Navigating the Telehealth Terrain: Recognizing the Limits and Knowing When to Pivot to In-Person Care

Before March 2020, only 17% of physicians regularly used telehealth, and now the majority of physicians do (Zhu et al., 2024). The numerous benefits of telehealth therapeutic services make this format desirable, especially for the treatment of OCD. Telehealth allows for greater access to care, provides a flexible option for families, and allows for exposure work at home, where compulsions may be strongest.

However, telehealth is not without its challenges; There are specific situations where telehealth is not the best treatment format. It is important not to prioritize convenience over effectiveness setting clear boundaries for virtual treatment and knowing when in-person care is needed.

Boundaries

Although there is already much to discuss with patients at the beginning of therapy, it is best to discuss the limits of telehealth in the first therapy session. Boundaries to consider and clarify for patients include:

1. When will you be available for sessions? While greater flexibility is a benefit of providing telehealth services, it can be challenging as it blurs the line between work and family life. Patients may assume that you can be available at any time, when this may not be the reality.
2. What type(s) of platforms will you use? Clarify whether you will use synchronous platforms (e.g., Zoom, Doxy), asynchronous platforms (e.g., texting), or both.
3. Where should the patient be located when joining a telehealth session? There are certainly times when you can ask your patient to join from a different location to make the exposure job easier; however, unless directed by the physician, patients should plan to attend telehealth sessions from a private, quiet space, and not in a moving vehicle, within the state in which the professional is licensed.
4. What is required of the patient/family during virtual sessions? The home environment can naturally create a more “relaxed” feeling, but it is important to convey to patients that “in-person” expectations also apply to virtual sessions. Appropriate attire is required, a parent must be accessible to minor patients, and patients must not engage in other activities during the session.

If a boundary is violated, speak to the patient or family immediately and let them know that telehealth may no longer be an option for sessions if future violations occur.

When in-person services are more appropriate

Aside from repeated boundary violations, other variables may indicate that in-person services are recommended over telehealth:

1. The patient is technologically challenged or does not have access to a private space. For example, if the patient repeatedly performs sessions from locations where the connection is poor or does not have constant access to a computer or mobile device, telehealth would not be recommended. Frequent technological problems are not just a “nuisance”; They can lead to misunderstandings and distractions that interfere with the success of treatment.
2. The patient has difficulty interacting virtually. Some patients demonstrate lower engagement and greater discomfort with virtual interactions, which can make it difficult to establish rapport. If the patient only responds via chat or gives repeated vague responses, in-person sessions may be helpful in generating more engaged interactions.
3. The patient exhibits challenging or avoidant behaviors during sessions. Patients participating in sessions from home may exhibit behaviors such as muting themselves, turning off the camera, leaving the room, leaving the session early, and/or not allowing contact with their caregiver. While these behaviors might be expected at the start of treatment, when they persist, it is a sign that telehealth is not a good option.
4. Clinical problems with telehealth. At times, continuing with telehealth can be clinically counterproductive. Have you completed all possible exposures inside the home? Would in-person exposures allow you to increase the difficulty or model brave behavior? Is the home a “safety signal” that diminishes the robustness of exhibits?

If in-person treatment is not available due to logistical factors, such as geographic location, transportation difficulties, etc., telehealth may be a “better than no treatment” option. However, when there are multiple treatment delivery methods, it is essential to consider the above factors when deciding which approach(es) will best move your patient toward their goals.

References

Zhu, D., Paige, SR, Slone, H., Gutiérrez, A., Lutzky, C., Hedriana, H., … and Bunnell, BE (2024). Exploring the practice of telemental health before, during and after the COVID-19 pandemic. Journal of Telemedicine and Telecare, 30(1), 72-78.