1. National Frontier & Rural ATTC
Terra Hamblin, MA
James Von Busch, PhD

2. www.nfarattc.org

3. • Data and Definitions
• Use of Technology
• Barriers to Treatment
• Telehealth Technologies
• Privacy, Confidentiality, Security
• Reimbursement
• License Portability
• Ethics
• Development of Therapeutic
Alliance Using Technology

4. DATA and DEFINITIONS

5. Over half of the country’s land mass
is designated as frontier or rural
(NRHA, 2008; USDA, 2000)

6. Approximately one quarter of the U.S.
population (62 million people) lives in
frontier/rural areas
16-20% of those individuals experience
substance dependence, mental illness, or
co-morbid conditions (NRHA, 2008)

7. Individuals residing in remote areas have
- higher mortality rates,
- higher suicide rates, and
- more severe alcohol/drug problems
(Baca et al., 2007; Goldsmith et al., 2002)

8. Studies show that those residing in rural
areas use substance abuse treatment less
often than those in urban areas because
of individual, structural, and geographic
barriers, as well as the stigma associated
with receiving treatment
(Finfgeld-Connett & Madsen, 2008; Oser et al., 2012)

9. (Finfgeld, 2002; Finfgeld-Connett & Madsen, 2008)
In rural vs. urban areas
• Perceived lack of privacy
• Women more stigmatized than men

10. lowest concentration of mental health
professionals was found in frontier/rural areas
(counties with less than 10,000 people)
2009 workforce study
(Ellis et al., 2009; HRSA, 2011)

11. Telehealth
‘the use of telecommunications and
information technologies to provide
access to health information and services
across a geographical distance’
Telemedicine
‘use of medical information exchanged
from one site to another via electronic
communications to improve patient
health status’
(Institute of Medicine (IOM), 2012)

12. Definitions
• Synchronous communications
- Videoconferencing
- Telephone
• Asynchronous Communications
- Email
- Web-based programs
• Some telehealth technologies include
both type of communications
(IOM, 2012)

13. 1879
TELEHEALTH
is not new
(Aronson, 1977; Backhaus et al., 2012; IOM, 2012; Wittson et al., 1961; Wittson & Benschoter, 1972)

14. Annually, 10 million
patients receive
telemedicine services
(IOM, 2012)

15. VA Services
 146 hospitals provided 55,000 community-based
outpatient clinic patients with 140,000 telemental
health visits
 6,700 patients received home-based telemental health
services
 25% decrease in hospitalization for receiving telemental
health services between 2006-2010
 30% reduction in admissions during the first 6 months
of care in 2011
(Darkins et al., 2008; IOM, 2012)

16. Indian Health Services (IHS)
• serves 2 million American Indians
and Alaska Natives representing
566 federally recognized tribes
• includes 600 hospitals, clinics, and
health stations under tribal
governance
• implemented mobile telemedicine
services in the 1970s
• Alaska Federal Health Care Access
Network utilizes telehealth
technologies
• Telenutrition Program - 2006
(IOM, 2012)

17. Addiction Treatment Lags Behind
There are few published works on the use of
telehealth technologies to provide or enhance
substance abuse services in rural areas.
(Balas & Boren, 2000; Benavides-Vaello et al., 2013; Ryan & Gross, 1943)

18. NASADAD Survey
• In 2009, Addiction Treatment Providers
in 16 of the 37 states responding to
the survey reported offering treatment
services using telehealth
• Of those 37 states, 25 reported
providing mental health treatment
services using telehealth

19. USE of TECHNOLOGY

20. 85%of American adults have
cell phones
53%have smart phones
(Pew Report, 2012)

21. 80%send and receive
text messages
(Pew Report, 2012)

22. Over HALF have gathered health
information on their phone
Almost 20% have a health app
(Pew Report, 2012)

23. 80%of Americans
use the Internet
(Pew Report, 2012)

24. (McClure et al., 2012)
• Survey of 8 urban drug treatment
clinics in Baltimore (266 patients)
• Client’s access to
- Mobile Phone (91%)
- Text Messaging (79%)
- Internet/Email/Computer (39 - 45%)
What do we know about clients?

25. Customer Demand

26. Customer Demand
• WellPoint Inc., the nation's second-biggest health
insurer, plans to offer a new service in all of its
employer and individual plans that will allow
people to consult with physicians on-
demand, using laptop webcams or video-enabled
tablets and smartphones
• Aetna Inc. and UnitedHealth Group Inc., offer
virtual-visit services as an option for certain
employers.
(Wall Street Journal December 31, 2012)

27. Survey by Mercer found
15% of very large employers use
some form of telemedicine, and
another 39% are considering it
Home Depot Inc., Booz &Co., and
Westinghouse Electric Co.
(Wall Street Journal December 31, 2012)

28. Barriers to Treatment

29. 3.3%
19.3 million people needed but did not receive treatment
for illicit drug or alcohol use
Did not feel
they needed
treatment
(NSDUH, 2011)
In 2011, 20.6 million people aged 12 or older met
the criteria for substance use disorders
Felt they needed
treatment – Did not
make an effort
Felt they needed
treatment – Did
make an effort

30. Barriers include
Travel Costs and Burden
(Rheuban, 2012)
Time Away From Work
(Berwick, 2008)
Child Care
(Berwick, 2008)
Lack of Service Providers
(Perle et al., 2011; Swinton et al., 2009)

31. Privacy and
Confidentiality
(Moyer & Finney, 2004/2005)

32. How do we facilitate a shift that will give
addiction treatment providers greater reach
and tools to serve the population that
experienced barriers to treatment and those
that needed but didn’t receive treatment?
(Kazdin & Blase, 2011; Perle & Neirenburg, 2013)

33. One Answer…
Telehealth Technologies

34. University of Virginia’s telehealth program
has documented the avoidance of
7.2 million miles of travel
(Rheuban, 2012)

35. Telehealth Technologies

36. ‘The research base for telemental
health-related interventions is slightly
more than 50 years old’.
(Richardson et al., 2009; Wittson et al., 1961; Wittson & Benschoter, 1972)

37. 2000 – 2008
the number of telemental health
publications TRIPLED from the
previous 30 years
(Backhaus et al., 2012; Richardson et al.,2009)

38. Literature Review
 Videoconferencing
 Computer-based Interventions
 Web
- Screeners
- Support Groups
- Virtual Reality/Video Games
- Disease Management Programs
 Web-Portals
- Videoconferencing
- Messaging (chat and email)
 Telephone
- Continuing Care
- Interactive Voice Response
 Mobile Phones
- Texting

39. Videoconferencing

40. Largest provider of telemental health services
using videoconferencing
(Godleski et al., 2008; Darkins et al., 2008; IOM, 2012; Deen et al., 2012; Godleski et al., 2012)

41. Systematic Review of
Videoconferencing Psychotherapy
• Patients and providers perceived a strong therapeutic
alliance over videoconferencing
• Studies that compared videoconferencing to in-person
psychotherapy reported similar satisfaction levels
between the conditions
• high levels of satisfaction and acceptance with
telemental health have been consistently demonstrated
among patients across a variety of clinical populations
and for a broad range of services
(Backhaus et al., 2012)

42. Videoconferencing Studies in
Addiction Treatment
• Opioid Treatment-group counseling
(King et al., 2009)
• Alcohol Treatment
(Postel et al., 2005)
• Alcohol Treatment
(Frueh et al., 2005)
• Teleconferencing Supervision (TCS)- MI
(Smith et al., 2012)
(Backhaus et al., 2012)

43. Computer-Based
Interventions

44. Use of computers to deliver some
aspects of psychotherapy or behavioral
treatment directly to patients via
interaction with a computer program
(Carroll & Rounsaville, 2010)
DEFINITION

45. To date, more than 100
different computer-assisted therapy
programs have been developed for a
range of mental disorders and
behavioral health problems
(Klein, et al., 2012; Marks et al., 2007; Moore, et al., 2011)

46. Clinician
Extenders
(Bickel et al., 2008; Carroll & Rounsaville, 2010;
Des Jarlais et al., 1999; Marsch, 2011)

47. Computer-Based Treatments
• Serve as Adjuncts to standard treatment
• Save clinician time
• Extend clinician expertise
• Integrate other EBTs to provide additional services
to clients with co-morbid conditions
• Provide access to computerized smoking cessations
programs or other health-related conditions
(Carroll & Rounsaville, 2010)

48. “Delivery of CBT could be subcontracted
to the computer…..”
(Carroll & Rounsaville, 2010)

49. Examples of Computer-Based Interventions
• CBT4CBT (Carroll et al., 2008)
– Outpatient clients
– CBT + 6 computer modules on CBT
• TES [Therapeutic Education System] (Marsch & Bickel, 2004)
– Community Reinforcement Approach + Incentives
– HIV/AIDS Intervention-Opioid treatment clients (2004)
– Outpatient Opioid Treatment- TAU + TES (2008)
– Outpatient Treatment-2hrs per week of TES + TAU (2012)
• Ondersma (2005/2007)
– single-session computer-delivered MI intervention reduced drug
use among postpartum women

50. Web-based Screeners

51. Web-Based Screeners
• http://rethinkingdrinking.niaaa.nih.gov
• www.CheckYourDrinking.net
• www.AlcoholScreening.org
• www.DrinkersCheckup.com
• http://www.downyourdrink.org.uk/

52. Web-Based Screeners for
College Students
• www.CheckYourDrinkingU.net
• www.eCHUG.com
• http://www.collegebingedrinking.net/
• https://www.mystudentbody.com/def
ault.aspx

53. Web-Based
Support Groups

54. Web-Based Support
Psychoeducational
Self-Help
Mutual Support

55. Virtual Reality

56. Mental health professionals are now
employing virtual worlds in treating
• Asperger Syndrome
(Mangan, 2008)
• Combat-related PTSD
(Reger & Gahm, 2008; Wood et al, 2009)
• Emotional Aspects of Physical Disabilities
(Chen et al., 2009)

57. Computer Simulation Games
• Male Veterans
– adjunct to treatment
– focused on relapse prevention
– Played computer simulation game for 8 weeks
– no different in relapse rates
– results show decreases in craving and
increases in self efficacy
(Verduin et al., 2012)
Guardian Angel

58. Web-Based Disease Management
Programs
• Cancer
(Gustafson et al., 2005)
• Diabetes
(Glasgow et al., 2005; Williams et al., 2007)
• Heart Disease
(Verjejjden et al., 2004)
• Mood Disorders
(Farvolden et al., 2005)

59. Web-based Disease Management
Programs - Addiction
• MORE (My Ongoing Recovery Experience)
– 7 recovery modules-content tailored
– 18 month period
– Journal/workbook
– Access to counselors and other individuals
in recovery
(Klein et al., 2012)

60. Centerstone’s v-recover.com

61. The U.S. Veterans Health Administration

62. Telephone

63. Telephone Continuing Care

64. Telephone Continuing Care for SUDs
• Telephone Monitoring and Adaptive Counseling (TMAC)
(McKay, 2004)
• Focused Continuing Care (FFC) (Betty Ford Clinic)
• Telephone Enhancement of Long Term Engagement (TELE)
(Hubbard et al., 2007)
• Individual Therapeutic Brief Phone Contact (ITBPC)
(Kaminer & Napolitano, 2004) ADOLESCENTS
• Telephone Case Monitoring (TCM)
(McKellar et al., 2012)
• Telephone Continuing Care (TCC)
(Godley et al., 2010)

65. Interactive
Voice Response

66. Interactive Voice Response
• Automated, computer-based interventions have
shown promise in treating substance use disorders
• Fully automated systems offer a number of
potential advantages including:
– low cost
– consistent delivery
– greater accessibility and availability of treatment
– increased flexibility of scheduling and convenience
(Cranford, Tennen, & Zucker, 2010; Mundt, et.al., 2006)

67. Mobile Phones

68. #&%

69. Alcohol-Comprehensive Health
Enhancement Support System (ACHESS)
• Explicitly designed to address three constructs
– coping competence
– social support
– autonomous motivation
• Primary hypothesis is that ACHESS will reduce
risky drinking days

70. ACHESS

71. ACHESS
• Monitoring and alerts
• Reminders
• Autonomous motivation
• Assertive outreach
• Care coordination
• Medication reminders
• Peer & family support
• Relaxation
• Locations tracking
• Contact with professionals
• Information

72. TEXTING -
Portable Contingency
Management
1-3 text reminders
about sending video
of breathalyzer results
• Vouchers earned for negative BAC tests
• Thank you texts

76. FINALLY…
Take home message.

77. “Given the elusive nature of motivation to
change substance use-related behaviors…
it is important to capitalize on the
teachable moment.”
Immediacy of many
telehealth technologies
(Copeland, 2011)

78. Privacy, Security, & Confidentiality
Issues with Telehealth

79. Privacy, Security, & Confidentiality
• HIPAA Privacy Rules - What situations can
individual health information be disclosed, no
matter its format (oral, paper, or electronic)?
• HIPAA Security Rules - How are disclosures in
electronic format made?
(Karasz et al., 2012; www.hhs.gov/ocr/privacy/hipaa/understanding/srsummary.html)
Privacy & Security
Rules are Different

80. Privacy, Security, & Confidentiality

81. Final Rule specifically states because "paper-to-
paper" faxes, person-to-person telephone calls, video
teleconferencing, or messages left on voice-mail
were not in electronic form before the transmission,
those activities are not covered by this rule (p. 8342).

82. To ensure the patient’s privacy during
treatment sessions, clinicians should consider
the use of HIPAA compliant portals or
encrypted videoconferencing software.

83. SKYPE

84. Counselors Use of Technology

85. Does your staff
EMAIL or TEXT
clients?

86. SO WHAT’S THE

87. More than one-third of cell phone users
http://www.saurageresearch.com/key-findings-novemberdecember-2009/
• have sent a text message to
the wrong person (38%)
• report that a text they sent
was misunderstood by the
reader (37%)

88. “Traditional Short Message Service (SMS)
text messaging is non-secure and non-
compliant with safety and privacy
regulations under HIPAA. Messages
containing ePHI can be read by
anyone, forwarded to anyone, remain
unencrypted on telecommunication
providers’ servers, and stay forever on
sender’s and receiver’s phones.”
(Brooks, 2013)

90. “It is not acceptable for physicians or
licensed independent practitioners to text
orders for patients to the hospital or other
healthcare setting. This method provides no
ability to verify the identity of the person
sending the text and there is no way to keep
the original message as validation of what is
entered into the medical record.”
The Joint Commission November 10, 2011
http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?
StandardsFaqId=401&ProgramId=1

91. Safe
Practices

92. maintain physical control
of your mobile
device/computer
(http://www.HealthIT.gov/mobiledevices)

93. unsecured
networks

94. unintentional disclosure

95. password protect EVERYTHING

96. check out what is
downloaded on your
mobile device/computer
and keep the security
software updated
(http://www.HealthIT.gov/mobiledevices)

97. activate wiping and/or remote
disabling

98. Implement policies & procedures to
restrict access to,
protect the integrity of, and
guard against unauthorized
access to e-PHI
(HHS Office for Civil Rights)

100. Telecommunications Act
of 1996 …
use of technology as a
treatment modality
(Benavides-Vaello et al., 2013)

102. Oregon’s Telehealth Policy

103. CCHP Report Highlights
• 44 states have a form of TH reimbursement
• Live video most prominent reimbursed
• 7 states provide Medicaid reimbursement
remote patient monitoring
• 10 states require informed consent
• 9 medical boards issue special
licenses/certificates for TH
• 13 states have pending legislation on TH

104. “No two states are alike in how
telehealth is defined and regulated.”
(www.cchpca.org)

105. Who Pays for
Services
Delivered Using
Telehealth
Technologies
?

106. Medicare has the Most
prescriptive policies for telehealth

107. Reimbursement Requirements
• Type of service (real-time)
• Facility Type
• Practitioner Requirements
• Geography
• Allowable Codes

108. Medicare does not reimburse for
“store and forward technology”
so the interaction between a
beneficiary (patient) and the
practitioner must be real-time.

109. Originating Site
must be located in a
Rural-Health Provider Shortage Area
or
Non-Metropolitan Statistical Area county
or
Federal telemedicine demonstration
project (Alaska and Hawaii)

110. Medicare Telehealth Reimbursement
Basics
• Services delivered through telehealth
technologies are billed at the same rate
• Originating site of service may bill separately
• Real time communication through audio or
video technology is required
• Patient must be present at originating site

111. CMS is proposing to modify how rural
sites are defined to be consistent with
HRSA Office of Rural Health Policy

112. Practitioner Requirements
• Physicians
• Nurse practitioners
• Physician assistants
• Nurse midwives
• Clinical nurse specialists
• Registered dietitians or nutrition professionals
• Clinical psychologists (CP) and clinical social
workers (CSW)
Licensed
Addiction Counselors
not included

113. States Define …
• Telehealth eligible services
• Populations to receive services
• Qualified practitioners
• Telehealth service location
• Define the services delivered in managed care
vs. fee for service arrangements

114. Medicaid’s Three-Legged Stool

115. Medicaid’s Three-Legged Stool
 Person covered by Medicaid
 Service (the use of interactive audio and video
AND the actual service provided) is covered by
Medicaid
 Provider is Medicaid registered and practicing
within the State’s scope of practice

116. • 32.5K adults ages 18-64 with substance use
disorders will have coverage for substance use
treatment under Medicaid expansion
• 52K adults ages 18-64 with substance use
disorders will have coverage for substance use
treatment within the Health Insurance Exchange
• This represents a two times increase in the
estimated prevalence within the existing eligible
Medicaid population (currently 37K)
Oregon

117. Kentucky-
• Mental health evaluation or management
service, individual or group psychotherapy, and
medication management
• psychiatrist
• Physician
• APRN
• psychologist
• licensed professional clinical counselor
• licensed clinical social worker
• licensed marriage and family therapist
http://www.americantelemed.org/get-involved/public-policy-advocacy/state-telemedicine-policy

118. • Either mandated in state law or
left up to carrier to decide
• No consistent standards
• 19 states require coverage
• 26 pending legislation
Private Insurance

119. http://www.americantelemed.org/docs/default-source/policy/state-telemedicine-legislation-matrix.pdf?sfvrsn=60

120. biggest drivers
behind an organization’s
or practitioner’s ability to be reimbursed for
services provided by telehealth technologies
Payers, federal laws, and
state laws/policies are the

121. And while most payers only reimburse
for services delivered through
videoconferencing…….
another driver

123. Customer
Demand

126. License
Portability

128. Ethics
Use of technology
by counselors
• is increasing
• presents unique
ethical dilemmas
(NBCC Policy, 2013)

129. Ethics
Need to be
re-written to
address
telehealth
technologies

130. • NAADAC (Association for Addiction Professionals)
• National Board of Certified Counselors (NBCC)
• American Counseling Association (ACA)
• American Mental Health Counselor Association
(AMHCA)
• American Association of Marriage and Family
Therapy (AAMFT)
• National Association of Social Workers (NASW)
Ethical Codes Related to the use of Technology
in Counseling/Therapy/Treatment

131. Ethical Codes
American Psychological Association (APA)
• recognizes the need for development of
guidelines
• in 2011 approved a joint task force to
develop telehealth guidelines for
psychologists
• telehealth technologies are not currently
included in the APA Code of Ethics

132. International Certification & Reciprocity Consortium
(IC&RC)
• does not create or maintain a Code of Ethics
• IC&RC member boards deal with matter
individually and recommends contacting
member boards directly
• contact information for all member boards
can be found at
www.internationalcredentialing.org/findboard
Ethical Codes

133. Ethical Codes related to 4areas of
telehealth technology
• Informed Consent
• Confidentiality/Privacy
• Records & Data
• Competency
(NAADAC Code of Ethics, Rev. March 28, 2011)

134. Can a meaningful clinical relationship be
developed if a client and counselor do not
share the same physical space?
(Chester & Glass, 2006)

135. Development of
Therapeutic Alliance Using
Telehealth Technologies

136. Definitions
• Synchronous communications
- Videoconferencing
- Telephone
• Asynchronous Communications
- Email
- Web-based programs
• Some telehealth technologies include
both type of communications
(IOM, 2012)

137. Therapeutic Alliance Building Using
Telehealth Technologies

138. Building Rapport
• Active listening
• Verbal engagement
• Emotional engagement
• Empathy
• Self-disclosure
(Evans, 2009)

139. How to do this
using Telehealth
Technologies

140. American Telemedicine Association, 2013

141. Practice Guidelines
• Verification of Location
• Verification of Patient/Professional
• Patient Appropriateness
• Informed Consent
• Physical Environment
• Patient Safety/Emergency Management
• Technical
• Administrative

142. Verification is Critical

143. Clinical Guidelines:
Verification of Location
• Compliance with relevant licensing laws
• Emergency management protocol is dependent
upon where the patient receives services
• Mandatory reporting and related ethical
requirements
• Provider payment amounts are tied to location
Who do you report to?

144. Clinical Guidelines:
Professional/Patient
• Contact Information
Verification for Professional
and Patient
• Verification of Expectations
Regarding Contact Between
Sessions

145. Clinical Guidelines:
Patient Appropriateness
To date, no studies have identified any
patient subgroup that does not benefit
from, or is harmed by, mental healthcare
provided through remote videoconferencing.
What about panic
disorder…?
(Day, 2002; O’Reilly et al., 2007; Ruskin et al., 2004)

146. Clinical Guidelines:
Patient Appropriateness
Considerations where professional staff are not
immediately available
• Patient expectations & level of comfort
• Patient takes an active & cooperative role
• Patient’s organizational & cognitive capacities
MOST IMPORTANT

147. Clinical Guidelines:
Patient Appropriateness
Other considerations:
• Patient’s Abilities with Technology….
responsible for equipment set-up, maintenance
of computer settings, and privacy at his or her
site along with technology competency
• Geographic distance to nearest emergency
medical facility, patient’s support system and
medical status
What is their
comfort level?

148. Clinical Guidelines:
Informed Consent
• Follow local, regional and national laws
• Document consent in medical record
• Information included is same as in-person
Conducted in
real-time

149. Clinical Guidelines:
Informed Consent
• Confidentiality
• Emergency Plan
• How patient information is documented
and stored
• Technical failure
• Contact between sessions
• Referrals to more intensive care

150. Clinical Guidelines:
Physical Environment
• Aim to provide comparable professional
specifications of a standard services room

151. Ensure Privacy

152. Announce Presence of Other People

153. Seating, Lighting, Camera Positioning

154. Patient Safety

155. Clinical Guidelines:
Emergency Management
1. Education and Training
2. Jurisdictional Mental Health
Involuntary Hospitalization Laws
3. Patient Safety in a Setting with
Immediately Available Professionals

156. Clinical Guidelines:
Emergency Management
1. Patient Safety in a Setting without Immediately
Available Professionals
2. Patient Support & Uncooperative Patients
3. Transportation
4. Local Emergency Personnel

157. Technical Guidelines
• Video Conferencing Application
• Device Characteristics
• Connectivity
• Privacy

158. Administrative Guidelines
• Qualification and Training of Professionals
• Documentation and Record Keeping
• Payment and Billing

160. Building Rapport

162. Fast or Touch Typing
(Center for Credentialing & Education, 2011)

163. Comfort with Internet
Modalities and Software
(Center for Credentialing & Education, 2011)

164. Not This……

165. Comfort to Respond Quickly
When Necessary
(Center for Credentialing & Education, 2011)

166. Expressive Writing Skills
(Center for Credentialing & Education, 2011)

167. Telephone

169. Absence of face-to-face cues
Skills/Attitudes when working via telephone
• Welcoming manner
• Voice tone/style
• Interactive nature
• Structure-checking in
• Summarization
(Center for Credentialing & Education, 2011)

170. “It takes practice for a
counselor to learn to
trust their “inner ear”
and rely only on what
they are hearing.”
(Rosenfield, 2003)

171. SILENCE

172. Change in Inflection
BLAH

173. Distractions

174. Distractions
For the Client
For the Counselor

176. Development of Therapeutic Alliance
using Telehealth Technologies
Skills/Attitudes when working via e-mail
• Warmth & Caring
• Conversational
• Contextualizing
• Descriptive Immediacy
• Similes, metaphors and stories
• Writing style (font, captions, colors)
• Empathic mirroring
(Suler 2004)

177. “I HAVE A VISUAL IMAGE OF YOU
TRYING TO JUGGLE YOUR
RECOVERY, COMMITMENTS TO FAMILY
AND SEARCH FOR A NEW JOB.”
WARMTH and CARING
(Suler 2004)

178. “I CAN SEE YOU SITTING AT YOUR
MEETING, JOHN, TRYING TO BE PRESENT
BUT DISTRACTED AND WORRYING
ABOUT COMPLETING YOUR JOB
APPLICATION AND GOING TO YOUR
SON’S BASEBALL GAME.”
DESCRIPTIVE IMMEDIACY
(Suler 2004)

179. WRITING STYLE SHOULD BE
CONVERSATIONAL AND LESS FORMAL
AND CONTAIN FREQUENT USE OF THE
CLIENT’S NAME. ATTENTION SHOULD BE
PAID TO THE WRITING STYLE OF THE
CLIENT AS WELL AS AN INDICATOR OR CUE
TO THE CLIENT’S ISSUES.
CONVERSATIONAL
(Suler 2004)

180. Successful Treatment Outcomes
• Extensive literature on use of the telephone
• Less literature on use of email and chat
(Gainsbuby & Blaszczynski, 2011)

181. Cultural Differences/Counselor/Client
Suitability
• Less verbal individuals or those with accents or
hearing difficulties may not feel comfortable working
over the telephone
• Clients who prefer chat usually want a more intimate
real-time connection without “lag time” between
their communications.
• Clients considering online counseling must have a
basic grasp of written language and be able to express
themselves in writing. These clients may also want
time to edit and reflect on their communications with
the counselor.
(Rosenfield, 2003)

182. There will always be a place for
face to face treatment….
(Kazdin & Blasé, 2011; Perle & Nierenberg, 2013)
No worries

183. However, something must change…
to overcome the limitations facing the
field and the notion that mental
health care services are often not able
to reach all those in need, particularly
those in rural or remote areas.
(Kazdin & Blasé, 2011; Perle & Nierenberg, 2013)
Reach all of
those in need

184. (Kazdin & Blasé, 2011; Perle & Nierenberg, 2013)
A major shift and expansion of
clinical practice must occur to
overcome the mental health burden
and facilitate positive change.
Must expand
clinical practice

185. (Kazdin & Blasé, 2011; Perle & Nierenberg, 2013)
From this, the question becomes,
how do we facilitate this shift that
will give mental health professionals
greater reach and tools to serve the
greater population?
Greater reach & tools =
TELEHEALTH
TECHNOLOGIES

186. Whether its Group Counseling
Like This or Like This

187. or Client Homework
Like This
or Like This

188. Telehealth
Clients’ and Providers’ Best
Interests
Expanding Enhancing
Treatment Services

189. Catch the
Telehealth Wave
Telehealth To Grow
Six-Fold By 2017

191. www.nfarattc.org
T h a n k