Teletherapy for people living with HIV

OHTNNX Conference Report

Speaking at the Northern Exposures conference in Dryden, in November, 2015, Travis Lovejoy describes his teletherapy intervention; how therapy has traditionally been face to face, but that is changing; how to build rapport within the context of teletherapy; how teletherapy can connect rural residents.



My name is Travis Lovejoy. I’m an assistant professor in the department of psychiatry, at Oregon Health and Science University. And I also work at the US Department of Veterans’ Affairs Hospital, in Portland, Oregon. My primary role is one of clinical researcher. My clinical work focuses on the intersection of chronic pain management, substance use, as well as HIV and HCV infection.

The particular therapy–teletherapy— that I was discussing in the workshop is called “interpersonal psychotherapy.” It’s a one-on-one counselling approach, essentially, for individuals who are depressed, and focuses on their interpersonal relationships. So understanding depression within an interpersonal context, as well as how to improve social relations, to hopefully reduce the depressive symptoms.

And this particular intervention that I discussing we’ve tested in a randomized clinical trial, and it’s currently ongoing, where we’re just completing the follow-up assessments for that particular trial. And we’re seeing some promising preliminary results, and hopefully that those are sustained over the course of the longer term follow-up.

The way it works is that these are the therapists, who could be psychologists, they could be mental health counsellors, social workers, they would connect with patients who are separated from them, typically by some geographic distance. So it allows individuals in rural areas, who would not otherwise be able to access these services to connect with a clinician who has the expertise in this particular treatment modality.

You know, historically, most counselling therapy has been face-to-face. So I think that there’s a certain expectation that when you engage in that type of therapy that you’re going to be seeing the person directly in front of you. I think that is changing with new telecommunication technologies, mobile technologies, I think we communicate more and more through our phones, through videos on our phones, through tablets and things of that nature. So I think that it’s definitely shifting the mentality of being able to do those things, and there are certainly proponents of it throughout the world of being able to do these telehealth interventions, but part of it just takes time and people having positive experiences, and wanting to go back to it.

So there are a number of different strategies to try and build rapport within a context of telehealth psychotherapy interventions. One thing that we’ll sometimes do is to ensure that we have an initial in-person meeting, so you have a chance to see the person face-to-face, and then subsequent meetings can be over the video conferencing or telephone. I think that that kind of sets a stage and ensures that everyone can put a face to sounds or the voices on the other line.

When I don’t meet with someone face-to-face ever, when it’s exclusively over the phone, as was the case in some of the studies, in some of the clinical trials that we’ve been doing, sometimes people will ask if I’d be willing to send them a photograph of me. So that they can actually see my image. I tend to be a little more open to self disclosures, if people want to ask those kinds of questions, and understand that they can’t see me so they just want to know a little more about me, and I’m open to those types of questions.

But I think it is a challenge to overcome. We have to be really sensitive to that, and what our own personal comfort level is with sharing and disclosing those types of information, which might not otherwise be brought up in the course of face-to-face therapy.

There are some similarities when we’re talking about working with individuals living with HIV, who are uncomfortable going into their own community to receive this care, or maybe the care isn’t available. It’s not uncommon in the US, in rural areas, for individuals to seek their medical care in more urban settings because there aren’t HIV specialists or even medical providers with experience working with people living with HIV in those communities.

And so they feel more comfortable driving the long distances or somehow getting themselves there to be able to receive that care. There are similarities within mental health because I think that people, not only do they want a mental health provider, but they want mental health provider with who they can identify—someone who has worked with other individuals who are living with HIV. And I think that’s why they interventions that we do are particularly well received by people living with HIV. Because we have that experience, we can talk, we get the lingo, we know many of the things they’re going through, you know, they can talk about CD4s and viral loads and not have us question, you know, have to pause and inform us what that means, and what they’re discussing.

We’re often times very familiar with other types of slang. Someone is saying, “you know, I was out last night doing crystal,” and we know what they’re talking about. So it’s really easy for them to be able to communicate with us, and I don’t think that they get that with traditional mental health services where they are.

Now some of the other challenges that I see, differentiating between mental health and medical care, certainly with medical care, so you can offer the verbal advice, but there are also certain things that medical practitioners will do when they have regular visits with their HIV positive patients. They’re going to draw labs, they might be prescribing, and so forth. And so depending on the nature of the health care system, someone might still have to go into a local clinic to have labs drawn, to fill prescriptions of that nature, and those can be very sensitive things. So having a local pharmacist dispense HIV medications might be very concerning for someone, whereas they might even want to go into an urban setting. So that’s one nice thing about the mental health piece is that the tele mental health that we are connecting over the phone and there aren’t any additional things that the person in the remote location would have to do that would potentially out them as being HIV positive.