Psychotherapy with the Unwilling Client

We sought to characterize how telemental health (TMH) versus in-person mental health consults affected 30-day postevaluation utilization outcomes and processes of care in Veterans presenting to the emergency department (ED) and urgent care clinic (UCC) with acute psychiatric complaints. This exploratory retrospective cohort study was conducted in an ED and UCC located in a single Veterans Affairs system. A mental health provider administered TMH via iPad. The primary outcome was a composite of return ED/UCC visits, rehospitalizations, or death within 30 days. The following processes of care were collected during the index visit: changes to home psychiatric medications, admission, involuntary psychiatric hold placement, parenteral benzodiazepine or antipsychotic medication use, and physical restraints or seclusion. Data were abstracted from the Veterans Affairs electronic health record and the Clinical Data Warehouse. Multivariable logistic regression was performed. Adjusted odds ratios (aORs) with their 95% confidence intervals (95% CIs) were reported. Of the 496 Veterans in this analysis, 346 (69.8%) received TMH, and 150 (30.2%) received an in-person mental health evaluation. There was no significant difference in the primary outcome of 30-day return ED/UCC, rehospitalization, or death (aOR 1.47, 95% CI 0.87-2.49) between the TMH and in-person groups. TMH was significantly associated with increased ED/UCC length of stay (aOR 1.46, 95% CI 1.03-2.06) and decreased use of involuntary psychiatric holds (aOR 0.42, 95% CI 0.23-0.75). There were no associations between TMH and the other processes-of-care outcomes. TMH was not significantly associated with the 30-day composite outcome of return ED/UCC visits, rehospitalizations, and death compared with traditional in-person mental health evaluations. TMH was significantly associated with increased ED/UCC length of stay and decreased odds of placing an involuntary psychiatric hold. Future studies are required to confirm these findings and, if confirmed, explore the potential mechanisms for these associations.

Mental health conditions (MHCs) are the most expensive conditions in the United States (US). The high MHC prevalence coupled with continued undertreatment of MHC has contributed significantly to this high economic burden. Despite policy changes to increase mental health parity and integrate mental and physical healthcare, the shortage of mental health providers remains a significant barrier to mental health (MH) treatment. Telemental health (TMH) has emerged as an alternative care delivery approach to meet the growing demand of MH care and shortages of MH providers. Understanding the adoption of TMH among mental health facilities is critical for informing the broad implementation of TMH in the delivery system of mental healthcare. As the use of TMH is determined by not only "supply" but also "demand," it is also important to understand TMH use among adults with MHC. Given that commercial insurance plays an important role in paying for mental health services and telehealth services, it is imperative to examine TMH use and the impact of TMH use on healthcare costs among commercially insured adults with MHC in real-world care settings. Therefore, this dissertation pursued three related aims: 1) to estimate TMH adoption and examine factors associated with TMH adoption among mental health facilities; 2) to characterize TMH use and identify factors associated with TMH use among commercially insured adults with MHC; and 3) to evaluate how TMH use influences healthcare costs. To comprehensively present TMH state of the art within the current mental health delivery system, the study used diverse data sources. These data sources were: the National Mental Health Services Survey (N-MHSS) for years 2011-2016; a geographically diverse claims database for commercially insured adults for years 2010-2017; the latest Area Health Resources File (2016-2017); and national reports of telehealth policies. We found that about one in four mental health facilities in the US adopted TMH in 2016. TMH adoption might be hindered by low facility-level information technology capacity and by state licensure requirements for cross-state telehealth practice. TMH use among adults with MHC was low (16 in 10,000) in this study of a commercially insured population. Current TMH use among adults with MHC was driven mainly by a greater need to access mental health specialists. TMH use was associated with increased MH service use and higher MH-related costs. However, TMH use did not have a significant impact on total third-party healthcare costs. In summary, these findings highlight the need for

BackgroundResearch indicates that treatment outcomes are poorer for people with long-term physical health conditions (LTCs) in Talking Therapies services (formerly known as Improving Access to Psychological Therapies). However, the impact of having an LTC on attendance at assessment and treatment appointments within Talking Therapies remains unclear. Internet-enabled therapies may be one way to overcome barriers to treatment engagement in Talking Therapies. However, their effect on engagement and the influence of LTC status on receipt of internet-enabled therapies is unknown.AimsTo explore the association between LTC status and assessment attendance, treatment engagement and internet-enabled therapy receipt within Talking Therapies services, and whether receipt of internet-enabled treatment bolsters engagement.MethodWe used anonymous patient-level data from two inner London Talking Therapies services during January to December 2022 (n = 17 095 referrals). Binary logistic regression models were constructed to compare differences between LTC and non-LTC groups on (a) assessment attendance, (b) engagement and (c) internet-enabled therapy receipt. In our regression models, we controlled for key clinical and demographic covariates.ResultsThere were no differences between patients with or without an LTC in assessment attendance or treatment engagement, after controlling for covariates. Across the whole sample, receiving internet-enabled treatment increased engagement. People with an LTC were less likely to receive an internet-enabled treatment.ConclusionsHaving an LTC does not negatively affect assessment attendance and engagement with talking therapies. However, receiving an internet-enabled treatment bolstered engagement in our regression models. People with an LTC were less likely to receive internet-enabled treatment.

Background: The COVID-19 pandemic has highlighted telemedicine use for mental illness (telemental health).Objective: In the scoping review, we describe the scope and domains of telemental health during the COVID-19 pandemic from the published literature and discuss associated challenges.Methods: PubMed, EMBASE, and the World Health Organization's Global COVID-19 Database were searched up to August 23, 2020 with no restrictions on study design, language, or geographical, following an a priori protocol (https://osf.io/4dxms/). Data were synthesized using descriptive statistics from the peer-reviewed literature and the National Quality Forum's (NQF) framework for telemental health. Sentiment analysis was also used to gauge patient and healthcare provider opinion toward telemental health.Results: After screening, we identified 196 articles, predominantly from high-income countries (36.22%). Most articles were classified as commentaries (51.53%) and discussed telemental health from a management standpoint (86.22%). Conditions commonly treated with telemental health were depression, anxiety, and eating disorders. Where data were available, most articles described telemental health in a home-based setting (use of telemental health at home by patients). Overall sentiment was neutral-to-positive for the individual domains of the NQF framework.Conclusions: Our findings suggest that there was a marked growth in the uptake of telemental health during the pandemic and that telemental health is effective, safe, and will remain in use for the foreseeable future. However, more needs to be done to better understand these findings. Greater investment into human and financial resources, and research should be made by governments, global funding agencies, academia, and other stakeholders, especially in low- and middle- income countries. Uniform guidelines for licensing and credentialing, payment and insurance, and standards of care need to be developed to ensure safe and optimal telemental health delivery. Telemental health education should be incorporated into health professions curricula globally. With rapidly advancing technology and increasing acceptance of interactive online platforms amongst patients and healthcare providers, telemental health can provide sustainable mental healthcare across patient populations.Systematic Review Registration:https://osf.io/4dxms/.

This study examined provider and client perspectives of tele-mental health (TMH) in early psychosis care during the COVID-19 pandemic. To achieve this goal, thirty-three mental health providers and 31 clients from Pennsylvania Coordinated Specialty Care (CSC) programs completed web-based surveys assessing TMH usage, experiences, and perceptions between May and September 2020. Three additional TMH-related questions were asked two years later of PA CSC Program Directors between Feb and March 2022. Descriptive statistics characterized responses. Open-ended items were coded and grouped into themes for qualitative synthesis. As early as mid-2020, participants reported extensive use of TMH technologies, including telephone and video visits. Although most providers and clients preferred in-person care to TMH, most clients still found TMH to be comparable to or better than in-person care; 94% of clients indicated interest in future TMH services. Providers also noted more successes than challenges with TMH. Nine themes emerged regarding provider-perceived client characteristics that could benefit from TMH and were grouped into two categories: client-level (access to technology, comfort with technology, transportation, young age, symptom severity, functioning level, motivation for treatment adherence) and interpersonal-level (external support systems and engagement with program prior to the pandemic) characteristics. Two years later, program directors reported continued perceived advantages of TMH in CSCs, although some barriers persisted. Despite the unexpected shift to TMH in early psychosis programs during the COVID-19 pandemic, findings indicated a relatively positive transition to TMH and perceived promise of TMH as a sustained part of routine care.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11126-023-10015-0.

COVID-19 accelerated federally qualified health centers' use of telemental health. However, factors associated with telemental health service delivery remain unclear. We examined telemental health delivery by clinician type and mental health workforce composition across the U.S. to understand how staffing and other organizational characteristics are related to telemental health delivery at health centers. Using data from the 2021 Uniform Data System, we characterized the proportion of mental health care delivered via elemental (i.e., virtual visits) at health centers in the U.S. that received HRSA grant funding (n = 1,270) overall and by state and clinician type. Then, we conducted multivariate beta regression analyses to assess the proportion of mental health visits delivered via telemental health at health centers as a function of mental health workforce composition, while adjusting for health center size, patient mix, and state. In 2021, health centers delivered 43% of their mental health visits via telemental health, with significant variation by state and clinician type. On average, the proportion of mental health visits delivered via telemental health was greater among psychiatrists (61%, P < .001) than psychologists (49%) and clinical social workers (45%). Factors significantly associated with the increased proportion of telemental health delivered by health centers included a higher supply of psychiatrists per patient, more grant dollars per patient, and a greater proportion of Asian patients served. Access to telemental health varies by state and across health centers based on mental health workforce composition. Future work is needed to examine funding and workforce strategies to increase telemental health service availability.

Background: The mitigation strategies for the COVID-19 pandemic pushed much of the mental health workforce to rapidly convert to full-time telemental health (TMH). For many people, this occurred in the context of working from makeshift home offices with novel distractions. We describe the results of an online survey of mental health clinicians and staff regarding their experiences in rapidly converting to full-time TMH and work from home (WFH) during COVID-19. Methods: Fourteen clinicians and 11 administrative staff from two outpatient mental health clinics in a large academic medical center completed the survey in May 2020. Results: More than 85% of participants rated the experience of providing or supporting full-time TMH care as "somewhat better" or "much better than expected." Clinicians and administrative staff reported perceptions that most clients were satisfied with TMH services. Identified TMH challenges included difficulty providing clinical forms and difficulties with technology. Identified benefits of WFH included lack of commute, time with loved ones, opportunities for self-care, and increased flexibility. Maintaining team cohesion and communication while working remotely, and setting boundaries between work and nonwork hours were identified as challenges. Nearly all respondents indicated a preference to continue some TMH from home in the future. Conclusions: Findings suggest that rapidly adopting TMH and WFH during a pandemic were well accepted. Should the progression of the pandemic require agile movement in and out of TMH and WFH, overcommunication and extra attention to supporting employee connection and morale are especially important.

The COVID-19 pandemic restrictions, uncertainties and management inconsistencies have been implicated in men's rising distress levels, which in turn have somewhat normed the uptake of telemental healthcare services (i.e., phone and/or video-conference-based therapy). Given past evidence of poor engagement with telemental health among men, this mixed-methods study examined Australian men's use of, and experiences with telemental health services relative to face-to-face care during the pandemic. A community sample of Australian-based men (N = 387; age M = 47.5 years, SD = 15.0 years) were recruited via Facebook advertising, and completed an online survey comprising quantitative items and open-response qualitative questions with the aim of better understanding men's experiences with telemental healthcare services. In total, 62.3% (n = 241) of participants reported experience with telemental health, and regression analyses revealed those who engaged with telemental health were on average younger, more likely to be gay and university educated. Men who had used telemental health were, on average, more satisfied with their therapy experience than those who had face-to-face therapy. Among those who had telemental healthcare, marginally lower satisfaction was observed among regional/rural based relative to urban men, and those who had to wait longer than 2 months to commence therapy. Qualitative findings highlighted positive aspects of telemental healthcare including comfort with accessing therapy from familiar home environments and the convenience and accessibility of telemental health alongside competing commitments and COVID-19 restrictions. Conversely, drawbacks included technical limitations such as crosstalk impeding therapeutic progress, disconnects and audio-visual lag-times and the 'impersonal' nature of telemental healthcare services. Findings broadly signal COVID-19 induced shifts norming of the use of virtual therapy services, with clear scope for improvement in the delivery of therapeutic practice using digital modalities, especially among help-seeking men.

7 - Business Aspects of Telemental Health in Private Practice

Decriminalising being Black with mental illness

Although the recent proliferation of telemental health care has transformed the delivery of outpatient mental health care for many individuals in the US, little is known about how outpatients are distributed across telehealth, hybrid, and in-person care. To characterize the national distribution of sociodemographic and clinical outpatient mental health groups across telehealth, hybrid, and in-person mental health care. This was a cross-sectional analysis of all telehealth, hybrid, and all in-person mental health care by adults (aged ≥18 years) in the 2021-2022 Medical Expenditure Panel Survey (n = 4720). Data were analyzed from January to August 2025. Average annual percentages of adult mental health outpatients who used all telemental health care, hybrid, and all in-person mental health care were calculated overall and stratified by sociodemographic and clinical characteristics. Differences in percentages using each modality were evaluated by sociodemographic and clinical strata adjusted for age, sex, and distress level (Kessler-6 scale). Type of mental health treatment used (telemental health, hybrid, or in-person). The analysis involved 4720 participants (2235 aged 18-44 years; 3007 female). Approximate one-fourth (27.8%; 95% CI, 25.7-29.8) of mental health outpatients received all telemental health care, 21.5% (95% CI, 19.8-23.1) received hybrid care, and 50.6% (95% CI, 48.2-53.1) received all in-person care. The percentage of patients receiving all telemental health care was higher for younger (aged 18-44 years; 31.7%; 95% CI, 29.0-34.3) than middle age (aged 45-64 years; 24.2%; 95% CI, 21.1-27.4) or older (aged ≥65 years; 19.4%; 95% CI, 16.1-22.7) adults, high school (23.1% 95% CI, 20.4-25.8) and college (34.5%; 95% CI, 31.5-37.5) graduates than those without a high school diploma (19.9%; 95% CI, 13.7-26.1), patients with incomes >400% federal poverty level (33.8%; 95% CI, 30.9-36.7) than lower (range, 20.6% to 23.7%), private (30.8%; 95% CI, 28.5-33.1) than public (20.2%; 95% CI, 17.4-23.0) insurance, and urban (29.2%; 95% CI, 27.0-31.3) than rural (14.0%; 95% CI, 8.6-19.3) residence. Compared to patients receiving medication alone (15.4%; 95% CI, 12.5-18.3), those receiving psychotherapy with (25.9%; 95% CI, 23.2-28.6) or without (41.6%; 95% CI, 38.0-45.2) medication were more likely to use all telemental health. Patients with less than moderate distress (29.2%; 95% CI, 26.1-32.3) were also more likely than those with serious distress (21.2%; 95% CI, 16.7-25.6) to use all telemental health. In adjusted analyses, patients treated by mental health counselors (10.9%; 95% CI, 7.0-14.7) or social workers (8.4%; 95% CI, 4.1-12.7) were also more likely to receive all telemental health than were patients treated by other mental health clinicians. The findings of this cross-sectional study indicate that telehealth has become a common means of receiving outpatient mental health care in the US, especially for resourced patients with less serious psychological distress who receive psychotherapy from mental health specialists.

Introduction: Telemental health is a growing medium for delivering psychotherapy to youth. While significant research has been devoted to relationship building in telemental health, creating meaningful relationships with youth remains complicated. Clinical tools are needed to support clinicians as they transition to telemental health due to the COVID-19 pandemic. This systematic review identifies recommendations for building rapport with youth over telehealth and serves as the basis for a clinician-friendly document to aid in clinician training and ongoing consultation. Method: Three major databases were searched: PsycINFO, Web of Science Social Sciences Index, and PubMed. A total of N = 18 works met inclusion. Three doctoral-level clinical psychologists double-reviewed all articles, extracted recommendations from each article, synthesized recommendations into conceptual themes, and combined recommendations in order to create a clinician-friendly list of recommendations for building the telemental health relationship. Results: Identified literature spanned a number of methodologies and characteristics. Recommendations were identified for all stages of the telemental health treatment span and included 195 recommendations spanning 12 broad themes. Some themes that emerged related to clinician behaviors, introducing and orienting to telemental health, and logistical considerations. Summaries of themes and recommendations are provided, as well as descriptive information related to reviewed works. Discussion: Recommendations were fairly consistent across works. We discuss implications of these themes for research on the telemental health relationship, clinical applications of our findings, and the need for increased resource-sharing and crowd-sourcing to support clinicians building telemental health relationships with youth.

The Mental Health Parity and Addiction Equity Act evaluation study: Impact on specialty behavioral healthcare utilization and spending among enrollees with substance use disorders

The basis of substance use disorders (SUD) is formed with regard to biopsychosocial aspects. By following the SUD biological model exclusively, the effectiveness of treatment is limited since all the formation aspects of SUD are not taken into account. By using the psychosocial model, however, the understanding and treatment of a substance use illness becomes enhanced and is more effective. A key role in this model is played by self-help groups and psychotherapy. The aim of this study was to determine the viewpoint of patients with substance use disorders in terms of the number of visits, duration of treatment, efficacy of self-help groups, and individual and group psychotherapy in different treatment methods. The participants were approached by researchers at two drug and alcohol services in Latvia. In total, 587 patients received questionnaires developed by the authors of the study. All the 587 questionnaires of both outpatient respondents (n=200, 34.1%) and inpatient respondents (n=387, 65.9%) were analyzed. Of all the outpatient department respondents, 41.5% (n=83) attended self-help groups, 28.5% (n=57) individual psychotherapy, and 14.5% (n=29) group psychotherapy; the inpatient department respondents were 2 to 4 times less often involved in the measures. The outpatient respondents were more frequently employed. They attended self-help groups and psychotherapy and obtained longer remission comparing with inpatient respondents. This study has shown that patients had a greater success rate in staying in remission, maintaining outpatient care and shedding the need of inpatient care.

Content &amp; FocusThe last two decades, in particular, have witnessed an increased interest in the clinical implications of attachment theory in individual adult psychotherapy. By and large, the majority of empirical studies on the importance of adult attachment patterns in individual psychotherapy have focused on exploring the effect of clients’ attachment organisation. The present paper reviewed the existing literature on the effects of therapists’ attachment organisation on the process and outcome of therapy. In particular, 14 known studies were reviewed, exploring how trainee and qualified therapists’, as well as other clinicians’, attachment styles could influence the working alliance, the depth of their interventions, their emotional empathy and psychological mindedness, their countertransference behaviours towards clients and finally the outcome of therapy.ConclusionsFindings from these studies showed that a secure attachment organisation in therapists could positively affect the process and outcome of therapy, whilst an insecure attachment organisation was negatively associated with both process and outcome of therapy. Nevertheless, a few studies provided us with different results. Overall, it can be suggested that the relationship between therapists’ attachment and the process of therapy is not as simple as we assume because other factors may interfere in this relationship.The findings, the methodological characteristics and limitations of the 14 reviewed studies are discussed throughout this paper.