For several months in 2015, Chris* called 911 as soon as he felt the symptoms of a panic attack coming on—a racing heart, sweaty palms and an impending sense of doom. When the ambulance would arrive at his home in rural Washington County, Texas, emergency medical technicians would often have to transport him to the hospital, located about an hour away, for additional tests or stabilization. Those ambulance rides and hospital stays cost Chris’s community thousands of dollars in medical expenses each time he experienced an attack. But with no access to a mental health provider, he had no one to help him understand the attacks and how to cope with them before they escalated.

Chris is one of many people living in the rural counties between Houston and Austin who, due to a shortage of mental health providers, rely on emergency room care for their mental health needs. According to a 2014 report by the Texas Department of State Health Services, more than two-thirds of the state’s licensed psychologists practice in the state’s five most populous counties: Harris, Dallas, Tarrant, Bexar and Travis. That leaves only one-third of the state’s psychology workforce—or about 1,600 psychologists—to cover its other 249 counties.

“People in these communities are suffering, both from chronic physical health problems as well as chronic mental health issues,” says Timothy Elliott, PhD, a psychology professor at Texas A&M University, located about 100 miles northwest of Houston. “It’s all so intertwined.”

But now, a new model of counseling and telecare is providing services in this area of Texas—and could serve as a model for other underserved communities nationwide. In 2009, Elliott worked with Jim Burdine, DrPH, a professor in the school’s health promotion and community health sciences department, to open the Telehealth Counseling Clinic (TCC), which provides free counseling and telepsychology services to underserved individuals throughout the Brazos Valley region of Texas. At the clinic, students in the APA-accredited counseling psychology doctoral program at Texas A&M provide counseling under the supervision of licensed psychologists, while public health students assist in research and outreach work for the clinic.

To date, the clinic has served more than 700 clients and provided more than 7,000 counseling sessions, says Carly McCord, PhD, the TCC’s director of clinical services.

Chris was referred to the TCC two years ago and spent three months attending telehealth counseling sessions. Now, he is managing his symptoms without needing to call an ambulance.

“We taught him about panic attacks and depression and ways to cope with his symptoms, and he didn’t utilize emergency services at all during his treatment,” McCord says. “He completed his treatment feeling confident that he could manage his remaining symptoms on his own.”

Expanding through the valley

Residents of these rural counties face many barriers to accessing care, including transportation, inadequate insurance, lack of providers and language or cultural barriers. In addition, dual relationships can be hard to avoid in rural places, and ethical dilemmas about the scope and role of the professional are common, says Jessica Chang, PhD, a clinical neuropsychology postdoctoral fellow at the San Francisco VA, who spent four years as a graduate student assistant at the TCC.

“When you go into these really small communities where everyone knows each other, even if there were a mental health provider in that area, people often won’t seek them out because they don’t want to see their therapist pumping gas next to them,” Chang says. “So clients are really receptive to seeing someone via telehealth.”

Originally funded by a telehealth network grant from the Health Resources and Services Administration (HRSA), the clinic’s first telehealth experiment expanded mental health care to the residents of Leon County, located about an hour’s drive north of the Texas A&M campus, Elliott says. The Leon County Health Resource Center provided a room for patients over age 18 to see TCC counselors via a high-speed T1 line and HIPAA-approved high-quality videoconferencing technology.

“Once one county had it and success stories started coming in, several other counties reached out and asked if the TCC would be willing to expand services to their county if they provided the space,” Elliott says.

Now, thanks to an additional HRSA grant and funding through the state’s Medicaid 1115 waiver program, the clinic conducts remote counseling sessions at sites in five Brazos Valley counties, all of which are designated mental health provider shortage areas: Brazos, Grimes, Leon, Madison and Washington. While clients still have to travel to these remote sites, which are mainly at community health centers, for most the commute is reduced from an hour or more to five or 10 minutes. In addition, once a client has been seen via video for a session, future sessions can be conducted over the telephone.

Because residents of areas with mental health provider shortages often go their entire lives without needed mental and physical health services, they often come to the TCC with complex and co-morbid physical and mental health symptoms—leaving the clinician with perplexing decisions about how to prioritize complaints, McCord says. For example, a client may present with substance use, trauma, diabetes, HIV, depression, anxiety, intense lower back pain and insomnia. To help counselors tackle these more complicated cases, they work closely, consult regularly and share notes with the physicians and other health-care specialists who are seeing the patients in person at the community health clinic. This helps ensure that medication and physical health needs are all being met, she says.

Providing video-based counseling to rural communities not only increases access to care, it saves health-care dollars, says McCord. “Research by the U.S. Department of Veterans Affairs shows that telepsychology services can reduce the number of people in inpatient mental health care by 25 percent, and while rates vary, it costs at least $400 a day to keep someone in an inpatient facility,” she says.

One reason the TCC has been so successful is that the staff works with community stakeholders to improve accessibility and quality of care to underserved populations, says Rev. Randy Wells, executive director of Faith Mission, which runs the Washington County community health clinic and provides a room for telemental health appointments with TCC counselors. Wells says countless homeless men and women have shown up at Faith Mission’s door after falling on hard times. They’ve gone on to get solid jobs and become self-sufficient after their basic needs, including mental health care, have been met.

“This allows us to finally say to our clients, if you’re willing and able to take your medication, if you’re willing and able to get talk therapy, you can live just as healthy and functional a life as anybody else,” Wells says. “It’s just been a great partnership and a great blessing.”

Interdisciplinary in more ways than one

The TCC also enables students from a variety of disciplines to apply what they are learning in the classroom to a clinic setting in an innovative way, says Donnie Kleine-Kracht, a fourth-year Texas A&M counseling psychology doctoral student who works as a service coordinator at the TCC.

“This is just such a rare, unique and special model with so much potential,” he says. Chang agrees, noting that telehealth is still relatively novel, particularly as a model for psychology trainees to take part in. “I definitely think the skills I learned at the TCC helped me to sell myself at internship and postdoc sites as having training no other applicant had,” she says.

In some ways, the telehealth aspect of it has even helped counselors connect more closely with clients in a way that face-to-face therapy might not, Kleine-Kracht says.

“I really found that there’s not a significant difference in terms of therapeutic relationship in this model, and particularly for some of our teenage clients it’s easier to connect with them through phone or video sessions,” he says. “They’re much more willing to be forthcoming with things when I’m not actually in the room with them.”

From a public health perspective, it’s easy to see why keeping the TCC running is crucial, says Kaysey Aguilar, a master’s student in public health at Texas A&M University who assists with TCC marketing. “Mental health, particularly in these underserved communities, is absolutely a public health issue because it is so tied to so many other health outcomes,” she says.

McCord says she’d also like to bring in more graduate students from other disciplines such as nutrition, medicine, nursing and pharmacy, as well as information technology, computer science and business, to help ensure the clinic is using the latest technologies and is as efficient as possible—and to enable these students and professionals to learn from each other.

“We live in a world where information doubles at such a rapid rate that one person can no longer be the expert,” McCord says. “We must work in teams and we must train our students to work in teams.”

The clinic is also providing consultation, custom trainings and online continuing education to equip other universities with the ability to add telehealth training components to their programs, McCord says.

“It’s crucial that we start to equip students for a future in psychology where technology will be woven into their practice,” she says.

*Name changed to protect patient privacy

The Monitor’s “Adventures in Integrated Care” series explores the work psychologists are doing as members of interdisciplinary teams. If you have a story to share, contact editor Sara Martin at smartin@apa.org.


APA’s Guidelines for the Practice of Telepsychology
Information on psychologists’ responsibilities in providing telehealth services.

"A Growing Wave of Online Therapy"
APA Monitor on Psychology, February 2017