There is a significant need for professional programs to provide training in the provision of telephone-delivered mental health services. Telephonic mental health services is an emerging practice approach that may meet the needs and the field’s commitment to addressing access to mental health services. We know that access to mental health services is limited for individuals in geographically underserved areas. This access gap is in part due to shortages of mental health professionals, and other determinants like limited transportation, stigma, impairments due to the mental health diagnosis and/or physical health, or limited physical mobility (Hoerster et al., 2014; Simms, Gibson, & O’Donnell, 2011; Smalley et al., 2010). Despite gaps in care, clinicians tend to think that telephonic mental health service is not the same as in-person therapy and, thus, less effective. This notion is further reinforced by many state licensing entities, and there is a lag among accreditation bodies to examine emerging forms of technology in practice (Christiane & Lambert, 2018).
These reasons negatively impact patients’ options for services that can be accessible, and contradict existing evidence-based practices such as Collaborative Care, which has a substantial telephonic component. Telephonic mental health service also has the potential to reach segments of the population that cannot access care in a timely manner (Gifford, Niles, Rivkin, Koverola, & Polaha, 2012).There is also preliminary data that suggests that patients enrolled in telephonic mental health services “attend”, on average, more sessions than patients who receive in-person treatment, which has consistently been at low levels. This may indicate that a segment of patients prefer telephonic services. Training the workforce in telephonic mental health services is even more critical now that four Medicare CPT Payment codes have been introduced – CPT99492, CPT99493, CPT99494, CPT 99484 – which allow for service reimbursement implemented through Collaborative Care, an evidence-based model that is primarily carried out through a telephonic modality. Collaborative Care is a renowned model demonstrating significant evidence for improving health outcomes for depression and anxiety (Carleton et al., 2018).
In our effort to learn about telephonic mental health services, we interviewed mental health clinicians who provide telephonic mental health treatment. We learned that clinicians’ perceptions towards telephone delivered care vary. One clinician commented “I didn’t know what to expect. I wondered if it would be less personable.” Another clinician said “I thought it would be mainly for two specific populations, the elderly or people who are disabled. But also, people who might have fear or stigma [towards] counseling or therapy.” Despite these differences, clinicians’ overall perceptions of patients’ acceptability of these services were positive. For the most part, we heard that “generally patients are satisfied”. In one interview, a clinician said “Everyone I spoke to has positive feedback. I always receive a lot of ‘thank you’s and patients are appreciative when I call them and when they receive help from me. It’s been very positive and seeing that is it helping them and that patients are really benefiting from the service.”
Unlike the sparse research in this area, clinicians we interviewed were not reluctant to provide non-in-person services. In fact, they perceived it as a convenient and beneficial modality for getting patients the care they needed, and even enrolling patients that would not have otherwise sought services. This was clear when one clinician said, “I feel that when people are in need of therapy it should be an option and it can definitely help and can be as effective” as in-person treatment.” In our interviews with clinicians, they often mentioned the therapeutic alliance with the patient as one aspect of their work that they had to adapt to in providing services over the telephone. Several clinicians mentioned having to pay close attention to their voice tone, their word choice, and actively listening to patients for “clues” to build rapport. In adapting to this modality and reinforcing her skills, one clinician said her experience over time changed: “I thought it would be harder to build rapport with patients, but patients have been able to engage over the phone.” The general consensus from clinicians was that the therapeutic alliance with their patients was not negatively affected in any significant way nor was treatment or quality of care compromised when they delivered care remotely. These comments support what we know from existing research which demonstrates that telephonic services are effective in treating mental health conditions like depression, and other behavioral health conditions (Boyden & Dobel-Ober, 2016; Datto, Thompson, Horowitz, Disbot, & Oslin, 2003; Ekeland, Bowes, & Flottorp, 2010).
Part of clinicians’ acceptance and adoption of telephone delivered mental health services stemmed back to initial training they received. It was clear that clinicians, who struggled using the telephone to do their work, needed more training. This has implications for clinicians who lack training in telephonic mental health services or who face providing therapy telephonically to patients. The field has long maintained that in-person mental health services to patients are the basis for providing care. Yet emerging technological approaches once considered “secondary” or “inferior” are no longer true as a growing number of mental health professionals are extending their reach through these modalities. This is an opportunity for the field to shape practice innovation by developing students’ and mental health professionals’ competence and confidence to effectively deliver telephonic mental health services.
About the authors. Micaela Mercado, PhD, is Director of Research; Virna Little, PSyD, is Chief Operating Officer; and Eunice Kim, LCSW, is Director of Training at Concert Health. All correspondences can be directed to Dr. Virna Little at virna@concerthealth.io.
