The Impact of COVID-19 on Provider Perceptions of Telemental Health

Client and family experiences with telehealth-delivered early psychosis services

OBJECTIVE

The COVID-19 pandemic prompted a significant shift to delivering early psychosis services using telehealth. Little is known about the experience of using telehealth in early psychosis services. This quality improvement qualitative project investigated the experiences of program participants and family members with telehealth services in OnTrackNY, an early intervention program for psychosis in New York State during the COVID-19 pandemic.

METHODS

The project team conducted individual interviews and focus groups. Data analyses used a matrix approach.

RESULTS

Nineteen OnTrackNY program participants and nine family members participated in five focus groups and nine individual interviews. Data were organized into five themes (a) accessibility: most individuals had a device and internet access and challenges were related to connectivity, such as image freezing and sound breaking; (b) convenience/flexibility: benefits included the reduced commute and costs; (c) levels of comfort/privacy with telehealth: program participants felt less judged and less anxiety leading up to in-person appointments while also expressing privacy concerns; (d) sense of connectedness: in-person social connections were deemed important and not replaceable by telehealth; and (e) suggestions: program participants expressed a preference for in-person group activities and suggested hybrid options, highlighting the importance of in-person visits to establish rapport at the beginning of treatment before transitioning to telehealth.

CONCLUSIONS

Telehealth services were generally well accepted. Suggestions for future service delivery include offering a combination of telehealth and in-person services based on program participants' preferences and prioritizing in-person services during the early phase of treatment.

Examining Burnout and Perspective on Videoconferencing in the Mental Health Workforce

Objective: To examine burnout and perspectives on videoconferencing over time for the mental health workforce. Methods: Members of an academic psychiatry department completed two anonymous surveys about virtual work and burnout 18 months apart (T1n = 274, response rate = 66.8%; T2n = 227, response rate = 36.7%). A subset completed the burnout subscale of the Stanford Professional Fulfillment Index (T1n = 145; T2n = 127). Results: Respondents were well satisfied with videoconferencing at both time points and satisfaction was higher at T2. Videoconferencing was not perceived to contribute to feelings of fatigue at either time point and burnout levels decreased from T1 to T2. Conclusions: Videoconferencing is well received by the mental health workforce and is not widely perceived to contribute to feelings of fatigue. Longer use of videoconferencing coincided with decreased levels of burnout. There are likely benefits to virtual work for the mental health workforce and virtual work may be protective from burnout.

Therapeutic alliance and clinical outcomes in teletherapy and in-person psychotherapy: A noninferiority study during the COVID-19 pandemic

Objective The current study aimed to inform the varied and limited research on clinical variables in the context of teletherapy. Questions remain about the comparative quality of therapeutic alliance and clinical outcome in the context of teletherapy compared to in-person treatment.Methods We utilized a cohort design and a noninferiority statistical approach to study a large, matched sample of clients who reported therapeutic alliance as well as psychological distress before every session as part of routine clinical practice at a university counseling center. A cohort of 479 clients undergoing teletherapy after the emergence of the COVID-19 pandemic was compared to a cohort of 479 clients receiving in-person treatment before the onset of the pandemic. Tests of noninferiority were conducted to investigate the absence of meaningful differences between the two modalities of service delivery. Client characteristics were also examined as moderators of the association between modality and alliance or outcome.Results Clients receiving teletherapy showed noninferior alliance and clinical outcome when compared to clients receiving in-person psychotherapy. A significant main effect on alliance was found with regard to race and ethnicity. A significant main effect on outcome was found with regard to international student status. Significant interactions on alliance were found between cohort and current financial stress.Conclusions Study findings support the continued use of teletherapy by demonstrating commensurate clinical process and outcome. Yet, it will be important for providers to be aware of existing mental health disparities that continue to accompany psychotherapy - in person and via teletherapy. Results and findings are discussed in terms of research and clinical implications. Future directions for researching teletherapy as a viable treatment delivery method are also discussed.

Telemedicine from Home or the Office: Perceptions of Mental Health Providers

Introduction: The COVID-19 pandemic led to a rapid transition to telemedicine for mental health care and redefined many providers' work environments and practices. The purpose of the study was to investigate the impact of work location on telemental health (TMH) benefits, disruptions, and concerns to further understand the rapid implementation of telemedicine for mental health treatment. Methods: A sample of 175 practicing TMH providers completed an online survey between July and August 2020. Providers answered questions about personal demographics and practice characteristics. Next, they answered questions about benefits, disruptions, and concerns regarding the use of telemedicine in their practice. Chi-square and independent samples t-test were conducted to identify work location differences for personal demographics and clinical practice characteristics. Three multivariate analyses of covariance were conducted to examine overall differences in perceptions of telemedicine benefits, concerns, and disruptions based on work location while covarying for provider race, ethnicity, percentage of caseload seen through telemedicine, practice type, specialty, and primary method of reimbursement. Results: TMH providers who primarily work from an office reported more benefit of reduced costs/overhead (ηp2 = 0.039), less benefit of limiting the spread of the virus (ηp2 = 0.028), and more concern about reimbursement (ηp2 = 0.046) than those who primarily work from home. We observed no difference in disruptions, patient access to care, quality of care, and work-life balance. Discussion: Exploration into work location of TMH providers aids in understanding of clinical workflows and provider wellbeing. Our findings suggest that telemedicine may be easily integrated into different types of clinical workflows and work locations.

Understanding psychology students' perspective on video psychotherapy and their intention to offer it after graduation: a mixed-methods study

Introduction

Video psychotherapy (VPT) demonstrated strong clinical efficacy in the past, with patients and psychotherapists expressing satisfaction with its outcomes. Despite this, VPT only gained full recognition from the German healthcare system during the COVID-19 pandemic. As society increasingly relies on new media, it seems likely that VPT will become even more relevant. Previous studies surveyed practicing psychotherapists and patients about advantages and disadvantages of VPT. In contrast, our approach targets a younger generation, specifically psychology students intending to become licensed practitioners after graduation.

Methods

Our mixed-methods study was conducted in an online survey format and had two main objectives. Firstly, we investigated which person-related variables are associated with psychology students' behavioral intention to offer VPT after graduation, using a multiple regression analysis. Secondly, we explored psychology students' perception of advantages and disadvantages of VPT and identified their desired learning opportunities regarding VPT in their study program, using qualitative content analysis.

Results

A sample of 255 psychology students participated. The multiple regression model explains 73% of inter-individual variance in the intention to offer VPT, with attitudes toward VPT showing the strongest relationship with intention to offer VPT. Expected usefulness, satisfaction with video conferencing, and subjective norm also showed significant relations. The students provided 2,314 statements about advantages, disadvantages, and desired learning opportunities, which we coded by means of three category systems. In terms of advantages, the most frequently mentioned categories were low inhibition threshold, flexibility in terms of location, and no need to travel. For disadvantages, the predominant categories included lack of closeness between patient and psychotherapist, lack of nonverbal cues, and problems with technology or internet connection. Regarding desired learning opportunities, training for technical skills, practical application through role-playing and self-experience, and general information about VPT were the most mentioned categories. In addition, we identified numerous other aspects related to these topics, reflecting a differentiated and balanced assessment of VPT.

Discussion

We discuss the theoretical and practical implications of our findings for training the next generation of psychotherapists and outline a specific five-step plan for integrating VPT into study programs.

Tele-mental Health Transitions for Pennsylvania Coordinated Specialty Care Programs for Early Psychosis During the COVID-19 Pandemic

This study examined provider and client perspectives of tele-mental health (TMH) in early psychosis care during the COVID-19 pandemic. To achieve this goal, thirty-three mental health providers and 31 clients from Pennsylvania Coordinated Specialty Care (CSC) programs completed web-based surveys assessing TMH usage, experiences, and perceptions between May and September 2020. Three additional TMH-related questions were asked two years later of PA CSC Program Directors between Feb and March 2022. Descriptive statistics characterized responses. Open-ended items were coded and grouped into themes for qualitative synthesis. As early as mid-2020, participants reported extensive use of TMH technologies, including telephone and video visits. Although most providers and clients preferred in-person care to TMH, most clients still found TMH to be comparable to or better than in-person care; 94% of clients indicated interest in future TMH services. Providers also noted more successes than challenges with TMH. Nine themes emerged regarding provider-perceived client characteristics that could benefit from TMH and were grouped into two categories: client-level (access to technology, comfort with technology, transportation, young age, symptom severity, functioning level, motivation for treatment adherence) and interpersonal-level (external support systems and engagement with program prior to the pandemic) characteristics. Two years later, program directors reported continued perceived advantages of TMH in CSCs, although some barriers persisted. Despite the unexpected shift to TMH in early psychosis programs during the COVID-19 pandemic, findings indicated a relatively positive transition to TMH and perceived promise of TMH as a sustained part of routine care.

Variations in the uptake of telemental health technologies in community and crisis mental health services during the early pandemic: a survey of mental health professionals in the UK

BACKGROUND

One of the many challenges faced by mental health services during the COVID-19 pandemic was how to deliver care during lockdown. In community and crisis services, this often meant rapidly adopting or expanding the use of telemental health technologies, including phone and video calls. The aim of this study is to explore variations in use and report staff views of such technologies during the early stages of the pandemic. The primary analysis compared rates of use between professions, demographic groups, genders, regions, and crisis and community services.

METHODS

We used data from an online survey conducted by the Mental Health Policy Research Unit in Spring 2020 regarding the impact of the pandemic on mental healthcare in the United Kingdom. We included quantitative data from all professional groups working in community or crisis services providing care to working age adults, including general and specialist services. Our outcome of interest was the percentage of clients whom clinicians primarily interacted with via videocall. We also collected demographics and professional characteristics such as the type of mental health service respondents worked in. In addition, we explored respondents' views and experiences of telemental health as a medium for providing care.

RESULTS

978 participants were included in the primary analysis (834 provided outcome data for community services, 193 for crisis services). In community services, virtually all staff reported stopping some or all face-to-face appointments following the onset of the pandemic, with a large majority using video or phone call appointments where possible instead. Telemental health use was higher in community than in crisis services, and amongst professionals who mainly provided psychotherapy or peer support than in other groups. There was also evidence of use being lower in regions in Northern England, Scotland, and Wales than elsewhere. There was no evidence of an association with staff gender, age, or ethnicity. Staff were generally positive about telemental health and intended to make more use of technologies following the pandemic. However, significant barriers to its use were also reported, often involving skills and available infrastructure.

CONCLUSIONS

Despite its rapid implementation, telemental health was viewed positively by clinicians who saw it as an effective alternative to face-to-face appointments in some contexts, including during the pandemic. However, adoption of the technology also has the potential to exacerbate existing or create new inequalities without effective management of training and infrastructure needs.

Patient and provider perspectives of the implementation of remote consultations for community-dwelling people with mental health conditions: A systematic mixed studies review

Remote, or tele-, consultations became a necessary form of mental healthcare provision during the COVID-19 pandemic. As the prevalence of mental health problems rises, they may have a role in future mental health services. We aimed to review the literature on patient and provider perspectives on factors influencing the implementation of remote consultations for community-dwelling people with mental health conditions. We searched five electronic databases (PubMed, EMBASE, Web of Science, CINAHL, and PsycINFO) for empirical research up to July 13th, 2022. Only studies of synchronous, interactive remote consultations conducted via video, phone, or live-messaging between patients and providers were included. Two reviewers independently assessed the quality of included studies using the Mixed Methods Appraisal Tool. We integrated qualitative and quantitative data from 39 studies into a single mixed-methods synthesis. We mapped reported factors to the domains of the Consolidated Framework for Implementation Research (CFIR). Acceptability was generally high among participants, despite concerns about the quality of care and the perceived impeded therapeutic relationship. A prominent facilitator was the increased accessibility and convenience of remote consultations, while lack of appropriate infrastructure and low patient comfort and competence were among the most prevalent barriers. This review highlights the importance of patient preferences and provider buy-in to the future of remote consultations.

The Good, The Bad, The Uncertain: Diverse Provider Experiences with Telemental Health During COVID-19

This study assessed mental health provider attitudes and perceptions of telemental health (TMH) prior to and during the COVID-19 Pandemic. The study expands on earlier work by providing a more detailed qualitative analysis of provider perceptions of TMH, including its efficacy, advantages, and limitations. The current study is part of a larger mixed methods project utilizing a repeated cross-sectional design. An online survey was administered to a sample of 1,448 mental health providers. Of the survey participants, 934 offered narrative responses to open-ended questions and were included in the present study. Qualitative data was analyzed using a coding team and the Consensual Qualitative Research paradigm. Providers described both positive and negative feelings about using TMH during the COVID-19 Pandemic. Several advantages were identified, with providers clearly appreciating the role of TMH in allowing them to work continuously and safely during the public health emergency. An array of negative views and concerns were also expressed, including that TMH may not be optimal or effective in certain settings or situations. A portion of respondents also indicated a preference for face-to-face care and illuminated ways they found TMH lacking or limited.

Overcoming Clinician Technophobia: What We Learned from Our Mass Exposure to Telehealth During the COVID-19 Pandemic

Mental health clinicians have migrated to telehealth during the COVID-19 pandemic and have reported their use of telehealth may be permanent. Understanding how stakeholders overcame hesitancy regarding the use of telehealth can potentially reveal how stakeholders can adopt future clinical technologies. The exposure therapy conceptual framework provides one explanation of how mental health clinicians can face their concerns about technologies that promise to improve clinical outcomes and worker well-being. We review available literature published since the start of the pandemic on the extent to which clinicians migrated to telehealth and their reactions to their transitions. In particular, we review available literature that describes negative attitudes and worries by clinicians as one of many barriers of telehealth implementation. We introduce the perspective that the necessary transition to telehealth at the start of the pandemic functioned as an exposure exercise that changed many clinicians' cognitive and emotional reactions to the use of telehealth technologies. Next, we provide guidance on how clinicians can continue taking an exposure approach to learning emerging technologies that are safe and can benefit all stakeholders. Clinicians can now reflect on how they overcame hesitancy regarding telehealth during the pandemic and identify how to build on that new learning by applying strategies used in exposure therapy. The future of clinical work will increasingly require mental health clinicians to better serve their patient populations and enhance their own well-being by overcoming technophobia, a broad term for any level of hesitancy, reluctance, skepticism, worry, anxiety, or fear of implementing technology.

Perceptions of Telemental Health Care Delivery During COVID-19: A Cross-Sectional Study With Providers, February-March 2021

The COVID-19 pandemic accelerated adoption of telemental health (TMH). Providers with limited TMH experience faced challenges during the rapid switch to remote patient care. We investigated TMH providers' perceptions about remote care one year into the pandemic according to when providers adopted telemedicine (i.e., before vs. after March 2020) and how much of their caseloads were served remotely (i.e., < 50% vs. ≥ 50%). Between February-March 2021, 472 TMH providers completed a cross-sectional, web-based survey that measured perceived benefits and satisfaction with telemedicine, therapeutic alliance, patient-centered communication, eHealth literacy, multicultural counseling self-efficacy, and facilitating factors of using telemedicine. Providers who began using telemedicine before the pandemic reported having better training, task-related therapeutic alliance with patients, and ability to conduct multicultural interventions, assessments, and session management. Providers who served ≥ 50% of their caseload remotely reported greater satisfaction with their practice, stronger beliefs about the benefits of telemedicine, and greater perceived effects of telemedicine on alleviating the impact of COVID-19. There were no differences in reports of patient-centered communication nor eHealth literacy. In conclusion, providers who adopted TMH more recently may require additional training and support to successfully establish a working alliance with their patients, especially with multicultural aspects of care.