Telepsychology training in a public health crisis: a case example

ABSTRACT

In early 2020, the world was thrust into a crisis with the advent of the COVID-19 pandemic. This resulted in the sudden expansion of telepractice in the mental health field for licensed mental health providers and trainees. Prior to the pandemic, few mental health training programs provided training opportunities in telehealth service delivery. The Texas A&M Telebehaviroal Care Program (TBC) is one of a few telemental health training programs in the world. The TBC has provided telehealth services to rural and underserved populations since 2009 with a hub and spoke model of care, but due to constraints related to the pandemic has recently transitioned to an all in-home model of telehealth service delivery. The present paper highlights recent policy changes to in-home telepractice and the TBC methodology for transitioning to in-home service delivery. Results include solutions to common pitfalls in areas such as communication and logistics, clinical supervision and consultation, and boundary setting. Recommendations are also provided for the development of training programs throughout the world to equip mental health trainees in telehealth service delivery. Mental health practitioners are poised to thrive in the face of adversity during the COVID-19 pandemic and trainees should not be left behind.

KEYWORDS:

• Telehealth
• counseling
• training
• mental health
• COVID-19

Introduction

On 11 March 2020, the World Health Organization (WHO) declared the COVID-19 virus a pandemic, announcing “118,000 cases in 114 countries, and 4,291 [having] lost their lives.” (World Health Organization, 2020). Subsequently, a cascade of events across the globe removed prior barriers to telehealth by adapting laws, regulations, and reimbursement policies as well as providing more guidance for the technology and security needed when using telehealth (Australian Government Department of Health, 2020; Olesch, 2020; Rockwell & Gilroy, 2020; U.S. Centers for Medicare & Medicaid Services, 2020; U.S. Health and Human Services, Office for Civil Rights, 2020; Webster, 2020). In many cases, requirements for the type of technology used for remote service delivery were relaxed to ensure maximum accessibility for both patient and provider. Additionally, steps have been taken to ensure payment parity whether mental health services are delivered in-person or via telehealth.

The circumstances surrounding COVID-19 have had far-reaching impacts on the practice of mental health providers. Many licensed practitioners have switched to providing telehealth services to clients and are learning how to manage their caseloads remotely. For trainees, who require supervision and oversight, it has had an even more pronounced impact. At many sites, trainees were deemed “nonessential” and were not allowed to return to work. Even in instances where sites allowed trainees to return to in-person work, training programs may have created restrictions for students to return to field placement sites. In other cases, sites and programs may have left it up to trainees to choose whether to continue to provide in-person services. This ambiguity required trainees to balance their own anxiety, fear, and wellbeing with the desire and need to serve clients, within the evaluative system of their training programs. Trainees may not have been well-equipped to make this decision for themselves.

Covid-19 impact on trainees

For student trainees and interns who were required or chose to discontinue services, they were likely forced to abruptly terminate with their clients, often by impersonal means, such as letters or via word of mouth of providers who were still on site. This disruption may have led both clients and trainee-providers to feel abandoned and confused. Especially in scenarios where decisions were made without input from trainees, they may have been left feeling powerless, and unable to provide support for clients even if they felt safe and wanted to do so.

Aside from the emotional burden that this has placed on trainees, COVID-19 has also disrupted training in more practical ways. For those who are not able to continue providing services to clients, they are no longer accruing direct clinical hours. This may impact their competitiveness in applying for future positions need to obtain hours to complete training programs and licensure, or, for those early on in their training programs, it may impact their ability to progress to advanced field placements. This disruption may mean that governing bodies may have to reduce hour requirements for cohorts affected by this disruption or that trainees may have to extend their time in the program to successfully meet their clinical requirements. This may be especially poignant for mental health trainees obtaining training within schools, who have been particularly impacted by the shut-down of schools.

A logical solution to allow trainees to continue to serve clients, receive training, and accrue hours would be to switch to a telehealth model. However, very few training sites were well-equipped to make that shift for their licensed practitioners, and even less so for their trainees. Given a finite amount of resources and human capital, organizations may first and foremost be concerned with their licensed providers before shifting attention and resources to determining how best to allow trainees to continue providing services. Making telehealth specific training available, providing supervision from a distance, and obtaining and configuring the technology are three logistical hurdles in transitioning to telehealth.

Telehealth specific training for trainees

One layer of consideration is telehealth specific training. Mental health providers' ethical guidelines require practitioners to operate within their competencies. For training clinics with no previous telehealth service provision models in place, they were likely not equipped to adequately provide their trainees or interns with telehealth training or may not have been able to afford to provide existing trainings for both licensed providers and trainees. This lack of training and knowledge in telehealth guidelines and best practices highlights the importance of including telehealth in the training program curriculum.

Telehealth supervision of trainees

Prior to the COVID-19 outbreak, some licensing boards limited the use of telesupervision, but as trainees across the globe faced disruptions to their training and supervision due to travel restrictions, a need for distance supervision arose, and licensing and accrediting bodies responded. For example, the Association of Psychology Postdoctoral and Internship Centers (APPIC) and the American Psychological Association Commission on Accreditation (CoA) relaxed in-person supervision requirements and promoted the use of videoconference and phone technology for supervision (American Psychological Association Commission on Accreditation, 2020). Many states in the US have followed suit and temporarily removed restrictions on telesupervision (California Board of Psychology, 2020; Pennsylvania Department of State, 2020; Texas State Board of Examiners of Psychologists, 2020).

Telehealth logistical hurdles

In addition to being unsure of how to provide supervision and training for trainees, there were also technological barriers to implementing telehealth service provision. Although the stipulations on HIPAA-compliant telehealth platforms have loosened since COVID-19 in many places, sites may not have known the regulations surrounding platforms or been able to afford an HIPAA-compliant platform. Even with relaxed requirements, many practitioners feel uncomfortable using unencrypted and less secure technologies for service provision.

Description of a telepsychology training program

The Texas A&M Telebehavioral Care Program (TBC) began providing videoconference and telephone counseling to rural, underserved areas using a hub and spoke telehealth model in 2009 (McCord et al., 2011; Wendel, Brossart, Elliott, McCord, & Diaz, 2011). Using an interactive system framework for replication, the TBC has launched 12 “spoke” sites at community resource centers, primary care clinics, and correctional facilities and will be creating access in regional schools starting in 2020 (Garney, McCord, Walsh, & Alaniz, 2016; Sanchez Gonzalez et al., 2018). The program has trained over 80 doctoral students from multiple APA accredited counseling, school, and clinical psychology programs in telehealth service delivery (see McCord, Saenz, Armstrong, & Elliott, 2015 for description of the training program). Since its inception, the TBC has served over 1,000 clients from surrounding rural counties and provided over 11,500 hours of counseling services. The TBC has provided individual counseling services to adults and adolescents, as well as couples and group counseling services (Chang, Sequeira, & McCord, 2016). Client presenting concerns include, but are not limited to, depression, anxiety, traumatic stress, substance use, and serious mental illness. Many of the clients served by the TBC are at higher risk, with 42% reporting recent suicidal ideation during their first session (Tarlow, Johnson, & McCord, 2018). In addition to clinical services, the TBC is actively involved in telehealth research and training and has an established relationship with important policy stakeholders in the surrounding communities.

Prior to COVID-19, TBC trainees provided counseling services from the clinic “hub” to clients who were located at community partner “spoke” clinics. This model provided trainees with a secure, structured environment from which to work and consult, and provided clients with a local clinic space, outfitted with adequate technology and internet connectivity to engage in services. The TBC is comprised of licensed staff psychologists and telesupervisors, graduate student staff, practicum student trainees, and an administrative assistant. Prior to COVID-19, all staff and trainees worked on-site at the clinic hub, other than telesupervisors.

In this paper, we demonstrate how a telepsychology training clinic transitioned from a primary hub and spoke service provision model to an in-home model for both trainees and clients. This presentation of the clinic’s decision-making logic and model provides solutions to common pitfalls and can inform implementation in other sites. We also hope to highlight the importance of telehealth training and encourage and empower other sites to follow suit and allow trainees to continue to serve clients during this uncertain time.

Methods

Transition from hub and spoke model to in-home model

In March 2020, the TBC transitioned from a hub and spoke model to an in-home model of service delivery for both trainees and clients. One priority the clinic established early on during the transition process was to continue to accept new clients given that many other low-cost clinics would be closing or slow to start telepsychology services. Prior to the pandemic, the TBC primarily served clients at spoke sites for a host of practical (e.g. lack of internet) and clinical (e.g. behavioral activation, increased safety) reasons. However, in some cases, clients would have gone without services if required to travel to the spoke site weekly so when clinically appropriate, some services were previously offered into the home. The TBC built on those procedures to move all counselors and clients to their homes (or another safe location).

When utilizing a hub and spoke model, the spoke partner clinics had the necessary technology to accommodate service provision. When moving services to clients’ homes, the eligibility criteria require that the client has the technology necessary to have a telehealth visit. The TBC requires, at minimum, the intake session be conducted over video so that a better assessment of the client’s symptoms and functioning can be evaluated. For example, information on grooming and hygiene and certain psychotic symptoms like response to internal stimuli (auditory or visual hallucinations) may be more easily detected when the client can be seen over video. With the platform that the TBC uses (Mend Family), clients need access to a reliable internet connection and a device with a video camera. Clients whose internet does not support a strong connection but can complete at least one session via video may continue their services via audio-only telephone. Additionally, clients are screened for access to a private location to conduct the session (e.g. room with a door, car, secluded area outside). If the client is not eligible for in-home counseling, they can be placed on a waitlist for when the hub-and–spoke model is open again. The TBC is currently working to obtain funding that would enable the clinic to provide internet-enabled tablets to clients who need them.

Transitioning clients to in-home counseling services

In order to determine eligibility for TBC services, a staff member conducts a phone screening session. This session involves reviewing clinic policies, identifying presenting problems, evaluating risk, and scheduling an intake appointment with a trainee. During the transition to in-home service delivery, it was determined that exclusionary criteria would remain in place; however, a clearer workflow for trainees and staff was developed to screen for technology and orient patients to in-home services. Existing exclusionary criteria include elements of both risk level and access to video technology. Clients who generally would not be suitable for outpatient services, particularly those with active, unmedicated, psychosis, and severe suicidal or homicidal ideation/intent/plan who are not agreeable to safety planning are ineligible for TBC services. These clients are often referred to inpatient services, and then later re-evaluated for eligibility.

After the initial telephone screening, clients are scheduled for a 15-min test-session with a staff member followed by an intake session with a trainee. The purpose of the test-session is to determine if the connection is strong enough to support a video session and review requirements for in-home sessions. Requirements include that the client must provide their location at the beginning of every session and they must be in the TBC service area. Other expectations reviewed during the test-session include the need for minimal distractions, privacy, timeliness, appropriate dress, no substance use, and no self-harm during sessions. The staff member also reviews limits of confidentiality and makes a contingency plan for emergencies and for a loss of connection.

The contingency plan for emergencies should include both medical emergencies (e.g. “if you have a heart attack, I will call 911 then your emergency contact on file”) and mental health emergencies. Clients are informed of emergency procedures staff will take if they refuse to safety plan and are imminently suicidal or homicidal. A contingency plan for the loss of connection may be that the follow-up session will be completed over phone audio if the video stops functioning. If the connection does not support a video session or the client does not agree to the other expectations or requirements, the intake session is canceled, and the client can be placed on the waitlist or discontinue services with the clinic.

Eligibility for in-home services is an ongoing evaluation and counselors are trained to consult with their telesupervisor and other staff members when any of the following situations occur: recent suicidal ideation, intent, or plan; ongoing or new self-harming behaviors; active unmedicated psychosis; alcohol/substance abuse; symptoms congruent with conversion disorder; endorsement of domestic abuse or the potential for abuse. While these scenarios do not in and of themselves disqualify a client from in-home services, they do require further evaluation to ensure client safety and appropriate level of care. Following the completion of screening procedures, consent forms, intake questionnaires, and routine outcome monitoring measures (e.g., PROMIS, GAD-7, PHQ-9) are sent electronically. The telehealth platform, Mend, allows trainees to assign assessments to clients to be completed through their browser or smartphone. The same routine outcome monitoring assessments are sent to clients prior to each follow-up session as well. COVID-19 did not significantly alter the workflow of assessments for clients. This workflow is shown in Figure 1.

Figure 1. Telebehavional care program client referral workflow for in-home Services

Transitioning trainees to in-home counseling sessions

Prior to COVID-19, trainees would conduct all telehealth psychotherapy sessions from the TBC clinic site utilizing TBC computers and psychotherapy rooms. Moving to in-home services, staff worked with trainees to conduct test sessions from the location they would be providing services. To help keep the environment professional, trainees were instructed to conduct sessions in a well-lit area with a blank background and nothing personal in view. The policy also included that trainees wore professional clothing and refrained from any distractions such as eating or having pets around during sessions. Trainees were instructed to utilize white noise to limit the potential for breach of confidentiality. Several options for white noise were found using additional devices in the trainees’ home (e.g., white noise machines, phone applications, Amazon Alexa, etc.). Many counselors chose to wear headsets to further limit the transfer of noise. Laptops, headsets, hotspots, and white noise machines were provided for those that needed them.

Results

Communication and logistics solutions

When the TBC transitioned to providing services from home, a critical priority was ensuring that trainees had the support they needed as they attended to clients from their homes. To address this need, the TBC has developed several different procedures. The first was the requirement of utilizing Microsoft Teams for clinic communication. This platform allows for trainees and staff to remain connected with one another in a virtual workspace, with easy access to chat rooms and video calling. Trainees are also able to easily see which staff members and licensed providers are online and available for consultation or supervision. Additionally, the use of Microsoft Teams created a streamlined system for sharing important updates quickly to the whole clinic without overwhelming email inboxes.

For counselors to maintain access to the clinic resources and client personal health information (PHI) that were originally only accessible in the clinic, counselors were given remote access to the secure remote desktop at the clinic. To have this access, counselors signed an official statement outlining the rules and regulations established by the clinic to ensure the security of all confidential information. These guidelines included signing into a secure VPN, accessing it only from a private and secure internet connection, not retrieving or distributing any confidential information, taking precautions to avoid others from seeing the data, and alerting the staff of any violations (purposeful or accidental) that might compromise the security of any PHI.

Early on, the ability to contact clients without access to the clinic phones presented a significant barrier for trainees and staff. To maintain professional boundaries, the clinic chose not to allow trainees to contact their clients directly from their personal cell phones. Initially, trainees would call their clients from a blocked number (by using *67). However, many phones now block unknown numbers, and clients were reluctant to answer calls from unknown numbers. This made it difficult, and at times impossible, for trainees to be able to communicate with their clients. In response, the clinic enabled a softphone solution (Cisco Jaber) as the primary calling service for trainees and staff to reach clients. Softphone solutions do not require a physical phone and places calls from the computer. Another benefit of softphones is that they allow users to emulate an established number, thus the call would appear to be coming from the clinic directly. This protected the trainees’ privacy and helped keep client calls routing back centrally. Additionally, since the softphones utilize the internet it reduces the use of trainees’ personal resources for sessions (such as cell minutes). As an additional method of contacting clients, the telehealth platform the TBC utilizes allows trainees to send a text message to the client’s cell device. This feature allows trainees to contact clients via text without compromising their own privacy. Notably, this feature does not allow for clients to respond to the text.

Trainee supervision and emotional support solutions

Since 2016, the TBC has been utilizing a telesupervision model to provide trainees with specialized instruction. Use of a telesupervision model allows the TBC to draw on the specializations of multiple licensed providers and offer the best available care to clients with a wide variety of presenting concerns. This includes training in areas of bilingual psychotherapy, psychotherapy with children and adolescents, and evidence-based treatments for trauma and serious mental illness. Due to the rural location of the TBC, without the use of telesupervision, trainees would be limited in their access to supervisors with this specialty knowledge.

Lack of available providers and by extension, supervisors, has been a significant concern for practicing mental health professionals in rural areas for decades (Gale, Janis, Coburn, & Rochford, 2019). However, policies requiring at least 50% of supervision to be in-person have made it impossible to utilize a full telesupervision approach. While there are significant gaps remaining (driven by regulations against it) in telesupervision research within mental health, the available evidence regarding telesupervision indicates it is comparable to in-person supervision (Chipchase et al., 2014; Conn, Roberts, & Powell, 2009; Gammon, Sorlie, Bergvik, & Hoifodt, 1998; Martin, Lizarondo, & Kumar, 2018; Reese et al., 2009; Tarlow, McCord, Nelon, & Bernhard, 2020). At the TBC, trainees are matched with a telesupervisor who meets their training needs and weekly individual supervision is conducted via secure video conference. Telesupervisors can also review notes and tape remotely. Before moving to in-home services, trainees recorded the audio and video of their sessions using camera equipment located at the hub clinic. The equipment captured the counselor in front of the camera and the client on the screen. These videos were stored on the secure shared drive that could be accessed by telesupervisors. Currently, trainees use the recording feature in Mend, which captures both the counselor and the client on screen and stores videos on a secure cloud. The files are later transferred onto the secure shared drive and accessed in a similar way. Prior to COVID-19, all students were required to complete group supervision in-person. With changes in telesupervision requirements in March 2020 in response to the COVID-19 pandemic, the TBC has continued individual telesupervision and moved group supervision online using Zoom. While Microsoft Teams support group video calls, Zoom supports large group calls, and could better accommodate all of the trainees at the TBC. Additionally, while both Microsoft Teams and Zoom offer HIPAA-compliant versions, the clinic only has a compliant version of Zoom at this time. This allowed trainees to discuss cases and PHI in a protected manner. Support for telesupervision following the pandemic holds the potential to reduce disparities in access to training and supervision after the pandemic subsides.

In addition to supervision adjustments to monitor clinical work, emotional support for the personal needs of trainees was also of vital importance. The clinic recognized that COVID-19 has brought many significant changes into the personal lives of the trainees, which could be affecting their personal mental health and their ability to provide services. Special attention was given to supporting the emotional well-being of all trainees and allowing them to process feelings of anxiety or stress arising as a result of the global pandemic. One-on-one check-in sessions were established where all trainees had time to speak to a telesupervisor about any personal stress they were feeling during this transition. Additionally, the clinic continued to use its weekly didactics and group supervision time as a safe place for trainees to explore their experience of adapting to the current situations. These measures are implemented to create an environment in which trainees are cared for and, in turn, they can continue the provision of efficacious services to clients.

Trainee crisis consultation solutions

In addition to scheduled supervision, it was essential that trainees had easily accessible means of receiving consultation in emergency clinical situations. Handling client crises, and supporting trainees in this process, is at the forefront of TBC clinic policy. Prior to COVID-19, when trainees were making decisions regarding client care (e.g., risk assessment) the TBC’s trainees were encouraged to first contact their direct supervisor (usually a telesupervisor) and then engage in peer consultation with the clinic staff. The clinic staff are advanced psychology doctoral students whose role is to help trainees create a plan for addressing the situation, aid in technical support, and contact the clinic’s onsite licensed provider if needed. Following peer consultation, trainees would then clear their plan with either their direct telesupervisor or the onsite licensed provider, depending on who was available. For more urgent situations, the onsite licensed provider was immediately consulted.

Following the TBC transition to in-home services for trainees and clients, trainees no longer have easy access to in-person peer consultation or on-site licensed staff. Therefore, a clear workflow was established and communicated to the trainees of what the emergency response procedures were. If a trainee finds themselves in a client crisis, their first line of contact is their clinical supervisor (usually a telesupervisor). If that individual is not available, or additional consultation is needed, trainees contact the on-call licensed provider. Utilizing Microsoft Teams, other members of the TBC team can be involved as necessary to contact law enforcement, inquire about available hospital beds, consult with other providers in the client’s care team, etc., while the supervisor and trainee are consulting.

Both supervisors and staff can also provide consultation through videoconferencing, covertly joining video sessions in Mend, or by being added into a phone session. For instance, the telehealth platform used by the TBC allows supervisors to join video sessions in “stealth mode” enabling them to directly observe the session and provide guidance to the trainee. In the instance of an emergency, trainees contact their supervisor via text, and the supervisor can join into the live Mend session through their browser. This feature is enabled only to those whom you grant permission. This feature also works for live supervision in non-crisis situations. Supervisors may also join the session and be visible to the client. Though trainees are practicing from home, they have many avenues to connect to staff for both clinical and technical support.

Boundary setting solutions

In moving to home-based services for clients and trainees, staff noticed a shift in the client-clinician dynamic. Several trainees noted an influx in personal questions from clients despite trainees taking measures to ensure minimal changes to the virtual session environment (e.g., no pets in the room and a plain, professional background). Offering services in-home to clients presents unique opportunities for clients to challenge professional boundaries and presents new possibilities for ethical challenges to arise. This prompted important clinic discussions on boundary setting with clients, as well as appropriate trainee disclosures that may benefit the therapeutic relationship.

This is not the first time psychologists have been presented with the challenges of working with clients in-home or via telehealth modalities, so the TBC drew from current literature regarding setting protocols for trainees. In this context, boundaries are defined as a predetermined set of implicit and explicit agreements, which differentiate the therapeutic relationship from a social, family, or business relationship (Knapp & Slattery, 2004). Boundaries encompass many aspects of the therapeutic relationship such as issues related to when and where the therapy will take place, how the client may contact their therapist, crisis procedures, and when it would be necessary for the counselor to break confidentiality. They also include more nuanced rules for what interactions are appropriate, including verbal self-disclosure of the therapist and physical touch (Drum & Littleton, 2014; Gottlieb, Younggren, & Murch, 2009; Zur, 2007). Having set professional boundaries in advance provides structure and safety to the therapeutic environment for both counselor and client (Borys, 1994).

At the TBC, trainees and staff are intentional about verbalizing boundaries, which may be unique to conducting therapy services via telehealth. Setting the stage for therapy in-home is an essential component that occurs as part of informed consent, in the initial test-session with a staff member, in the intake appointment with the trainee, and is reiterated as needed throughout the therapeutic process. Examples include informing the client that they are expected to be dressed appropriately for the appointment, be in a private, safe location (no driving, etc.), that it is not appropriate to use substances such as alcohol or nicotine during the session, and that they will be responsible for minimizing distractions, such as calls, in the same way that they would in an office visit. When one of these predetermined boundaries is crossed, trainees are instructed to directly address the situation and discuss with the client why it is critical for them to work together to uphold these agreements.

While not all boundary crossings are innately harmful and may be flexible depending on the context, boundary violations are defined as severe and impose a significant risk to the client and/or clinician (Gutheil & Gabbard, 1993). One such violation includes the client engaging in self-harm on camera. Self-harm is a complex phenomenon, with many reasons as to why someone may engage in this behavior. In some cases, self-harm is a means of intentional boundary pushing, despite clinician discussion of not engaging in this behavior during the session. This could also apply to a client threatening to attempt suicide in session, while not being agreeable to safety planning or responding to de-escalation. In instances where the clinician is threatened or otherwise endangered, which we interpret to include psychological trauma, the guidance of at least one mental health professions’ ethics code, APA (2017) ethics code section 10.10, is to terminate therapy, including the present session. The clinician should do their due diligence to ensure client health and safety, which may include calling local emergency responders and/or requesting a welfare check by local law enforcement. The trainee should also provide the client with a list of referrals, which may include inpatient services or other options best suited to the client’s needs.

However, it is also vital to note that there is some flexibility in boundaries due to the myriad of factors unique to each client-clinician dynamic, such as the client diagnosis and clinician orientation (Drum & Littleton, 2014). For some TBC trainees, clients began to verbalize greater interest in the trainee’s personal experiences of facing COVID-19 or of working from home. Trainees were encouraged to use the same therapeutic skills they would utilize in tackling other difficult topics: curiosity, unconditional positive regard, and humor when appropriate. Trainees were also encouraged to continue the mutual discussion of boundaries, inviting the client to join them in exploring the role of boundaries in the context of therapy and how they may serve and protect both the client and counselor.

Discussion

With the inception of COVID-19, the TBC staff and trainees were poised to transition to in-home telehealth service delivery due to the extensive telehealth training prior to the pandemic. Some unexpected clinical issues that arose were handling an increased demand in services when referrals were expected to decrease during shelter in place orders and responding to the spike in paranoid symptomology due to the stress of the pandemic. Anecdotally, it seemed that both trainees and clients showed mixed responses to the switch to in-home services. Seemingly falling in a normal distribution, the majority of clients did not experience much change in process or outcomes in therapy; however, a few clients had significant difficulty with distractability and avoidance and a few thrived and made greater therapeutic gains (especially in trauma treatment) from the comfort of their home. The same was true for trainees. A few struggled with isolation, depression, and anxiety from the lack of separation between clinical work and home life, a few thrived in their new work from home environment, and the majority of trainees experienced no significant differences. Future research should test these conclusions with qualitative and quantitative analyses of client and trainee outcomes and experiences.

Despite the expertise of the TBC, extensive effort was needed to develop new policies and procedures to provide solutions to concerns related to the transition from a hub and spoke model to an in-home model of service delivery for both trainees and clinic staff. Unfortunately, for many in the mental health field, telehealth is new to their practice and may not yet be within the boundaries of their professional competence. In emergency situations, such as COVID-19, mental health ethics codes promote a balance between providing services to clients who otherwise would not have access to psychological care and undertaking the relevant training, consultation, and supervision to obtain competence (APA, 2017). Movement toward telehealth in the face of COVID-19 highlights the necessity of telehealth training for all practitioners, even after this emergency has passed.

For training programs looking to add telehealth service delivery opportunities for trainees for the first time, there are several recommendations for initiating this type of service delivery. First, it is recommended to review all ethical and legal requirements for providing telehealth services and identify resources for training to increase telehealth competence. Utilize resources such as the International Society for Telemedicine and eHealth, Center for Connected Health Policy (US), and the National Consortium of Telehealth Resource Centers (US). Consult your licensing board, ethical code, and available telehealth guidelines and look specifically for regulations, codes, or best practice suggestions that would apply to your telehealth practice.

Second, it is imperative to develop multiple avenues for communication and a clear chain of command. There are many technology resources available to enhance communication with trainees and with clients. While regulations have been relaxed for security and encryption, continue to think about the long term and sustainable options if regulations are reinstated. Even with multiple options for communication, it can be psychologically difficult for trainees to reach out for fear they may be burdening someone or are asking something they should know already. This exists in in-person training, but trainees at the TBC have reported that working from a distance exerts an extra force that makes them think twice about reaching out, so it is the licensed providers’ duty to remove as many obstacles to communication as possible. It is important to have a clear plan in case of emergencies, both physical and psychological. Always document the location of the client at every contact.

Third, training programs need to protect the safety and well-being of trainees through policies that set appropriate boundaries for in-session behavior and screen clients to determine appropriateness for the developmental needs of the trainee. Empower trainees that in some extreme cases it would be okay to terminate a telehealth session for their own psychological safety. Trainees may need additional support for the stressors now experienced in their own lives due to COVID-19 and because the technology that helps keep us physically safe and distant from clients is bringing us closer than ever to the psychological impact of the stress, illness, and death of the pandemic.

In conclusion, let us return to the remarks from Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization which declared the COVID-19 virus a worldwide pandemic (2020):

There’s been so much attention on one word. Let me give you some other words that matter much more, and that are much more actionable. Prevention. Preparedness. Public health. Political leadership. And most of all, people. We’re in this together, to do the right things with calm and protect the citizens of the world. It’s doable. I thank you. (para. 3)

In mental health fields, “prevention” comes by overcoming disparities in access to information and treatment that makes us more resilient in the face adversity. “Preparedness” comes from equipping both our current workforce and the next generation of mental health providers to be ready for providing counseling services that are not bound within the walls of a clinic. “Public health” means mental health providers do not wait for clients to come into their office, and they apply research and evaluation skills to positively impact population mental health. The conscientious mental health providers of 2020 and beyond partner with communities and other disciplines. Universities, tribal, and non-profit organizations who are often poised to receive grant funds for targeted services to underserved populations have additional potential to impact the mental health field in innovative ways when not constrained by tradition and reimbursement restrictions. Mental health providers are poised not to just to survive this pandemic, but to thrive and emerge as the leader in telepractice if they sustain the positive trajectory they have been put on by unfortunate events.

Disclosure statement

No potential conflict of interest was reported by the authors.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This work was partially supported by the Health Resources and Services Administration under Grant [D40HP33362] and Grant [G01RH32158].

Notes on contributors

C. E. McCord

C. E. McCord, PhD, is a licensed psychologist and the Director of Telebehavioral Care (TBC) at the Texas A&M Health Science Center. She is also a Clinical Assistant Professor in the Departments of Psychiatry and Educational Psychology. She has a proven and documented expertise in providing high-quality mental health services via long-distance technology, engaging rural communities in order to reduce mental health disparities, and starting a successful and innovative training and supervision model for telepsychology. She systematically studies the mental health needs of clients of the TBC program and the communities in which they reside, develops and refines intervention approaches, investigates the effectiveness of interventions, and evaluates satisfaction with services. In both research and practice, she is well versed in underserved populations, training and supervision, and telehealth.

K. Console

K. Console, MEd, is a third-year doctoral student at Texas A&M University in the Counseling Psychology program. She holds a Master of Education in Educational Psychology from Texas A&M University and a Bachelor of Science in Psychology and Spanish from Harding University. She is a Program Coordinator at the Telebehavioral Care Program. Her research interests include multicultural counseling competence, telepsychology, and disparities in mental health care. Her clinical interests include working with diverse populations, including Spanish-speakers, and individuals with complex psychological presentations.

K. Jackson

K. Jackson, MS, is a second-year doctoral student at Texas A&M University in the Counseling Psychology Department. She holds a Master of Science in Clinical Psychology from Abilene Christian University and a Bachelor of Science in Psychology from Texas A&M University. She is a Program Coordinator for the Telebehavioral Care Program. Her research interests include mental health care disparities, access to mental health care, and telepsychology. Her clinical interests include trauma, integrated behavioral health care and working with diverse populations.

D. Palmiere

D. Palmiere is a second-year doctoral student at Texas A&M University in the Counseling Psychology Program. She holds a Master of Education in Educational Psychology from Texas A&M University and a Bachelor of Science in Psychology from the University of Texas. Débora was born and raised in Brazil, and moved to Austin, Texas at the age of 9. Currently Débora works as an Intake Specialist at the Texas A&M Telebehavioral Care Program. She holds professional membership in the American Psychological Association. Débora’s research and clinical interests include treatment outcomes, resiliency, and providing care for underserved populations.

M. Stickley

M. Stickley, MEd, serves as a Program Coordinator for the Texas A&M Telebehavioral Care Program. She is a third-year doctoral student in the Counseling Psychology program at Texas A&M University. She holds a Master of Education in Educational Psychology from Texas A&M University and a Bachelor of Science in Psychology from East Tennessee State University. Mariah grew up in rural Appalachia and has a passion for working in rural and underserved communities. Broadly, her research interests include medical resident education and treatment of behavioral health concerns in rural settings. She holds professional memberships in the American Psychological Association, the American Psychological Association—Division 22 Rehabilitation Psychology, and the Texas Psychological Association.

M. L. C. Williamson

M. L. C. Williamson, PhD, is a licensed psychologist for the Department of Primary Care and Population Health within the College of Medicine at Texas A&M Health Science Center. She is also a clinical assistant professor and faculty member of the Texas A&M Family Medicine Residency, where she is in charge of behavioral health curriculum and service delivery along with wellness for family medicine resident physicians. Dr. Williamson specializes in integrated behavioral health treatment in outpatient and inpatient medical settings. She has a strong background in addressing psychosocial issues related to chronic health conditions including obesity, diabetes, tobacco use, chronic pain and insomnia as well as common mental health conditions. Furthermore, she has grant funding to conduct interprofessional training in behavioral health for medical residents, medical students, and psychology graduate students. Dr. Williamson’s research focuses on clinical outcomes in integrated behavioral health settings and physician wellbeing. In her current position, she specializes in physician-patient communication and prepares medical residents to treat behavioral health concerns in rural settings. Through these activities, she obtained a profound understanding of the need for sustainable interventions targeting diverse individuals at risk for chronic medical and mental health conditions.

T. W. Armstrong

T. W. Armstrong, PhD, is employed as a postdoctoral fellow for the Telebehavioral Care Program, a part of Texas A&M Health. He graduated from the Counseling Psychology program at Texas A&M University, and he is a licensed psychologist in the state of Texas. His research interests include telepsychology, psychotherapy outcomes, statistical modeling/analyses, and the impact of sensory loss. His clinical interests include adjustment to disability, blind rehabilitation psychology, personality and telepsychological assessment, and the interface between technology and telepsychology.