There is a lot to be said for physical presence. As licensed
mental health care providers (LMFT in my case), we are taught to diagnose and
treat in person. Connecting with people
in a therapeutic, healing, and professionally intimate manner over a
telemonitor is difficult at best. It is possible to read body language and tone
through a monitor, but the amount of emotional energy it takes to convey
compassion, empathic presence, and sound clinical interventions through a
virtual space is harder than it sounds.

 

While tele-presence is better than no presence, and
comparable to in person care [1-2],
there are patients who distrust technology, who display emotions that
can be hard to help regulate in a virtual space, who have hearing deficits, who
speak a different language than the provider (more challenging over telehealth
than in person), and any number of other barriers. A thorough assessment of
functioning can be made more difficult without the benefit of having all senses
available. For example, if a patient is not bathing regularly, this could be a
sign of poor self care related to level of depression and impairment. Poor
hygiene can be difficult to assess in a virtual environment.

 

Advantages include the elimination of provider safety issues.
The two times that I can think of in the past 2 years that someone made
sexually inappropriate comments and/or gestures on the telemonitor, I didn’t
have to worry about a panic button or alerting someone to come help me. All I
had to do was give a warning to the patient, and when that warning was not
heeded, I let them know I was disconnecting due to their inappropriate
behavior, hung up, called the nurse on site to follow-up with the patient, and
voila! All bases covered.

 

Another great thing about Telehealth is that it is a
therapeutic modality that is evolving in terms of technology available and as a
billable service. When I first started in telehealth in the mid 2000s, telehealth
really meant talking on the phone…a land line at that! Imagine doing therapy
with a blind fold on and the client is the next town over! Now, we have
sophisticated HIPAA compliant, encrypted teleconferencing hardware and
software. At a teleconference conference in Maryland earlier this year, I saw
an actual telehealth robot that moved around the room seemingly independently.

 

In my current position I work with patients who live in
rural areas with no or limited access to specialty care. The teleconferencing
equipment is in their primary care physician’s offices, so they still have to
travel to receive care. As such, there are the typical no show rates and
transportation issues. There are connectivity issues, but there are also huge
pay offs and success stories.

 

I think about the woman with the 30 year old gunshot wound
who presented to telehealth for rising A1C, gastrointestinal distress, a
colostomy bag, and poor diet compliance. This woman had been seen for years in
her primary care clinic and there was no evidence in her chart that any
provider had ever asked her the origin of her gunshot wound or colostomy bag,
or the reason that her diet was so incompatible with her diabetic and
gastrointestinal status. A brief conversation about her social and emotional
environment revealed that she was in a long term abusive relationship, that she
was still living with the partner who shot her, and that the partner’s new form
of control of her was to prepare and monitor the patient’s food intake, with
violent consequences if she did not conform to his expectations.

 

By having access to a behavioral health provider with the
time and the skill set to assess for psychosocial stressors that could be
impacting her medical compliance, she was able to disclose the abuse, problem
solve around her options, and make strategies with regard to maintaining her
health as much as possible within an abusive environment. Knowing her home environment was directly
related to her inability to manage her A1C and gastrointestinal issues, it took
someone to ask her a direct question about her home environment for her to
disclose.

 

With this information, I was able to work with her physician and a
nutritionist to tailor her treatment goals to her particular situation. This is an uncommon example, but I continue
to be amazed at what is revealed in telehealth sessions that are designed to be
about health behavior, but so frequently are tied in to relational and systemic
issues.

1.
Bashshur,
R. L., Shannon, G. W., Smith, B. R., & Woodward, M. A. (2015). The
empirical evidence for the telemedicine intervention in diabetes management.Telemedicine
and e-Health,21(5),
321-354.

2.
Izquierdo,
R. E., Knudson, P. E., Meyer, S., Kearns, J., Ploutz-Snyder, R., &
Weinstock, R. S. (2003). A comparison of diabetes education administered
through telemedicine versus in person.Diabetes
care,26(4),
1002-1007.

 

Dr. Banks is a clinical assistant professor at East Carolina University at the Family Medicine Center. She has a PhD in Marriage and Family Therapy and is a AAMFT Approved Supervisor. In her current role, she provides telebehavioral health services to people with diabetes and co-morbid behavioral health challenges. In addition to her clinical work, she teaches at both the undergraduate and graduate level. She serves on the CFHA Research and Evaluation Committee and is Continuing Education Chair for the North Carolina Association for Marital and Family Therapy. She is also a member of the American Telemedicine Association, She currently has 6 journal publications and has presented 24 times at local, state, and national levels.  She is particularly passionate about keeping issues of social, human, and relational justice alive in our personal and professional roles.