Acceptability of Telehealth for Multidiagnostic Suicidal Patients in a Real-World Dialectical Behavior Therapy Clinic During the COVID-19 Pandemic

Introduction

The outbreak of COVID-19 led to unprecedented challenges for mental health care providers and consumers. In March 2020, the World Health Organization issued guidelines limiting in-person contact.¹ As a result, many behavioral health clinics adopted telehealth, transforming the delivery of behavioral health care from in-person services to synchronous technologies such as videoconferencing.² The COVID-19 crisis thus presents an opportunity to study the benefits and liabilities of telehealth, including whether telehealth is acceptable for understudied populations.

Telehealth is defined as the delivery of mental health services through telecommunication technologies, including phone, videoconferencing, internet, and digital apps.³ Current research supports the efficacy and acceptability of telehealth for numerous clinical populations and interventions. While telehealth introduces elements to clinical interactions that may impact consumer satisfaction, including attitudes toward technology and quality of the audio and video component of the interaction,⁴ patients in primary and specialist care settings express willingness to participate in synchronous telehealth appointments^5–11 and satisfaction with telehealth is comparable to, and in some cases greater than, satisfaction with face-to-face services.^7,9,12 Patients in behavioral health settings report similarly high rates of satisfaction and most believe telehealth is comparable to in-person therapy when technology issues are minimized,^4,13–20 although several studies indicate preference for face-to-face services.²¹ A systematic review of 40 articles indicated high satisfaction with group psychotherapies delivered through telehealth as well.²²

In addition to positive satisfaction ratings, outcomes of treatment delivered through telehealth are comparable to those of in-person treatments for adults diagnosed with anxiety,²³ depression,^24–26 psychiatric and somatic disorders,²⁷ substance use disorders,^28,29 and insomnia,³⁰ and for children and adolescents with depression and anxiety.^31–33 Telehealth-delivered cognitive behavior therapy, interpersonal psychotherapy, acceptance and commitment therapy, and psychodynamic therapies are similarly effective³⁴ and initial outcome studies show promising results for remote interventions delivered to adults with serious mental illness who were at risk of psychiatric hospitalization,³⁵ adults with severe health anxiety,³⁶ and adults with eating disorders.³⁷

Furthermore, telehealth eliminates known barriers to accessing evidence-based practices (EBPs). Whereas EBPs exist for most behavioral disorders, access is limited by availability, lack of information, cost, social stigma, lack of childcare, and other factors.^38–44 Documented advantages of telehealth include access to EBPs, cost effectiveness, greater retention of materials, time saving effects, and increased flexibility for users and professionals.⁴⁵ Individuals residing in rural areas report high satisfaction with telehealth due to ease of travel, safety, and cost concerns,⁴⁶ and patients in behavioral health settings report increased access to care, convenience, reduced wait times, low cost, greater privacy, and reduced stress.^14,47 Limitations of telehealth range from negative patient and clinician attitudes to legal and ethical regulations, barriers to dissemination, and a relative shortage of transdiagnostic interventions to effectively manage comorbidity.⁴⁵ Telehealth may be less advantageous to clinical populations that are societally marginalized or have severe and persistent mental illnesses.⁴⁸

No published study to date has examined the acceptability of synchronous telehealth for severe, suicidal patients treated with Dialectical Behavior Therapy (DBT), an evidence-based cognitive behavioral treatment for complex, multidiagnostic, suicidal, and self-harming individuals.⁴⁹ Standard outpatient DBT is a multimodal treatment consisting of individual therapy, group therapy, phone coaching, and weekly consultation meetings for therapists.⁵⁰ One existing study evaluated telehealth satisfaction among 37 patients with borderline personality disorder treated at a specialty clinic offering DBT, mentalization-based therapy, and a “common factors” treatment program. Participants endorsed benefits of telehealth (e.g., no commute, feeling more relaxed) as well as disadvantages (e.g., difficulty making progress, staying engaged). The majority of participants reported that some aspects of telehealth were more effective than in-person treatment and, given the choice, would prefer telehealth to remain an option.⁵¹

The study did not differentiate those who received DBT from those who received other treatments, and thus it cannot be concluded that findings represent satisfaction with DBT delivered through telehealth. Two additional studies surveyed DBT providers’ perceptions of telehealth during COVID-19. Topics of concern included management of therapy-interfering behaviors, issues conducting therapy through telehealth (e.g., lack of access to materials, lack of group cohesion, accidental invalidation of nonverbal cues, etc.), and treatment adherence.⁵² Clinicians reported that skills groups were more difficult to provide through telehealth, but were satisfied overall and believed telehealth was acceptable to patients.⁵³

Currently, there is limited data regarding DBT patients’ experiences and perceptions of telehealth. To address this gap in the literature, we aimed to evaluate the acceptability of DBT delivered remotely using videoconferencing. We did so by determining how satisfied a sample of consumers enrolled in standard outpatient, group-only, and intensive outpatient DBT were with telehealth; whether there was a difference in satisfaction between those who had previously experienced face-to-face treatment then transitioned to telehealth and those who commenced services through telehealth (and did not experience face-to-face treatment); what participants’ experiences were regarding ease of telehealth over time; whether consumers believed telehealth influenced their progress; preference for in-person versus telehealth or hybrid; and reasons for satisfaction and dissatisfaction.

Methods

SETTING

The study was conducted at a private, free-standing specialty DBT outpatient clinic located in the Pacific Northwest region of the United States. The clinic is certified by the Linehan-DBT Board of Certification for its program’s fidelity to DBT and serves over 600 patients with severe and complex behavioral problems at any single point in time. Data were originally collected for program evaluation purposes to ensure patient safety and satisfaction following the transition to telehealth. Permission to publish was granted by the Behavioral Health Research Collective Institutional Review Board (IRB).

SATISFACTION SURVEY

An original survey was developed by DBT experts in the United States and Australia to measure participants’ satisfaction with DBT delivered through telehealth. We used an iterative process of development, seeking feedback from patients and providers to ensure measure clarity. Items identified as redundant or unclear were eliminated or edited to increase clarity. The final survey consisted of 41 fields, formatted as a combination of multiple choice, free response, and Likert scale questions. For a list of survey questions, see Supplementary Appendix SA1.

PROCEDURE

Between December 2020 and April 2021, authors and research assistants recruited participants from DBT skills training groups; therapists reminded patients about the survey during weekly individual therapy sessions. Study flyers were also distributed, including a brief description of the study and a link to access the survey on the clinic website. Patients were notified that the survey was voluntary, anonymous, and would not affect the services they received. Additionally, patients were told that the intent of the survey was to assess service quality following the transition to telehealth. After consent was obtained, participants completed the satisfaction survey, developed and distributed through WordPress, an open-source content management system. Participants were not compensated for their participation. Over 320 patients were informed of the study.

ANALYSES

Statistical analyses were performed using IBM SPSS version 27. Descriptive statistics were calculated for demographic, program, and telehealth satisfaction data. A multiple linear regression was conducted to examine relationships among demographic variables, telehealth items, and overall satisfaction.

Results

PARTICIPANT DEMOGRAPHICS

Participants were 163 adults (ages 18+) enrolled in a telehealth-delivered DBT program. Participants’ average age was 40.38 (±12.16, range = 18–71), with 72.4% (n = 118) identifying as female, 19% (n = 31) as male, and 7.4% (n = 12) as nonbinary, agender, genderqueer, or genderfluid, with two participants (1.2%) electing not to respond. Participants labeled their sexual orientation as heterosexual (54%, n = 88), bisexual (13.5%, n = 22), pansexual (12.3%, n = 20), queer (6.7%, n = 11), lesbian (4.9%, n = 8), gay (3.7%, n = 6), and asexual (1.8%, n = 3), with 5 participants (3%) choosing to report an unlisted sexual orientation. Participants identified their race/ethnicity as White (85.9%, n = 140), mixed race (7.9%, n = 13), Hispanic/Latinx (1.8%, n = 3), Asian/Pacific Islander (1.2%, n = 2), and Black/African American (0.6%, n = 1), with 2.4% (n = 4) of respondents declining to select a racial/ethnic identity.

All participants were required to be physically located in the State of Oregon at the time of service. Participants selected their residential designations, self-reporting 48.5% (n = 79) urban, 44.2% (n = 72) suburban, and 6.7% rural (n = 11), with one participant (0.6%) electing to not respond.

DESCRIPTIVE STATISTICS

At the time of the survey, 79.8% (n = 130) of participants were enrolled in outpatient DBT, 11.7% (n = 19) were enrolled in an intensive outpatient program (a specialized DBT program that meets 5 days per week), and 6.1% (n = 10) did not respond. Four participants (2.5%) erroneously reported being enrolled in a partial hospitalization program, a service that was not offered at the clinic. These responses were recoded as missing variables. Participants were asked to specify the device they used to access telehealth, with 82.2% (n = 134) selecting “computer,” 8.0% (n = 13) selecting “phone,” and 9.8% (n = 16) selecting “tablet.” The average number of months enrolled in DBT was 6.64 (standard deviation [SD] = 6.42, range = 1–36) and the average number of months enrolled through telehealth was 4.97 (SD = 3.23, range = 1–12).

Around 31.9% (n = 52) of participants transitioned from face-to-face services, 65.6% (n = 107) commenced services posttransition, and 2.5% (n = 4) declined to respond. The majority (98%, n = 51) of participants who transitioned from face-to-face services to telehealth (n = 52) responded to a follow-up item asking whether their satisfaction improved, decreased, or stayed the same posttransition. Around 21.6% (n = 11) reported that satisfaction improved, 58.8% (n = 30) reported that satisfaction stayed the same, and 19.6% (n = 10) reported that satisfaction decreased.

Participants were asked to rate their overall satisfaction with telehealth on a scale of 1 to 100, with higher ratings indicating greater satisfaction, and reported an average satisfaction rating of 82.26 (±18.71). Most participants indicated that telehealth became easier (54.6%, n = 89) or stayed the same (38%, n = 62), although 7.4% (n = 12) of participants reported that telehealth became more difficult. With regard to patients’ perception of telehealth’s impact on their goals, 36.8% (n = 60) reported a positive impact, indicating faster progress, 17.8% (n = 29) reported a negative impact, indicating slower progress, and 45.4% (n = 74) reported no impact.

When participants were asked how they would prefer to access individual sessions once COVID-19 is no longer a factor, 33.7% chose face-to-face (n = 55), 30.1% (n = 49) chose a combination of both, 23.9% (n = 39) chose telehealth, and 12.3% (n = 20) were unsure. When asked the same question regarding group sessions, 33.1%, chose telehealth (n = 54), 29.5% (n = 48) chose face-to-face, 26.4% (n = 43) chose a combination, 9.8% (n = 16) were unsure, and 1.2% (n = 2) did not respond.

Participants also rated the degree to which they found certain factors to be relevant to their satisfaction and dissatisfaction. The factors with the highest proportion of “relevant” or “very relevant” ratings (Table 1) included saving time and money (71.7%, n = 117), increased access to care (64.4%, n = 105), increased comfort (58.3%, n = 95), decreased social anxiety (47.9%, n = 78), and ease regulating emotions due to access to items participants find comforting (42.3%, n = 69). Of the statements asking about potential factors of dissatisfaction, most were rated as “not relevant” by the majority of participants (Table 2). The exception was that 49.1% (n = 80) rated as “relevant” or “very relevant” feeling less connected to others and 35.6% (n = 58) rated as “relevant” or “very relevant” feeling less connected to their therapist.

ANALYSIS

Age, gender, residential designation, race/ethnicity, group status (telehealth-only vs. transitioned from face-to-face to telehealth), and perceived difficulty of telehealth over time were not significantly related to satisfaction. However, after controlling for these variables, satisfaction was significantly related to beliefs participants held regarding telehealth’s impact on their progress in therapy. Participants who believed telehealth negatively impacted their progress were significantly less satisfied than individuals who believed that telehealth positively impacted their progress (p < 0.001) or had no impact (p < 0.001), rating their satisfaction 31.2% lower, on average, than those who reported a positive impact, and 24.7% lower than those who reported no impact. Table 3 reports the unstandardized regression coefficients, significance levels, and effect size for this analysis.

Discussion

This is the first study of its kind to demonstrate that synchronous videoconferencing is acceptable for the delivery of DBT to complex, suicidal patients. Overall, patients were satisfied with telehealth, believed telehealth positively impacted or did not impact progress, and the majority reported that telehealth became easier over time. Eighty percent of those who transitioned from in-person services to telehealth indicated that satisfaction stayed the same or improved. Despite this, when asked their preference for telehealth versus face-to-face treatment, most indicated a preference for face-to-face or hybrid for individual sessions, although participants reported a slight preference for telehealth for group skills training.

We found no significant difference in satisfaction when controlling for demographics, telehealth group status (telehealth-only vs. transitioned from face-to-face to telehealth), and perceived difficulty over time. However, beliefs regarding telehealth’s impact on progress were significantly related to satisfaction. Patients who believed telehealth positively impacted or did not impact progress were significantly more satisfied than patients who believed telehealth negatively impacted progress.

This study highlights several factors that seem to influence patient satisfaction and are consistent with previous research on telehealth’s advantages and limitations.^14,45,47 For example, participants reported that telehealth allowed them to save time and money and increased their access to care. Given that mental health disparities are prevalent in the United States and globally, and that many individuals who experience severe mental health problems do not receive treatment,^54,55 the potential of telehealth to increase access to EBPs is noteworthy and should be taken into consideration as treaters and policymakers envision the future of behavioral health care postpandemic. Providing telehealth services may, additionally, reduce barriers that have interfered historically with DBT implementation (e.g., lack of physical space).⁵⁶ Additional factors identified as reasons for liking telehealth (comfort in own home, lessened social anxiety, and easier regulation of emotions during therapy) may assist with engagement in DBT for consumers who might otherwise be reluctant.

Simultaneously, these reasons may be counter to therapeutic goals by facilitating avoidance behaviors, denying consumers the opportunity to generalize skills use, and hiding behaviors that would otherwise be targeted in therapy. Hence, such factors should be explored with consumers individually. Further research is needed to determine the impact of telehealth on clinical outcomes of DBT. Ideally, this should include rigorous trials to determine who benefits versus who does not, and should guide developments necessary to address issues presented by telehealth to increase its efficacy and acceptability for complex, suicidal patients.

Despite encouraging findings, there were several notable limitations to the study. Our sample was less racially and ethnically diverse than the Oregon population,⁵⁷ and was not representative of national or international racial and ethnic diversity. White individuals, women, and urban and suburbanites were overrepresented in this study; only one percent of participants identified as Black or African American. Around 54.0% of participants identified as heterosexual, compared with 93.5% of individuals in the State of Oregon.⁵⁷ Given that behavioral health services are disproportionately available in urban and suburban areas,⁵⁸ participants residing in rural locations are most likely to benefit from increased access through telehealth. However, rural participants constituted 6.7% of the sample. As such, the “rural” designation was excluded from statistical analyses, and it could only be determined that there was no statistically significant difference in satisfaction between urban and suburban respondents. Socioeconomic status was not assessed, and thus, it is unclear whether there is a difference in satisfaction based on this factor.

This area requires further research to understand the utility of telehealth in socially, economically, and/or geographically marginalized communities. Precise data on the number of patients who declined to participate were not available. However, it is estimated that the survey was distributed to 320 active patients, yielding a response rate of ∼51% (N = 163). As the transition to telehealth was mandatory, self-selection bias was minimized. It is worth noting that sampling bias may play a role in these results, as the survey was delivered through a web-based platform. The same barriers that prevent consumers from utilizing telehealth may also keep them from answering an online survey or being involved in treatment altogether. Thus, these findings reflect the satisfaction of consumers who were engaged in DBT through telehealth, rather than overall satisfaction levels.

In conclusion, our findings suggest that, despite no published data on the outcomes of DBT delivered through telehealth to date, from the point of view of patient satisfaction, telehealth appears satisfactory for delivery of DBT. The overall level of satisfaction with telehealth expressed by consumers suggests that it can play an increasing role in providing DBT beyond COVID-19 and may allow access to consumers for whom treatment was previously out of reach.

Authors’ Contributions

N.D.: Conceptualization, methodology, investigation, data curation, formal analysis, writing—original draft preparation (lead), and writing—review and editing. C.J.W.: Conceptualization, methodology, writing—original draft preparation, and writing—review and editing. E.M.: Investigation, data curation, formal analysis, writing—original draft preparation, writing—review and editing, and visualization. C.W.: Data curation, formal analysis, writing—original draft preparation, writing—review and editing, and visualization. L.A.D.: Conceptualization, methodology, supervision, and writing—review and editing.

Disclosure Statement

N.D., E.M., and C.W. have no conflicts of interest to disclose. C.J.W. provides training and consultation for Behavioral Tech, LLC. L.A.D. receives royalties from a published book on DBT and co-owns Portland DBT Institute.

Funding Information

No Funding was received for this article.

Supplementary Material

Supplementary Appendix SA1