Article 1 - February 2021

Adapting Clinical Skills to Telehealth: Applications of Affirmative Cognitive-Behavioral Therapy with LGBTQ+ Youth

Shelley L. Craig, Gio Iacono, Rachael Pascoe, Ashley Austin

From abstract: Online social work services (e.g., telemental health; telebehavioral health; virtual care; telehealth) present significant opportunities for clinical social workers to provide effective care to marginalized populations, such as LGBTQ+ youth. The COVID-19 pandemic has led to an increased focus on telehealth, and while there are excellent resources to guide ethics, standards, and legal decisions (NASW, n.d.), there is less guidance in the literature to specifically inform the adaptation of offline clinical skills to telehealth, particularly for LGBTQ+ youth. To address this gap, we present examples from our experience offering AFFIRM, an affirmative cognitive behavioral therapy (CBT) group intervention now being delivered through telehealth. Specifically, this paper will: (a) describe the key considerations for the delivery of CBT via telehealth to youth; (b) detail specific clinical skills and strategies to enable successful online implementation; (c) describe the adaptation approach through a case study of cognitive restructuring with a transgender youth; (d) and offer specific guidance to support clinicians to adapt their clinical skills to the virtual environment.

As the need for culturally sensitive therapeutic approaches for the LGBTQ+ youth population increases, this article addresses much needed adaptations for telemental health with specific details of online adaptations of the AFFIRM model. Telehealth interventions can support vulnerable populations, such as LGBTQ+ youth, to deal with stressful situations and obtain critical guidance from affirming communities, even if they are unable to modify their current offline environments. The authors created an electronic fillable AFFIRM workbook in which LGBTQ+ youth could complete thought records and ABCD worksheets directly on their computers or electronic mobile devices. Many suggestions are given on how to adapt the intervention to the virtual environment and include:

• More repetition of therapist verbal expressions of LGBTQ+ affirmation throughout each session.
• Utilize grounding strategies (e.g., mindful awareness of senses) at the beginning and end of sessions as needed to support acclimating to an online environment and addressing stress and anxiety as a result of global events
• Make use of the group chat on Zoom to share cognitive restructuring (e.g., disputing beliefs) outcomes to better grasp cognitive skills online.
• Adapt behavioral experiments and exposures (i.e., testing and challenging unhelpful cognitions through specific actions) to online platforms—collaboratively working with LGBTQ+ youth in setting up behavioral experiments and exposures online utilizing video (e.g., FaceTime, WhatsApp, Google Hangouts) or telephone.

This article provides great detail and instruction support for clinicians wanting to serve and support LGBTQ+ clients with evidence-based treatment.

Article 2 - June 2020

Feasibility and effectiveness of a telehealth service delivery model for treating childhood posttraumatic stress: A community-based, open pilot trial of trauma-focused cognitive–behavioral therapy.

Regan W. Stewart, Rosaura Orengo-Aguayo, John Young, Megan M. Wallace, Judith A. Cohen, Anthony P. Mannarino, Michael A. de Arellano

From abstract: This pilot study examined the feasibility and potential effectiveness of trauma-focused cognitive– behavioral therapy (TF-CBT) delivered via telepsychotherapy in community-based locations of either schools or patient homes. Telepsychotherapy treatment was delivered to 70 trauma exposed youth in 7 underserved communities. Of these, 88.6% completed a full course of TF-CBT and 96.8% of these treatment completers no longer met diagnostic criteria for a trauma-related disorder at posttreatment. Results demonstrated clinically meaningful symptom change posttreatment, with large effect sizes evident for both youth and caregiver-reported reduction in posttraumatic stress disorder symptoms. The results observed in this pilot evaluation are promising and provide preliminary evidence of the feasibility and effectiveness of this novel treatment format. The COVID-19 pandemic has resulted in an unprecedented need to rethink how mental health services are delivered, which is particularly applicable to high base rate conditions related to posttraumatic stress. Given the existing network of nationally certified TF-CBT therapists, and many international TF-CBT therapists, these findings suggest the potential for providing effective and accessible telepsychotherapy intervention during this public health crisis (as well as those that will occur in the future).

This study, conducted over three years ago helps to support TMH applications of evidence-based therapies. While it talks about implementation in response to the COVID-19 pandemic, it is a good general reference to cite related to TMH and TF-CBT. For additional research and supports related to this modality, please refer to https://tfcbt.org/telehealth-resources/ .

Article 3 - April 2020

Telehealth for Rural Diverse Populations: Telebehavioral and Cultural Competencies, Clinical Outcomes and Administrative Approaches 

Donald M. Hilty, Melanie T. Gentry, Alastair J. McKean, Kirsten E. Cowan, Russell F. Lim, Francis G. Lu

From abstract: “This scoping review from January 2000 – July 2019 was conducted to see if the literature had data for two related research questions, “What are the components of culturally competent, telepsychiatric clinical care, and what approaches have clinicians and systems taken to implement and evaluate it?”… From a total of 1,118 papers, the authors found 44 eligible for full text review and found 7 papers directly relevant to the concepts. Few studies specifically discuss skills and competencies of both telehealth and cultural factors. Many organizations are attending to cultural competencies and approaches to care, but there are no specific competencies that integrate telepsychiatry or telebehavioral health with culture.”

This study involved the review of literature related to providing telehealth within rural health care settings to clients from culturally diverse backgrounds with a variety of behavioral health disorders. The authors found that more research and work towards training clinicians in culturally specific practices is needed. The application of technology to clinical practice and training and workforce issues were reviewed as well. This article provides a blueprint for suggestions moving forward.