeutic approaches. Therapists in such studies tend to follow very strict procedural dictates. Often, the recipient of care is given written materials and assignments that coincide with specified topics for each meeting.
Conducting a mid-pandemic online qualitative survey of mental health care professionals in the Netherlands, Feijt and colleagues (2020) reported, “Regarding the mediated nature of communication, the most frequently reported challenge concerns the lack of nonverbal signals that practitioners normally use in face-to-face communication, such as posture and hand movements, but also general demeanor, including smell. Practitioners find it more difficult to connect with their client or clearly communicate their intended message. This is even stronger when sessions are conducted by telephone when there is only audio to rely on.” Such a conclusion seems warranted, given that in-person training often teaches practitioners to rely on visual stimuli to render a diagnosis, develop and deliver a treatment plan. In evidence-based telehealth professional training, especially in competency-based certificate programs of professional training, many of these issues can be addressed using protocols tailored to the clinician’s specific client for one’s patient population, setting, state, and professional requirements. On the other hand, clinicians who use communication technology without professional training are likely to be as confused by the online delivery of healthcare as someone accustomed to using a handset telephone which now is handed a smartphone to make a simple call.
Therapist Vulnerability in Telephone Telehealth?
Assessing a client or patient’s emotional state from voice alone can be problematic, particularly if the professional’s prior telephone habits involve multitasking. As Hilty, Randhawa, Maheu, McKean, Pantera & Mishkin (2020) discuss, distractions are the #1 problem with digital interventions. Don’t we all multitask when on the phone? Where then does distractibility leave the busy professional who typically multi-tasks during telephone therapy?
Professionals who allow their workspace to be impinged by devices that regularly emit incoming messages, beeps, flashing lights, and other forms of alerts will likely find it difficult to stay focused on the voice input they now are attempting to use to deliver the same standard of care as in-person. Some therapists even so boldly encourage their clients and patients to “take a walk” while they themselves stroll about their neighborhoods or other local public areas while offering telephone therapy. All the while, these professionals profess to be delivering the same standard of care as when the client is seated in front of them in a closed room. Could these realities be used to discredit an earnest professional attempting to deliver quality care via telephone telehealth to people in need?
Telehealth Service Delivery is Not Intuitive
Telehealth service delivery is not intuitive, regardless of one’s experience in person or the client’s need. Faulty assumptions, lack of knowledge, undeveloped skillsets, and naive attitudes can lead to preventable error and potential harm. Pierce, Perrin, & McDonald (2020) stated, “Organizations interested in encouraging telepsychology use should adopt policies supporting the use of telepsychology and provide adequate training to do so.” Such calls for training are common to published reports and mimic telehealth in general for more than two decades. In 2000, Maheu and Gordon reported the results of an extensive survey assessing psychologist’s assumptions regarding the legal and ethical requirements for telehealth. Fourteen years later, a similar article was published by Maheu and a larger team of researchers who assessed roughly the same variables. In the 2020 study, two-thirds of clinicians endorsed items suggesting that standard legal and ethical mandates don’t apply to telehealth delivery of psychotherapy (Maheu & Gordon, 2000). Glueckauf, Maheu, Drude, Wells, Wang, Gustafson & Nelson (2018) showed that the number had decreased to one-third in a more extensive survey. However, the disturbing fact is that while two-thirds of clinicians endorsed items suggesting an awareness of legal and ethical mandates, it cannot be assumed that those clinicians understood how those mandates apply to their everyday telehealth practices.
Where does this leave the average clinician who has no or minimal telehealth training yet is confident that they are delivering quality care because they “feel good about it” and because it is “needed?” Therapists, too, are vulnerable to emotional reasoning…
Courtroom Realities of Telephone Therapy
Knowing how litigating attorneys work, it is quite conceivable that opposing counsel in a lawsuit against a therapist would wield several such recently published telehealth articles in the direction of an unwitting therapist who blithely offers telephone therapy without the proper documentation to prove that they indeed were actually trained in evidence-based telephone telehealth. Perhaps the COVID emergency would tempter such accusations, depending on the circumstance. However, the worrisome issue is that most clinicians have never been taught the reality of what actually happens in courtrooms. Such training can be a difficult awakening.
To help our readers better understand the issues involved with delivering clinical care in an area with a lack of professional training, we will make you privy to a training video that we regularly show in our 2-day certificate training programs. It features Attorney Joe McMenamin demonstrating his litigation skills as a prosecuting attorney for the defense in a “mock deposition.” This video demonstrates exactly how a prosecuting attorney would “prepare” their case against a witness’s testimony for a trial wherein the therapist is being sued by an angry client. The video is painful to watch. Our only solace at TBHI is that Mr. McMenamin has not only worked for decades as a prosecuting attorney for the defense, but he is also a physician. He understands and shares the ethos of many healthcare professionals and has worked these many years to defend us in court. That’s his motivation for working with TBHI for decades to develop training materials and peer-reviewed books and articles – to help professionals who are poorly informed of what can happen when one is led by the unbridled desire to help rather than a firm grounding in telehealth theory and practice.
While this type of cross-examination wouldn’t happen to professionals who deliver telephone telehealth during the pandemic because we are currently in a state of national emergency, but if telephone telehealth were to be approved long-term, this is precisely the type of rigor that would be expected of professionals delivering professional services to people in need. As all licensed professionals know, there is a high bar for the delivery of professional services. Practicing licensed healthcare professional in the United States or Canada, as well as in many other countries, isn’t something one does in the same manner as they would if they were talking to a family member on the phone, multitasking, opening email, glancing at texts, perhaps outside strolling about the park — while the other party probably is also multi-tasking and/or strolling about as well.
When we share the video below, please use this information to extrapolate how a skilled professional needs to defend the amount of training they have obtained in any new area of practice, including telephone telehealth sessions alone, when a litigating attorney has them on the witness stand. Please note, we at TBHI are not saying this process is fair or right. It simply is reality.
Courtroom Realities of Telehealth Malpractice
Before watching, please let us explain what is happening in the video. First, this is one of the many training videos that we typically share with our training audiences.
You will see how the attorney discredits the psychologist, named “Dr. Joanne Johnson,” acted by Dr. Marlene Maheu for this role-play. The cross-examining attorney is Mr. Joe McMenamin, a litigating attorney, and physician in real life. He, however, defends practitioners in court rather than a prosecuting attorney, which he depicts in this audio lesson. However, having litigated against attorneys who prosecute, he is in a unique position to show you exactly what happens in court, should you ever have the misfortune of experiencing it firsthand.
The interactions portrayed in the audio recording are abbreviated because Dr. Johnson provided additional information rather than doing as witnesses are instructed, and that is to give yes/no answers when possible and offer as little as possible unless directly asked. You will see that Dr. Johnson actually offers a fair amount of information to get to the demonstration point. Upon experiencing the agony of witnessing such an exhaustive exchange, but in real life, it would behoove you to obtain the advice of a defense attorney about offering as much information as is depicted. The purpose of the demonstration, in this case, was to show you what a skilled litigator can do to disarm a well-intentioned professional during a deposition. The attorney goes on to explain his rationales, strategies, and how opposing counsel (which he is role-playing) would generally use the information gathered to discredit the plaintiff in court. This first training video is 37 minutes in length.
TBHI Position on Telephone Therapy
Just to be clear, TBHI is in complete support of phone therapy sessions alone for all clients and patients who need or are interested in such healthcare. However, having been the Chair of the CTiBS Committee on Telebehavioral Health Competencies, the Founder of TBHI is acutely aware of the lack of competence in psychotherapists who deliver such care.
Clinicians do not typically know how much they don’t know about using the technology until they start a serious course of telehealth training. Only then do they realize how many basic assumptions are incorrect and many of the strategies that they learned in school now need to be re-considered to meet legal and ethical standards.
All untrained professionals then are encouraged to consider serious telehealth training if they wish to be competence and legally and ethically compliant with the evidence base. Review the course outlined below for yourself, your colleagues, and your students.
Castro, A., Gili, M., Ricci-Cabello, I., Roca, M., Gilbody, S., Perez-Ara, M.A., Seguí, A. & McMillan, D. (2020) Effectiveness and adherence of telephone-administered psychotherapy for depression: A systematic review and meta-analysis. Journal of Affective Disorders, 260, 514-526, ISSN 0165-0327,https://doi.org/10.1016/j.jad.2019.09.023
Coughtrey, A. E., & Pistrang, N. (2018). The effectiveness of telephone-delivered psychological therapies for depression and anxiety: a systematic review. Journal of telemedicine and telecare, 24(2), 65-74.
Feijt, M., de Kort, Y., Bongers, I., Bierbooms, J., Westerink, J., & IJsselsteijn, W. (2020). Mental health care goes online: Practitioners’ experiences of providing mental health care during the COVID-19 pandemic. Cyberpsychology, Behavior, and Social Networking, 23(12), 860-864.
Glueckauf, R. L., Maheu, M. M., Drude, K. P., Wells, B. A., Wang, Y., Gustafson, D. J., & Nelson, E. L. (2018). Survey of psychologists’ telebehavioral health practices: Technology use, ethical issues, and training needs. Professional Psychology: Research and Practice, 49(3), 205.
Hilty, D. M., Randhawa, K., Maheu, M. M., McKean, A. J., Pantera, R., & Mishkind, M. C. (2020). A Review of Telepresence, Virtual Reality, and Augmented Reality Applied to Clinical Care. Journal of Technology in Behavioral Science, 1-28. https://doi.org/10.1007/s41347-020-00126-x
Maheu, M. M., & Gordon, B. L. (2000). Counseling and therapy on the Internet. Professional Psychology: Research and Practice, 31(5), 484.
Pierce, B. S., Perrin, P. B., & McDonald, S. D. (2020). Demographic, organizational, and clinical practice predictors of US psychologists’ use of telepsychology. Professional Psychology: Research and Practice, 51(2), 184.
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