There has been a worldwide increase in telehealth by psychologists since Covid-19 began. There is considerable research into telehealth therapy, however when looking at telehealth therapy particularly for trauma and even more so for using EMDR to treat trauma the research is much reduced. Thus, this blog post will look at the following areas:
1. Telehealth therapy in general
In my own practice I use mainly video-conferencing telehealth (Microsoft Teams), however telehealth services can also include phone calls and some digital services also include email and chat. Prior to the Covid-19 pandemic telehealth therapy was only available to clients in ruraland remote settings to be funded under Medicare in Australia. Medicare now allows Telehealth to be used throughout Australia for providing Better Access services, while it is extremely advantageous for people in rural and remote settings, telehealth can also be useful for reducing travel time for all clients, continuing therapy when a client or practitioner may be contagious with a virus and just general convenience.
A review (Thomas et al. 2021) of videoconferencing to deliver psychological therapies to adults conducted in 2021 found that:
Videoconferencing is an efficacious means of delivering behavioural and cognitive therapies to adults with mental health problems
Trial evidence has established it is no less efficacious than in-person therapy for prolonged exposure, cognitive processing therapy, and behavioural activation.
While therapists report nonverbal feedback being harder to judge, and clients can take time to adapt to videoconferencing, clients rate the therapeutic alliance and satisfaction similarly to therapy in-person.
Videoconferencing provides opportunities to integrate therapeutic exercise within the person’s day-to-day environment.
A systematic review (Berryhill et al, 2019a) found no difference in anxiety outcomes for clients who received face to face treatment or videoconferencing. In 67 percent of studies there was a significant reduction in anxiety levels from pre to post treatment. Similarly, Berryhill et al (2019b) found that out of 16 controlled studies mostly videoconferencing resulted in similar or better outcomes for depression than in person treatment, one study found better outcomes for in person post treatment but at follow up the outcomes were the same.
Therapeutic alliance is one of the best measures of likely successful outcomes for psychological therapy. It is understandable that clients may be concerned about therapeutic alliance when using video conferencing. A study looking at clients in rural Western Australia found that clients felt the therapeutic relationship increased over time and generally the measures for therapeutic alliance were good. Some challenges were encountered by participants in the study, but importantly with time, preparation and flexibility many of these challenges can be overcome.
Barriers to treatment for posttraumatic stress disorder (PTSD) include distance from providers, cost, privacy concerns, lack of specialty mental health providers and perceived stigma. Telehealth can help to overcome many of these barriers by providing confidential access to specialist providers in a client’s own home. A review of findings for the use of telehealth interventions to treat PTSD (Morland et al 2020) found that the dropout rates and outcomes were comparable to face to face interventions. Importantly this review also found that using videoconferencing didn’t compromise the therapeutic process.
Eye Movement Desensitization and Reprocessing (EMDR) is a type of therapy often used to treat trauma. In 2021 during the Covid-19 pandemic a study examined the use of EMDR combined with other treatments to treat severe or complex PTSD, as a result of multiple traumatic events, mostly during childhood. The study was conducted intensively over 4 days, after treatment four of the six patients no longer met criteria for PTSD or complex PTSD and all scores reduced significantly. Even more importantly no patients dropped out, there were no personal adverse events and no reliable symptom worsening occurred. The authors concluded that “intensive, trauma-focused treatment of severe or complex PTSD delivered via home-based telehealth is feasible, safe and effective and can be a viable alternative to face-to-face delivered intensive trauma-focused treatment” (Bongaerts et al 2021).
It is well known that EMDR is not just helpful for trauma but can also be helpful in treating depression and anxiety (which are often associated with PTSD). A study conducted in 2022 compared virtual EMDR to face to face treatment. They found that there was a similar change in depression and anxiety scores for clients who engaged in virtual EMDR and those who engaged in-person EMDR (Liou et al 2022).
While these studies looking into the use of EMDR are only small and there is still much work to do in this space, they give some good indications that EMDR conducted via telehealth is effective and safe; like the findings for telehealth in general. Throughout the Covid pandemic I used EMDR as a trauma therapy via telehealth with numerous clients. During this time, and in the work, I continue to do using EMDR over telehealth I have not found clients to have negative experiences and generally their mental health improves. It is reasonable to have concerns about conducting trauma therapy via telehealth. But it is important to remember that Eye Movement Desensitization and Reprocessing (EMDR) is an 8-stage process. Clinical judgment is particularly important in the telehealth setting in deciding when a client is ready for entering the reprocessing stage. Additional preparation may be required in some cases.
3. How to get the most of your telehealth appointment
Telehealth consultations can feel less safe or less engaging than face-to-face consultations. To help optimise your telehealth experience, there are some actions you can take. These include:
Location
Set up your computer/tablet/laptop/telephone in a location where you have privacy, feel secure and will not be interrupted by others.
Therapeutic space
Try to have your appointments in the same location each time – this will help move you into therapy mode faster. Choose a seat that is comfortable and have tissues nearby. Perhaps also a glass of water or a hot drink.
Distractions
In your home environment it is easier to be distracted. Limit distractions for yourself and the therapist by not eating during sessions, removing yourself from other people, pets and external noise including music. Using earphones may be beneficial. Ideally close doors so others cannot interrupt you.
Time
Ensure you are ready a few minutes prior to your appointment so you do not feel rushed. Log in to the virtual waiting room and allow yourself to consider anything you wish to raise during your appointment.
Concerns
Please raise anything that is concerning you during the appointment. This may be related to what is being discussed but may also be related to the technology, the audio or visual quality, any discomfort (physical or emotional) or anything else that is disturbing you.
References
Berryhill, M. B., Halli-Tierney, A., Culmer, N., Williams, N., Betancourt, A., King, M., & Ruggles, H. (2019a). Videoconferencing psychological therapy and anxiety: a systematic review. Family practice, 36(1), 53-63.
Berryhill, M. B., Culmer, N., Williams, N., Halli-Tierney, A., Betancourt, A., Roberts, H., & King, M. (2019b). Videoconferencing psychotherapy and depression: a systematic review. Telemedicine and e-Health, 25(6), 435-446.
Bongaerts, H., Voorendonk, E. M., van Minnen, A., & de Jongh, A. (2021). Safety and effectiveness of intensive treatment for complex PTSD delivered via home-based telehealth. European Journal of Psychotraumatology, 12(1), 1860346.
Hannelies Bongaerts, Eline M. Voorendonk, Agnes van Minnen & Ad de Jongh (2021) Safety and effectiveness of intensive treatment for complex PTSD delivered via home-based telehealth, European Journal of Psychotraumatology, 12:1
Liou, H., Lane, C., Huang, C., Mookadam, M., Joseph, M., & Hecker DuVal, J. (2022). Eye movement desensitization and reprocessing in a primary care setting: Assessing utility and comparing efficacy of virtual versus in-person methods. Telemedicine and e-Health, 28(9), 1359-1366.
Morland, L. A., Wells, S. Y., Glassman, L. H., Greene, C. J., Hoffman, J. E., & Rosen, C. S. (2020). Advances in PTSD treatment delivery: Review of findings and clinical considerations for the use of telehealth interventions for PTSD. Current Treatment Options in Psychiatry, 7, 221-241.
Thomas, N., McDonald, C., de Boer, K., Brand, R. M., Nedeljkovic, M., & Seabrook, L. (2021). Review of the current empirical literature on using videoconferencing to deliver individual psychotherapies to adults with mental health problems. Psychology and Psychotherapy: Theory, Research and Practice, 94(3), 854-883.
