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Reflections in TeleHealth

Posted By Elizabeth Banks, Wednesday, February 15, 2017



There is a lot to be said for physical presence. As licensed mental health care providers (LMFT in my case), we are taught to diagnose and treat in person. Connecting with people in a therapeutic, healing, and professionally intimate manner over a telemonitor is difficult at best. It is possible to read body language and tone through a monitor, but the amount of emotional energy it takes to convey compassion, empathic presence, and sound clinical interventions through a virtual space is harder than it sounds.


While tele-presence is better than no presence, and comparable to in person care [1-2], there are patients who distrust technology, who display emotions that can be hard to help regulate in a virtual space, who have hearing deficits, who speak a different language than the provider (more challenging over telehealth than in person), and any number of other barriers. A thorough assessment of functioning can be made more difficult without the benefit of having all senses available. For example, if a patient is not bathing regularly, this could be a sign of poor self care related to level of depression and impairment. Poor hygiene can be difficult to assess in a virtual environment.


Advantages include the elimination of provider safety issues. The two times that I can think of in the past 2 years that someone made sexually inappropriate comments and/or gestures on the telemonitor, I didn’t have to worry about a panic button or alerting someone to come help me. All I had to do was give a warning to the patient, and when that warning was not heeded, I let them know I was disconnecting due to their inappropriate behavior, hung up, called the nurse on site to follow-up with the patient, and voila! All bases covered.


Another great thing about Telehealth is that it is a therapeutic modality that is evolving in terms of technology available and as a billable service. When I first started in telehealth in the mid 2000s, telehealth really meant talking on the phone…a land line at that! Imagine doing therapy with a blind fold on and the client is the next town over! Now, we have sophisticated HIPAA compliant, encrypted teleconferencing hardware and software. At a teleconference conference in Maryland earlier this year, I saw an actual telehealth robot that moved around the room seemingly independently.


In my current position I work with patients who live in rural areas with no or limited access to specialty care. The teleconferencing equipment is in their primary care physician’s offices, so they still have to travel to receive care. As such, there are the typical no show rates and transportation issues. There are connectivity issues, but there are also huge pay offs and success stories.


I think about the woman with the 30 year old gunshot wound who presented to telehealth for rising A1C, gastrointestinal distress, a colostomy bag, and poor diet compliance. This woman had been seen for years in her primary care clinic and there was no evidence in her chart that any provider had ever asked her the origin of her gunshot wound or colostomy bag, or the reason that her diet was so incompatible with her diabetic and gastrointestinal status. A brief conversation about her social and emotional environment revealed that she was in a long term abusive relationship, that she was still living with the partner who shot her, and that the partner’s new form of control of her was to prepare and monitor the patient’s food intake, with violent consequences if she did not conform to his expectations.


By having access to a behavioral health provider with the time and the skill set to assess for psychosocial stressors that could be impacting her medical compliance, she was able to disclose the abuse, problem solve around her options, and make strategies with regard to maintaining her health as much as possible within an abusive environment. Knowing her home environment was directly related to her inability to manage her A1C and gastrointestinal issues, it took someone to ask her a direct question about her home environment for her to disclose.


With this information, I was able to work with her physician and a nutritionist to tailor her treatment goals to her particular situation. This is an uncommon example, but I continue to be amazed at what is revealed in telehealth sessions that are designed to be about health behavior, but so frequently are tied in to relational and systemic issues.

1. Bashshur, R. L., Shannon, G. W., Smith, B. R., & Woodward, M. A. (2015). The empirical evidence for the telemedicine intervention in diabetes management.Telemedicine and e-Health,21(5), 321-354.

2. Izquierdo, R. E., Knudson, P. E., Meyer, S., Kearns, J., Ploutz-Snyder, R., & Weinstock, R. S. (2003). A comparison of diabetes education administered through telemedicine versus in person.Diabetes care,26(4), 1002-1007.


Dr. Banks is a clinical assistant professor at East Carolina University at the Family Medicine Center. She has a PhD in Marriage and Family Therapy and is a AAMFT Approved Supervisor. In her current role, she provides telebehavioral health services to people with diabetes and co-morbid behavioral health challenges. In addition to her clinical work, she teaches at both the undergraduate and graduate level. She serves on the CFHA Research and Evaluation Committee and is Continuing Education Chair for the North Carolina Association for Marital and Family Therapy. She is also a member of the American Telemedicine Association, She currently has 6 journal publications and has presented 24 times at local, state, and national levels.  She is particularly passionate about keeping issues of social, human, and relational justice alive in our personal and professional roles.

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