Jay H. Shore, MD, MPH

FROM THE NATIONAL NETWORK OF DEPRESSION CENTERS

Telepsychiatry has moved from an esoteric curiosity to mainstream practice. It has been challenged along the way at many turns. Some degree of scientific skepticism is required when considering any health care innovation. While the utility of telepsychiatry seemed obvious to many, it was always necessary to develop a robust literature in support of its effectiveness and for acceptance of this health care innovation and associated technology. That task was achieved long ago.

An outgrowth of the supporting evidence has been the creation and adoption of guidelines to assist clinicians in the implementation of telepsychiatry. The efforts at guidelines began shortly after the earliest attempts at instituting telemedicine practices. Historically, the 

 (APA) was a slow adopter of telepsychiatry. To its credit, over time it has moved from skepticism to gradual embrace, to acceptance and enthusiastic promoter of telepsychiatry.

Telepsychiatry has its origins in the 1950s. However, the more modern incarnation grew from Internet advances and the ubiquity of adequate bandwidth. As with any novel technology or practice, mainstream acceptance could only follow pilot projects and pioneering efforts. Protocols and processes were created from scratch for these initial programs. Those who are the first to put new tools into use do so without the benefit of established guidelines. However, it is only through such efforts that the data and evidence can be collected and the field refined to allow for the development of the standards that follow.

In this regard, telepsychiatry is no different from any other area of medicine where technical developments have moved from theory to established and routine practice. Activities, disciplines, and methods that are available to identify, implement, and monitor the available evidence in health care are called “

 Such guiding principles must hold up to the scrutiny of those who are active in the field. Those protocols developed during the early adoption of a new technology must withstand repeated challenges if they are to garner wide acceptance and mainstream implementation. The evolution of telepsychiatry has followed this process. Specific technical organizations formed and grew to support such innovation. These groups then give back to the field through the aggregation of data followed by thoughtful synthesis and promulgation of this material to others who are prepared to follow.

Current best practices for videoconferencing-based telemental health

With suitable fanfare, the most recent version of 

Best Practices in Videoconferencing-Based Telemental Health

 was adopted by both the APA and the American Telemedicine Association (ATA) in the spring of 2018. The foundational texts were updated, streamlined, and harmonized and culminated in this co-branded document. While the chair of the APA telepsychiatry committee is a psychiatrist by definition, it is not a given that a psychiatrist, or even a physician necessarily, would happen to hold either of the two key ATA offices. This fortuitous arrangement of office holders and the opportunity to synchronize between the two organizations greatly facilitated the creation of this document.

When the writing committee convened to begin work on the new co-branded document, they drew upon precursor works that dated back to 1998.

 On the APA side, it required the merging and updating of ATA works from 

A writing committee composed of 11 thought leaders from both organizations undertook an iterative writing process that produced the new document. Support staff from both organizations also contributed to the success of the final product. Once a working draft was completed, it was distributed to larger groups within the two organizations including the Telemental Health Special Interest Group (TMH SIG) of the ATA, the APA Committee on Telepsychiatry, the ATA Standards and Guidelines Committee, as well as both ATA and APA staff. Feedback from this extended review was incorporated into the final work, which has been received with widespread acceptance within the field.

The final product serves as an example of high level collaboration between large organizations working toward a common goal. The document became available online on the websites of both APA and ATA and was recently published in 

, the leading journal of the telemedicine field.

 The document itself stands as a succinct summation of accepted best practices for deploying telemedicine technology in the service of mental health care.

The process by which the document came into existence, was refined, and ultimately promulgated should also serve as an example. Other areas of the medical field where multiple groups are working in an area with intrinsic and overlapping interests in the success and growth of that initiative could benefit from emulating this process. Writings on technology topics are prone to having relatively short shelf-lives as the technologies themselves rapidly evolve. This concern was embraced by the writing group through a focus on outlining principles and practices that are less likely to be subject to obsolescence in the face of technological progress. Hopefully the stage has been set for future collaborations of this sort. When the time for an inevitable updating of the document is required, perhaps a similar representative group of professionals will come together for that task as well.

Dr Caudill is Professor, Director, Psychiatry Resident Training Program, and Director, Telemedicine and Information Technology Programs, Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY; Dr Shore is Chief Medical Officer, AccessCare (a company that provides telemental health services). Dr Caudill reports no conflicts of interest concerning the subject matter of this article); Dr Shore reports that he receives royalties from American Psychiatric Association Publishing, and he serves on the Board of Directors of APA.

, of which Drs Caudill and Shore are the co-chairs. NNDC’s goal is to foster collaborative research to advance scientific discovery and drive forward improved care for patients with depression and mood disorders. NNDC is an American-based initiative and is a content partner of 

What is “best practice” in health care? State of the art and perspectives in improving the effectiveness and efficiency of the European health care systems

Practice guidelines for videoconferencing-based telemental health: October 2009

Association. Practice Guidelines for Video-Based Online Mental Health Services

 Shore JH, Yellowlees P, Caudill R, et al. Best Practices in Videoconferencing-Based Telemental Health. 

Articles

Telepsychiatry has its origins in the 1950s and has moved from an esoteric curiosity to mainstream practice. However, it has been challenged along the way at many turns.

The History and Value of Guidelines for Best Practices of Telemental Health

Although psychiatry brings tremendous value to the amelioration and treatment of mental distress and illness, at times it falls short in providing holistic care within a patient’s broader cultural framework. Traditional healing and medicine often offer a more comprehensive, patient-centered approach to mental health treatment, which can encompass a patient’s spiritual beliefs, cosmology, and world view. For certain patients, a combination of Western psychiatric treatment and traditional healing has significant potential to alleviate symptoms within the context of physical health, spiritual life, and social milieu. In some traditions, mental health is particularly relevant, cross-cutting various conceptualizations of symptoms and illnesses. Based on our experience, we share a model for psychiatrists interested in collaborating with traditional healing and medicine.

Our focus is on traditional medicine arising from a country’s indigenous cultures. We spotlight specific examples of North American indigenous healing traditions that figure importantly in our clinical and program experience with rural Native American veterans. Our purpose is to illustrate the possible synergies that promise greater benefit for these patients than either practice pursued independently.

The use of traditional medicine is found in cultures throughout the world, and it is often encountered by US psychiatrists working with immigrant and refugee populations. Incayawar and colleagues

 provide a number of specific examples of other cultures and conceptual models of collaboration between psychiatrist and traditional healers.

The literature pertaining to traditional healing practices in mental health is largely descriptive and therefore is limited in its rigor by today’s scientific standards.

 Indeed, there is an active debate as to whether current Western scientific methods are appropriate for examining the nature, processes, and outcomes of traditional healing. Part of this debate revolves around a historical monopoly of the study of traditional healing by Western, nonindigenous researchers whose views typically lie outside the cultural perspectives that inform a particular healing tradition.

The description of indigenous healing traditions in North America dates to the 1500s, when early European settlers began co-opting and adapting treatments with Native American traditional healing.

 The earliest reports from “modern” psychiatry date to the 1940s and are best illustrated by the Leightons’

 work on psychotherapeutic aspects of the Navajo religion. Since the 1940s, a rich body of literature augmented by more recent epidemiological research began to document the importance of concurrent use of biomedical and traditional healing among Native Americans across a diverse range of tribes.

 described parallel therapeutic processes and the possibility of integrating Native American concepts and healing traditions into psychotherapy.

Several major themes have emerged. Among them are the importance of concurrent, rather than mutually exclusive, pursuit of biomedical and traditional healing, and the feasibility as well as benefit of combining these approaches as treatment for Native American patients.

 However, this literature is largely silent with respect to how clinicians can address these issues in their individual practices and programs.

Incorporating traditional healing in practice

 presents our model for incorporating traditional healing in psychiatric practice; 5 key components influence the successful inclusion of traditional healing:

• The Western system of care in which treatment takes place

• The traditional healing in the context of the community

For each of these components, we identify factors that can either facilitate or impede therapeutic implementation. By highlighting these factors, we hope to provide guidance on how to incorporate traditional healing in the clinical setting to maximize the likelihood of successful patient engagement. Our experience has shown that many of the impeding factors can be minimized if clinicians are able to identify them and develop plans to overcome these barriers.

Openness toward and a desire to use traditional healing are perhaps the most important qualities for a psychiatrist to embrace in order to move with comfort between different frameworks for disease, illness, and healing. The psychiatrist must commit to becoming a “serious student” of the specific healing tradition and culture within which he or she hopes to work.

 Moreover, he must understand the need to collaborate with cultural facilitators as needed. Specific recommendations are presented in the 

While the psychiatrist is encouraged to pursue all of these activities, the most valuable may be identifying and working with mentors who represent the healing tradition of interest and with psychiatric colleagues who have experience working with traditional healers. Our VA programs support two types of cultural facilitators: employees referred to as tribal/telehealth outreach workers (TOWs) and volunteers who are tribal veterans’ representatives (TVRs). TOWs and TVRs are most often veterans as well as members of the specific community in which they work. Each engages community members in the treatment system and educates health care professionals about key aspects of the local context critical to therapeutic process and patient outcomes.

It is important to recognize whom to appropriately engage in dialogue about traditional healing and its personal relevance. The 

lists general patient characteristics that suggest a potential place for traditional healing in the process of care. The psychiatrist performs a detailed cultural history as well as a general history of the patient, with general components as outlined by the DSM-5 cultural formulation. The cultural history consists of information on native language, cultural background, spiritual views, and personal religious history. The general history includes cultural beliefs surrounding healing, mental health, and medical illness, as well as any past experience with traditional healing. Ultimately, the patient decides whether to engage a traditional healer in the treatment process.

The psychiatrist provides education, links to information, and referral to local options, but he does not prescribe traditional treatments or practices. It is appropriate to discuss the risks and benefits of traditional treatment in the context of other medical illnesses. For example, a patient with depression, diabetes, and cardiovascular disease who wishes to participate in a Northern Plains Sweat Lodge Ceremony should be informed of the potential impact on health resulting from dehydration and fasting. In such cases, the patient should be encouraged to discuss this type of ceremony with his primary care physician and the Sweat Lodge leader so that he can anticipate and minimize the potential medical risks.

Once it is determined that the patient is seeking traditional healing, the patient and psychiatrist embark on a sustained dialogue about the perceived effects of the treatment.

One of the most important factors for psychiatrists who work for a health care system is knowing how their system regards traditional healing-namely, whether there is formal acknowledgment, policies, and structures in place to support collaboration with traditional healers. An example of such a formal system endorsement can be found in the Indian Health Service, which for several decades has endorsed and provided guidance for mental health professionals who work with traditional healers.

In some instances, patients might request the involvement of traditional healing in a hospital or clinic setting. This works best when the health care system has processes in place to guide the collaboration. The first step is that a dialogue takes place between the Western medical treatment team and the traditional healer(s) about roles, treatment processes of the two systems, and pathways of communication regarding patient care.

Clinicians who actively endorse both Western medicine and traditional healing can initiate conversations with patients on these issues and can help develop respectful, appropriate lines of communication with local traditional healers. A willingness on the part of traditional healers to involve non-community members in traditional healing-as observers, consultants, or even collaborators-is strongly related to the historical relationships that are part of the cultural identity of the principals and deeply affect whether special, often protected, knowledge is shared.

In addition to the factors noted above, traditional healers will vary in their interest and willingness to collaborate with Western practitioners. Respectful, authentic inquiries by the latter, in an effort to meet the needs of their patients, often are well received. Although constrained by local protocols regarding disclosure and protection of special knowledge, many traditional healers welcome the opportunity to educate patients and Western practitioners about their healing traditions and treatments.

Special considerations: psychiatrist as traditional practitioner

Some psychiatrists may be familiar with or acquire training in a specific technique or intervention (the roots of which spring from local healing traditions) that can pose special challenges. A psychiatrist actively engaged in traditional healing practices should be well versed in such practices, exquisitely sensitive to determining when they are appropriate, and openly endorsed by the community. The psychiatrist must be clear about patient informed consent for treatment as well as the conceptual model guiding his therapeutic efforts and recommendations. Awareness of potential ethical issues that can arise when providing traditional treatment, including dual roles, boundaries, and providing spiritual treatments to patients, is essential, as is consultation with colleagues who are well versed in both the Western and the traditional systems.

A 28-year-old Native American military veteran who lives on a rural Northern Plains reservation is being seen in a VA telepsychiatry clinic. He had served 2 combat tours in Afghanistan as a Marine. He had presented with significant PTSD related to military trauma. He had been in treatment for 2 years and previously underwent 12 sessions of exposure therapy, with some decrease in specific memories and intrusive thoughts. At the time of the initial involvement in traditional healing, he was taking prazosin 5 mg nightly for nightmares but was not interested in additional medications. Although the prazosin and exposure therapy reduced his PTSD symptoms, the patient continued to struggle with appreciable anger at work that caused conflicts with co-workers and jeopardized his employment status.

The patient had been raised by his grandmother, a fluent speaker of their tribal language. He grew up engaged in cultural activities affiliated with his tribe, including attending pow wows and other ceremonies. But he had not participated in these activities since returning from military service. The psychiatrist explored the patient’s previous cultural experiences. He determined that the patient was interested in renewing this aspect of his previous life, which led to discussions about traditional healing options.

The psychiatrist consulted the clinic’s VA tribal outreach staff to identify a local healer experienced in working with veterans. The healer, psychiatrist, and tribal outreach worker met to discuss the VA program, possible collaboration, and how to appropriately introduce traditional healing into the therapeutic process.

The patient subsequently began working with the healer while continuing his psychiatric treatment through the clinic. He participated every other week in Sweat Lodge ceremonies. Within a month of engagement, the patient showed significant improvement in managing his anger and stress, and was able to function well at work. The psychiatrist continued to work with the patient to manage the pharmacological regimen and better align supportive therapy with discussions, dialogue, and encouragement of continued participation in the Sweat Lodge.

This article builds on the work of James Shore (1940-2013),9 who was among the first cohort of Indian Health Service psychiatrists whose career focused on improving the mental health of American Indians and Alaska Natives. He was a colleague and mentor to us and to a generation of mental health providers in this arena. His ideas, guidance, and principles of respect and collaboration form the foundation of these models.

This work was supported by the Veterans Rural Health Resource Center-Western Region, Salt Lake City, Utah-Field Office for the Office of Rural Health. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. This manuscript was reviewed by the Office of Rural Health.

Dr Shore is Native Domain Lead at the Veterans Rural Health Resource Center-Western Region, Office of Rural Health, Department of Veterans Affairs, Salt Lake City, and an Associate Professor at the Centers for American Indian and Alaska Native Health, School of Public Health, University of Colorado Denver, Aurora. Mr Richardson is Minority Veterans Program Coordinator for the VA Rocky Mountain Healthcare Network (VISN 19), Fort Harrison, Mont. Dr Bair is Director of the Veterans Rural Health Resource Center-Western Region, Office of Rural Health, Department of Veterans Affairs, Salt Lake City. Dr Manson is Director of the Centers for American Indian and Alaska Native Health, School of Public Health, University of Colorado Denver, Aurora. The authors report no conflicts of interest concerning the subject matter of this article.

 Incayawar M, Wintrob R, Bouchard L, eds. 

Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health

 Henderson J. Legitimacy and contextual issues in traditional Lakota Sioux healing. In: Incayawar M, Wintrob R, Bouchard L, eds. 

Psychiatrist and Traditional Healers: Unwitting Partners in Global Mental Health

 Leighton AH, Leighton DC. Elements of psychotherapy in Navajo religion. 

 Marbella AM, Harris MC, Diehr S, et al. Use of Native American healers among Native American patients in an urban Native American health center. 

 Buchwald D, Beals J, Manson SM. Use of traditional health practices among Native Americans in a primary care setting. 

 Novins DK, Beals J, Moore LA, et al; AI-SUPERPFP Team. Use of biomedical services and traditional healing options among American Indians: sociodemographic correlates, spirituality, and ethnic identity. 

 Gone JP. Psychotherapy and traditional healing for American Indians: exploring the prospects for therapeutic integration. 

 Shore JH, Shore JH, Manson SM. American Indian healers and psychiatrists. In: Incayawar M, Wintrob R, Bouchard L, eds. 

 Shore J, Kaufmann LJ, Brooks E, et al. Review of American Indian veteran telemental health.

 Kaufmann LJ, Richardson WJ Jr, Floyd J, Shore J. Tribal veterans representative (TVR) training program: the effect of community outreach workers on American Indian and Alaska Native veterans access to and utilization of the Veterans Health Administration. 

 Livingston R. Medical risks and benefits of the sweat lodge. 

 Department of Health and Human Services: Indian Health Service. Special General Memorandum 94-8. Indian Health Manual; 1994. 

http://www.ihs.gov/ihm/index.cfm?module=dsp_ihm_sgm_main&sgm=ihm_sgm_9408

The authors share a model for psychiatrists interested in collaborating with traditional healing and medicine.

Jay H. Shore, MD, MPH

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