Essay: Changes to Telepsychology Guidelines During the Pandemic

Several changes have been made to the practice of telepsychology following the onset of this global pandemic. In this paper, I will explore modifications to guidelines made in Canada and the United States. In America, the American Psychological Association (APA) called for state policymakers and insurers to “…temporarily suspend state licensing requirements for telepsychological services…” as it would “…allow patients greater access to their providers and ensure continuity of care during this crisis.” (American Psychological Association, 2020). They highlighted the necessity of psychological services to “meet the needs of their patients and communities during this difficult time, without further increasing the risk of contagion” (APA, 2020). Furthermore, private insurers were called to “approve payments for videoconferencing for all providers without limitation, as well as telephone-only services, and psychological and neuropsychological testing” (APA, 2020). Moreover, the APA asked for licensing laws and regulations to be suspended to allow licensed psychologists to provide service across stateliness during this critical time.
As previously mentioned, Interim Ethical Guidelines for Psychologists Providing Psychological Services via Electronic Media was updated by the CPA in 2020 in light of the current crisis (CPA, 2020). In contrast, Practice Guidelines for Telepsychology Services was not updated by CAP to reflect the circumstances surrounding COVID-19 (CAP, 2018). These guidelines, that were approved in 2018, still require Registered Psychologists from Alberta to “…be registered with the regulatory body in the location in which the client is receiving services and where the psychologist is providing services (if required by the distant jurisdiction)” (CAP, 2018). As well, the guidelines state that “Out-of-province/country psychologists wanting to provide psychological services to a client in the province of Alberta must pursue registration with the College of Alberta Psychologists prior to offering telepsychological services.” (CAP, 2018).
In comparison to the novel strategies for telepsychology requested by the APA, at the time of writing, the CAP and CPA are seemingly doing less to assist with the COVID-19 crisis in terms of facilitating accessibility to telepsychological services across provinces. It is unclear why the CPA cannot, or has not, request(ed) similar changes to the practice of psychology. In light of this global pandemic, and the immense mental distress it has caused, it is certainly in the best interests of the general public for the CAP and CPA to temporarily ease restrictions on telepsychology. Not only will it allow more psychologists to assist a larger population, but more patients will benefit these changes as well.
Several ethical guidelines derived from the principles of the Canadian Code of Ethics for Psychologists could be considered to be problematic in context of current circumstances (CPA, 2020). These guidelines, the impacts of these guidelines, and steps to are discussed next. First, under the principle of Respect for Dignity of Persons and Peoples, the guidelines advise psychologists to arrange in-person contracting sessions for “clients for whom capacity to consent or freedom of consent may be an issue” to maintain the informed consent and freedom of consent. As well, substitute decision makers needed to provide consent are required to verify their identity in person for the protection for vulnerable persons (CPA, 2020). These guidelines call for in-person verification, an act that is currently impractical and strongly advised against. Therefore, alternate means of verification should be provided to psychologists to facilitate adherence to these guidelines. While I am aware that these guidelines are just that, guidelines, identity verification is a serious matter and should have secondary verification procedures in place to avoid imposter concerns when in-person verification is unavailable.
Second, under the principle of Responsible Caring, Risk/Benefit analysis call for psychologists to “ensure that prospective clients for e-services receive an adequate assessment of their needs…” and should it require in-person assessment, psychologists should “…provide…or arrange for such assessment…prior to beginning e-services”. There are two problems with this guideline. Mainly, in-person contact is currently restricted. The restrictions imposed by hospitals and clinics on the number of in-person cognitive testing in an attempt to reduce patient exposure to the coronavirus, and the reluctance of patients themselves to attend appointments in public locations have limited the possible provision of in-person psychological services. However, perhaps more importantly, recently enforced social distancing measures have led to the discontinuation of psychological testing services as we know it. Further, it is recommended that “To prevent the loss of security of assessment techniques, psychologists do not administer electronically any psychological tests for which such administration would put the security of the assessment techniques at risk or would violate any copyright restrictions…”. Neuropsychological services, in particular, have been directly affected by these limitations (APA, 2020). Should psychologists administer cognitive or neuropsychological tests via Skype for Business and risk maintaining test integrity? Or should psychologists abstain from administering assessments online and minimize benefit/maximize harm to the client? In the context of COVID-19, it becomes essential to strike a balance between providing the necessary services to the clients, while ensuring that the benefits do not outweigh the risks – both to the client, and to the psychologist.
While the APA has offered six updated principles for conducting tele-psychological testing while social distancing (APA, 2020), I was unable to find similar guidelines through the CPA or the CAP. The six principles presented by the APA require psychologists to maintain test security while understanding the limits of tele-testing and preserving traditional, in-person procedures as much as possible. One principle underscores the limited data quality available for online testing, and another asks psychologists to “widen confidence intervals when making conclusions and clinical decisions” and to use their clinical judgements. These principles represent the lack of preparedness on the part of the telepsychological practice to handle situations in which there are limitations to the provision of in-person psychological services. For instance, administering traditional, in-person psychological assessments through technological modalities when they have not been designed for that purpose could be considered as risking test security. Instead, I believe that there should be a demand for psychological assessments to be designed in a format that can be accessed and delivered online. In fact, neuropsychological testing for measures of verbal memory and auditory attention has been conducted with success and with high reliability values (.74) in a study by Jacobsen, Sprenger, Andersson, and Krogstad (2003). Another study presented high correlation coefficients (0.981 – 0.997) for cognitive assessments for intellectual ability in children with specific learning disorder administered in person and through an online platform (Hodge et al., 2018). However, though there is some evidence for the success of telepsychological assessments, the number of available tele-assessments are not extensive and has a narrow research base. Indeed, online administration of assessments that take into account stimulus-based subtests (e.g., Block Design) pose an obstacle. To remedy this current situation, either existing test batteries need to be updated to a format that can be delivered online, or novel assessments need to be developed in a manner that is compatible with remote testing.
In addition to the assessments, the APA guidelines states that psychologists should be mindful of data quality as it is “likely [to be] affected by the alternate administration format”. Further, given that “…test data derived from non-standardized administration procedures broadens the margin of error”, APA asks psychologists to “…use their clinical judgement to interpret test scores, including their margin for error, within the context of individual and contextual factors” (APA, 2020). Clinical judgement, in terms of interpretation and diagnosis, has been found to be unreliable in a number of prior studies (Garb, 2005; Garb and Wood, 2019). Therefore, it seems especially careless to implore psychologists to use clinical judgement in such an unprecedented time, and with an unfamiliar assessment delivery system. The solution to this predicament seems simple, but it is one we do not presently have time for: research the “equivalency of testing in a remote, online format compared to a traditional, face-to-face format” (APA, 2020) and to develop standardized administration procedures for remote testing. Likewise, to reduce the need for clinical judgement, more research regarding population norms for remote assessments are necessary.
Finally, as previously mentioned, CPA ethics guidelines advice psychologists to “…inform themselves of jurisdictional requirements regarding licensure or certification and are licensed or certified in any jurisdiction that requires licensure or certification of psychologists providing e-services to persons who reside in that jurisdiction.” (CPA, 2020). In my opinion, this guideline proves to be a barrier in expanding the reach and utility of telepsychology. I would recommend that the CPA eases restrictions placed on registered psychologists in providing psychological services while social distancing is in effect to allow accessibility to a wider client population.
In summary, it is evident that shortcomings related to ethical guidelines at the federal and provincial levels are not all that is limiting telepsychology; there are other weaknesses to telepsychology that hinders patients from receiving its maximal benefits.
Conclusion
This paper examined the utility of telepsychology in a COVID-19 world. In recent times, with a global crisis in the form of the novel coronavirus, the significance of telepsychology is highlighted. This paper examined the efficacy, acceptability, and attrition rates of telepsychology to assess its utility and value during this time. It was found that telepsychology was effective, i.e., telepsychological services both improved symptoms in patients and was comparable to that of in-person psychological service and those that received psychological aid through a technological modality reported high satisfaction rates regarding the services. Mixed results were observed for attrition rates in telepsychology. While some studies observed equivalent attrition rates between in-person and electronical means of service, others observed high attrition rates for telepsychology.
Current ethical guidelines and principles surrounding telepsychology were examined to determine the applicability of these guidelines to current circumstances. It was determined that several changes in terms of existing ethical guidelines could be made to improve the accessibility of telepsychology to a broader client population. Lastly, current shortcomings and potential features for expansion of telepsychological facilities were deliberated. Limitations that concerned psychological assessment, such as a dearth in online assessments, were underscored, and recommendations for designing novel online assessments and updates to assessment norms were discussed.
I asked earlier whether telepsychology was ready for a world in the midst of a global pandemic. Given all that was discussed here, I would still say, “Not quite yet.” Nevertheless, I do believe that COVID-19 took the training wheels off, so to speak, and set a course to galvanize the progress of telepsychology that may have otherwise taken decades to ensue.