Working across contexts: critical events in rural teletherapy in Alaska

Teletherapy may increase mental healthcare access in rural and remote communities that have limited access to mental health care. Clinicians practicing rural and remote teletherapy must be responsive to the ways that rurality and remote service provision impact their patients and practice. However, the unique challenges of remote clinical practice, when clinicians and patients are located in different settings, are not well understood. It is often not feasible for independent clinicians to provide rural teletherapy using models developed by large healthcare institutions, and current teletherapy practice guidelines underemphasize the ways rural, situational, and environmental pressures impact teletherapy with rural and remote patients, especially in culturally and geographically diverse settings like Alaska in the US. Therefore, to better understand these challenges, this study explored the critical events that informed Alaskan clinicians' approaches to teletherapy with rural patients, and how those 'turning point' events subsequently influenced their practice.

This qualitative study used the critical incident technique and thematic analysis to explore critical events that most informed Alaskan clinicians' approaches to rural and remote teletherapy. Participants (n=26) were licensed mental health clinicians who had provided teletherapy to rural patients in Alaska and did not live in the patients' community themselves. Each participant provided written responses to an anonymous online survey that asked them to describe a critical event relating to rural teletherapy practice, their perceived outcome of the event, and an optional narrative describing what would have better prepared them for the critical event. The study's authors followed an iterative process of coding, reflexive discussion, consensus, and recoding throughout the thematic analysis of critical events.

Participants' narratives revealed situations where clinical, cultural, ethical, technological, and/or administrative concerns interacted with rural environmental pressures to create novel situations that required thoughtful and complex responses. Many narratives illustrated advanced integration of teletherapy and rural mental health competencies. Specific themes included attending to rural cultural and contextual (situational and environmental) factors; responding to crises, traumas, and complex clinical concerns; navigating technological barriers and ethical challenges; and practicing clinical and administrative flexibility in light of unique circumstances with their rural and remote patients. In response to what would have better prepared them for these events, participants identified greater awareness and experience, more training and education, and better resources and infrastructure.

The results suggest a need to integrate and expand existing teletherapy and rural mental health competencies to include contextual assessment, responsivity, and reflexivity, as well as to integrate specific teletherapy skills into a cross-contextual framework. This study introduces the concept of contextual humility, an expansion of the previously established concept of cultural humility in rural teletherapy, which emphasizes responsiveness to situational and environmental factors as they overlap with, but are distinct from, cultural dimensions of rural teletherapy.

Insights from Alaskan clinicians who have adapted to the unique challenges of rural and remote teletherapy highlight the need for clinical training tailored to rural and remote settings and updated approaches to teletherapy that integrate contextual humility across competency domains.