Speaking of Psychology - Bonus Episode: How to Obtain Teletherapy During the Pandemic with Jared Skillings, PhD

Episode Date: May 13, 2020

With most of us still following shelter-in-place rules, getting mental health care for people who need it can be a challenge. Fortunately, many psychological practitioners have been offering telemental health services for years, using electronic and telecommunications technologies to engage in psychotherapy virtually or by phone. APA’s Dr. Jared Skillings explains how to get this care and discusses how it compares to traditional face-to-face therapy. Join us online August 6-8 for APA 2020 Virtual. Learn more about your ad choices. Visit megaphone.fm/adchoices

With most of us still following shelter-in-place rules, getting mental health care for those among us who need it can be a challenge. You're probably very familiar with the act of going to the office of a practitioner to engage in psychotherapy, but that's not an option now, both for patient safety and for the safety of the practitioner. Fortunately, many psychological practitioners have been offering telemental health services for years, and by telemental health, I mean using electronic and telecommunications technologies to engage in psychotherapy virtually or by phone. The COVID-19 pandemic has led to many recent changes in the laws and state regulations governing telemental health care. But what are the rules where you live? How do you get set up with a provider to receive therapy virtually? How do you know if your insurance

will pay for it? And is telemental health care as effective as face-to-face psychotherapy? These are some of the questions we will explore today on Speaking of Psychology, the flagship podcast of the American Psychological Association. I'm Kim Mills. Joining me today to walk us through the ins and outs of telemental health is Dr. Jared Skillings, chief of professional practice for the American Psychological Association. Dr. Skillings leads the association's efforts to promote the practice of psychology and advocates for practicing psychologists through federal and state legislation, legal and regulatory initiatives, and public education. Before joining APA in 2018, Dr. Skillings held leadership positions within large group practice settings and complex integrated health systems.

Thank you for joining us today, Dr. Skillings. My pleasure. Really glad to be here, Kim. My first and probably an obvious question is this. The COVID-19 pandemic is causing people quite a bit of stress and anxiety. And some folks could probably use professional help but don't have a mental health provider. How should these people go about finding one? Where do they start? Yeah, it's really important to know how to access services when you need to.

there's a couple of places that you should turn first. One of the things I would suggest is to consider talking to your primary care doctor. Even if you don't feel comfortable going to them in person, a number of them are offering telehealth visits. And so doing a mental health wellness checkup with your primary care doctor through the computer, they could give you some initial ideas about how you're coping and then make a referral to a mental health specialist if needed. Another option, if you have, for example, a known history of having a mental illness or diagnosis where you've been treated before, is you could actually go to your insurance company online and to look at what providers are available and find a psychologist who would be available to take patients in person or probably during the coronavirus crisis, preferably in telehealth as well. How can people check that a mental health provider is qualified or can handle the particular problem that a person has? You really want to make sure you find someone who knows what they're doing.

just like you wouldn't send your mother to get a surgery to a surgeon that is not licensed, you don't want to do that with mental health issues either. What I suggest is you want to look up in the state where you're at to double check that your provider is licensed. That's an easy way to do that. What you want to do is go to Google and you can type in health license lookup or psychology license look up and then put your state. Missouri, Nebraska, et cetera. And what that will do is that will take you to the Board of Psychology

webpage where they keep track of everybody who's licensed. And just for folks to know, licensure is the minimal requirements to practice psychology and a number of other professions like counseling and social work. And what about your insurance company? Can they provide guidance as well? They can. Insurance companies will not credential your psychologist if they don't have a license. So if your insurance company suggests that you go see Dr. Jones, you can be assured that Dr. Jones, in fact, will have a license. One of the things that would be helpful during this crisis is there are a lot of people who are non-licensed, who are offering services that are coaching or other kind of encouragement. And that might be okay in some settings and some ways. But when you really want to get an evaluation, you have to make sure that your person is licensed.

I would even recommend that you should check in to see whether they're board certified as well. What does that mean board certified? Board certified in psychology is advanced competence. So let me give you an example. So we've heard about an increase in trauma significantly during the coronavirus crisis, as well as difficulties with sleeping and eating. There are specializations in some of those areas. And so if you have a board certified psychologist, that proves not just that they have a general ability to

practice, but they have a real specialization in an area and their peers and standards have been met, their peers have evaluated them to make sure they have met the standards to be able to practice that specialty. So how does telehealth work exactly? Do you just meet up with a psychologist on FaceTime or Zoom? Well, I wouldn't suggest just meeting up with somebody. You don't want to just meet with somebody like a Facebook. Not a random person. I mean, once you get a referral. Good. No, no, don't do that. What you do want to do, however, once you find a provider who's a good fit for the kind of services that you need, it is a little bit like just meeting up in an office.

And in fact, what you'll do is you'll make an agreement that the psychologist will pick the kind of platform you want to use. For example, there's some of them that are compliant with HIPAA. HIPAA is a whole big law that was passed by the federal government years ago that was supposed to protect. and does when it works well, protect patient privacy. So the psychologist will choose a telehealth platform. You mentioned a couple of very common ones. Skype, FaceTime, there's a whole bunch of other ones that are even more protective of the patient's private information. And so the psychologist will pick one of those and then send you information about how to log in.

So that way, it's like showing up for an appointment in the office. You'll log in five minutes early. You'll make sure that it works and that your microphone's working. And then when the session's about to start, the psychologist will come on and walk you through the process. Psychologists often keep notes when they're working with people. Do they keep these recordings? Do you know? Not unless you agree on it. There's a whole range of options for that.

I know of patients, let me go back to the trauma example for a minute. When I was seeing patients, I had some patients who had a previous history of trauma when they were working through developing coping skills that they they would ask to record parts of this session with like a handheld recorder. This probably shows my age. I was going to say cassette recorder. So they would bring it in and they would just push record and record parts of it. That's possible to do through even easier through telehealth, but you have to make sure that both parties are in agreement. I'm not a lawyer, but I know there are state laws that vary from state to state about whether that's okay and when.

So you have to make sure that you both agree on it. But that is possible. What about people who are over 65 and have Medicare as their insurance? Does Medicare cover these kinds of sessions? Medicare does cover these kinds of sessions. And in fact, they have done a terrific job of providing access. One of the things we know about the coronavirus is that folks who are older adults are at a higher risk. And so we have specifically recommended that they consider telehealth options for psychology during the crisis. Just so the public, so folks listening to this podcast will be aware, the good thing that Medicare is not only have they approved telehealth or video conferencing options, but they have approved

phone-only services. So that, for example, if you don't have a computer or an iPad that will work very effectively, or you're not really comfortable with that, your psychologist can work with you just through the telephone and be able to provide high-quality services that way. Is psychotherapy via the internet as effective as traditional face-to-face psychotherapy? The research is admittedly a little more limited because, to be honest, before the coronavirus, there were some practices that we're using telehealth, but that was definitely not the norm. Most people were still providing services, medical services and mental health services, in a normal in-person office. So we do have research, and the research that we do have, although it's kind of limited, shows that it really meant mental health services delivered through telehealth or in person. You get the same benefit from both. They both will really work well. I know there's research into psychotherapy that all kinds of psychotherapy can be effective. There's research into that, right?

That's true. Across the board, one of the things that we know is that developing a therapeutic relationship with a psychologist who can guide you through some of the most difficult things in your life that you may talk about in a private psychotherapy session and helping the patient work through those issues in a system. way is overwhelmingly positive and helpful. That's right. What about people who don't have insurance? Is there a way for them to get this kind of care? That is one of the most difficult things to deal with right now is that the way our health system is structured is that most health insurance is set up through your job. So when people right now are losing their jobs or don't have access to health insurance. Because of that, it makes it impressively hard to keep up with their health needs, which is just really an awful tragedy. So there's a couple of options. One is that there's a lot right now during the coronavirus crisis of free services. There are help lines that you can call to be able to find where you can find pro bono or free services in your community. There's also a lot of mental health practitioners that are offering options through various community channels. so that you can join a group conversation about coping skills or managing your money or your time or your emotions, many of which are free.

I would offer one last suggestion, which is if you do have a job or if you may have just lost your job, a lot of, which is far too common these days, a lot of employers have an employee assistance program or an EAP, and you can often continue those kind of health benefits. fits for some period of time, even after you might have left your current job. And they do short-term treatment to try to get you through. There's a lot of publicity around mental health apps that you can download on your phone. Do they provide the same degree of help for people who are under stress or anxious? Mental health apps can be really helpful. I want to say that they probably don't provide the same kind or the same level of support. Mental health apps, I'm going to speak in real generalities, because there's a, huge different range of different kinds of apps. And some of them are really good. Some of them

are not. Some of them actually potentially could be harmful if you're not careful. So what I would suggest overall is that if you can find some good ones, what they'll do is they provide general information and some specific instructions that are tailored to the overall population. So if you have a pretty common concern, let me give an example that's unfortunately too common these days. If you have someone in your family who's passed away recently and you're struggling with grief and loss, that's a pretty common experience as part of the human condition. And so some of the, some of the apps, for example, will walk you through about how to recognize grief and loss symptoms and emotions, some ways to think and feel and behave differently. But again, that's a

pretty common experience. If you have a more unusual set of circumstances in your life or a more unusual set of symptoms, apps tend to be less helpful. And no matter whether your symptoms are more common or more rare, there's still always significant benefit of having a connection with another person who can hear your individual story, offer some empathy, and then guidance about what to do. I hear a lot of ads and promotions about these apps where you can text a professional at any time of the day or night and get help. Does that really work? Not really by itself. It's texting is a really helpful service in the context of a larger

treatment. In fact, I'll say myself, I've used texting with patients who I have already been working with. So when you have a relationship, the psychologist has a relationship with the patient and you know each other and you know the issues, sending a quick text back and forth can be very helpful just to check in, offer some reassurance for the patient to check in, like I'll give you an example. So if you're working on depression symptoms, the patient might send a text every day of the week or a couple days a week to say what level their depression symptoms are at, or if there's an emergency and they need some help. Those are all great ways to use texting. One of the things that's going on right now is there are some apps that are allowing mental health

practitioners to work with people and the patients are anonymous. You don't have to identify yourself and while that might sound like a really interesting idea, like I could have totally, totally private therapy, it's really a huge risk because you don't know, you don't really know each other. And therefore, if something really awful happens, there isn't a way for the psychologist to try to help care for you or get you help in an emergency basis if they don't really know where you are or who you are. Yeah, where do you send the ambulance when somebody is in distress? That's a problem.

That's precisely right. It is. It's really risky. And a lot of times people don't think about what happens in an emergency. but in this circumstance, that's part of our job here at APA to think about all the different situations. How should people choose a mental health app? Are they screened or rated by any kind of authoritative body?

The best one that I'm aware of so far is called Cyber Guide. You can look that up online. They do a really good job, not just of reviewing the, whether the apps follow psychological science, but also the usability. What I would suggest is you have to be careful about the ratings, on, for example, the iTunes or Google Play Store, because really what that really tells you is how much people generally like it. Those kind of general ratings in public don't tell you whether or not the app is actually based in psychological science because there's a lot of things people

enjoy but have no scientific basis and may not actually help them help their symptoms get better. They may kind of feel good, but that's why I would suggest this other option called Cyber Guide. there are a lot of cases of students who had to go home when their schools stopped holding face-to-face sessions. And now they're back with their parents. So maybe you went to school in California and you had to go home to New Jersey. Can you see the therapist that you were seeing in California when you go back to New Jersey? What are the rules? That's a terrific example about college kids really struggling to find access to care.

I think there's actually several other examples. I have heard of older adults who are sheltering in place with their kids. kids or family members doing that. So I think that's happening across the whole country. One of the things that's true about mental health services, just like medical services, is that your license is dependent on your state. So if you're licensed, I'm from Michigan. So I'm licensed in Michigan. I am not allowed, therefore, to see patients in a normal circumstance in Nebraska or Ohio. During this crisis, however, a number of states have loosened those restrictions to allow the example, Kim, that you just brought up. If a college student needs

access to their therapist, then hopefully, depending on the state law, they'd be able to continue to see them. This is, from my memory, I think it was only about half of the states, in fact, agreed to that. So some of them will allow it. Some of them will not. We'd like to see during the crisis for that to roll out over the whole country to provide better access to mental health care. So do you call your state health department to find out? How do you check? up on things like this. Yeah, where do you find out? The psychologists have been given resources that the APA developed so that they should know or have a way to know which states allow what. If you're in the public, the best thing to do is to simply just contact your mental health

provider to ask. If you've been seeing someone, let's use your example, Kim. If you're a college student in California and your therapist is in California, you should contact your therapist and ask them whether they continue to see you. That is really their job as a professional to know whether they can or cannot do that or to look that information up. What if you have a situation where you and the psychologists agree that medication would be helpful, but most psychologists aren't able to prescribe? How is that dealt with? True.

There's a few states where psychologists can prescribe medications, but it's not very many. Normally, psychologists will partner with primary care doctors and or psychiatrists. These days, psychiatrists tend to focus on more serious or more specialized kinds of diagnoses. Primary care doctors will prescribe medication for a whole range of different mental health conditions and symptoms. And so it's much more common for psychologists to work with primary care. And that may be, in fact, a primary care physician or a nurse practitioner or physician assistant who is serving as a primary care provider as well. So if a patient needs medication or the psychologist and them decide that that's a good next step, then usually primary care is the first place you might turn just to get the most easy access. Wearing your practitioner hat now.

What kind of advice would you have for people who are feeling anxious as they try to deal with the pandemic? This is such a difficult time for people. There is – I appreciate you're bringing up anxiety. There's a lot of anxiety about what has already happened with the crisis, what's going to happen. So anticipatory anxiety. And it's not just anxiety, but a lot of grief and loss and anticipatory grief and loss, afraid that people have actually and will continue to lose loved ones, lose jobs or afraid of losing jobs or having income cut, not being able to provide for their families. what I would suggest is that I want people to know that they are not alone. Even though we are supposed to be socially isolating to try to flatten the curve, you have to make sure you remind yourself that we're doing that together as a country, as the whole world, and to try to reach out and get social support.

People need to continue to have a rhythm and a routine to keep up. the things that keep them going. Make sure you're getting good sleep. Make sure you're eating healthy food. Try to get outside and exercise while staying six feet away. Those kind of general health suggestions and maintaining social supports and relationships so that you know you can just feel that there's support and that there are others in this with you.

That's really crucial right now. That was all really great advice. Thank you, Dr. Skillings. I really appreciate you joining us today. I know you're really busy, but this is all important information that I think our listeners are going to be able to use. Thanks so much. I just want to wish everyone well and hope that people stay healthy and stay connected to each other. Definitely.

The American Psychological Association has many resources and tipsheets available on our website for help in navigating the pandemic. Visit us at APA.org. You can also find previous episodes of Speaking of Psychology on our website at speakingof psychology.org, and you can subscribe on Apple, Stitcher, or wherever you get your podcasts, and please, while you're there, give us a rating. If you have comments or ideas for future podcasts, you can email us at speaking of psychology at APA.org, that's speaking of psychology, all one word, at APA.org. Thank you for listening. For the American Psychological Association, I'm Kim Mills.