Practitioners’ perspectives on preparing for and delivering remote psychological support in Nepal, Perú and the United States during COVID-19

Abstract

INTRO:

The COVID-19 pandemic has propelled a global paradigm shift in how psychological support is delivered. Remote delivery, through phone and video calls, is now commonplace around the world. However, most adoption of remote delivery methods is occurring without any formal training to ensure safe and effective care.

OBJECTIVE:

The purpose of this applied qualitative study was to determine practitioners’ experiences of rapidly adapting to deliver psychological support remotely during COVID-19.

DESIGN:

We used a pragmatic paradigm and applied approach to gain perspectives related to the feasibility and perceived usefulness of synchronous remote psychological support, including views on how practitioners can be prepared.

METHODS:

Key informant interviews were conducted remotely with 27 specialist and non-specialist practitioners in Nepal, Perú and USA. Interviewees were identified through purposeful sampling. Data were analyzed using framework analysis.

RESULTS:

Respondents revealed three key themes: (i) Remote delivery of psychological support raises unique safety concerns and interference with care, (ii) Remote delivery enhances skills and expands opportunities for delivery of psychological support to new populations, and (iii) New training approaches are needed to prepare specialist and non-specialist practitioners to deliver psychological support remotely.

CONCLUSIONS:

Remote psychological support is feasible and useful for practitioners, including non-specialists, in diverse global settings. Simulated remote role plays may be a scalable method for ensuring competency in safe and effective remotely delivered care.

Introduction

The COVID-19 pandemic intensified mental health problems and disrupted related services globally; arguably, the most detrimental impact of COVID-19 was the widening of pre-existing inequities to mental health care access [1–6] such as in low-and-middle income countries (LMICs) where nearly 90% of those in need of mental health services go without, representing a formidable mental health care “gap” [7, 8]. To mitigate the impacts of massive disruptions to existing mental health services, roughly 70% of 130 countries surveyed swiftly shifted to remote delivery of services in 2020 [3, 9]. This included expanding mental health task-sharing models, wherein non-specialists (e.g., primary care workers, community workers, teachers, family members, and peers) are trained and supervised to deliver brief psychological support remotely [1, 10–15].

Although many countries shifted to remote methods for psychological support delivery, inequitable access to Internet, digital infrastructure and technologies still exist in LMICs, such as Perú and Nepal, compared to high-income countries (HICs), such as the USA [16, 17]. For instance, Alvarez-Risco and colleagues report that Perú rapidly implemented telemedicine services (consultation, monitoring etc.) in response to the COVID-19 lockdown protocols, yet access to Internet ranges from 33–63% across the three Perúvian geographic regions [18]. Similarly, in Nepal, telehealth services, including for mental health, were initiated nationally in March 2020 in response to the COVID-19 lockdown; however, factors like inadequate infrastructure, specific requirements for reliable Internet connectivity and preferred electronic devices, and lower “digital literacy” limited the amount to which Nepali health seekers could access care [19, 20]. Comparatively, prior to COVID-19, the USA was identified as a “frontrunner” in telemedicine invention, implementing and optimizing telehealth programs nationally and with a stronger infrastructure to meet the increased demand for mental health services post-COVID-19 [16]. Similarly, in these settings, mechanisms and regulatory standards to monitor and evaluate quality mental health training and delivery vary widely, or lack completely, such as when implementing task-sharing models. Moreover, in both high- and low-income settings, many practitioners or organizations that switched to remote services had to do so rapidly, due to the COVID-19 humanitarian crisis, and therefore little is known about the level of training these practitioners had–or needed to have–to ensure quality care delivery.

The latest World Mental Health Report [21] includes a global call to 1. expand the mental health workforce using quality training and supervision to ultimately ensure practitioners have the minimum competencies needed to deliver care competently, and 2. for an increase in the application of digital technologies and remote services to support access to mental health care. However, there is a lack of evidence on the feasibility of delivering mental health services remotely in under-resourced settings. Likewise, little is known about practitioners’ perspectives on key competencies and training methods that could support both specialist and non-specialists in the delivery of remote services.

Most qualitative research has been conducted in high-income settings, predominantly among Caucasian mental health specialist populations, to identify competencies and education practices for remote delivery (e.g., telehealth and telepsychiatry programs). For example, qualitative interviews were conducted with postgraduate psychiatry residents in Canada to learn about their experiences with telepsychiatry training during their specialist program [22]. Important aspects identified by the participants included key competencies for skillful delivery of telepsychiatry (e.g., technical, assessment) and methods for how to best learn these skills. Similarly, phenomenological research was conducted to understand experiences of former graduates of a family therapy master’s degree program on ‘distance delivery’ (using videoconferencing to deliver mental health services) [23]. In these interviews, respondents revealed hesitancy about delivering distant care, a desire for various levels of training (e.g., coursework, supervision), and technological barriers and ways to overcome them when using videoconferencing as a delivery method. Interviewees from both studies had been trained specifically for remote delivery, but neither study described in detail the format or methods of training or competency assessment.

A rapid review was conducted on competencies and competency frameworks for remote psychological support [24]. Core skill domains, such as remote consent procedures and literacy in technology, were identified across the included studies. However, the literature was limited to high-income settings with specialist mental health practitioners, and the framing, prioritization, and measurement of competencies were mixed with gaps for standardized guidance on implementation –a problem also identified in the competency literature for the broader health services field [25].

Considering the global, urgent shift to deliver mental health services remotely during and post-acute COVID-19, and existing gaps in the literature, we conducted a study to understand practitioners’ experiences of adapting to delivering mental health and psychological support remotely during COVID-19 in three country settings: Nepal, Perú and the United States. We explored areas of feasibility, acceptability, and perceived usefulness of using synchronous remote methods (e.g., video or phone connection) to deliver mental health and psychological support during and beyond the COVID-19 humanitarian crisis, including respondents’ views on what competencies and training tactics practitioners need to be prepared.

METHODS

We used the pragmatism paradigm (what is useful, practical, and ‘works’) [26] as our philosophical framework for this study and therefore conducted this research using an applied approach. We developed a conceptual framework, with support from the literature, to guide our research processes.

Participants and sampling procedure

Purposeful sampling was used to identify mental health specialists and non-specialists who had some experience training, supervising, or delivering remote mental health services. We defined specialists as practitioners with a minimum educational background of a master’s degree in clinical psychology, social work, or counselling with 3+ years of experience delivering psychological support. Non-specialists were defined as practitioners with a minimum of a high school degree, some brief training in psychological support (e.g., between 3–15 days), and less than 2 years of experience delivering services. Participants were accessible to us given our previous or current work with their organizations. Specialists included psychiatrists, third-year psychiatric residents, psychologists and social workers. Non-specialists included community health workers and bachelor and master students (nursing, public health, social work, counselling) who participated in either a 3-day remote training in foundational helping skills (e.g., communication skills, empathy, goal setting, promoting hope for change), of which are core to any mental health, psychological, or psychosocial support [27–29]; or, in a 10-day remote training in the World Health Organization’s (WHO) low-intensity manualized psychological intervention, Problem Management Plus (PM+), aimed to support distressed adults affected by adversity [10, 30].

At the time of the interviews, participants were working in different settings (Nepal, Perú, and USA) and with different organizations (non-profit academic institution or non-governmental organization; for-profit private practice or hospital), and all were currently under lockdown measures or social distancing restrictions due to COVID-19.

Data collection and ethical consideration

We conducted key informant interviews (KII) using semi-structured guides to capture a deeper understanding of the participants’ perspectives [31]. Recommendations vary, but it is suggested for in-depth interviews to interview 5–50 participants for saturation [32]. The KII guide addressed experiences of rapidly adapting or preparing to deliver synchronous remote psychological support due to the COVID-19 pandemic, such as engaging with someone via video or telephone connection, technology issues, and considerations for building practitioners’ competencies. After permission from the participant, interviews were audio recorded. Process and debriefing notes were taken during and after the interviews. Interviews were conducted remotely via Zoom with a password login to ensure confidentiality. Each interview was between 30 minutes to an hour. Interviews were conducted in English, Nepali and Spanish. Interviews conducted in Nepali were directly transcribed into English, and interviews conducted in Spanish were transcribed in Spanish and then translated into English for analyses.

Confidentiality procedures were described during the consent process, including use of the data and discussion of additional security measures that can be taken (private room, headphones, etc.) during the interview. All participants were aged 18 years or older and literate in their native language. This study was approved under George Washington University IRB NCR191797, Nepal Health Research Council ERB 604/202P, The New School IRB 2020-91, and the Universidad Peruana Cayetano Heredia CIEI 19021.

Data analysis

We used framework analysis to allow for a combination of inductive and deductive modes of coding and analysis, offering us the ability to move back-and-forth across theory and data and constantly refine themes [33]. All qualitative data were coded in Dedoose, a cross-platform application for analyzing qualitative and mixed methods research [34]. To develop the codebook, we used open and axial coding to create categories which were then compared to a theme matrix informed by the conceptual framework and interview guide [35]. The final refined codebook resulted in 9 parent codes and 10 child codes. A selection of 54 excerpts across 4 transcripts were used to check for inter-coder reliability (ICR) among four coders using the “Test” function in the Training Center on the Dedoose platform. Multiple coders were used to facilitate coding timeline and to support rich data analysis and data trustworthiness [36]. After coder agreement was reached (ICR, 90%), transcripts were randomly divided (approx. 5–7 transcripts per coder) and independently coded at the paragraph level.

We used a code summary template to summarize codes and prepare for analysis. We further identified linkages and patterns in the data running queries and matrices in Dedoose, such as descriptors by code count and code co-occurrences. Measures were taken continuously to ensure rigor, credibility, and threats to validity, including triangulation of multiple data sources (process and debriefing notes, audio recordings) and referring to the literature as needed to help coders reflect on general tone and responses from participants and help interpretation when it was not clear solely from the interview transcripts. To ensure consensual validation, the coders had multiple discussions throughout the process and consulted outside stakeholders (two experts in global health and global mental health qualitative research at The George Washington University) on our interpretations. The study followed the COnsolidated criteria for REporting Qualitative research (COREQ) guidelines (see Supplement)[57].

RESULTS

Sample Characteristics

In total, 27 respondents (8 specialists and 19 non-specialists) participated in the study, of which 9 were from Nepal, 10 from Perú, and 8 from the United States of America (USA) (see Table 1 for details). Some respondents had been delivering in-person services and had to rapidly switch to video conferencing or telephone delivery, for their first time, to continue care or see new clients. Some had training, remotely or in-person, for delivering psychological support and only experienced delivering care remotely due to COVID-19. Overall, respondents included in this study had very little to no training in techniques for how to deliver synchronous care remotely.

Table 1.

Participant demographics

	Specialist (N=8)	Non-Specialist (N=19)
Country, # of practitioners	Nepal, N=2 Perú, N=2 USA, N=4	Nepal, N=7 Perú, N=8 USA, N=4
Amount of training in delivering services remotely (# of practitioners)	0 days (N=7) 2 weeks training in using remote service platform (N=1)	0 days (N=3) ½ −1 day of role play practice (N=16)
Remote platform/modality used	Zoom Viber Skype Telephone (mobile or landline)	Zoom Microsoft Teams Telephone (mobile or landline) Viber WhatsApp

Overview of themes

Data analysis highlighted three main areas that respondents reflected on the feasibility, perceived benefits and practitioner competencies related to remote psychological support across the three settings for both specialists and non-specialists (Figure 1).

Figure 1.

Conceptual framework of synchronous delivery of remote psychological support: an applied approach

Theme 1: Remote delivery of psychological support raises unique safety concerns and interference with care.

Respondents identified challenges to remote psychological support and the skills needed to mitigate them. Three subthemes were identified and described. A selection of respondent quotes representing each subtheme can be found in Table 2.

Table 2.

Selection of respondent quotes by subtheme for qualitative Theme 1

THEME 1: Remote delivery of psychological support raises unique safety concerns and interference with care	Subtheme1.1: Different safety and privacy concerns hindering care
	I think, for example, whatever challenges wouldn’t be occurring in-person, like shutting the door. Everything [remotely] you have to show them, like to assure them you know, “We have kept the doors closed, like the windows are shut,” so like you know, it’s a private conversation.
	You know I [the practitioner] can just click ‘leave room’ on Zoom while someone is having a panic attack. It’s so tempting. If you don’t want to deal with it, to just leave the room, or what? …And then all of a sudden, you’ve left, you have abandoned your patient having a panic attack. And that could just be horrible for a patient.
	Subtheme 1.2: Interference with ‘natural’ therapeutic engagement
	Like we have to look at the screen right, you shouldn’t be like directly seeing the person, like we shouldn’t look directly in the eyes--these kinds of things they had told us. And it’s like now we will obviously happen to stare at the screen, that does not connect I felt, and like they [clients] might feel slightly nervous I felt. Plus, if we have to do it virtually itself then that connection should be [improved].
	I certainly feel like it’s very different and there seems to be a lot missed in terms of, like you know, we’re forging a connection and the therapeutic alliance. It’s all on the computer so that’s a very different experience than when you’re sitting next to someone, and you know, talking and connecting with them.
	Subtheme 1.3: Technology aspects that cause disruptions during sessions
	We had some difficulties with the internet signal and the audio, but nothing else. I have had no problems with the Zoom platform because I already knew how to use it.
	Only thing was, while sitting in front of the laptop and phone screen, it was a bit stressful, and we felt eye pain, headache and body ache sometimes.
	So, the idea that, like in a face-to-face conversation we can feed off of each other and talk at the same time, and still hear each other. But sometimes Zoom, because the audio will prioritize one person over the other, you might miss stuff. So, it’s sort of, it sometimes slows down the conversation, which is great, but it also can take away some of the natural flow of conversation.

Subtheme 1.1. Different safety and privacy concerns hindering care.

Respondents described having low confidence and competence to meet a client’s needs because the limited visual of clients blocked practitioners’ abilities to “pick up on certain cues”, especially when considering a client with severe distress or “dysregulation.” Privacy issues were raised when clients took sessions from their homes or in shared spaces during lockdown. Practitioners described their fears that others may listen in on the session and mentioned that clients also voiced these fears during sessions.

Opinions were expressed about lacking control, or wanting more control, over the environment and how that impacted the capacity to meet clients’ needs. For example, respondents acknowledged that the client or practitioner could walk away, leave the room, or “shut off anytime” during a session or from the longer-term treatment goal. Similarly, respondents were concerned about managing ethical and procedural issues. This included issues like the client’s ability to record sessions without permission, the possibility to manipulate or “take words out of context” to use against the practitioner, or the ability of remote modalities to act like the “therapist version of a police body cam [camera], right?”

Subtheme 1.2. Interference with ‘natural’ therapeutic engagement.

Respondents described interference with communication and their ability to “naturally” engage or comfort the client. For example, if the client preferred to use telephone, or to turn their camera off when connecting over videoconferencing, practitioners had more difficulty showing body movements that could signal they are listening or recognize if the client’s facial cues match-up to their voice or a problem they are discussing. They also mentioned that clinical note-taking processes interfere with holding “virtual eye contact” compared to in-person. Respondents acknowledged remote care might make clients ‘too comfortable’ and potentially cross professional boundaries or cause them to disengage. Actual experiences were described, including a client lying in bed, driving a car, taking an Uber, walking in the grocery store, running errands, or not wearing a shirt during a session. Finally, respondents described increased distractions from both clients and practitioners, such as pets barking or walking in front of the video screen, and disruptions from children, parents, or roommates when living in shared spaces.

In contrast, some respondents recognized an advantage to this ‘comfort level’, pointing out that the client may be more open to sharing their feelings because they feel more comfortable in their environment. They also saw these benefits for the practitioners, such as wearing relaxed clothing (e.g., T-shirts) that was still professional-looking could help them to feel more comfortable.

Subtheme 1.3. Technology aspects that cause disruptions during sessions.

Obstacles with technology included connection lags and difficulty navigating video platforms due to lack of training. Maintaining a stable internet or telephone connection was a major concern for all respondents, especially for those working in Perú and Nepal and those delivering care to clients living in rural areas in the USA. Other disruptions included the computer or telephone losing battery in the middle of the session, and a practitioner’s increased “screen fatigue” when having a full day of video sessions. Some respondents noted that simply having access to high-quality internet service and better devices could mitigate many of the obstacles.

Theme 2: Remote delivery enhances skills and brings opportunities for delivery of psychological support.

Respondents’ reactions to challenges were often followed by thoughtful reflections on their confidence and skills to manage and adapt to challenges “on the spot.” They also identified unique opportunities and benefits that remote support offered compared to in-person. Three subthemes were identified. A selection of respondent quotes representing each subtheme can be found in Table 3.

Table 3.

Selection of respondent quotes by subtheme for qualitative Theme 2

THEME 2: Skills and opportunities included with successful remote psychological support compared to in-person support	Subtheme 2.1: Enhancing communication and engagement remotely
	I think working through the problems, like through the challenge of doing it over remote, actually kind of leads to you know more connection and like when that works, I think, in some ways, you can always get more out of it, because you have to overcome that to work together.
	I need to be more mindful, like more aware…Sometimes you know we can find the clues like…He or she’s laughing or making the smile on her face, at that moment, a mismatch can be there, you know? And at that moment I reflect that I’m hearing your words as this, and your facial expression is like in this way…and what is the meaning? In this way I confront, you know, I confront and [ask the client] …what are you noticing in your body now?
	Subtheme 2.2: Increasing access to care with convenience
	I don’t really see the downsides to it, I really only see the upsides…. I see it as the great equalizer and ability to really connect people in a way that we weren’t really willing to do before. And, by the way, the same is happening in medicine…why not mental health?
	Advantage also being accessible, like many people can use it, some may not, but it is a little more accessible. Like people have been doing it through a phone call, using the helpline and like they don’t even need to look at a screen, because you just have to express like about what you are feeling…at least someone is there to listen…
	Subtheme 2.3: Remote modalities increasing pathways to quality care
	I can imagine [remote modalities] being helpful for patients with eating disorders, or let’s say body dysmorphia, or who are living in, you know, different circumstances, like poverty, where being seen in their natural environment can be associated with shame, or shame or guilt or whatever, whatever negative emotion they don’t want us to see.
	I think what you’re seeing in the background isn’t all an indicator, but it can be right, like I don’t think it’s a good telltale sign, but it could be an indicator, especially if things drastically changed.

Subtheme 2.1. Enhancing communication and engagement skills remotely.

Many described how the obstacle of limited physical cues led to mobilizing the client’s input, working collaboratively, or motivating the practitioner to be flexible in their approach. For example, respondents described actively guiding the client to self-identify and verbalize their personal comfort and body signals during sessions, actively simplifying content and presentation throughout the session (e.g., using more metaphors), and learning how to continuously check-in and ask the client for feedback (e.g., “Does that make sense?” “What do you think of that?”).

Subtheme 2.2. Increasing access to care with convenience.

Respondents felt that remote modalities increased access to mental health care overall during the COVID-19 pandemic and saw potential for continuing with it beyond lockdown scenarios. Many recognized the time and cost-saving benefits, such as reducing long-distance commutes and simplifying scheduling, as there is less concern for cancellations and more options for agreeable times for the practitioner and client to meet. These time and cost savings were seen as a pathway to continuing care, especially for those being reached in “really remote, or already in remote or rural settings.” Other advantages were related to the multiple options for remote connection (e.g., through mobile phone, laptop). This was especially relevant for respondents working or living in Perú and Nepal or working with rural populations in the USA, where accessibility is hampered by long-distance travel.

Subtheme 2.3. Remote psychological support increases pathways to quality care.

Respondents reflected on how using remote connections supported their competence in delivering care. They described how being limited to a small screen in videoconferencing encouraged them, as practitioners, to be attentive to client details that they may otherwise overlook if meeting in-person. For example, a few respondents mentioned that seeing a client picking at their face or ‘seemingly’ acting jittery were reminders to check-in and see if the practitioner needed to “slow things down,” change the topic, or ask if another person may have entered the client’s space (e.g., assess privacy and risk). A few respondents specifically raised the unique aspect of meeting a client in their personal space or surroundings, even if their space was small or there were added distractions, like when clients take sessions “in their shoe closet,” “mother’s closet,” “in the complete dark,” or “in front of their kids”. Such personal insight about the clients helped practitioners to offer more tailored care and attention. Consistently seeing (e.g., through multiple sessions) the client’s home-background was also seen as an opportunity for proactively identifying psychosocial barriers, risk or harm over time. Similarly, a few respondents commented that voice-only connections (e.g., telephone) are advantageous to video or in-person sessions, because they offer a type of anonymity that seems to help clients “open-up more”.

Several respondents saw remote modalities as an opportunity to increase supervisor engagement and attendance, and as a pathway for scaling quality services—particularly quality task-sharing services delivered by non-specialist practitioners. They described the convenience of having a supervisor on-call or available when they “logged in” on a platform, and it was easier to “have supervisors on the remote connection [with the non-specialist] to ensure safety.” Many practitioners also felt that remote modalities could increase clients’ acceptability, or willingness, to begin or continue care, and saw potential in offering different choices to the client or using hybrid solutions (a mix of remote and in-person).

Some respondents expressed their hesitancy to use remote connections, particularly in the case of specialized care (e.g., medication or specific psychotherapies) and the breadth of nuanced situations wherein remote care may or may not work for individual needs or locations. One Nepali specialist practitioner reflected on their personal experience of managing three suicidal attempts remotely during COVID-19. They expressed that in-person care is preferable to remote, but “something is better than nothing.” They also advised that if connecting remotely, to encourage using video rather than phone or voice-only, as it is better for “convincing them” [to reduce risk of suicide deaths].

Theme 3: Preparing practitioners to deliver psychological support remotely.

Given that many respondents reported little to no previous training in remote delivery techniques, we explored respondents’ thoughts on optimal training methods and key competencies. Three subthemes were identified. A selection of respondent quotes representing each subtheme can be found in Table 4.

Table 4.

Selection of respondent quotes by subtheme for qualitative Theme 3

THEME 3: Preparing practitioners to deliver psychological support remotely	Subtheme 3.1: Practitioner competencies for remote delivery
	I think there are ways to find around it, like you can plan ahead. “OK, I need to make sure my head is in the screen,” or “I need to make sure I have a solid background and not alcohol in the back.” Or even if you know that your kids are around, to at least just say, “Hey, by the way, today my kids are kind of in and out.”
	…know when to stop, when to pause, when to make a sign so that the person does not feel that he is speaking [just] to speak. Not just keep quiet, but at least make a sudden “uhm” gesture with my hands… Suddenly my hands interact so that the person feels that I am listening, only that sometimes before I did not do that, and only I spoke.
	Safety and security, I mean trustworthy environment or privacy. I try to ensure, before starting the session, by informing [the client] about the process and…maintaining privacy…I ask them…is there any possibility to break…if someone came or who is not aware about the session, at that moment what to do…And then, like, usually, we use a symbol so that I can understand that someone is going to bring someone in, something is interrupting or trying to interrupt the session.
	Subtheme 3.2: Use of role plays to prepare for remote delivery
	[The first role play] made me very nervous…because there was an unknown person sitting in front of me and I was like … how can I help him?
	…role plays have us more or less prepared for a moment that is going to be real and people who need us to be present to respond to their problems. I am a shy person and role play helps me to have confidence by gaining experience simulating those situations that we have not yet experienced.
	I think we have to focus more on the learning process and using role plays for these scenarios, because you haven’t experienced them as you would experience in real life, right? So, in normal education you’re just thrown into all of it– a whole host of different types of things. And, so, maybe a few role plays you’re good at for an unusual situation. But the remote area, it’s relatively new, and so we need role plays, we need scenarios to get that same coverage, because we don’t have years and years of being patients ourselves and clients ourselves on the one end of it and we don’t have that kind of like medical team or mental health team experience.
	Subtheme 3.3: Key role play scenarios and safety concerns
	The thing that I liked most is…sometimes there is an unpredictable situation through the client … like a real case scenario … Because these are not the things that can be experimented within clinical trials…. because this is part of treatment … so trainers acted like clients and then we practiced with them … that part was good.
	This [role play scenario], for me, was very beneficial because that way I can collaborate with the community, help them in the way that I have been able to develop myself and what I have learned is to promote hope for change. Even more so at this time, because many people, like in the [role play] interactions with the actresses, many are now going through difficult times due to the COVID disease, then they have different anguish problems. So, in that way, it allows me to help them.
	…a little bit more in terms of how to set up my camera or you know my body language, how I want to be looking at the person, you know how to make eye contact remotely, right? Like kind of all these things that would be more natural if we were in person, so I think the role plays help me at least try some of those things out.

Subtheme 3.1. Practitioner competencies for remote delivery.

All respondents mentioned that many of the foundational helping competencies used during in-person sessions (e.g., communication, rapport building, confidentiality and assessing for suicidal behavior) are needed, but they must be adapted to remote settings. Suggestions for adaptations were similar across specialists and non-specialists and across countries. For communication, they included: using more creative cues with their hands, taking more opportunities for pauses, using proper eye contact by looking directly into the screen, and using more verbal cues (e.g., reassuring words, verbal check-ins). Adaptations useful for rapport building and confidentiality included supporting a comfortable environment by asking the client if they need to use the bathroom or get a drink of water before the session starts, creating mutual ground rules to mimic in-person sessions (e.g., agree to both sit in a chair, find a quiet space, have enough light to see each other’s faces), and eliminating any visual or audio distractions from the practitioner’s side. Adaptations for competence in assessment of suicidal behaviors and other potential harms included using code words during sessions, confirming the client’s location and the best way to contact them at the beginning of each session, having emergency protocols prepared, knowing the local resources available to the client, and understanding or verbalizing any legal or ethical adaptations needed to existing country or organization-specific laws or regulations (Table 4).

In addition, respondents described needing training on remote-specific competencies, for example, knowing how to ‘start up’ sessions on virtual platforms, how to navigate technical problems (e.g., microphone or speaker issues, dropped calls, lags in connection) during sessions, and how to use ‘special’ technical features (e.g., “share screen” function, hiding “self-view mode”, and sharing video and private links for session work). They also recommended being competent in guiding clients through these technical issues. Similarly, respondents felt that practitioners should know how to optimize remote technology for consensual and legal purposes, such as using and conducting consent for recording and transcription functionalities to enhance clinical note taking and to “create an optimal environment so we can provide the best care as possible without having behaviors misconstrued via remote videos.”

Subtheme 3.2. Use of role plays to prepare for remote delivery.

All respondents agreed that role plays are a helpful training technique for a practitioner to enrich their competence. The ‘practicality’ of a role play was mentioned most often due to the enhanced learning and skill application through simulation, particularly for complex and unknown situations prior to real-world within the new realm of remote delivery. Respondents described how role plays can improve training and supervision approaches. For example, by helping trainees “ease into” using their skills, or for demonstration purposes (by trainers or supervisors) to show trainees how even the trainer “screws up” and to promote learning and working through mistakes. Other participants saw role plays as a “super super duper important” training tool and essential for enabling trainers and supervisors to observe and offer tailored feedback for directed skill building in the areas needed most.

Subtheme 3.3. Key role play scenarios and safety concerns.

Respondents described a range of scenarios that could be used for role plays. Many specifically described role plays that address risk of harm, such as walking through a safety plan with a client remotely, establishing a code word with the client, or contacting the supervisor while connected to a client who is presenting harmful thoughts. They also described practicing the “basics” of remote connections (e.g., walking a pretend client through a remote set-up), role playing verbal, non-verbal and empathy competencies through a remote connection, and rehearsing potential technology challenges, like when a connection or call drops in the middle of a conversation. Context-specific role plays to practice using competencies “in the moment,” such as having a pretend-client present problems related to COVID-19, were also mentioned.

Using role plays to practice worst-case scenarios or “your worst possible nightmare and then get through it” was also recommended, often stemming from the respondent’s personal experiences over a remote or in-person connection or their own “what-if”-based concerns. For example, a client attempting suicide or masturbating in front of the practitioner over a remote connection, or a client that is experiencing paranoia or making threats while “having a knife.” Alternatively, a couple of participants pointed out that role plays will not always be a practical learning tool. Complex and unexpected scenarios, such as simulating a power outage or capturing psychotherapeutic dynamics (e.g., transference and countertransference), were suggested to be best learned through methods such as protocols, team discussions, or long-term, real-world application.

Finally, respondents pointed out possible risks when performing in role plays, such as bringing feelings of discomfort, awkwardness, and increased nerves for a practitioner-in-training. Additionally, they suggested that role plays can potentially cause emotional harm depending on the practitioner’s personal experiences (e.g., a family member with COVID-19, suicidal behaviors). Suggestions to mitigate these concerns included establishing a safe and controlled role play experience, such as not over-dramatizing the pretend client’s experience or situation, and having trainers and supervisors guide the practitioners through the role play process while consistently checking in on their comfort.

DISCUSSION

Delivery of psychological support through remote connections (videoconferencing, telephone) is increasing globally, with a significant surge due to the COVID-19 pandemic. This research addressed the lack of evidence on feasibility and key practitioner competencies of remote delivery on a global scale, particularly by non-specialist practitioners working in low-and-middle-income settings or who have had minimal training in using remote connections to support clients. This study is important because it identifies experiences of having to rapidly adapt to delivering psychological support remotely, via synchronous connection, due to a humanitarian crisis among practitioners from three country settings: Nepal (37%), Perú (37%) and the United States (30%).

Respondents generally agreed that remote psychological support should continue to increase care access, but like other studies, they expressed needs for key competencies, training and supervision to be met [22, 23, 37, 38]. However, particularly when comparing specialists and non-specialists, it’s important to point out that very few evidence-based resources, including competencies and competency frameworks, vary and are deployable in low-income settings as compared to high-income settings for remote delivery of care [25].

For example, when discussing safety and privacy issues, Nepali and Perúvian specialists and non-specialists described the need for competencies and related role play practice specific to directly identifying risk of harm (e.g., identifying harm to self, such as suicidal behaviors and identifying harm from others, such as domestic harm from persons living in the same household), particularly as rates of mental health and gender-based violence increased globally during COVID-19 [39, 40]. Specialists in the USA also recommended competency assessment and practice in the assessment of risks, but typically suggested that the strong referral networks and infrastructures (specialists, hospitals) they rely on in urban areas be included in training plans. Yet, Perú, Nepal, and USA are dealing with a shortage of specialists to manage referrals and offer quality supervision among task-sharing programs with non-specialists, especially in rural areas [41–45].

Similarly, telehealth regulations for addressing privacy and confidentiality vary or are lacking for specialists and non-specialists around the globe [16, 46]. US-based laws (e.g., Health Insurance Portability and Accountability Act of 1996, HIPAA) do not apply for various telehealth models, and although permissions were made during COVID-19, HIPAA laws post-pandemic are limited to audio-only telehealth and legal requirements for remote technologies continue to vary across states [47, 48]. The Perú health sector has national governing texts for protection and privacy of personal data, including the Telehealth Framework Law that passed in 2019, but these may look different depending on the health profession [49]. Nepal does not currently have a unified data protection legislation, but laws exist to regulate privacy-related issues (e.g., Privacy Act) and an information technology bill is currently under review [50].

Considering the number of innovations for remote psychological support occurring in LMIC [11, 12, 51], as well as ethical concerns raised by USA-based participants in this study (e.g., specialist practitioner turning camera off or leaving session), development of competency tools, or the adaptation of existing materials that do not require specific licensure or organizational infrastructures, should be considered to promote a more equitable approach to training and supervision and to ensure safety in remote delivery of care. In March 2022, the WHO and UNICEF launched the Ensuring Quality in Psychological Support (EQUIP) platform (www.equipcompetency.org) [52], a freely available resource that aims to improve the competence of practitioners and the consistency and quality of psychological support training, supervision, and service delivery. One of the EQUIP competency assessment tools focuses on core competencies for remote delivery of care (ENACT-Remote) [24] and could be used immediately by trainers and supervisors for identifying and removing potentially harmful behaviors and identifying and building helpful behaviors among practitioners (see Supplement for the ENACT-Remote tool). Such implementation has been successful with similar tools in Jordan [53]. The EQUIP platform also offers sample role play scripts and role play videos from multiple country settings, of which trainers and supervisors could culturally adapt and implement to support role play based training and assessment. Organizations in Nepal, Perú, and the USA are encouraged to use example scenarios as described in this study. For instance, the study findings could inform development or adaptation of relevant role play scripts and competencies that address areas on assessment of risk remotely, such as how to ask a client about risk of harm, how to contact a supervisor during a telephone or video call, and how to stay connected or reconnect with a client when Internet or telephone connection breaks.

Although this study population was predominately made up of non-specialist practitioners (70%) some subthemes in this study had a somewhat uneven respondent contribution. For example, only 42% of non-specialists commented directly on how remote delivery can enhance care (Theme 2), compared to 75% of specialists. Also, both specialists and non-specialists described technology interfering with care, however most of the concerns came from non-specialists (78%; 7 from Nepal [100%], 4 from Perú [50%], and 4 from the USA [100%]). This could be in part to resources specialists have access to, such as Zoom subscriptions, laptops, and secure network connections provided by their organizations that comply with HIPAA or related regulations.

Limitations

This study does not include perspectives representing low-income economies, but only lower-middle, upper-middle, and high-income economies [54]. Given the heterogenous digital landscape globally, more research is needed on feasibility and usefulness of remote technologies in low-income settings. This study is limited to the perspectives of practitioners and not of their clients. A client’s or service user’s perception is critical to understanding the dynamic mechanisms for what constitutes competency and ultimately quality care, and they hold invaluable insight on experiences of receiving care remotely compared to in-person. Variation in interview times, interviewer styles, and the semi-structured format may have contributed to an uneven respondent contribution across themes identified in this study. Similarly, other social, political, or contextual factors, such as practitioners’ attitudes toward their employing organization, may have impacted responses but were not examined.

Also, future research could explore how race, gender or ethnicity as social constructs might influence attitudes and experiences with remote psychological support. In this study, a male practitioner described his male client masturbating on their video connection, while another male practitioner described his male client leaving his shirt off during a session. As evidence is building on the pronounced cyber-harassment among women compared to men [55], it will be important to investigate whether scenarios like the ones described in this study occur more often in a remote setting and, of which, have any relation to a practitioner’s gender identity, race, or sexual orientation.

Recommendations

The competencies and adaptations that were described by respondents in this study have some similarities to those identified in previous research, however agreement on consistent training approaches and competency benchmarks is lacking. The following are initial considerations based on our research findings:

1. Enlist diverse stakeholders from LMICs to build consensus on core competencies and benchmarks required to support safe and effective remote psychological support globally. Non-specialists within task-sharing models are currently the dominant workforce providing mental health care across LMICs. More investment is needed to reach agreement of core competencies for effective and safe care, and non-specialist practitioners must be included as key stakeholders in consensus building exercises (e.g., Delphi study) to inform how competencies are framed (e.g., behavioral versus functional), how they can be adapted, and for determining a minimum benchmark for practitioners to meet. Expansion of stakeholders must also reach beyond practitioners and academics and include service users’ feedback and advocacy for establishing, monitoring, and rating practitioner competency.

2. Immediately incorporate, share, and build upon the existing evidence-supported materials and techniques for remote psychological support. Freely available training and supervision resources for safe remote psychological support that are promoted by large non-governmental organizations (NGOs) should be utilized, promoted, and built upon. In addition to the EQUIP competency assessment tools and resources, E-learning modules are available on the platform that cover guidance on how to assess and support people experiencing suicidal behaviors or intimate partner violence remotely, and how to deliver care and supervision remotely (www.equipremote.org). The International Federation for Red Cross and Red Crescent (IFRC) offers guidance on delivering psychological first aid remotely [56, 57]. Additionally, organizations are encouraged to share materials and resources on open access platforms, such as the Mental Health Innovation Network (MHIN, https://www.mhinnovation.net/resources). Finally, participants discussed advantages to remote delivery, including having a supervisor join by telephone or video call, or to be on ‘stand-by’ via a remote platform such as Microsoft Teams. Organizations could implement these supervision methods immediately to increase accessibility and availability of supervision during remote care.

3. Prioritize research for the adaptation, training and delivery of remote psychological interventions in LMICs. Social and cultural factors impact key practitioner competencies and best practices for effective remote training and supervision. Further research is needed on how to culturally adapt remote psychological interventions and related competencies to ensure feasibility, applicability and effectiveness across different LMICs and HICs as well as organizational settings. For instance, during COVID-19, Socios en Salud in Perú successfully adapted and delivered the WHO’s Thinking Healthy Program using video or telephone calls [58], and developed and mobilized the digital tool “ChatBot-Juntos” to increase access and delivery of Psychological First Aid [51]. For competency assessments and training, future research could include adaptation and application of the role play scenarios and competencies described in this study and test their effects on training outcomes or client outcomes.

Conclusions

Results of this study provide insight into the feasibility and usefulness of delivering remote psychological support and identify attitudes on what key competencies and training methods are optimal for preparing practitioners to implement safe, quality care in Nepal, Perú and the United States of America. Respondents also identified challenges with remote support and training needs, which warrants development of standardized training methods and increased resource allocation for technologies. Our results may support development or adaptation and refinement of existing materials used in competency-driven approaches to training. More research is needed on client perspectives and experiences of remote psychological support and required competencies for safe and effective care.

Data availability statement:

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.