Introduction
The last time I tried to run a group was certainly pre pandemic and this was an in person group. And it was really hard to find a group of people who could physically be at the hospital at the same time each week. The idea of being able to bring people together more easily over telehealth and have that social interaction.
And that sense of being able to be around other people who are experiencing similar things to what you are, was incredibly beneficial for the folks that I've worked with. So far that to me and to the patients that I've talked with, that's been the number one benefit.
When we think about access for patients, particularly with upper extremity injuries, amputations, or conditions that affect dexterity like Ms using a computer or using a device that requires a lot of dexterity was not necessarily as acceptable or accessible as we would anticipate the benefit was accessibility from the perspective of coming to a health center, when there's a public health crisis.
The ability to attend a session virtually was certainly an added bonus of the accessibility piece.
A lot of my patients will join. And if they're having a particularly bad fatigue day, they will keep their video off. And one of my patients shared that, the reason she does that is because it's cognitively overwhelming for her to look at everything.
On the video and look at herself and by turning her video camera off and just sort of listening to the session, she can feel more engaged and feel less overwhelmed. And initially I had a bit of a reaction to that. I wasn't sure whether that was still useful. And what I noticed is that people were more likely to return.
That was allowed. They were also more likely to participate more regularly if that was allowed. Not everybody does it every time, but there are some people who will do it intermittently. We
may be the first experience someone has when they meet someone else with that condition and how powerful that can be and how we can be an agent of effective change and safe change for them so that it doesn't devolve into something that is unhelpful for the individual patients when they come away from the.
Welcome to find empathy, a continuing education podcast for therapists, where we discuss the interaction between health and emotions. My name is Dr. Megan Byer, a clinical psychologist who specializes in chronic illness and disability. Our current series is focused on using telepsychology to work with medical populations while the topic stories and case studies are relevant for every therapist who uses telepsychology with medical populations, the topics covered were created specifically to meet the criteria needed to satisfy side pack requirements for psychologists and American psychological association, the association of state and provincial psychology.
And APA insurance trust telepsychology guidelines. I hope you enjoy this episode.
Individual Telepsychology
Welcome in this podcast course, we will be discussing the use of technology for telepsychology in the outpatient setting. We'll spend the first half of our discussion discussing the use of telepsychology for individual psychotherapy, with medical popul. In the second half, we will discuss bringing psychotherapy groups online.
During that discussion, we will focus on several different styles of groups with couples, individuals, with multiple sclerosis, stiff person syndrome and chronic pain. Our experts for the session today are Dr. Abbey Hughes, an assistant professor at the Johns Hopkins department of physical medicine and rehabilitation who works primarily with multiple sclerosis and stiff person syndrome.
She is also the division training director and will speak on how to incorporate trainees into telepsychology models. We also have Dr. Nicole Schechter also an assistant professor at the Johns Hopkins department of physical medicine and rehabilitation. And Dr. Schechter specializes in chronic pain and also helps to run the patient engagement program, which trains medical professionals who use basic motivational interviewing skills to partner with their patients.
Welcome Abbey and Nicole. Let's start with Dr. Hughes. Can you please share a little bit about yourself, your background and your role at Johns Hopkins.
Thank you so much, Meghan, it's a pleasure to be here. And as you said before, I'm an assistant professor here in the Johns Hopkins department of physical medicine and rehabilitation.
And I do a combination of research and clinical practice predominantly in Ms. And. More recently, introducing some groups for individuals with stiff person syndrome, stiff person syndrome is a pretty rare autoimmune mediated neurologic condition, uh, that comes with quite a bit of chronic pain and unpredictable spasms.
So when we talk about managing the unpredictability and uncertainty of this condition, there's a lot of overlap with Ms. In the advent of the pandemic, we've certainly shifted a lot of our practice to virtual, which has had some advantages and disadvantages that I'm really looking forward to speaking with you all later today.
Thanks so much Dr. Hughes, Dr. Schecter, can you share a little bit more about yourself, your background and your role at Johns Hopkins?
Sure. Thanks for having me, Megan pleasure to be here. You already mentioned I'm assistant professor in the department of physical medicine and rehab. My primary role, um, is to work in the outpatient clinic.
I, as you mentioned, I work with individuals primarily with chronic pain and those individuals are experiencing chronic pain for many different reasons. Uh, sometimes a chronic pain disorder. Sometimes they are experiencing chronic pain, secondary to cancer. Or spinal cord injury. So a, a wide range of individuals with different kinds of experiences.
I work very heavily with some of our postdoctoral fellows. I run the externship program and so have some contact with our graduate student externs as well. When they're rotating and learning about rehabilitation psychology. And you mentioned this, I work in our patient engagement program. Which is one of my greatest joys and I never expected to, to be doing that and have adapted our program, our training program in communication, healthcare communication, to virtual as well.
And so that, I think there's been a lot to learn both in running, uh, psychotherapy, virtually in individual and group that I'm excited to discuss. And perhaps can also speak a little bit to how we, uh, work with other healthcare professionals in the virtual space.
So excited to have both of you today, before we get into the details.
I'd love to hear from both of you keeping in mind, HIPAA, a story, or a situation that you didn't expect when we had to quickly switch to telemedicine at the start of COVID.
Yes. This is a great question. I think one of the biggest, uh, surprises to me. Twofold and they're tied together. The first was how quickly my no-show and cancel cancellation rate dropped.
Once we switched over to telehealth practice, I found, and perhaps it's because of the, the individuals we're working with, many of whom have, uh, medical complexities, physical and other disabilities. They were much more able to access care, working via telehealth. And so people were showing up to their appointments much more regularly than ever before.
So I became, my practice became much busier than it had been previously. And then the second biggest surprise that I found was being able to see them as an example, either in their car or in their homes. So being able to get a very different perspective of what someone's life looked like and. And their environment and who was around, which in many ways, uh, helped the care that, that we were working on together. Uh, and sometimes could be barriers depending on what was going on.
I can relate to both of those. Dr. Hughes, can you share a story or a situation that you didn't expect when switching to telemedicine?
I think at the beginning of the pandemic, we had a lot of parallel processes happening with our patients in the shift. And parallel processes are when a therapist or a provider is experiencing a similar event and coping and navigating that with their patient.
And with the start of pandemic, you know, there's lots of things that have changed over the past two years, but initially many of us didn't have the internet bandwidth that we thought we did at home. Uh, what we were used to watching maybe Netflix in the evenings didn't work quite the same at two o'clock in the afternoon when suddenly everyone was using the internet at the same time for some pretty, uh, significant bandwidth needs.
So navigating the bandwidth piece was certainly a challenge and really brought to light the privileges that depending on where you live in the country, the type of internet access you have in your city or region, all of those came to light very, very quickly.
The other part would be working style. Um, many of us were forced into places within our home that were not necessarily a home office or something that was conducive to a peaceful therapeutic environment.
As Dr. Schechter mentioned, we were able to see patients in their own settings. Um, but to be honest, from a therapist perspective, as we had our own children and partners and people at home for, for some of us, that was an additional thing to navigate so that we could still serve the patients and put patients first, while we, while we were all experiencing this pretty unprecedented major event.
Thank you both for sharing. What are some of the initial hurdles that you had to overcome with individual psychotherapy? When we first switched to telemedicine?
One of the initial barriers that we noticed was for new patients who we had not had a chance to establish a one-on-one relationship with. It's a little harder, at least it was initially, a little harder to develop that therapeutic rapport and relationship. Part of that was due to connectivity issues with. Part of, it was also just us being used to having the face to face in person environment. In addition to that, not just with patients, also our trainees, uh, I serve as the training director of our program.
Um, at the time I was not in the role of overarching training director, but was working very closely with trainees. And so navigating things like. We used to be used to popping into the next room, to talk with the trainee about a clinical issue, and then going back to our own sessions. That became much more difficult in the zoom environment because we weren't used to that quick cognitive flexibility.
Great. And are, are you aware of any policy changes that happens at the beginning of COVID or as telemedicine has become a more regular practice?
In terms of hospital policy, whenever emergency, uh, authorizations went into place, every state had its own emergency status and then individual insurance companies also had their own policy changes about whether they would cover telehealth or not.
So in many ways we relied on the state of emergency to be directing the degree to which we could do telemedicine. An additional layer of that was also licensing boards and any requirements of states that required in person supervision of psychotherapy. We've been fortunate here in Maryland, that remote supervision in the presence of state of emergency, uh, was feasible.
However, if trainees happen to live out of state, and if you live in an area that's a Tri-Cities area or where you are frequently crossing state boundaries. That was a significant ethical question that was coming across all of our list serves and email lists among training programs and supervisors.
Thank you so relevant, Dr. Schechter, what were some of the initial barriers that you faced when you switched to telemedicine and how did you overcome those barriers?
One of the barriers that we encountered when we first switched over to telemedicine at the beginning of the pandemic was with new patients as well. How to, uh, convert what we normally did in office with paperwork or a, an intake battery.
I'm not speaking about cognitive testing, but I'm talking about psychological testing. So we have a pretty robust battery of psychological testing that we do for our chronic pain patients. To get a sense of either psychological functioning, their disability perception, uh, and many other aspects of their experience.
Um, we used to do that in office. They would fill out the paperwork while they were in the waiting room. And then we would review that together. And incorporate that into the evaluation. We very quickly had to figure out a way to get those evaluations because they're extraordinarily helpful in treatment planning to the patients in a way that they could fill them out virtually.
So we quickly had to shift. We use domains like Qualtrics, uh, sometimes red cap. To establish a, an online method for gathering this information, uh, and distributing it to patients in a way that they could as easily as possible access it. So that was one of our challenges. This took a, a, a lot of work on our end to convert over to an online platform.
And then also to communicate clearly with patients what we needed from them. This was a pretty easy conversation to have in person in a waiting room. Much more difficult to do this in advance of an initial appointment when you don't have that relationship with the patient already. So that was one barrier.
The second is similar in nature, but thinking about, uh, using, uh, cognitive behavioral therapy, as an example, dialectical behavioral therapy or acceptance and commitment therapy, what some of the most common, uh, modalities that we use for individuals with chronic pain and using work. And other kinds of paper documentation that we ask folks to work on in between sessions, uh, was another challenge to get those papers and forms and, uh, worksheets that we wanted them to use, uh, to the patients in a way that they could use them.
Some folks have printers at home. And so we, we could send these as PDFs or in secure chats in their medical record. Uh, and some folks did not have that kind of access or that ability. And so having to be thoughtful and consider patients access and their resources and how to adapt, uh, treatment and their care, uh, along those lines.
Great. I wanna ask a follow up question. You mentioned Qualtrics and Red Cap. And I'm wondering if you can discuss how you thought about those different platforms. What made you choose those? Was it just availability within your system or, um, were you thinking about any of the ethical considerations, like HIPAA compliance and what worked the best for you in terms of platform?
So both of these programs that were mentioned are HIPAA compliant and they were available through our university system. So when things first developed, we had had previous experience using these platforms through research, which also has very strict HIPAA guidelines. So we felt comfortable enough using these for clinical purposes.
Unfortunately, what we, what we wish to happen is have all of these measures available through the electronic medical record system, uh, which we currently use epic. And over the years, epic has grown its survey library considerably. However, if there's a certain validated measure in the population that you're working in, that's not available through epic you can explore these other technology options.
So for therapists who might be working in a more, uh, remote setting or not part of an institution that again provides us this privileged account, there might be other options. So working with other private practitioners, there might be a way to collaborate, to have a shared account with it as part of a group practice.
And a follow up question for you, Dr. Hughes, expanding a little bit on what you were just saying. There have been lots of different programs that have popped up to provide that video telecommunication with patients both individually and in group settings. Would you mind sharing what platform you use and what are the pros and cons of that platform or other platforms that you've tried?
Sure. And with the caveat that I, I'm not, uh, in any way financially tied to any of these products, zoom and a WebEx based tool that is done through MyChart have been the primary modalities that we use for video based sessions. And doximity is a third option that I've had some familiarity with. Honestly, the reason for adopting these tools has been coming from recommendations at the institutional level of what is safe to use, what is accessible, and then based on our experiences as providers, particularly for us, uh, working with individuals with disabilities, there are some tools that at the time, uh, and currently still have greater disability accessibility features. Um, for example, closed captioning, clear audio, clear video settings, ability to screen share, ability to send documents through a secure chat feature. All of those are things that I particularly keep in mind when working with people who may be using different types of devices, like an iPad or an iPhone.
How do you ensure the confidentiality of the session that you're doing? We can now kind of zoom into people's homes, right? They're talking to us from their house and there may be other people in the environments that we have less control over than we did in the clinic. So what are the particular ways that you go about ensuring that confidentiality?
Yes, the confidentiality is of course, extraordinarily important. Dr. Hughes covered one already, which is our choice of platform that we are using, right. Where we have, uh, our institution has guided us to use specific platforms that are shown, or at least the institution is stating, are more secure and have features that have, have allowed them to be more secure.
So that's one, that's one method personally, you know, in my, in my encounters with patients, I. Few extra things. So one, we, uh, have incorporated, uh, informed consent regarding confidentiality of telehealth in particular, uh, that is now part of our process, which we had never had to think about before. So ensuring that the patient understands in full during an informed consent process that we will be using telehealth platforms. The benefits of that, the risks of that, uh, the considerations that, that we, uh, have in mind that we ask them to have in mind, things like using private wifi, being in a place where it can be quiet and private, uh, for, to allow who they want to be able to hear, to hear, uh, what they're talking about. Things like that as part of our informed consent process. So that's one thing we do at the beginning at the start of care. Along with our other informed consent processes that psychologists, uh, do as part of our ethical, uh, principles.
The second thing that I do is at each session, I, uh, check with the patient when we're first starting that they are in a safe, secure space and that they would like to proceed with the care for that day over the telehealth platform.
I do this because as you described. Different people. If they're in their home might be around then we're around last time. So I wanna be sure that the patient continues to be comfortable, uh, having a session no matter who is around and who is present. So I give them that opportunity at the beginning to confirm that they're still comfortable moving forward.
Uh, and then last, I always describe who is in my space. Not that anyone is in my space listening to the session, but. Who may be in my environment, uh, or usually just providing assurances that I am in a private, quiet space. And no one, uh, can hear, uh, from, you know, what I am saying or what the patient is saying.
So those are some of the things that I do to try to enhance confidentiality each session.
And a quick follow up question for you. Uh, Nicole, after you administer the questionnaires, how do you ensure the confidentiality of the answers of those questionnaires? If they're not incorporated into the epic system?
That's a great question, Meghan. So the responses are gathered via a secure system, so the responses live there. And then when we write or document about, as an example, an initial evaluation, where I would be incorporating the questionnaire responses, uh, that goes into then the secure, epic, uh, EHR, electronic health record.
Uh, and so. We are sure that when we are sharing that data, just like any other process that we are not including any raw data we're describing standard, uh, scores and we're describing categories rather than actually giving raw data in the same way that we would. If someone had done that in the office.
Great. That's great. And I really like that you brought up the idea of private wifi in your previous answer, because we didn't really think about the fact that wifi and in places like the library or Starbucks or something like that could be tapped into. And so it's important for patients to be aware that those are not secure places, so all really great information.
Sorry. I was gonna add, you know, I've had some, some interesting experiences with patients because they can access the appointment essentially from everywhere along those lines. Not necessarily in a coffee shop, but I have had patients join their session with me in the lobby of a hospital.
Mm-hmm, taking a family member there or they're taking, uh, themselves to another appointment. They're trying to fit appointments together to be resourceful. Uh, and so having to have these conversations around. This being a, a confidential space on the platform itself. However, asking them, encouraging them and eliciting for them to consider who is around and are they absolutely comfortable with who might actually hear them talking whether or not someone is tapped into a public wifi?
Absolutely. Yeah. I, I think that's a really good point. I've had situations where people were driving in their car with family members and then when they brought up certain topics were uncomfortable to talk about those topics. So really encouraging people to think ahead about wanting to be in a safe space, a space there that they are.
That they can speak freely and openly. Um, so it doesn't hinder the appointment.
I wanted to follow up with a question for Dr. Hughes. Um, you had mentioned kind of cross states, you know, um, and even though PsyPact is growing and there are many people who are part of PsyPact and we're starting to be able to see people across state lines, that's relatively new, but how do you ensure your own license and ensure, ensure that the patient is in a place where you're able to see them?
Sure. Um, this is again an ongoing question that has been present. I think in most. Licensed boards and list serves. At this point, when we begin a session, we always ask the patient to confirm their current location, not necessarily the address that is on file in their record. And there are instances where patients are on vacation or they're traveling across state lines in many ways.
In, in many ways, we need to trust that what is being reported is accurate. And that is what we document. Uh, but we don't go through any additional. Geo coding or verification process. We do have some administrative staff who provide instructions ahead of time, uh, that if you register for an appointment, based on your home location, information is provided about being in that location.
Although there have been mistakes and that, and that has been. A point of frustration, both for clinicians and patients. I'm sure that if a patient thought that they were supposed to be in a certain state and that's the only place that they could get treatment, we did have the experience of patients driving from, for example, Virginia, into Maryland.
Thinking that they had to be in Maryland to be seen by a Maryland psychologist, with the advent of PsyPact that was no longer the case because both of those states were PsyPact states. But this is an example of a really evolving process where the laws are changing by the day. In Maryland we were fortunate that right around the time that the first state of emergency was set to expire was also around the time that PsyPact was passed.
And so we did not have a significant lag in access for our patients, at least for patients who were in PsyPact states for those patients who are not in PsyPact states, we had to have conversations around either referral to a local psychologist, uh, who they could see otherwise or discuss delaying or pausing treatment until we could next see them in clinic.
For a lot of our patients, they are traveling to Maryland or to Baltimore for other medical care. So it wouldn't have been a very long time before we would potentially see them in person again, but these were all very individualized conversations based on the patient's, uh, unique circumstances and location.
I, I
totally echo everything that you're saying. Abby, I, I also have had many patients who feel frustrated by some of the limitations, even though so much has expanded. I've had people who are on vacation or visiting family members and wanted to have a session or even people who've moved to states that are not part of PsyPact and then are frustrated that they can't continue to see us, um, in the same way they did in a different state.
And you know, some of that. Really having open and honest conversations with our patients about the, those limitations and the frustrations that they're experiencing and maybe echoing, uh, or empathizing with those frustrations.
Both of you are involved in trainee education and, you know, Abbey, you as the training director and, um, Nicole, as the externship training director, I'd love for both of you to speak a little bit to the unique considerations, uh, There are when working with trainees.
So you had spoken a little bit Abbey about, you know, having to set aside specific times to check in with our trainees rather than just sort of popping into the next room, but are there any other unique considerations that you had to think about in terms of switching to telemedicine with your trainee?
Sure again, this process has evolved over the pandemic, but I found, uh, myself navigating the dilemmas of what is policy and then what is value driven based on my own philosophy of supervision and engagement with trainees. Um, so we often turn to guidance with the hospital of what we were allowed to do from a telemedicine standpoint, from in person, uh, standpoint of what was considered safe and an ongoing debate arose around, particularly for psychology trainees, if we are essential personnel, but we're not essential for in person the risk benefit analysis of what was considered safe for a trainee to come into the hospital to do training. For example, in our inpatient rehabilitation units, many of whom had active COVID patient, uh, populations.
And navigating that, um, power dynamic of noting that our trainees are at a disadvantage in that power differential. So the expectation of coming in person during a public health emergency during a time when perhaps trainees might have a disability or the immunocompromised had not disclosed that and were forced to disclose in the context of the pandemic.
So the, again, the policy, you might be allowed to do something, but then bringing in our psychology ethics around just because we can do something, uh, should we?
And taking an open, um, and curious approach tended to be my, my approach with trainees, and also recognizing that while trainees are at a lower, um, Status of power within an academic medical system, also respecting the autonomy and the incredible independence of our trainees, who are at the postdoctoral level.
And. Also have their own insights in wanting to help, right. Wanting to be present to help on that. Uh, Nicole May have some other views from an externship standpoint because there's an additional power differential when it comes to externs, but certainly it was ongoing open conversations of what fellows felt comfortable with when there were medical conditions to take into account and then navigating that policy versus ethics as we went forward.
Yes. I completely agree. Of course, with what Abbey is describing, I would add an additional boundary challenge, which I experienced as well in the faculty position was the switch to telehealth in so many ways, made it easier to pack a schedule, so to speak didn't have a commute anymore. Right? And so it, it made it easier in many ways to have a more full schedule.
And while I did that a bit at the beginning of the pandemic, I also was experiencing a fair amount of burnout. And I bring this up because this was also the case for post-doctoral fellows and our externs as well. So considering. Boundary setting around schedules and how as a faculty member, I was experiencing advantages in so many ways and privilege in so many ways.
And I myself was experiencing burnout giving, given how much, uh, extra I was adding to my, uh, clinical caseload and, and wanting to be very conscious and aware of what my postdocs or my, or the externs were seeing me do. And having discussions around my choices and what was causing me to make certain choices to add extra patients.
And then also when I shifted my practice back because of my burnout experience, how to have conversations with postdocs around that. I found at some point in the pandemic that I was modeling the wrong things, modeling, you know, kind of sacrificing some of my own needs and my own, uh, energy. Uh, for that of my patients, which ultimately did not make me as good of a clinician or made me not as an, of an attentive clinician, I, I expect, or I suspect and wanting to be sure that my postdocs were be being very thoughtful about their schedules and how they were serving patients during a very stressful time.
It's a really important consideration. And I think many of us who saw our, our templates expand or had fewer no-shows felt similar things. So I think it's really important to be aware of that and, and build in that extra time for trainees as well as ourselves, um, to get notes done and things like that. I wanted to ask kind of a two part question to both of you.
What are some of the unique challenges, working with medical populations or rehab populations using telemedicine? And what are some of the biggest benefits that you see using this technology?
Sure. Both a challenge and a benefit is accessibility prior to the start of the pandemic. Most of my exposure to telehealth had been in the context of research studies, particularly randomized controlled trials that were adequately funded to include some pretty comprehensive.
Uh, patient care coordination, including technical support. So I came into the pandemic almost with an assumption that it would also be that quote, easy or accessible. If we pivot to zoom with our entire patient population, particularly those with disabilities and chronic health conditions. And what I, um, should have known and, and became very aware of acutely was having that care coordination team, from the research experience, is usually not the case in clinical practice.
Insurance does not often reimburse that level of care coordination. And because of pandemic, we lost quite a bit of administrative staff who would be essential for that kind of support. Um, so the, the disadvantage was when we think about access, uh, for patients, particularly with upper extremity injuries, amputations, or conditions that affect dexterity like MS using a computer or using a device that requires a lot of dexterity was not necessarily as acceptable or accessible as we, we would anticipate.
The benefit was accessibility from the perspective of coming to a health center. You know, when there's an, when there's a public health crisis, a lot of our patients are immunocompromised or they're on medications that suppress the immune system. So by having. The ability to attend a session virtually not have to navigate the parking garage and mobilizing across an entire hospital to get to our office was certainly an added bonus of the accessibility piece.
So disadvantages were, were certainly there were aspects of assessment that we just can't do. By video. Um, I, I can't do a lot of motor dexterity tests on zoom and that's also an important piece for neuropsychological evaluations. And one of the benefits was we could do an abbreviated cognitive screening tool that then later when things opened up, when vaccines became available, which was a pivotal time in accessibility, we could then more safely bring people back into the office to flush out that evaluation.
Great. Thank you, Dr. Schechter do you have anything to add?
I'd like to add one thing that a few of my patients brought up with me and I hadn't thought about it before. Uh, they brought it up, which is a disadvantage or how, what they viewed as, as a disadvantage. And these are folks that I was seeing prior to the pandemic and then were with me when we switched into telehealth.
And these are folks with chronic pain. And one of the disadvantages of telehealth that they brought up was that so much of our work at the time was. Uh, focusing on increasing activity levels and other methods of behavioral activation. And so the actual activity of getting out of their house to come to their appointment with me in and of itself was sometimes.
The activity that they were doing for the week and the thing that they were working on, uh, in terms of activity pacing, and some of the other strategies that we think about when people are managing chronic pain. And so losing in, in that way, the opportunity, that particular opportunity, um, for kind of requiring themselves to complete that activity.
Uh, their perspective was they did not feel as held accountable to some of their physical activity goals or their behavioral activation goals that were structured around coming to my appointment or coming to the appointment with me. And I thought that that was really interesting. Certainly we worked together to find other methods and other goals for physical activity and activity pacing. It was just a bit of a transition.
Great point. Um, and I think that's true for many of our MS patients as well. I have a few more questions from the individual side, but I wanna make sure that we spend some time talking about groups. So I'm gonna just ask one more. Are there any particular types of patients, or are there any characteristics of patients that would allow you to say, Hey, this may not be the greatest fit for telepsychology.
Are there any types of patients that you might say? Um, I'd rather see them in person.
I always start with the preference of the patient provided the coming in person is a safe, alternative option that if patients have expressed explicit preference for coming in, then I do wanna honor that preference. Other considerations would be if a person does not have a private space in their home or the internet connection was not reliable, then we would problem solve around whether, whether telephone sessions alone were potentially covered by their insurance and we could alternate potentially telephone and in person sessions for that.
Additionally, there were also patients that if they struggled with the technology piece, if we were spending too much time on the technology or the, the frustrations around that, then we weren't necessarily getting to the reason that they were hoping to come to therapy or come to an evaluation process in the first, in the first place. Um, so that would be, uh, one piece of that. A, a predictor of patients who have tended to do really well with telehealth were particularly the patients who were further from clinic, who maybe we're only able to come once a month or once every few months, which from an evidence based standpoint is now particularly strong in psychotherapy. Now they could have weekly or biweekly sessions. Um, so that distance, I think was a major factor too.
Group Telepsychology
I'm gonna switch gears to talking about groups. I would love it. If each of you would share the group that you're currently running. And I think Dr. Hughes is running two different types of groups. Um, but just so we get a general gist of, um, what are the types of groups that, uh, you'll be speaking about and Dr. Schechter can you start?
Sure. So I started running a cognitive behavioral therapy, uh, pain treatment group. So cognitive behavioral therapy for chronic pain, uh, done in a group format
And Dr. Hughes?
Uh, I've run two different types of groups over the course of the pandemic. One was part of a randomized controlled trial funded by the National MS Society to compare dialectical behavior therapy, to traditional peer support for people with MS and their support partners. Um, and so actually Meghan and I, co-led the peer support group while a collaborator for our, with expertise in D B T. Ran the D B T portion of the study. Those were rolling admission groups where each couple or each pair a person with MS and their support partner were enrolled for 13 consecutive weeks and they completed pre-assessments and post-assessments as part of that study. That was our first foray into group based psychotherapy as that study started right at the beginning of the pandemic.
The second group that I lead is in our clinical setting, in partnership with the Hopkins Stiff Person Syndrome Center, uh, which is directed by Dr. Scott Newsome. And for this group, it is a six week group based on acceptance and commitment therapy for people with a diagnosis of SPS. And that is, uh, also funded. Uh, so it is free of charge to patients, um, who are, who, who have the diagnosis and who have been followed in the center. Um, so I think between Nicole and I, and also, um, Meghan, we can probably speak to lots of different ways that when you change one variable about a group, it can change the experience of those dynamics.
Oh, yeah, absolutely. And I will just jump in and say that where it makes sense. I will also talk about the group that I'm running, um, which is a multiple sclerosis group. And that group is a little bit different than I think both of yours because it's ongoing, it's kind of rolling acceptance. So if somebody wants to join, they can join any week and they can drop in and out of the group as is helpful. It's kind of more of a, uh, didactic and psychotherapy group where the first half is, uh, didactic about a particular psychotherapy skill. And the second half is more of how to apply that skill to everyday life. Um, so there's some unique, uh, differences about that group that I think, uh, that may be interesting to talk about when we're talking about, um, what you both are running. Nicole is, is yours a time limited group?
Yes, I was just, I was just gonna add, I, I did not give enough detail. So we are doing a 10 session group. Each session is 90 minutes and the idea is we start with a cohort and we end with that cohort. So we're not adding folks, uh, throughout, so people start with session one and, and hopefully they stick with us through session 10.
We're following Bev Thorn's group manual. I believe the most recent one is up, was updated in 2017. We've adapted it a little bit, but we do follow that manual pretty closely. And that is a 10 session, uh, group C B T manual for those with chronic pain.
Great. So I, I wanted to start off by just talking technology really quick. I use zoom for our group because it's pretty easy. Most people know how to use it. And it works well with, uh, multiple people joining in. Do you both use zoom as well?
We use zoom too, for all the reasons you describe Meghan, the biggest feature on zoom. And again, we're not paid by zoom, but one of the things that has been helpful for us is that their share screen, the share screen on zoom seems to work really well. Uh, and so that's been, that's been great for us.
I would echo that as well.
What are some of the ways that you all orient people to the group and what are the consent procedures, especially keeping in mind, the telemedicine piece, how is it different than your kind of in person group?
Sure I can speak to the research study.
And in one, in some respects, this was an advantage of doing a study in that we have a pretty extensive informed consent process as part of our research ethics, whenever someone is joining a study. So we had dedicated time to walk through each person who was enrolling in the study, each pair of people with MS and their support partners.
Answer the questions even schedule a demo or a tutorial so that they knew how to join the session, um, and become familiar with those procedures. When we started the clinical group, I realized that we did not have that same level of support initially. And so I've integrated that now in our groups to offer a phone call or a zoom demo for five minutes with a patient in advance of the first session, uh, to increase comfort level with that, um, or more recently.
I've extended the protocol for the six week group to actually seven weeks with the goal of the first week being orientation, meet and greet and working out the technical aspects of that. So we don't really get into the meat and potatoes of that first initial therapy session until technically the second session.
But I'm hoping that with that initial orientation session, it brings everyone to be on the same page initially. Other strategies that we use, uh, include engaging our trainees and fellows in part of that orientation process. So one of our MS post-doctoral fellows will be helping co-lead this group, which is helpful if someone joins the session and then loses connection, one of the group leaders can go and check on them and call them and work them through the technology.
If you're just running a group by yourself, uh, it's a little bit harder to do.
Yeah. Having a co-leader is very useful. I, I run my group independently and there's been times where I've kind of had to put everybody on hold so I can mute myself and call somebody if they're having technology issues. So I, I would echo that having a co-leader is super useful.
Yeah.
We were lucky to learn a lot from Abbey and her experience, uh, as she was the first one to start this, you know, running groups in our, in our division. So we incorporated a lot of what Abbey just said because she guided us in that direction. Another choice that we made and Abbey, I'm not sure if you all did this too.
We made a choice to only, uh, include patients in our group who previously, uh, completed an initial evaluation with one of the psychologists in our division. So it didn't have to be me or one of the postdoctoral fellows who was co-leading with me, but it did, they did have to have an initial evaluation done by someone in our division.
And what this allowed us to do is to ensure that they had our initial thorough informed consent forms done, uh, and that they were determined to be appropriate for the group so that we didn't have to go through all of the steps of informed consent. Again, they were already familiar with rehabilitation psychology in general.
And so then we were able to focus that first session specifically on consenting for group, rather than understanding again, all of the confidentiality aspects. Uh, the general confidentiality aspects or the general, you know, what is rehabilitation psychology types of things. We were able to focus on confidentiality as it applies to the group specifically.
And I found that useful. There are some disadvantages to that too, though, uh, kind of limits who can participate in the group.
I'm also wondering, you know, what were some of the biggest surprises or barriers that both of you faced when you were starting your groups or as the groups have continued.
Yeah, I have a quick answer for this one.
The number one hardest thing for us to work out in starting our group was determining. How to bill insurance and not necessarily which C P T code cuz those are pretty well outlined for us, but to be able to gather a group of people who could participate in the group and whose insurance companies could be billed for the same C P T code.
So to be more specific. People know, you can do psychotherapy in a group setting using mental health diagnostic codes. Or in our practice, we can also do group health and behavior intervention, which is billed under medical C uh, diagnostic codes. And so we initially started out looking to bill for psychotherapy and then found that our group of individuals that we had gathered didn't have enough coverage.
There weren't enough people who had coverage under their psychotherapy benefit. And so we had to switch gears to look at the health and behavior benefit, which was different and made some people capable of participating. And some people were not capable because of their insurance coverage.
That was really tricky.
I would imagine that this is a little bit different, um, for each person, but depending on their benefits and it, and it may be handled differently in a academic medical center or hospital setting versus an outpatient center. So we're gonna be diving into more details about insurance coverage with Dr. Agranovich, so I'm, I'm really glad that you brought that point up.
Abbey, any surprises or barriers that you faced with groups.
Yes. And I'll say with a caveat that our group for stiff person syndrome is funded by neurology for a time limited period. And so I have not faced the same insurance barriers, but can certainly appreciate what a headache that has been, uh, for providers and for admin to offer this resource. And. And still have it be something that is valuable and, um, value added to our program.
One of the main, uh, barriers that I've encountered is particularly because of the amount of distress that patients are often in, by the time they come to see us, they may have been on a wait list for a very long time, or they may have been living with, again, this immuno compromising condition for so long.
There's so much thirst and need for social interaction and connection, and so much uncertainty about managing an unpredictable disease or condition like MS and like SPS that I found that the first session in particular. Particularly for patients who maybe have met, met with a mental health professional before, or who've never met another person with this condition.
There was almost this rush to compare notes. Everyone wanted to talk about what medications they're on, what they've tried, what they haven't. And it, in some ways it was this really powerful energy that that folks brought in trying to learn how to manage their condition more effectively. And as a provider, as a psychologist where I am not uh, a prescriber and I don't have expertise in medications or dosing. I had to be very mindful about the ethics around facilitating that kind of discussion and bring it back to the psychological skills and why we're here to learn self-management behavioral interventions for this condition and make sure you reach out to your neurologist or your healthcare team about those medication questions.
Um, I think that will be a continued. Not necessarily barrier, but just a factor to keep in mind as psychologists that we may be the first experience someone has when they meet someone else with that condition and how powerful that can be and how we can be an agent of effective change and safe change for them so that it doesn't devolve into something that is unhelpful for the individual patients when they come away from the group.
And
I just wanted to share something that is a little different than what both of you shared. So in my group, one thing that I noticed is that a lot of my patients will join. And if they're having a particularly bad fatigue day, they will keep their video off. And, um, one of my patients shared that, the reason she does that is because it's cognitively overwhelming for her to look at everything.
On the video and look at herself and by turning her video camera off and just sort of listening to the session, she can feel more engaged and feel less overwhelmed. And I have some people who lay down during their session. And initially I had a bit of a reaction to that. I wasn't sure whether they were.
Fully engaged or whether that was still useful. And as I kind of sat with it, um, what I noticed is that people were more likely to return if that was allowed. Um, they were also more likely to participate more regularly if that was allowed. Not everybody does it every time, but there are, are some people who will do it intermittently.
And I found that that's okay. And, and one of the reasons that I also have. Sort of an ongoing group rather than a time limited group was that I found that, you know, people would have other appointments popping up or if they were in the workplace setting and they really weren't able to commit to weekly sessions.
This was a way that they could still stay engaged, still learn some skills, but maybe not feel the pressure of having to attend for six weeks in a row. And so it's a little bit different and I'm sure that there are. Pros and cons to the model that I did, but I felt that it worked well with many of my patients who were juggling a lot of different appointments.
I wanted to ask also about the benefits. You know, one of the benefits that I saw, uh, was that, that people were able to attend a group. And I think that we have talked about groups, uh, in our clinic. For a long time and haven't really been able to get them off the ground. And so I found that using technology was really useful because people could join, um, without having to take a lot of time off of work.
And it was less time consuming. But I wonder what other benefits that you all saw with using technology?
Yeah, I wanna echo what you said, Meghan. The last time I tried to run a group, uh, was back in, I think it was 2017, so certainly pre pandemic. And this was a, an in person group. And it was really hard to find a group of people who could physically be at the hospital at the same time each week and continue to participate in that way, because of all of the other, you know, things and responsibilities they had going on between work and also.
Lots of medical appointments like you described. So the group setting via telehealth really helped with that. So I wanted to echo, I think the second biggest benefit Abbey mentioned before, which is for folks with chronic pain, especially. But I think many of the folks that we work with with disabilities, there's a fair amount of isolation that they were experiencing during the pandemic and not only isolation related to the pandemic because of being immunocompromised and being on medications that, that limited their immune systems, but also, not even with the pandemic, just not knowing a lot of other people who were experiencing chronic pain in the way that they were. And so the idea of being able to bring people together more easily over telehealth and have that social interaction and that sense that I think Yalom really points to when he developed this idea of group psychotherapy, of being able to be around other people who are experiencing similar things to what you are, was incredibly beneficial for the, the folks that I've worked with so far.
That to me and to the patients that I've talked with have that's been the number one benefit for them.
Great. And I'll give Dr. Hughes the final word. What are some of the benefits that
you saw? One of the most significant benefits, especially in our research group was the ability to integrate support partners and family members into treatment.
Uh, this crosses both individual and group based therapies as rehabilitation psychologists. Part of our competencies are working within systems, right? Working within healthcare systems, but also working within family systems. And particularly for people with disabilities, having a support partner who give some kind of support, whether that be emotional, physical, or in a more formal caregiving kind of role, having them involved in treatment.
Is a really important part of the process and for in person treatment that was usually not feasible. Um, oftentimes the caregiver would potentially be doing their own healthcare or their own self care during the time that we were in session. And so by having telehealth, we have the opportunity to engage caregivers in certain context with informed consent.
As part of that, and, and I'm looking forward to the future of potentially for having separate caregiver roles or support partner groups to address that as well.
Great information. Thank you both so much for your time and energy and expertise on these important topics of outpatient individual and group psychotherapy and the unique aspect of medical populations when we're thinking about telepsychology.
So I just really appreciate all the time and energy that you spent in talking with me today.
Thanks so much, Meghan.
Great to be here.
Conclusion
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