Debunking common virtual therapy myths and tips for new patients [PODCAST]

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“While the COVID-19 pandemic exposed and normalized the need for increased mental and behavioral health services over the last year and a half, addressing mental health issues as a regular form of their wellness will persist beyond the pandemic. However, as the adoption of virtual technologies continues to open up more access to care, the potential to successfully meet the rising demand for these services is promising. The last 18 months have shown us that providers are making huge strides in helping patients from all walks of life facilitate their own care virtually. Even with the challenges we are still experiencing in the current pandemic, it’s an exciting time for the evolution of mental health care.”

Sara Smucker Barnwell is a licensed clinical psychologist and clinical director of behavioral health, 98point6. She can be reached on LinkedIn and at her self-titled site, Sara Smucker Barnwell PhD.

She shares her story and discusses her KevinMD article, “Debunking common virtual therapy myths and 4 tips for new patients.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Sara Smucker Barnwell. She is a clinical psychologist, and she is clinical director of behavioral health at 98point6, which is an on-demand, text-based primary care app. She wrote the KevinMD article “Debunking common virtual therapy myths and 4 tips for new patients.” Sara, welcome to the show.

Sara Smucker Barnwell: Thanks so much. Delighted to be here.

Kevin Pho: We’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Sara Smucker Barnwell: Surely. I’m a clinical psychologist by training, and I’ve worked in the telehealth space for about 20 years now. My great passion was access, ensuring that we promote access to evidence-based behavioral health care to anyone who needs it. Too often, clients are not able to access the type of care that they need, the type of specialist that may best suit them, because of diverse reasons. Perhaps it’s geography; perhaps it’s other physical or medical limitations that prohibit their ability to access that care. So for me, telehealth was an obvious match.

I’ve had this really fortunate and fun career, wherein I’ve worked in a diversity of circumstances, inclusive of academic settings. I was director of telemental health for VA Puget Sound Health Care System for many years, and in recent years I have been working in private industry, again with the explicit mission of increasing access to evidence-based mental health care for everyone who needs it. When it comes to behavioral health, I think telehealth is an ideal match, given the lack of access in many parts of the country.

Kevin Pho: Now, before the pandemic, what were some of the barriers that prevented telehealth from really becoming more mainstream?

Sara Smucker Barnwell: That’s a great question. I think that some were quite practical logistics: at that time, having adequate infrastructure in terms of technological applications that facilitated connecting patient and provider, and having adequate support from legislative bodies to help navigate some of the issues around practicing remotely. And then I think there was just also adoption.

We’ve seen telehealth democratized meaningfully over the last year and a half, wherein people previously may have had hesitations, and when I say people, I mean both provider and patient, and all of a sudden, this really aligned with what people needed for their behavioral health care. As such, we saw people really having a willingness to adopt. We saw technology rising to meet the challenge and giving us different ways to support the milieu, and we saw our legislators step up and really support us, ensuring that not only could care be delivered, but it could be covered by people’s insurance.

Kevin Pho: Now, if and when the pandemic ends, what do you see as some of the lasting effects when it comes to the telehealth space?

Sara Smucker Barnwell: I believe that, moving forward, we will see a hybrid model of practice. Sometimes folks speak in terms of, “Well, when the pandemic is over and things go back to normal,” and I think that may not be how this proves out. Indeed, we will see, moving forward, meaningfully, that clients want telebehavioral health and that providers want to provide it. So I think that we will see an adaptation wherein practice really does look different, that we can anticipate having in-person clinic as well as remote clinic meaningfully, and as such, that we should be investing in schedules and equipment, in the infrastructure to support that type of adaptation.

Kevin Pho: All right, let’s transition now to the KevinMD article that you wrote. It’s titled “Debunking common virtual therapy myths and 4 tips for new patients.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Sara Smucker Barnwell: Absolutely. In my role, over the years, I’ve had many opportunities to work with clinicians who are either beginning to develop a telehealth practice, or perhaps, in the circumstances of the pandemic, they were thrust into needing to deliver telehealth to their patients, or alternatively, they’re thinking down the road and saying, “OK, this is going to be here to stay.” A lot of times, there are concerns that they hold, themes such as, “Will virtual therapy be as effective? Will my clients feel as connected to me?” So I really want to take a moment to speak to those clinicians, because I think the good news is that the answer to most of these questions is more positive than perhaps people may have anticipated.

Indeed, in the clinical literature, we see that most outcomes are pretty comparable in video conferencing conditions compared to in-person conditions, and even in some telephone-based studies, we see very highly effective behavioral health interventions being delivered remotely. We see tremendously high levels of patient satisfaction, and the capacity to really establish clinical engagement through a distant milieu.

I think that’s really important for folks to know, because I think there has been this reticence about either initially adopting or, alternatively, staying in the milieu: “Am I giving something up? Am I delivering a high standard of care to my patients?” And I think that when we look to the clinical literature, we find that we really are, and that we can have some of the best of both worlds. We can have good clinical engagement, we can have sound clinical outcomes, and we can have that increased access that is so important in the current context.

Kevin Pho: Now, I’m a primary care internal medicine physician, and last year during the pandemic, we were just kind of thrown into this virtual health environment, really without any training. Now, for those clinicians out there who continue to do virtual health, and especially behavioral health issues on a telemedicine platform, what kind of advice can you give to these physicians who really have no background or training in doing that?

Sara Smucker Barnwell: I think really invest some time. It’s a daunting task, and it can feel like it’s a steep learning curve, but once you get there, maintaining those competencies is pretty straightforward. I mean that in the most practical and mundane of ways, such as: Make sure you have a place in your home that is private, that is quiet, that is appropriate, if you’re working out of a home office, as many people have. If you’re in your professional office, ensure that you adapt that space to work well for the type of distance milieu you’re delivering care in, and be it telephone, be it video, be it text-based, whatever the case, invest in the technology, invest in the space. This is very silly, but get a good chair. Ensure that your ergonomics are set up in a way that this is sustainable.

Additionally, be thoughtful regarding how you’re going to collect documentation, how you’re going to communicate with patients in between meetings, and how you’re going to manage things such as payment and insurance submission without the patient physically present. I think the investment in a thoughtful administration of these themes creates a more seamless experience for the patient and creates a lot less stress for the provider.

So it really is that investment of time. Go ahead and take a CE on it; goodness knows there are quite a few right now. Maintain those competencies, and invest time and invest in your infrastructure to make sure that you are meaningfully set up to do this in the long run.

Kevin Pho: Now, in your article, you also talk about tips for patients. From the patient perspective, what are some tips and advice that you could give them to get the most out of their virtual visit?

Sara Smucker Barnwell: Absolutely. Some of these would be very similar to what I would advise someone seeking in-person care, but I think perhaps these issues are heightened somewhat in the context of distance therapy. And that is: Take the time to find the right fit for you. Read the provider biography. Ask questions. When you go to that initial meeting, a behavioral health clinician is aware of these issues. We are very much aware that the client needs to feel a sound rapport. They need to feel a good connection, and if that doesn’t feel right to you, it needs to be a theme that you’re allowed to talk about. If you would prefer to meet with someone of a specific gender, or of a specific cultural background, or someone who shares some characteristic with your own background, I really want to encourage folks to say, you know, that’s OK. You’re allowed to ask for what you need. And I think, again, being prepared to put in a little bit of time so that you make sure that you have the best match possible.

Be prepared to find a comfortable, private space in your home. A year and a half ago, I had never met with a client in their closet or in their car. Now I have, and we do what we can. But I think, again, if you’re going to meaningfully, over time, receive care remotely, thinking about where that could happen, and this is a privilege, to have space and to have access to something like this, but trying to find a space that is private, that is comfortable, I think is going to be more conducive to doing the work you need to do.

Be ready to ask questions. And again, as always, it’s the same as in-person care, realizing that, I think, in therapy, a lot of the work happens in session, but perhaps even more happens between sessions. So there’s the good work that you’re doing with your clinician, but then there’s the actual sort of realization of the changes that you’re working to see in your everyday life. So come with that benchmark expectation that you will be working in between those sessions, until your next clinical meeting.

Kevin Pho: We’re talking to Sara Smucker Barnwell. She is a clinical psychologist and clinical director of behavioral health at 98point6, which is an on-demand, text-based primary care app. Sara, for those clinicians who want to make virtual care a more permanent part of their practice, what kind of advice can you give these physicians going forward?

Sara Smucker Barnwell: It’s a great question. I think there are themes such as: What will your relationship be to your intake process? Do you want to meet with clients exclusively remotely, or do you prefer to see them in person first? How are you going to assess appropriateness for virtual meetings? There are few evidence-based reasons to exclude someone from remote care. That being said, people have their own preferences, so some clinicians prefer not to see clients who are experiencing emergent symptoms remotely; others do. But I think each clinician would need to think through what their inclusion-exclusion criteria for remote care would be and determine how they’ll navigate that intake process.

How will you respond to emergencies? Always ascertaining a sound emergency plan, ascertaining where that client’s going to be and what emergency services you would contact for the client in case of emergency, again, in advance of anything emergent happening, will make life much less stressful.

And then thinking about what your relationship to physical space will be: Will you continue to maintain a physical space for those clients that either do not fit what you believe is your inclusion-exclusion criteria for remote care? Will you want to be able to see somebody in person on some specific interval, and how do you want to navigate that? So I think being thoughtful about your inclusion-exclusion, your physical space, and then how you’re going to navigate themes such as intakes, such as documentation, such as emergent circumstances, would probably be the best advice I could give.

Kevin Pho: Now, from a financial standpoint, how viable is it for a clinician to have a completely remote practice, whether in primary care or behavioral health?

Sara Smucker Barnwell: I think it’s tremendously viable from a financial perspective. Certainly, your overhead costs are fewer, because you don’t have the same demand for physical space. You’ll, of course, need to invest in technology products that will support the practice, and make sure that you have smoothed over some of those rough edges of how to communicate and capture documentation appropriately.

I think folks find that their referral sources and outreach may differ somewhat. So for their in-person practice, perhaps they had one referral source, but they find that for the remote practice, they’re working with other referral sources, and I think that takes some time and some investment of relationship building to ensure that you are well connected to those referral sources that have the types of patients who want to be seen remotely, who would benefit from this care.

I know some folks work explicitly with certain communities that have limited access to behavioral health. I know when I was in the VA system, that was a strong focus: doing outreach to our communities who maybe didn’t have local behavioral health resources. We were sure to really know those primary care clinics. We were sure to really know those EDs, to make sure that we could bridge those gaps and help the patients get the care they need.

So I would say it’s absolutely financially viable. There have been changes in legislation that have allowed for reimbursement with parity for telehealth services. That may be shifting somewhat in the coming months, so that’s the one thing people want to keep an eye on: There were some provisions allowed that reimburse telehealth services at the same rate as in-person services, and now there is some question as to whether or not that will remain. So we’re seeing a lot of movement on that front. That’s the only thing I would say to keep an eye on, that insurance reimbursement legislation.

Kevin Pho: And my final question: What’s your take-home message you want to leave with the KevinMD audience?

Sara Smucker Barnwell: My take-home message is, I think, if you have an inclination to do this work, it’s tremendous work. It is an opportunity to deliver evidence-based behavioral health care to folks who would never have access to it otherwise. For me, that’s why I got into health care: making sure we connect the right patient with the right provider and really help them get better. That’s it. And I think that this is a wonderful vehicle to do it. I really want to thank everybody for the good work they do and encourage them to keep on keeping on.

Kevin Pho: Sara, thank you so much for joining me and sharing your time and insight, and thanks again for being on the show.

Sara Smucker Barnwell: Thanks so much for having me.

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