Telepsychology revolution in the mental health care delivery: a global overview of emerging clinical and legal issues

Abstract

 

Since the outbreak of the COVID-19 pandemic, remote healthcare delivery by technological devices has become a growing practice. It represented an unprecedented change in personal and professional activities, allowing health specialists to continue working online by assisting their patients from home. Psychological practice greatly benefited from this innovation, guaranteeing diagnostic and therapeutic effectiveness through cyber counseling. However, in many countries there have been no enactments of specific laws nor adaptations of the professional deontological code aimed at regulating this new psychological practice dimension, generally defined as telepsychology. This article aims to briefly review the scientific literature on this tool’s effectiveness and especially analyze the legal and operational framework in which telepsychology has been to date practiced in Italy and other national realities, thus providing a global overview that may be useful to understand how to improve this valuable but still immature practice.

Key points

• The coronavirus pandemic exposed to short- and long-term increase in psychological and psychiatric imbalances.

• Cyber counseling has been proven to be effective to treat a wide range of psychological disorders.

• Many of the current national and international legislations concerning the telepsychology practice are still immature.

• Ad hoc legal frameworks are required for each national context to guarantee a safe and effective cyber counseling delivery.

Introduction

In 2020, the World Health Organization (WHO) reported the impact of the COVID-19 pandemic, affirming that 94% of countries experienced disruption to essential health services. Indeed, the coronavirus pandemic exposed the weaknesses and dysfunctionality of every healthcare system, including the Italian one [1]. Mortality could also have been higher than the one reported in the official epidemiological surveys because of false-negative cases and people dying from COVID-19 who were never tested [2].

As this public health emergency was going, we have witnessed a short-term and long-term increase in psychological and psychiatric matters and pathologies, such as isolation, anxiety, depression, substance abuse, post-traumatic stress disorder, and burnout [3, 4].

Overall, the spread of infection and the excess of mortality led to a functional overload for primary care services and general hospitals, thus producing physical and psychological impairments among most fragile individuals [5–8], but also health practitioners and those dealing with death daily [9, 10].

Consequently, because of the SARS-CoV-2 pandemic, the use of cyber counseling has significantly increased to overcome the physical distance between counselor and patient, especially in the psychological field [11, 12].

Telepsychology is identified in all professional actions offered by new communication technologies, aimed at informing, sensitizing, supporting, preventing, taking care of, and rehabilitating patients with psychological distress [13].

However, this technological development in the psychological assistance provision has not always been accompanied by a specific juridical regulation or national/international guidelines issued by ad hoc scientific societies and consistent with good clinical practices. In Italy, e.g. the Online Psychology Italian Service (SIPO), as other online psychological care services, are only based on synthetic and generic guidelines established by the National Council of the Order of Psychologists (CNOP) [14]. It is a public and non-economic body designed to protect the citizens’ health and justice needs through the excellent maintenance of the psychologists’ professional register, ensuring the continuous training of psychologists and their compliance with professional standards and law, assuring ethical and deontological practice. Nevertheless, there have been no adaptations of the professional deontological code nor enactments of specific laws aimed at regulating this new psychodiagnosis and psychotherapy practice dimension.

This lack or inadequacy of regulation in the cyber counseling practice causes a higher exposure of both therapists and patients to various risks [15], such as hacking [16], privacy violation [17], identity verification problems [18], difficulties in obtaining informed consent [19], and non-adherence to hours of work (https://www.sipsiol.it/articoli/il-problema-dei-confini-terapeutici-nei-servizi-di-telepsicologia), resulting in harassment of the counselor.

Effectiveness of telepsychology services

Psychological cyber counseling services, delivered via telephone or video conferencing, have been proven effective such as in-person therapy to treat a wide range of disorders [20], concerning adult patients as well as children and adolescents [21].

However, many psychologists still have doubts regarding the use of telepsychology and its efficacy [22]: ~60% of psychologists state that they would not recommend telepsychology to their patients [23]. In particular, the counselors complain of a lack of capability in offering empathy and support during online sessions due to inadequate opportunities for cyber counseling training [24] or, at best, they did not experience significant differences in self-efficacy [25]. On the other hand, the patients perceived their therapists as significantly more empathic and supportive during the online sessions [25]. This statement is relevant since empathy is a strong predictor of therapy outcome [26], determined by an alliance between counselors and clients [27].

A systematic review [28] focused on synchronous and asynchronous telepsychology stated that cyber counseling is generally efficacious. Another systematic literature review [29] concerning synchronous telepsychology for the treatment of depression concluded that it was as efficacious as in-person sessions in diminishing depression symptoms. Moreover, four individual randomized control trials assessed telephone-delivered therapy for a range of disorders (i.e. generalized anxiety disorder, depression, and obsessive-compulsive disorder) comparing it with in-person therapy [30, 31], treatment as usual (TAU) comparisons [32–35], and online therapy [36, 37]. All of these studies’ results supported the telephone-delivered therapy, which has proved to be as effective as standard in-person treatment and better than TAU in gaining a range of outcomes [20].

Online sessions seem to be functional in psychological practice: indeed, during video conferencing psychotherapy, the counselor, thanks to the web camera, can observe in the meantime their expressions and those of the patient, honing their ability to be empathic and supportive [38–40].

Furthermore, in the literature, there is evidence that cyber counseling is more convenient for certain patients than others [41]. Concerning criminal justice and substance abuse clients, it turns out that online mental health services are related to clinical outcomes comparable to those from face-to-face sessions [42–44]. Moreover, telepsychology counseling services for juvenile offenders seem to improve their social skills and education [45]. However, detainees with hallucinations or paranoid ideations may experience troubles establishing a therapeutic alliance with the psychologist through a TV screen [46, 47].

Cyber counseling seems to be also a plausible solution to treat people who fear social stigma, such as veterans: actually, it allows them to have access to therapy from a safe space (such as their own home or a local office). In this way, telepsychology increases privacy associated with mental health services provision, thus preventing the negative stigma and embarrassment veterans might perceive during in-person sessions or while waiting in a lobby for an appointment. Online therapy appears to be efficacious in treating common mental health conditions experienced by veterans [48, 49], such as post-traumatic stress disorders (PTSDs) or other trauma and stressor-related imbalances [50], anxiety [51, 52], depression [53], intermittent explosive disorder [54], and substance use disorders [55]. Veterans reported statistically significant high satisfaction ratings regarding online treatment [56], suggesting that cyber counseling is comparable to face-to-face therapy for veterans.

In general, videoconferencing-based telepsychology generally has moderate-to-strong efficacy in treating trauma and depression, while telephone-based telepsychology seems to guarantee moderate effectiveness. The study makes it possible to conclude that the efficacy of cyber counseling practice is practically equivalent to face-to-face one [57].

In detail, short-term internet and video-based telepsychology have proven effective in reducing the severity of depression and anxiety symptoms (including PTSD) [48, 58–62]. Moreover, a significant reduction in fear reactions, suicidal ideation, and insomnia could be appreciated [61, 62]. However, given the recent spread of this practice, the long-term effectiveness of telepsychology, in comparison to face-to-face psychodiagnosis and psychotherapy, could not yet be confirmed [63–66].

National and international ethical-legislative frameworks of telepsychology

In Italy

Cyber counseling should be considered a fundamental stronghold for citizens’ right to health protection: indeed, it allows everyone to access psychotherapy services, in total respect of Articles 32 of the Italian Constitution [67] and 12 of the International Covenant on Economic, Social and Cultural Rights [68]. The former establishes that: “The Republic safeguards health as a fundamental right of the individual and as a collective interest and guarantees free medical care to the poor. Nobody may be forcefully submitted to medical treatment expect as regulated by law. That law may in no case violate the limits imposed by the respect for the human being”. The latter states that: “Health is a fundamental human right indispensable for the exercise of other human rights. Every human being is entitled to the enjoyment of the highest attainable standard of health conducive to living a life in dignity. The realization of the right to health may be pursued through numerous, complementary approaches, such as the formulation of health policies, or the implementation of health programmes developed by the World Health Organization (WHO), or the adoption of specific legal instruments. Moreover, the right to health includes certain components which are legally enforceable”.

In Italy, the telepsychology practice is also based on the principles of the Italian Psychologists Code of Ethics [69] and the Code on the Protection of Personal Data (Legislative Decree n. 196/2003) [70].

Moreover, in 2017, the CNOP’s Typical Acts Commission promulgated specific guidelines to define how to provide telepsychology services [71]. Three different articles set out these guidelines’ legal aspects: Article 8—“psychologists must know and respect all laws and regulations in providing online services to patients, especially when jurisdictional and/or international boundaries are crossed”; Article 9—“for the storage of data and information, the current legislation has to be followed”; Article 10—“the psychologists have to clarify to the patients that their qualification allows them to provide online services”.

Despite the abovementioned ethical and regulatory references, with the onset of the SARS-CoV-2 pandemic, Italy was unprepared to offer different telemedicine services, including safe and methodologically structured psychology cyber counseling. Indeed, these services have not yet been included among the essential levels of care guaranteed to all Italian citizens within the public health system, and the use of these services relies on out-of-pocket payment. For this reason, too, they were often rejected by patients and doctors during the pandemic, as nowadays [72].

In Europe

The first step in terms of European cybersecurity legislation is the Network Information Security directive, promulgated in 2016 [73]. This directive establishes that clinical data must be used only for therapeutic and scientific purposes, with interdiction of their general diffusion. Thus, it ensured sensitive data protection, even those concerning cyber counseling practices.

During the same year, in Europe, it has also been promulgated the General Data Protection Regulation (GDPR) [75], to which all health professionals had to adhere from 2018. GDPR states that the healthcare providers must follow the principles of integrity, confidentiality, and accuracy of clinical data, which have to be strictly related to the service to carry out.

Moreover, Article 25 of GDPR asserted the principle of “data protection by design and by default”, which requires establishing ahead the organization, tools, and adequate measures to carry out the cyber counseling practice. In this way, this regulation promotes the accountability of healthcare professionals in proper decisions about processed clinical data protection.

During the SARS-CoV-2 pandemic, different psychology organizations worldwide, including the European Federation of Psychologists’ Associations (https://www.efpa.eu/), quickly developed resources to allow patients to become accustomed to telepsychology services [22].

Overseas

In 2013, the American Joint Task Force for the Development of Telepsychology Guidelines for Psychologists developed the Guidelines for the Practice of Telepsychology [76], adopted by the American Psychological Association (APA) (https://www.apa.org/education-career/training). These guidelines, inspired by the Ethical Principles of Psychologists and Code of Conduct [77] and the Record Keeping Guidelines of the APA of 2007 [78], are divided into eight parts, addressing critical components and special considerations for telepsychology services provision. One potential weakness of the APA guidelines is that they are aspirational and not prescriptive. On the other hand, the aspirational nature may allow for flexibility as telepsychology practice evolves [79].

Moreover, in 2017, the American Telemedicine Association drafted the Telemental Health Guidelines [80], which informs, together with the Child Telepsychiatry Practice parameters, “reasonable steps” for cyber counseling practice [81].

Under the COVID-19 emergency declaration in 2020, many policy changes improved the telepsychology services delivery in the USA. Such changes allowed certain applications use (e.g. Skype and FaceTime) for telepsychology by loosening security and privacy requirements of the Health Insurance Portability and Accountability Act [82] and reimbursement of online visits at the same rate as in-person visits [83]. Furthermore, psychology boards in several states, including Arizona, California, and Texas, suspended typical inter-jurisdictional requirements to allow psychologists not licensed from their state to provide treatment in their jurisdiction. Training programmes have also been implemented by organizations such as the TeleBehavioral Health Institute (2020) [84] and the APA, which developed tools and resources to aid psychologists in telepsychology adoption [22].

In 2020, the Ontario Psychological Association and the Canadian Academy of Psychologists (CAPDA) (https://www.capda.ca/) drafted the Guidelines for Best Practices in Psychological Remote/Teleassessments (https://www.psych.on.ca/OPA/media/Public/OPA%20Guidelines%20and%20Reviews/GUIDELINES-FOR-BEST-PRACTICES-IN-THE-PROVISION-OF-TELEPSYCHOLOGY.pdf?ext=.pdf). They have been written to inform cyber counseling practitioners about virtual psychological evaluation in various settings (such as pediatric, geriatric, and legal contexts).

Meanwhile, the Australian Psychological Society (APS) (https://psychology.org.au/) promulgated in 2011 the Ethical Guidelines for providing telepsychology services and products [85]. These Guidelines, based on the APS’s established Code of Ethics (2007) (https://psychology.org.au/getmedia/d873e0db-7490-46de-bb57-c31bb1553025/18aps-code-of-ethics.pdf), were written to cover a wide range of circumstances, including the type of technology used (e.g. email, videoconferencing, etc.) and services to administer (e.g. counseling, assessment, research, consultation, synchronous and asynchronous services, etc.).

This document is organized and specific about the cyber counseling practice. It strongly emphasizes the maintaining of professional boundaries within interactions with clients. On the other hand, these guidelines lack consideration of multicultural issues [79].

In 2012, the New Zealand Psychologists Board (NZPB) (https://psychologistsboard.org.nz/) developed the Practice of Telepsychology (https://psychologistsboard.org.nz/wp-content/uploads/2023/08/BPG_The_Practice_of_Telepsychology_FINAL_131212.pdf), a guideline to supplement the NZPB’s Code of Ethics of 2002 [86] and the Core Competencies of 2006 [87]. This document has been designed to manage the telepsychology practice risks and benefits by detailing how to administer the psychometric assessments via electronic means [79].

On the other hand, in Saudi Arabia, as in Arabic and Middle Eastern countries, despite many telemedicine programs launched since the 1990s, healthcare providers, including psychologists, faced a lack of precise guidelines. Indeed, during the COVID-19 pandemic, they had to provide online health services without specific training [88]. Thus, in 2020, a group of Arabic researchers tried to establish a telepsychology guideline to properly deal with the pandemic, relying on physicians’ knowledge, attitude, barriers, and challenges in adopting telemedicine [89].

Conclusion

The existing literature on cyber counseling services suggests that it is a clinically appropriate modality for a wide range of patients, as the traditional face-to-face psychodiagnosis and psychotherapy: indeed, it is associated with assessment and treatment outcomes that are comparable with in-person modality [90–92].

Moreover, telepsychology proved to be a successful tool to enforce the therapeutic alliance and renovate the concept of psychotherapy itself [20, 91]. In fact, during an online session, patients can experience a more neutral psychodiagnostic and therapeutic space, in which they could develop an increased predisposition to self-awareness and collaboration [93]. Furthermore, online psychotherapy may help to reduce relapse and recidivism among substance abusers and offenders [91].

During the COVID-19 pandemic, telepsychology services also allowed psychologists to maintain the treatment of their patients while following social distancing recommendations [94]. Even with the current end of the state of emergency, cyber counseling is still a valuable way to shorten the distance between counselor and patient, especially to reach underserved populations.

Overall, the peculiar conditions health professionals operate within during the COVID-19 pandemic represented a growth opportunity from which a virtuous cycle should trigger [95]. However, analysis of the legislative state of the art concerning the telepsychology practice revealed that many of the current national and international regulations are still immature, focusing almost exclusively on sensitive data protection and the general principle of preserving individual privacy. On the other hand, there is a lack of specific references about modalities and clinical criteria to observe for best telepsychology practices.

Telepsychology practice is a valuable diagnostic and therapeutic means whose implementation deserves to be strengthened and observed in its long-term effects. It should be better and more broadly promoted by fully enacting a transition to a more modern model of care, with cyber counseling integration in the arsenal of healthcare services [72]. In this way, it could be possible to allow the emergence of clinical evidence to inspire specific guidelines for quality services provision. At the same time, it is advisable to promulgate ad hoc laws suitable for each national context, thus guaranteeing a safe delivery of these health services and ensuring patients’ interests, as those of operators in terms of professional liability.

Authors’ contributions

Sara Sablone, Mara Bellino, Valeria Lagona, Tamara Patrizia Franco, Matthew Groicher, Roberta Risola, Maria Grazia Violante, and Ignazio Grattagliano all contributed to the conceptualization, and helped to draft, review, and edit the manuscript. All authors contributed to the final text and approved it.

Disclosure statement

None declared.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.