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Reaching out to provide PTSD care

Telehealth studies span seas, mountains

January 8, 2009

When Leslie Morland, PsyD, began work at the VA Pacific Islands Health Care System nine years ago, much of her time was spent flying. The scenery was nice—looking down over white-sand beaches and shimmering blue ocean waters—but the mission was critical: providing counseling to veterans with PTSD and other issues who lived in farflung Hawaiian or Pacific islands.

Next best thing to face time—John Fortney, PhD (on screen), and Jeffrey Pyne, MD, are leading a study using videoteleconferencing to provide PTSD care to veterans in Arkansas, Louisiana and California, mostly in rural areas. (Photo by Jeffery Bowen)

"I flew to Hilo twice a week, Kona once a week, and Guam periodically," says Morland, a psychologist with the Honolulu division of VA's National Center for PTSD.

Today, Morland still flies now and then, but more of her time is spent seeing patients on a video screen. She is the "telemental health" lead for her VA region. She is also one of several VA researchers exploring the use of videoteleconferencing (VTC) in PTSD care.

In a typical VTC setup, a group of veterans meets in a room at a VA community-based outpatient clinic, along with a facilitator. They are all visible on camera to the person at the other end: a psychologist or other trained therapist, usually based at a VA medical center. The therapist can see all the group members, although catching the nuances of facial expressions and body language may be a bit more challenging.

No technology can replace face-to-face contact, but according to studies by Morland and others, the outcomes with VTC are about the same as those with inperson therapy. Researchers have seen reductions in PTSD symptoms—usually the main study outcome—but they've also seen ample evidence that the technology doesn't crimp relationships among veterans who are in group therapy together, or between veterans and providers.

Morland's group recently concluded a study with 127 veterans who had PTSD and needed help with anger management. About half received in-person therapy, while the others participated in video sessions at VA outpatient clinics on Hawaii's Big Island, Maui or other outlying sites.

"We found both approaches to be clinically effective," says Morland, "and we found no difference in process variables like trust, satisfaction, cohesion. We had very low attrition." The psychologist says that "a big issue with PTSD care is making sure people continue to come to therapy."

The anger study was a particularly good test of VTC, notes Morland. "One of the research questions we had was whether we could work with a lot of 'affect' in the room—a lot of emotion, people getting angry before they even come into the group. We found it wasn't a problem."

In today's era of Webcams and iPhones, the technology of VTC may seem ho-hum. But there's a lot of coordination required before and during each session, says Morland. Her group's anger study proceeded with hardly any glitches. They held 120 video sessions and never had to cancel or reschedule due to technical problems.

She acknowledges that because they were doing a funded study, enough resources were in place to prevent any mishaps, both in terms of staff and equipment. Still, she asserts that with good coordination, VTC can be used smoothly in routine clinical settings.

Coordination is key

One of the keys, she says, is having an information-technology person on call to troubleshoot technical snags. Another is making sure there is adequate bandwidth. It also helps to make calls between only two points, rather than involving multiple sites. Above all, staff at both ends have to call and email ahead of time to make sure everything is in place.

"When things aren't planned, that's when things can go wrong," warns Morland. "That's when veterans and providers say, 'I don't want to do this.'"

It's especially important that the first few sessions go well, she says. "You have only a couple of opportunities to show it will work; otherwise, veterans may start to get frustrated."

The Honolulu group just launched a new study of VTC for cognitive processing therapy, one of the evidence-based PTSD treatments used most commonly by VA clinicians.

Morland stresses that the research focuses not on validating the treatment itself—it's already been shown effective in many studies—but on showing whether VTC can produce the same results as inperson therapy.

She points out that not everyone is an instant believer. "Anytime there's something novel, there's going to be a segment of the population that's resistant." That's the case with patients and perhaps even more so with the providers who have to deliver the service, she says. Getting their buy-in is crucial to spreading the use of VTC and other telehealth methods in VA. But with VA's increasing needs to serve veterans in rural areas—and a strong evidence base for psychotherapy for PTSD—even skeptics are finding it hard to deny the promise of telehealth. Further research may win them over for good.

"We need to look at whether we're going to achieve the same clinical effectiveness," says Morland. "If we are, then we can say this isn't a second-rate service. We know this works."

This article originally appeared in the January 2009 issue of VA Research Currents.

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