Emma is a rehabilitation psychologist who works in a rural area and counsels 15 people per week. Whereas her colleagues could see their clients in an office in 2 days on a light schedule, Emma had to travel nearly 400 miles weekly. Her work consists of providing rehabilitation services to people with injuries or conditions that cause disability, and most of those consumers are not able to pay visits to her office. Like most rehabilitation psychologists, Emma works primarily with people who have had strokes, amputations, patients who suffer from spinal cord injury (SCI), those with traumatic brain injuries (TBIs), and she also treats co-occurring disorders like depression, anxiety, and pain.
In addition to conducting neuropsychological assessments for rehabilitation facilities and providing assistance to their patients, Emma teaches and researches at a local university and is a proud mother of two children. Naturally, she must organize her time very well to be able to fulfill all her responsibilities and this is not an easy task.
The COVID-19 pandemic forced Emma to reframe her practice and find ways to continue working. The internet quickly became indispensable and videoconferencing software that, until recently, she had no idea existed, now became her main, and most valuable, tool. Even though she was understandably reluctant at the beginning, she was able to see the advantages of this new working modality: she doubled the number of patients that she helps gain more independence and opportunities and she stopped spending long hours at the wheel—which reduced the risks fatigue causes and saved her much time. Not only does she do all of this without neglecting her work at the university, but she also spends more time with her children and in the comfort of her home.
Although Emma did not know it, what she just started is a practice that has been going on for several years and is called “telepsychology.”
Telemedicine and Telepsychology
Academic literature offers many terms related to telepsychology as a “new” discipline of study. The quotation marks appear for two reasons: firstly, and as we will see later, telepsychology is not really a discipline itself; and secondly, it is not so recent, temporally speaking. To understand what it is about, we must go back to another concept, one that is wider, older, and on which its procedures are based: telemedicine.
Telemedicine is a term that has many definitions. Etymologically speaking, it means “to cure at distance,” and its definition varies according to the criteria applied by different authors and organizations. Essentially, it refers to the application of information and communication technologies (ICT) to improve patient outcomes and increase access to care and medical information.
Although there are literally hundreds of definitions of telemedicine, the World Health Organization (WHO) has adopted a rather broad concept:
The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnoses, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities (1998, p. 10).
Most definitions converge on the idea that telemedicine is a science in constant development. This is largely due to ongoing technological advances, the changing needs related to health care, and the circumstances of each society. Another element on which existing definitions agree is the purpose of telemedicine, which is to provide clinical support. The discipline intends to improve health outcomes through various types of ICT, overcoming geographical barriers, and connecting with users who are in different locations.
In the field of psychology, the use of information technologies also finds many terminological variations. Several authors use synonyms such as online therapy, cybertherapy, e-therapy, telehealth, e-health, and online psychological interventions for their studies.
From a practical point of view, “telepsychology” and “telepsychological interventions” will be used interchangeably in this chapter, denoting the American Psychological Association (APA) meaning. The APA defines telepsychology as the provision of psychological services through the use of technologies instead of, or in addition to, in-person communication, and that includes the use of telephone, email, text messaging, videoconferencing, mobile applications, and structured programs on a web page.
Although there is practically no information available about rehabilitation telepsychology, dozens of studies, metaanalyses, and reviews on general telepsychology have shown very favorable results and, almost all of them, agree upon the effectiveness of telepsychological interventions. For instance, Backhaus et al. performed a metaanalysis focusing on 65 articles on videoconferencing psychotherapy that found procedures to be feasible, with good user satisfaction, and similar clinical outcomes to traditional psychotherapy. Varker et al. assessed the evidence for synchronous telepsychology interventions and found that video teleconferencing and telephone-delivered interventions provide an effective mode of treatment delivery. Hilty et al. performed a metaanalysis that suggested the efficacy of telehealth for diagnosis and assessment goals was similar to in-person treatments, and increased access to care.
This metaanalysis and most studies available—including randomized trials, reports, and less rigorous research—suggest that telepsychology is as effective as face-to-face psychotherapy, and evidence indicates positive results in process variables—such as satisfaction and rapport—outcome variables, and treatment acceptance and credibility.
In the modality of telepsychology, both evidence-based psychotherapeutic treatments and diagnostic and evaluation processes have shown very similar results compared to in-person treatments. These findings are consistent across different populations and settings, and for numerous disorders. Proof thereof are the Practice Guidelines of the American Telemedicine Association, which state that there is no evidence of users who do not benefit from or are harmed by remote videoconferencing health care services.
Telepsychological interventions can be applied to almost all cases that require psychological assistance in rehabilitation. This includes diagnoses traditionally associated with rehabilitation—such as brain damage, SCI, TBI, or amputations—and newer target populations, for example, those in intensive care units and transplant recipients.
Despite the relevance and increasing use of ICT, relatively few psychologists make use of telepsychological interventions. Many, like Emma, would never have done it because they did not know what it is about, others refuse because they are afraid of it, and some mistakenly assume that it requires too much professional updating. Regardless of the reasons, there are still many barriers to overcome for millions of users to remedy time or distance limitations and access psychological services.
Telerehabilitation in Psychology
Interestingly, one of the first documented references to telemedicine was in the “psy” field. In 1959 faculty members of the Department of Psychiatry at the University of Nebraska implemented a two-way closed-circuit microwave television to share demonstrations and information with students on campus and with Norfolk State Hospital.
Since then, both the uses and the technological means have changed substantially and, although telepsychology is mostly used as a way of providing services, its uses are not limited to that. The scope is very broad and comprises asynchronous media—those that include a certain time lag between transmission and reception, such as email or text messaging—and synchronous media, communications that take place in real time, commonly through videoconferencing, chat, or instant messaging.
Telerehabilitation, understood as a branch of telemedicine whose objective is to control rehabilitation at a distance, uses many telepsychological interventions.
Telepsychology uses four general types of services:
Direct-to-consumer: patient-initiated synchronous two-way voice or video virtual visits;
Remote patient monitoring: a client at home being monitored by a clinician from a remote location using two-way video or an electronic device;
Store and forward: collecting clinical information and sending it electronically to another site for asynchronous evaluation;
Mobile health applications: mobile and wireless technologies to support the achievement of health objectives.
Since technology has become so relevant in our everyday life, almost all psychologists use some technological means for their professional activity—from phone calls to arrange appointments, to bibliographic searches on the internet for research. Some psychologists use these as routine and incorporate them into their daily tasks—like Emma, who now assesses and sees all her patients through videoconferencing—and some use them only occasionally. However, information regarding the use of telepsychology for individuals with disability continues to expand, with care of individuals in some diagnostic groups having more evidence basis than others. Ownsworth et al. identified and appraised 13 studies evaluating the efficacy of telerehabilitation for adults with TBI (10 randomized controlled trials and 3 pre- and postgroup studies) and found that the evidence of efficacy was somewhat mixed: telephone-based interventions showed positive effects at postintervention with reports of improvements in global functioning, posttraumatic symptoms and sleep quality, and depressive symptoms. Internet-based interventions support feasibility, but their efficacy could not be determined because of insufficient studies.
In a systematic review, Tran et al. included six studies that met the criteria to evaluate whether technology facilitates interdisciplinary teamwork for the care of people with TBI. The review identified four different telehealth interventions: electronic goals systems, telerehabilitation, videoconferencing, and a point-of-care team-based information system. Both barriers and facilitators were found in the use of eHealth: on one hand, eHealth interventions seem to support interdisciplinary teams, but on the other hand, the existing literature is not enough to recognize barriers and enablers of a successful interdisciplinary telehealth model for people with TBI. Some authors like Pierce et al. state that TBI may be difficult to treat via telepsychology because of the need to coordinate care with in-person services such as medical examinations and physical therapy.
Although much more research is needed, studies that focus on stroke show that teleinterventions have either better or equal effects on motor, higher cortical, and mood disorders compared with traditional face-to-face therapy and they contribute to overcoming distance barriers. Furthermore, tools like virtual reality (VR) have demonstrated an increased motivation in users, allowing longer and more training sessions in community-dwelling stroke survivors. In the field of family support, home-based teleintervention programs like that by Kim et al. in South Korea have proven to be cost-effective and supportive in reducing family caregivers’ burden by providing prompt, relevant information for their needs.
To date, only a few studies have focused on teleinterventions in SCI. In a review of 29 studies, Irgens et al. found that the use of telehealth in people with SCI seems to be positive where treatment and follow-up are concerned, as well as having socioeconomical and environmental benefits. Research that focused on VR and SCI shows that VR may not be more effective than conventional physical therapy in improving functional performance, but if VR is combined with conventional physical therapy, interventions could have a greater impact in achieving the intended effects on balance recovery after SCI. Moreover, one study tested a teleintervention consisting of an hour-long counseling session each week to enhance need satisfaction, motivation, physical activity, and quality of life among adults with SCI. Its findings showed that the intervention group reported greater autonomous motivation and increased their leisure time physical activity levels after 8 weeks of coaching.
As can be seen, there is little information available about telepsychology and the aforementioned conditions. However, there is even less information about the impact of telepsychology for persons with amputations. One exception is the work on phantom limb pain of Bahirat et al. They have developed a mixed reality-based framework to generate a virtual phantom limb in real time to manage the pain, and it has proven to be feasible and have potential value for pain management.
Although humans can be extremely resilient and can overcome many challenging circumstances, people who have suffered injuries or experienced conditions that cause disability often also experience depression, anxiety, posttraumatic stress disorder (PTSD), suicidal thoughts, social phobia, and/or substance abuse. Evidence-based psychotherapies like cognitive-behavioral therapy, family therapy, crisis management, exposure therapy, coping skills intervention, behavioral activation, and mindfulness-based interventions have shown to be successful and cost-effective. Additionally, those interventions that focus on changing users’ behaviors, feelings, thoughts, and relationships have been shown better than no therapy and often produce better outcomes than medications.
The provision of optimal treatment for people who need psychological services is one of the biggest goals in the field. For those purposes, evidence-based practices should be adapted to the online modality. As said before, there is strong evidence that suggests that telepsychological interventions are an effective mode of treatment delivery. All the mental health conditions mentioned earlier have shown similar outcomes when teleinterventions are compared with treatments delivered in person.
In addition to the intervention itself, telepsychological rehabilitation services include prevention, counseling, monitoring, evaluation, consultation, supervision, and education tasks. Evidence shows that such services can be carried out throughout the lifespan and generally in a process that involves other professionals or paraprofessionals. Because telerehabilitation is so broad, the environments in which it takes place are also broad, ranging from clinics, hospitals, and other health care settings, to schools, homes, or other community spaces.
In addition to monitoring the efficacy of telepsychology on patient care, there have been some successful telehealth psychological training programs. Frank et al. reviewed the literature and found that online training can improve therapist knowledge and skill in the short-term, and outcomes in use of the intervention, and satisfaction with training also showed beneficial results.
Health care providers (and especially those who work with people with disabilities) often experience higher levels of stress. Some mindfulness-based online training programs for professionals and paraprofessionals have proven to relieve stress response, increase emotional intelligence and the use of effective coping strategies, enhance resilience, and decrease anger and negative affect through a convenient, affordable, and easily accessible virtual format.
Whatever the services provided, telepsychology implies the use of any technological means. In 2013 the APA published its Guidelines for the Practice of Telepsychology, which emerged from the work of the Joint Task Force for the Development of Telepsychology Guidelines for Psychologists. In these guidelines, they argue that the telecommunications used in telepsychology involve the “preparation, transmission, communication, or related processing of information by electrical, electromagnetic, electromechanical, electro-optical, or electronic means” (p. 792). This includes the use of traditional and mobile telephony, videoconferencing services, email, chat, messaging, and the internet (websites, blogs, and social networks). They also point out that the information transmitted—which may be written or include images, sounds, and so on—can be synchronous or asynchronous, and that technology can:
augment traditional in-person services (e.g., assigning reading material after the face-to-face meeting),
be used as a service itself (such as the use of videoconferencing), and
be combined in different ways depending on the purposes.
According to the criteria of Barnwell, Brennan et al., and Rutledge, Table 18.1 lists the technological tools that can be used to implement telepsychological interventions.
|Applications (apps)||A stand-alone software program designed to do a particular thing often downloaded to a mobile telephone||Psychological clinical training (simulated clinical interviews and feedback), assessment, intervention, providing instructions|
|Artificial intelligence||Computer systems that perform tasks that normally require human intelligence (such as visual perception, speech recognition, decision-making, etc.)||Psychological clinical training (simulated clinical interviews and feedback), assessment, and intervention|
|Augmented reality||The use of technology to overlay digital elements onto real experience||Delivering clinical interventions (e.g., surgical simulations and treatment for phobias and PTSD)|
|Bots||Programs that automatically run tasks, like gathering email addresses, posting ads, etc.||Addressing administrative issues|
|Captology||The study of computers as persuasive technology to influence behaviors and attitudes||Behavioral interventions|
|Email, text, and fax||Methods of exchanging messages between people using electronic devices||Follow-up on patient care and providing clarification of advice, creating a written record of information, providing patients with a summary of useful information (e.g., contact information for referrals, test results, and procedural information), educating patients with articles and links, extended contact with patients beyond office visits, and delivering clinical interventions|
|Forums and chat rooms||An online place to have conversations by posting messages (often text and images)||Delivering clinical interventions and providing a lifeline to treatment and social support|
|Landline telephone||A system for transmitting voices over a distance using wire or radio by converting acoustic vibrations to electrical signals|
|Smartphone||A mobile phone with more advanced capabilities, which generally include a variety of apps and the ability to access the internet and browse the web|
|Social media||A set of internet technologies that enables social tools for collaboration, categorization, creation, and sharing||Self-publishing tools (e.g., WordPress or Twitter), aggregators and social news sites (e.g., Technorati and Digg), social networking sites (e.g., Facebook and LinkedIn), content communities (e.g., YouTube and Instagram), virtual worlds based on games or social connection (e.g., Second Life), collaborative projects that create large bodies of crowd-curated information (e.g., Wikipedia)|
|Tablets and iPad||Portable, flexible devices with multiple functions due to the almost limitless number of apps||Supporting rehabilitation programs and functions|
|The cloud||Communication network that connects a large number of computers, services, or software||Documentation storage and file transfer|
|User experience||The psychological impact of the user interface. It is an evaluation of how something is experienced.||Assessing the user’s behavior, emotions, and attitudes about using a product, system, or service|
|Videoconferencing||A technology that allows users in different locations to hold face-to-face meetings without having to move to a single location together||Delivering clinical interventions|
|Virtual reality||A computer simulation that completely immerses a user in a simulated environment||Delivering clinical interventions (e.g., surgical simulations and treatment for phobias and PTSD)|
|Wearable technology||Devices that can be worn by the user that track and measure information, and allow data manipulation||Safety monitoring, health and wellness monitoring, home rehabilitation, assessment of treatment efficacy, early detection of disorders, or noncompliance|
|Websites||A “place” or “page” on the internet with their own address||Making and seeing upcoming appointments online, asking providers questions, getting hours and directions, accessing and downloading new patient forms|
To better understand the telepsychological interventions that can be implemented in rehabilitation, we will first consider the definition of Rehabilitation Psychology held by the APA:
(…) the study and application of psychological principles on behalf of persons who have disability due to injury or illness. Rehabilitation psychologists, often within teams, assess and treat cognitive, emotional, and functional difficulties, and help people to overcome barriers to participation in life activities. Rehabilitation psychologists are involved in practice, research, and advocacy, with the broad goal of fostering independence and opportunity for people with disabilities.
As the specialty addresses behavioral and mental health challenges of people with an injury or chronic disability condition, interventions usually target their:
mental and psychological status,
behaviors that promote positive adaptation to disability, and
minor adjustment issues and/or severe psychopathology.
As said before, the difference between psychology and telepsychology resides in the means used and not in the ends pursued, and therefore the practical domains of the discipline are the same in both cases. Bearing those practical domains in mind, we shall next discuss the procedures used in telepsychological interventions in rehabilitation.
Use of Telepsychology for Assessment Purposes
Administration of standardized and nonstandardized tests and behavioral observations fall within the competence of rehabilitation psychologists to assess the psychological and cognitive functioning of users.
Evidence suggests that telepsychological assessments can be reliable, feasible, and accepted for many conditions, psychological, psychiatric, and neurological, and in different populations. Not only do teleassessments provide access, convenience, and cost savings for consumers, but they also seem to be a very good resource for clarifying diagnoses, and incorporating client strengths, challenges, and preferences into treatment plans.
For some time now, and especially since the COVID-19 pandemic began, many tests that required in-person interaction began to be replaced by videoconferencing, remote platforms, and other technological means.
When assessing major depression, bipolar disorder, obsessive-compulsive disorder, panic disorder, substance abuse, schizophrenia, PTSD, cognitive functioning, and suicidal thinking, videoconferencing appears to be the most reliable and acceptable option; in fact, most commonly used measures for assessing those disorders have been validated in the online format and demonstrated the reliability and acceptability of videoconferencing assessment.
In general, distance assessments follow the same principles as face-to-face assessments, but with some adaptations. In particular, it is suggested that psychologists adapt both their communication skills and the assessment instruments—many of which already have this new format—to telecommunication.
Of course, more research and large-scale studies are still needed to ensure equivalence between remote and face-to-face evaluations, but the overall picture is very promising. In the meantime, it is recommended that before using technology in the assessment process, the clinician becomes aware of what types of tests are used, their limitations, their standardization procedures, and their quality and security. At the same time, it is also recommended to consider the adaptation of all clinical interviews, behavioral records, checklists, questionnaires, and recording applications to the digital format and in a culturally sensitive manner.
Cultural issues are especially important when it comes to assessment processes. Not only because of the methodological implications, such as cross-cultural equivalence or construct, method, and item bias, but also because the construct of culture itself is difficult to define and measure, and psychologists should guarantee to provide nondiscriminatory assessments.
Use of Telepsychology for Treatment
Treatment in rehabilitation psychology often involves both individual and family/caregiver coping and adaptation. Individual and group interventions include counseling and psychotherapy, cognitive remediation, behavioral management, enhancing use of assistive technology, and facilitation of healthy team functioning.
As the provision of telepsychological services does not differ greatly from face-to-face services, providers are advised to consider all the factors that guarantee quality services, and to commit to general competence as practitioners.
Békés and Aafjes-van Doorn have examined psychotherapists’ attitudes toward online therapy during the COVID-19 pandemic and found that most of them acknowledged a positive attitude toward online psychotherapy, suggesting they were likely to keep using it in the future. One of the reasons for those findings might be related to the fact that synchronous interventions such as videoconference meetings have practically the same characteristics as face-to-face interaction and that asynchronous interventions offer multiple benefits. Regardless of whether the interventions occur in real time or with delayed interaction, telepsychological treatments require adapting the procedures to the peculiarities of each case. These adaptations must consider adjustments in communication and in the way the working alliance is established—based on age, settings, culture, diagnoses, and so on. At the same time, providers should also adapt the techniques they use, for example, behavioral activation, live exposure, cognitive restructuring, guided imagery, and so on, for the online format.
In order to achieve these goals, a few specific guidelines are provided, but broadly speaking, practitioners are encouraged to adopt best practice principles.
Best Practice Principles in Telepsychology
Nelson et al. have summarized consensus documents from several authors and associations that work in tele–mental health and they suggest adopting the following 10 principles for a telepsychology practice:
The basic standards of professional conduct governing psychology are not altered by the use of telehealth technologies to deliver health care, conduct research, or provide education.
Confidentiality of client visits, patient health records, and the integrity of information in the health care information system is essential.
All clients must be informed about the process, its attendant risks and benefits, and their own rights and responsibilities, and must provide adequate informed consent.
Telehealth services must adhere to the basic assurance of quality and professional health care in accordance with psychology’s clinical standards.
Psychology, as a discipline, must examine how its patterns of care delivery are affected by telehealth and is responsible for developing its own processes for assuring competence in the delivery of telepsychological interventions.
Documentation requirements for telepsychology services must be developed that assure documentation of each client encounter with recommendations and treatment, communication with other health care providers as appropriate, and adequate protections for client confidentiality.
Clinical guidelines should be based on empirical evidence and professional consensus among involved health care disciplines.
The integrity and therapeutic value of the relationship between clients and psychologists should be maintained and not diminished by the use of telehealth technology.
Psychologists do not need additional licensing to provide telepsychology services, and telehealth technologies cannot be used as a vehicle for providing services that otherwise are not legally or professionally authorized.
The safety of clients and practitioners must be ensured, so safe hardware and software, combined with demonstrated user competence, are essential components of safe telepsychology practice.
Technology is allowing infinite possibilities in the health care field in general and in rehabilitation psychology, in particular. Although it offers many benefits, there is also another side of that coin and challenges are also present.
We shall briefly analyze some of the main benefits offered by telepsychological interventions and contrast them with their disadvantages and limitations.
As discussed earlier, one of the main contributions of technology to rehabilitation practice is the removal of barriers.
If we go back to the introductory vignette, we can see how telerehabilitation becomes a cost-effective alternative for Emma. Unlike traditional rehabilitation services, telepsychology reduces the costs and difficulties related to travel. But, in addition to removing geographical barriers, telepsychological interventions also make it possible to reduce problems that emerge from the socioeconomic status of users and their financial situation, contribute to reducing social isolation, help with physical limitations and mobility, and even assist in breaking down attitudinal barriers while simultaneously increasing access to specific expertise. Moreover, services can be offered across the lifespan and in a continuum of care.
Such benefits are not limited to clinical work but may also be present in other areas of psychological practice such as prevention, supervision, education, and research. In this way, ICT can increase the scope and quality of services and even provide services in places or settings that would otherwise be very difficult to access.
The fact that the technology makes it possible for a psychologist to be present in other cities, states, and even countries helps to overcome the maldistribution of clients and providers while reducing travel costs, difficulties that may be experienced with public transportation, and long waiting lists for treatment.
On the other hand, the tools used in telepsychology do not usually require specialized equipment. Almost everyone has a phone that can be used to solve many clinical and administrative issues, and smartphones with internet access are a great tool because of all the advantages pointed out earlier. The use of software and hardware for videoconferencing offers possibilities of virtual interaction that do not require much more than a built-in webcam and adequate processing speed (which most recently built computers offer), and an average speed internet connection.
Particularly in the area of telerehabilitation, videoconferencing tools have special importance because of the advantages they can bring to patients with physical disabilities by avoiding the need to travel to appointments.
Of course, new solutions also bring new challenges. Just as technology brings many benefits, it also carries risks, ethical considerations, and some drawbacks. To avoid these negative aspects, it is vital to follow best practices and specific guidelines that serve as support to reduce such risks as much as possible.
Telepsychological interventions pose challenges at different levels, such as technological, legal, deontological, and clinical; therefore psychologists must be responsible and aware of the possible risks.
Even though several guidelines and standards are available, to date there is no specific protocol for telepsychological practice. That means that the implementation of the available resources varies according to the practitioner’s criteria. On top of that, professional practice is also influenced by the availability of access to technology for all the intervening actors and the limitations of each type of technology.
While the great majority of technological tools are within the reach of any internet user, the alternatives are many, varied, and wide. Logically, not all of them are free of privacy risks or offer Health Insurance Portability and Accountability Act (HIPAA)-compliant service, secure digital signatures, or secure information storage, so it is recommended to pay special attention when choosing the media. It is strongly suggested that practitioners prioritize best practices and consider ethical and legal rules to avoid inappropriate use and client privacy violation, and to be aware of the security and personal data protection issues.
It should be also noted that while clients value and benefit from listening to the recordings of their sessions, sometimes those recordings are done without the practitioners’ knowledge, and that might pose legal issues. Even if users do not record their visits to find fault with a professional, there is always the chance of a malpractice lawsuit and specialists suggest that physicians should always assume that their patients are recording their conversations.
As obvious as it may sound, psychologists must have specific skills to implement technology-mediated interventions, and this is an issue that should not be neglected. These skills range from familiarity with the technological systems or devices available to fundamental knowledge and functional skills, such as policy and procedure development, and troubleshooting.
Although telepsychology is having a large impact on professional practice, there are still many professionals who lack the necessary knowledge to carry out an ethical and competent practice, and there seem to be few training options available to achieve the necessary competencies.
Table 18.2 synthesizes the main advantages and limitations of telepsychology.