With the rapid spread of the novel coronavirus (COVID-19) and the subsequent increase in mental health distress, telepsychology has become an essential service worldwide. Therefore, it is necessary to examine the efficacy, acceptability, and attrition rates of telepsychology to determine its utility and value during this time. Furthermore, it becomes important to investigate whether the current guidelines and ethical principles in place for psychological practice are the most effectives for the crisis situation as we are facing today.
COVID-19 Crisis
It is possible that there has never been another time in history where telehealth, the delivery of health services using technological means, has been so necessary and whose impact has been so profound. With the onset and rapid spread of COVID-19, health services and governments around the world have required changes to the manner of health care provision, and rightly so, to minimize the spread of infection and to flatten the curve of virus transmission. These new regulations placed on the degree of face-to-face contact in daily life limits the amount of time individuals can spend in their communities, grocery stores, parks, bars, and, perhaps more importantly, with their loved ones. Social distancing and working from home have become the norm for most, and hand washing or applying hand sanitizer after doing almost anything, an instinct. There are obvious signs of spreading fear in communities, i.e. panic-buying is prevalent and hoarding toilet paper and Lysol© wipes has led to bare shelves in grocery stores for weeks on end. For some there is an added strain due to being laid off from their jobs, but for essential workers there is the added stress from risk of being exposed to the virus. Media, of course, does not help ease the panic and stress of the situation, but has become a trigger for stress and anxiety instead, fostering an atmosphere of high risk and looming threat with updates on the newest number of COVID-19 cases worldwide, country-wide, in province/state-wide, and city-wide.
During this time, pervasive feelings of unease, panic, and hopelessness, with persistent worry and anxiety, compounded with reductions in normal social support systems only serve to escalate mental distress in individuals (Canadian Psychological Association, 2020; Zhou, et al., 2020). In fact, during the initial phase of COVID-19 in China, where the disease originated, Wang et al. (2020) determined that the psychological impact of this disease was rated as moderate to severe in more than half the respondents queried. Additionally, nearly one-third of participants in this study reported moderate to severe anxiety. These results indicate that it is precisely now that we need psychological services to perform at its best, but it is also now that these same services are not available in person. Fortunately, the practice of telehealth has been up and running for over a decade, providing services to rural communities and to individuals that are unable to receive health care in person (CPA, 2020). With the advent of the internet, telehealth services have expanded and become increasingly accessible to those that require it. In a world that is in the midst of a global pandemic, telepsychological services have never become more relevant nor essential for people’s physical and mental health. But, is telepsychology ready for a world in the midst of a global pandemic?
What is Telepsychology?
Telepsychology, or the provision of psychological services using electronic communication resources and other information technologies, such as e-mail, telephones, videoconferencing, cell phones, and Internet services, can be used in conjunction with and/or in lieu of traditional methods of mental health care delivery (College of Alberta Psychologists, 2018; O’Connor, Munnelly, Whelan, & McHugh, 2018; Godine & Barnett, 2013). According to College of Alberta Psychologists (CAP) Practice Guidelines, as with traditional psychological services, telepsychology may be used to “offer clinical support, engage in … formal assessment, provide education and training, engage in research and/or contribute to policy development…” (CAP, 2018). As with any psychological service, there are guidelines and policies in place that adhere to ethical principles for professional practice for psychologists who are considering the use of/currently using telepsychology (CPA, 2020; Clay, 2017).
Brief Discussion of Canadian Psychological Association Guidelines for Telepsychology
The Canadian Psychological Association (CPA) have implemented guidelines that are derived from the ethical principles of the Canadian Code of Ethics for Psychologists to apply to this mode of psychological practice (CPA, 2020). These guidelines offer advice and information on a number of key issues:
Informed Consent. Based on the Principle I: Respect for Dignity of Persons and Peoples, the guidelines suggest that psychologists should include information regarding the particular risks and benefits associated with using electronic modalities, such as privacy limitations, as well as other alternative modes of psychological services available to clients. As well, psychologists should endeavour to arrange for in-person sessions for informed consent for clients that may have issues with their capacity to consent.
Protection for Vulnerable Persons. Based on the Principle I: Respect for Dignity of Persons and Peoples, this guideline suggests that in the event a substitute decision maker is required to provide consent, the psychologist should verify the identity of the substitute decision maker in person.
Privacy and Confidentiality. Based on the Principle I: Respect for Dignity of Persons and Peoples, the guidelines suggest that psychologists should educate themselves on the practice of telepsychology, secure electronic modalities utilized for communication (e.g. video conferencing or email applications), the availability of such devices, and to use means that best protect client privacy. Additionally, as part of informed consent, the psychologist should notify the client of their security practices. Moreover, in the event of imposter concerns, steps should be taken to have a method of verifying the client’s identity.
Competence. Based on the Principle II: Respect for Dignity of Persons and Peoples, the guidelines suggest that psychologists should take steps to stay up to date on the literature on telepsychological practices and should use this information when deciding the services that will be provided to different clients. Further, psychologists should have shown competency in addressing problems in-person prior to addressing it through technological modalities.
Maximize Benefit and Minimize Harm. Based on the Principle II: Respect for Dignity of Persons and Peoples, the guidelines suggest that psychologists should have hard copies of electronic communications with the client, ensure the service methods align with the client’s needs, confirm that procedures to follow in the event of an emergency are in place, establish a system for addressing client’s communications that are left when the psychologist is unavailable (i.e. replying to e-mails based on the psychologist’s availability), and offer alternative in-person methods of services are available to the client if needed.
Avoidance of Conflict of Interest. Based on the Principle III: Integrity in Relationships, the guidelines suggest that psychologists should set appropriate boundaries with the clients concerning the psychologist’s availability and ensure that the convenience and economic advantages of using telepsychological services do not outweigh best interests of the client.
Beneficial Activities. Based on the Principle IV: Responsibility to Society, the guidelines suggest that psychologists should find methods to maintain the integrity of testing instruments (i.e. not administering assessments or other testing materials online that were originally designed to be used in person), acquire liability insurance for their services, and provide the client with contact information for certification/regulatory bodies.
Respect for Society. Based on the Principle IV: Responsibility to Society, the guidelines suggest that psychologists should familiarize themselves with the laws of different jurisdictions where they provide services.
Benefits and Drawbacks of Telepsychology
Although the telepsychology has a relatively short history in comparison to traditional methods, already this mode of mental health care delivery offers a number of advantages over conventional methods of psychological care. Among many, these include: increased access to mental health care for individuals who are geographically distant from a service provider or otherwise unable to receive in-person services, greater flexibility in access to services, reduced need for waitlists and increased contact between client and clinician, and the incorporation and integration of other online materials and technologies to enhance existing methods of therapy (CAP, 2018; O’Connor et al., 2018; Stoll, Muller, & Trachsel, 2020; Varghese, Nolan, Ali, Anderson, & Southerland, 2019). With its many advantages alongside rapidly evolving technological means, it becomes evident that the use of telepsychology, either as a stand-alone medium or used in conjunction with conventional therapy, will only escalate in the future (Regueiro, McMartin, Schaefer, & Woody, 2016). It is here that the question of whether innovative methods of telepsychology are truly comparable to traditional methods of in-person psychotherapy arises. Consequently, it becomes necessary to understand the effectiveness of conducting therapy and other psychological services using a technological modality in comparison to previously established methods of psychological practice. Therefore, this paper will address the efficacy of telepsychology in the provision of psychological services.
In spite of the many benefits attributed to telepsychology, it is not without its criticisms. Availability of the psychologist to respond to the client in a timely manner, client accessiblity to the necessary modality for service delivery, therapist or client attitude towards telepsychology, and maintenance of professional boundaries over a less formal technological modality may deter either party from utilizing telepsychology (Stoll, Muller, & Trachsel, 2020; Chakrabarti, 2015; Fantus & Mishna, 2013). Ethical arugments posed against telepsychology primarily include concerns regarding privacy, confidentiality, and safety (Stoll, Muller, & Trachsel, 2020). While the CAP Practice Guidelines outline standards for managing risk and protecting client confidentiality by using encrypted websites, firewalls, and secure e-mails, the risk of technological failures and subsequently the risk of compromised data security and breaches of confidentiality remains (CAP, 2018; Stoll, Muller, & Trachsel, 2020). In addition to breaches of confidentiality through technological failures, frequently used video-conferencing applications like Skype do not meet requirements for security set out by the Health Insurance Portability and Accountability Act, which may contribute uneasiness on the part of the client or the psychologist (HIPAA Journal, 2017). Therefore, these potential risks and ethical issues bring possible concerns regarding acceptability of telepsychology among the general public into light. Therefore, this paper aims to discuss the acceptability of telepsychology in the provision of psychological services. This paper will further compare attrition rates between telepsychology and traditional modes of in-person therapy.
The practice of telepsychology includes internet-based therapy and counseling, mobile or internet applications, virtual or augmented reality, intelligent wearable devices, and other methods that do not require the direct services of a psychologist. For the purposes of this paper, these means of telepsychology will be excluded. The information presented in this paper is restricted to tele-psychotherapy conducted by psychologists.
Aims
Over the last few months telepsychology has become the major avenue for receiving psychological services for many, and as such, it is necessary to address the utility of telepsychology. To examine the value of this electronic service, I will address the efficacy of telepsychology and discuss its acceptability among both psychologists and clients in the provision of psychological services. I will further compare attrition rates between telepsychology and traditional modes of in-person therapy. Furthermore, I will discuss the gaps in telepsychology and critique the aforementioned ethical guidelines as it relates to the current COVID-19 crisis. Finally, I will present recommendations and ideas to bridge these gaps in telepsychology.
Efficacy, Acceptability, and Attrition Rates of Telepsychology
In the interest of length of this paper, fifteen studies that examined the efficacy, acceptability, and attrition rates of telepsychology were reviewed. These studies were retrieved through a PUBMED search and an informal search through the Google search engine for articles that were published between 2000 and 2019 using the key words: Telepsychology, one-on-one therapy, mental health disorders, efficacy, and Usefulness, Acceptability, and Satisfaction rates, Attrition, Drop-out rates, Depression, PTSD, OCD, Panic Disorder, Agoraphobia. Papers were included only if they referred to teleservices provided by a registered psychologist.
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