Toward establishing telepsychology guideline. Turning the challenges of COVID-19 into opportunity

Abstract

Introduction

The COVID-19 pandemic has obstructed the classical practices of psychological assessment and intervention via face-to-face interaction. Patients and all health professionals have been forced to isolate and become innovative to continue receiving and providing exceptional healthcare services while minimizing the risk of exposure to, or transmission of, COVID-19.

Aim

This document is proposed initially as a guide to the extraordinary implementation of telepsychology in the context of the COVID-19 pandemic and to extend its implementation to use fundamentally as the main guideline for telepsychology services in Saudi Arabia and other Arabic communities.

Method

A professional task force representing different areas of professional psychology reviewed, summarized, and documented methods, policies, procedures, and other resources to ensure that the recommendations and evidence reviews were valid and consistent with best practices.

Results

The practice of telepsychology involves the consideration of legal and professional requirements. This paper provides a guideline and recommendations for procedural changes that are necessary to address psychological services as we transition to telepsychology, as well as elucidates and demonstrates practical telepsychology frameworks, procedures, and proper recommendations for the provision of services during COVID-19. It adds a focused examination and discussion related to factors that could influence the telemedicine guideline, such as culture, religion, legal matters, and how clinical psychologists could expand their telepsychology practice during COVID-19 and after, seeking to produce broadly applicable guidelines for the practice of telepsychology. Professional steps in practical telemedicine were illustrated in tables and examples.

Conclusion

Telepsychology is not a luxury or a temporary response. Rather, it should be considered part of a proactive governance model to secure a continuity of mental health care services. Arabic communities could benefit from this guideline to telepsychology as an essential protocol for providing mental health services during and after the COVID-19 pandemic.

Introduction

In response to the coronavirus disease (COVID-19) pandemic, several health settings in Saudi Arabia have enhanced their telemedicine services, offering desirable and appropriate virtual face-to-face interventions. These health services became convenient at a time when all were fighting COVID-19, and social distancing was the model to break the virus's spread.

The psychological impact of the COVID-19 epidemic on the general public, patients, health practitioners, children, and older adults has been reported in several studies. With such a crisis projected to last months, coping with the psychological impact on the self or family while managing social distancing, quarantining, or home-based isolation will be psychologically harmful and stress-provoking [1]. Psychosocial services, therefore, must be accessible during the COVID-19 pandemic, i.e., delivered remotely [2].

Social distancing is the cornerstone of COVID-19 prevention responses. During COVID-19, we engage in “social distancing” and reduce, for example, most visits to older adults and other high-risk groups. At the same time, we must mitigate older adults’ social isolation and loneliness. To use more professional language, they could experience “physical distancing” rather than “social distancing” [3]. In fact, the effect of social distancing due to COVID-19 is not limited to old people or high-risk groups; rather, everyone, including children and adolescents, could be affected by this new psychosocial experience. Understanding the connection among social distancing, mental health, and social health may be especially important for adolescents, who are possibly at high-risk of psychological effects from COVID-19 social distancing [4], [5]. Providing telepsychology intervention and support may reduce the burden of comorbid mental health conditions and ensure the well-being of all those groups of people.

As stated by the British Psychological Society [6], the best model of delivering psychological services must include a consideration of the risks of COVID-19. This means that, at times, psychological services that previously would have been provided face-to-face will need to be transferred to telepsychology. For example, in China, integrated telepsychology service systems, including online cognitive behavioural therapy for depression and anxiety, have been developed as interventions for psychological crises during the COVID-19 pandemic [7].

However, several countries suffer from a lack of official regulations and frameworks to authorize and integrate telepsychology services in their healthcare systems, mainly in emergency and crisis situations [8]. To be effective as parts of an emergency response, telemedicine in general, and telepsychology in particular, must be routinely used in everyday health services.

In the meantime, psychologists are facing new practical challenges that require the adaptation of their clinical practices and the use of telepsychology services. They have found themselves altering the way they deliver necessary therapies, and they wish to ensure that telepsychology is safe, that they are ready for clinical practice, and that they have the competencies needed in their communities.

Telepsychology has the potential to bridge the gap between health settings and the home by using all telecommunication technologies to support clinical and nonclinical services. Bridging the gap between telepsychology and practice has been documented as an area in need of improvement. Access to telepsychology services should be accompanied by guidelines on ethical issues and transparent telepsychological information about privacy and security.

Psychologists in Saudi Arabia always provide clinical services in accordance with codes of ethics and professionalism in light of cultural competency [9]. However, the existing Saudi ethical code of conduct and related guidelines and policies does not explicitly address telepsychology in details (Table 1 ). Furthermore, telepsychology during the COVID-19 pandemic might raise unique ethical challenges and new clinical and professional issues that had not been introduced to psychologists in the Saudi mental health field. Literature has revealed that professional guidelines commonly lag behind developments in clinical practices [10], [11].

Table 1.

A General notes for telepsychology services.

Apply all legal requirements for psychologists: all legal requirements or protocols that are applied to a psychologist in face-to-face clinics apply equally to the practice of telepsychology

Apply all legal requirements for facilities: all legal requirements and protocols applied to healthcare facilities apply equally to entities providing telepsychology services

Telepsychology must include visual consultation: according to the Saudi regulations, telepsychology cannot be solely audio. It must involve a video consultation. However, it is not obligatory to be synchronous

Telepsychology could be chargeable: telepsychology services can be chargeable, and private healthcare insurers must provide coverage for COVID-19-related psychological symptoms within their insurance provision

Telepsychology and data security: the practice of telepsychology must be compliant with the health information exchange policy in Saudi Arabia, including all appropriate data security and patient privacy requirements

Trained in telepsychology: according to the current regulations, all psychologists must be trained in telepsychology before practicing telemedicine. Such training must be accredited by the Saudi Commission for Health Specialties

Sign a consent form: all patients seeking telepsychology must sign a consent form in relation to the consultation. It is recommended that this be done prior to undertaking a consultation

Identify the patient for telepsychology: psychologists should have sufficient evidence to identify the patient who is seeking and eligible for telepsychology and should have access to all the relevant patient health and medical information where available

Documentation telepsychology: all telepsychology procedures and activities should be formally recorded within the patient's medical records and should include information relating to the telepsychology service provider, the location of the consultation, the activities undertaken, the date and time of the consultation, and details of all the psychological procedures and services provided together with all observations made during the consultation

Other general notes for telepsychology services (based on literature in telemedicine)
Telepsychology for someone outside KSA: policies and location of care, for example, arise as major concerns for psychologists involved in providing telepsychology services. Licensed Saudi psychologists are officially legalised to provide telepsychology services anywhere within KSA. However, a clinical psychologist who aims to provide care for a patient located outside of the country was recommended to consider the circumstances of each incident of service
Appropriate for telepsychology: not all psychological consultations are appropriate for telepsychology. Psychologists must use their best clinical judgment to determine whether or not the telepsychology services are safe, effective, and manageable for every patient
Provide plan B: there should be appropriate emergency plans or alternative tracks in the event of equipment failure [27]. Training for preparing such alternative tracks is essential, mainly for critical psychological cases
Telepsychology is not for serious cases: there are potential limitations of treatment with high-risk patients (such as suicide risk or violence). For example, it is not commonly recommended to provide telepsychology services for serious cases such as suicidal or seriously demented people, unless no alternative face-to-face services are available. Consequently, the management of suicide risk and patient safety during telepsychology requires additional considerations and training (see table)

Adaptation based on telemedicine regulation: by SHC, 2018.

Telepsychology could mean that we have a new subspecialty that requires psychologists to develop technical competencies in order to adapt traditional psychological services and to serve remote patients through telecommunication technologies [12]. Many psychologists in Saudi Arabia and other Arab countries are cautious about providing telepsychology services in light of the limitations of having the proper professional protocols, policies, and guidelines necessary to provide legal and professional health services during a pandemic like that of COVID-19 and during the daily routine of providing health services.

Aim

The COVID-19 pandemic highlights the need to urgently increase readiness in telepsychology services for mental health. The need for telepsychology services increased rapidly, for both community and frontline workers. No official forms document telepsychology, nor was e-mental health available in Saudi Arabia or other Arabic countries.

This guideline will be developed to assist clinical psychologists in providing assessment, psychological intervention, and/or consultation using telecommunication technologies, and to enhance clinical practice, quality outcomes, and patient-centred care during the COVID-19 pandemic and after, in Saudi Arabia and other Arabic communities.

Method

A professional task force was created to enlist others in the process of transforming and adapting the existing general guidelines and protocols in telepsychology for psychologists in Saudi Arabia. The task force members represented different areas of interest and expertise that are characteristic of the profession of psychology.

The current document maintains the major parts of the methodological approach of the general guideline [9], and the following methodological steps were applied.

Step 1

The first step of this document involved the review of existing ethics guidelines to develop a new set of draft ethics guidelines that specifically address the procedural changes necessary to providing telepsychology services during COVID-19. Several documents containing telepsychology guidelines were comprehensively reviewed. The international guidelines and protocols during the COVID crisis were also reviewed and categorized using a “top-down” approach. The initial draft of this document was outlined, adopted, modified, or subject to inculturation.

Step 2

An initial draft was sent for review to experts in professional psychology: licensed consultant psychologists, both male and female, holding a PhD degree, with many years of experience. Issues of ethics, professionalism, and protocols were discussed, and opinions were solicited about the proposed telepsychology guidelines developed in the first part of this study.

The main comments were about using the term “telepsychology” alone (and not “telemedicine” because it is more general) and applying it throughout the document. Another point here was that all of the terminologies and principles of the psychology guidelines in Saudi Arabia should be preserved and that this guideline should be considered an additional protocol for solitary telepsychology only during a crisis. The document was revised by the authors accordingly.

Step 3

The draft underwent an internal review by the experts who had specific expertise in telemedicine in general and telepsychology in particular. The final copy of this proposed guideline was revised by the authors accordingly.

Results

“Telemedicine” and “telehealth” are the comprehensive umbrella terminologies that cover all health services provided remotely [13]. “Telemedicine” is the official term that has been used in Saudi Arabia. The most relevant term in this document is “telepsychology”, which is defined as “the provision of psychological services using telecommunication technologies” [14] and which provides access to psychological assessments, diagnosis, interventions, psychological consultations, and supervision by telecommunication technologies or across distances [15]. Telecommunications is the preparation, transmission, communication, or related processing of information by electrical, electromagnetic, electromechanical, electro-optical, or electronic means [16]. Several technologies may be used for different purposes in telepsychology services, including, but not limited to, mobiles, mobile apps, videoconferencing, telephone, email, text, blogs, websites, and social media. So, the use of telepsychology extends from the utilization of email or telephone to real-time video around the globe [17].

Telemedicine is a relatively new concept in Saudi Arabia. In 2011, the Ministry of Health established the first national project for telemedicine [18]. The Saudi Health Council (SHC) has the official role of legislating all the related health regulations to ensure coordination and integration among health stakeholders and to improve and enhance health care. One of the main departments of the SHC is the National Health Information Centre (NHIC), which has been designed to be linked organizationally to health services and to be connected to an electronic network of health information with the Ministry of Health and other relevant government agencies. Recently, NHIC published the general telemedicine regulations and set out the specifications and requirements for telemedicine practices within Saudi Arabia. The regulations state that telemedicine is available for screening, triage, consultation, diagnostics, treatment support, and the monitoring of medical conditions (Table 2 ). All of these regulations were designed to improve the quality and actability of health care services among patients and healthcare providers [19].

Table 2.

Protocol and framework for telepsychology during COVID-19.

Pre-visit
Obtain verbal/written/email/informed consent by any appropriate telecommunication applications from patients or their caregivers
To apply verbal consent, it is preferable to have two health care professionals together at the time when the patient or caregiver provides consent
Offer passable anonymity and privacy to help eliminate barriers to engaging in telepsychology
Pre-visit, confirm COVID-19 in the patient (current or in the past) and whether the patient has been quarantined
Pre-visit, confirm COVID-19 in the patient, his family, or close relatives
Send patient questionnaires, handouts, or other forms to patients via email, or any appropriate telecommunication applications (you could provide the patient with a convenient resource such as WhatsApp, but this needs official approval from the provider)
Identify local collaborators (e.g., patient support persons, suicide risk management committee, domestic violence line/committee) that can be called upon to support patient safety during the crisis (COVID-19), and review the suicide risk assessment guide
Discuss technical troubleshooting with the patient. Agree upon a method for re-establishing contact during service disruption (e.g., via telephone)
Assess the quality of the environment (e.g., sound, lighting, privacy, etc.) and equipment (e.g., computers, microphones, cameras, etc.)
Use tele-tools with good quality and recommend that your patient do the same
Ensure that your tech support provider is qualified and trustworthy
Obtain the patient's local emergency contact information
Consider what will be done if the patient doesn’t “come” to the telepsychology session
Will you make contact in case it is a technical problem, or something else?
Make a decision about when the patient misses the telepsychology session for any reason, and open a flexible channel for the patient to be rescheduled
Review available local and international policies, guidelines, and regulatory rules to support the use of telepsychology in order to ensure that the psychologist is engaged in appropriate and legal practices
Weekly supervision meetings and multidisciplinary team meetings must still take place but do not need to be in person (it is very important to carry on with regular multidisciplinary meetings)
Establish a pathway for when and how to refer patients with severe psychological conditions

Setting
Psychologist side	Patient side
Professional and well-placed lights in the office. Patients prefer a quiet and private room	Have well-placed lights
Be professional and aware of the effect that clothing may have on the patient's experience	Ensure that there will be no background noises
Make sure the background has minimal distractions (no background noises) and that any decor is professional	If needed, have a caregiver or family present
Telephone ring tones and subsequent conversations may disturb the patient. Be sure that all electronic devices are muted	Ring tones may disrupt the session. Be sure that all electronic devices are mutes
The position of the camera is important. The ideal position of the camera is directly in front of the provider's face, just above eye level	For the patient, the position of the camera is important. The ideal position of the camera is directly in front of the patient's/caregiver's face, just above eye level. Ask the patient to position the camera appropriately
Guideline for answering calls. It is recommended that the psychologist develop a complete template for patients attending telepsychology sessions, including: patients’ information, assessments, and intervention	Patients/caregivers can be trained via telepsychology to deliver services
	The patient should prepare an explanation of the problem that he or she is having, a list of questions to ask, and any concerns that the patient would like the telepsychology session to address

Body of the telepsychology session
Psychologist side	Patient side
Check the mic and the camera on each side	The patient and parents/caregivers confirm and introduce everybody on their side
Confirm the patient details on the ID label OR the file number. Confirm that you are talking to the right person before you start, and especially before giving out any information	The patient answers the questionnaires (if any)
Introduce yourself and your team members, if any: give the patient the opportunity to establish the true identity of the psychologist and his/her certifications	The patient answers (Qs about COVID-19): have you been diagnosed with COVID-19? Or has anyone in your family been diagnosed?; are you waiting for test results?; do you work on the frontlines? Do any of your families work on the frontlines? and; in the event of COVID-19, obtain isolation information (isolation information for patients, including the discontinuation of home isolation and the effectiveness of quarantining for COVID-19)
If this is the first session, give a brief overview of the sessions and your telepsychology services
Start by welcoming each side one by one
Introduce everybody inside your clinic, including assistants, interns, nurses, and others (must list all in your documentation)
Confirm the patient location (city, place) and your location as well (hospital, home, other) and make sure to document that
Obtained verbal consent (if not obtained before)
Protecting patients’ privacy: confirm everybody present on the patient's side, to promote privacy and protect confidentiality
Focus on the patient's psychological history
Focus on current psychological statistics during COVID-19 assessments (see Qs about COVID-19)
Apply an official and proper telepsychology intervention guideline as appropriate; could be PFA to apply an appropriate psychological intervention such as iCBT, for example
Apply an official and proper telepsychology intervention guideline as appropriate; could be PFA to apply an appropriate psychological intervention such as iCBT, for example
If indicated by risk level (such as suicide risk or violence): apply a multi-step safety plan and provide the patient with an e-copy of the plan. Determine how transportation, if necessary, will be handled and whether to utilize a local collaborator and; try to remain connected to the patient via telepsychology services or telephone while coordinating the involvement of third parties. Involve secondary telepsychology staff and notify third parties as warranted

Timing of the telepsychology session (suggestion)
The psychologist should inform all that
The main session will be divided into four parts, plus a five-minute conclusion
Five-minute introduction
Five minutes to view and discuss any video recording (home movies) about the patient, and to read and explain any previous results
Ten minutes to apply a proper telepsychology intervention (i.e., BPS Guidance for COVID-19)
Five minutes to recommend initial home/family psychological management
Five-minute conclusion: summarise outcomes, identify key points, make referrals, and ask for new assessments needed. Thank everyone and ask for evaluation forms to be filled in and returned
If full psychological intervention is needed, 30 minutes could be added for applying an appropriate psychological intervention such as iCBT

The guideline, endorsed by the telepsychology task force, emphasised that redeployment of the psychologists during COVID-19, as it was applied in other countries [6], should not be premature, and must be managed in a way that minimises disruption to psychological interventions and treatments that are already underway, such as telepsychology services, and follow the following professional values.

Keeping psychological services open through COVID-19

To take steps to reduce the spread of COVID-19, psychologists could refuse to see patients face-to-face. While COVID-19 has transformed the way in which many psychological services are delivered, the services must remain open – at least telepsychology services. Psychological services are vital services that can save lives [6].

Past influenza pandemics offer some experience of how the overall trajectory of a virus such as COVID-19 would affect mental health. Common consequences of COVID-19 could include anxiety, stress, panic, depression, anger, confusion, and uncertainty, with estimates of about 30% of the community experiencing high levels of worry and anxiety during similar pandemics [20]. This means that healthcare services are more likely to face higher rates of accessing psychological interventions and supports.

Provide telepsychological screening and support for COVID-19 patients

In past influenza pandemics, patients who experienced life-threatening illnesses were at risk of several psychological disorders such as posttraumatic stress disorder or anxiety, months to years following their influenza pandemics [21].

Appropriate telepsychology services must be put in place to assess patients psychometrically, to screen for common mental health problems, and to provide early psychological supports. This type of telepsychological screening must be documented (Table 3 ) and connected to the national data collection to allow for the official and proper psychological responses over time [22]. Such responses could include providing psychological support such as self-coping strategies in a timely manner in order to reinforce resilience to mitigate anxiety, stress, and other psychological disorders.

Table 3.

Items that must be documented at telepsychology sessions.

Documentation
Telepsychology specialists must document everything that had been discussed with the patients and the patients’ parents/caregivers, as well as the treatment plan. It is recommended to document these notes following the subjective-objective-assessment-plan (SOAP) format. Be sure to document all the session details
The psychologist should document the time, date, and total time spent rendering this service
Note the mode of telepsychology (audio, video, or other), and the remote site location of both the psychologist and patient
Document current psychological statistics during COVID-19, assessments (see Qs about COVID-19)
History of present illness including information related to COVID-19
Chief complaint or reason for seeking telepsychology
Referral source to telepsychology
Past medical, family, and social histories
Current psychological intervention, including medications and ongoing intervention
Psychological status assessments
Case conceptualization (case formulation)
Psychological intervention plan
Follow-up at the telepsychology clinic
Make any referrals if needed
Document in detail the risk cases, if any
Discharge the patient from telepsychology

However, psychologists are encouraged to be knowledgeable and account for the suitability for diverse populations, as well as limitations on telepsychology screening and its administration or interpretation [14].

Competence and good practice

Competence is the most essential of all ethical standards. Psychologists practice within their scope of practice and professional experience. Competency in telepsychology is critical, and providing services in a crisis such as COVID-19 is another critical situation which need further level of training and competency. Competent psychologists, for example, in providing face-to-face interventions, may find that their effectiveness does not transfer to telepsychology services without further training [23].

Training for telepsychology

Meeting face-to-face with patients will put things on the right way for better patient care. This scenario would be absent in telepsychology clinics, even if a real-time video was provided. In telepsychology, several psychological clues can be missed, such as olfactory clues (e.g., smoking or alcohol on the breath) and physical clues (e.g., tapping of the foot). Psychologists who are competent at providing psychological assessments and interventions could find that their clinical effectiveness does not transfer to telepsychology practices without additional training. Training for telepsychology service is essential for such clinical scenarios and mainly for COVID-19.

While most telepsychology patients are highly satisfied with their therapists, many psychologists revealed discomfort regarding the limitation to establishing meaningful clinical relationships over telepsychology. They are concerned that they could miss important clues such as foot-tapping and myriad other nuances that face-to-face care will capture [24].

It has been recommended that a special telepsychology training program be provided for all postgraduate applied psychology students (e.g. clinical and counselling psychology) that includes several forms of psychological assessment and therapy [25].

Special telepsychology training programs that integrate the use of telecommunication technologies are needed to equip students for the current needs and service delivery in psychology. Training opportunities in telepsychology can prepare students to improve, implement, and assess advanced modalities for psychological health care [26]. This document highlights the need for training with sufficient cultural competency skills, which will be paving the way for trainees to obtain better telepsychology skills in Saudi Arabia and other Arab countries [9].

Standards of telepsychology services

Psychologists must be sure that the codes of ethical and professional standards of practice are met during the telepsychology services they provide [14]. Telepsychology does not entail new guidelines but needs awareness of further issues and actions that arise in the context of providing medical care remotely [23]. Three-quarters of the telepsychology guidelines (APA, 2013) are standards of the Ethical Principles of Psychologists and the Code of Conduct [27].

Therefore, this guideline for telepsychology services during COVID-19 is considered an additional protocol based upon the background of the general psychology guideline in Saudi Arabia [9]. Core values endorsed by the available telepsychology guidelines are that process and practical management should be followed in the same way as in the clinical face-to-face consultations [28].

Informed consent agreement

Psychologists endeavour to document informed consent that precisely addresses the unique concerns related to telepsychology services (Table 4 ). It is usually recommended that informed consent be obtained from patients or their caregivers prior to the start of any kind of telepsychology services and that it be confirmed that the patients recognize the limitations of the techniques for delivering telepsychology, as well as the potential benefits [28]. With telepsychology services, it is highly recommended to ensure that the patient has a full understanding of the increased risks of the loss of security and confidentiality in the use of this service [14].

Table 4.

Informed consent protocol during COVID-19.

Items	Description
Sample telepsychology message to (patient, parents, caregivers) to establish virtual visits	Dear (patient, caregivers), Due to COVID-19, for your health and safety, we are transforming our in-person services to telepsychology services. We would like to see you virtually for your visit on (date). There are several options to meet virtually through, for example: FaceTime, Google Duo, Skype, and telephone (for follow-up visits ONLY). If you agree to this, an informed consent form is mandatory. Below is the informed consent. Please review and sign it prior to the start of your telemedicine. Please review before you sign it. Below is an alternative to telepsychology services (if available).
Informed consent	Before initiating telepsychology services, the psychologist must obtain informed consent for all psychological services, such as assessment, treatment, consultation, and knowledgeable consent for the gathering, use, and disclosure of personal health information (see Table 3).

	Telepsychology providers	Patients
Consent guide	Understand that the psychologist will not record any of our telemedicine sessions without the patient's written consent	Understand that patients are not allowed to record or photograph any telepsychology sessions without written consent from the provider
	The requirement for the psychologist to obtain patient consent is the same as in in-person patient interactions	Patients are not allowed to distribute any images or recordings of the telepsychology sessions
	The psychologist should clearly outline the nature, benefits, risks, limitations, and potential outcomes of the telepsychology services	Patients should have the opportunity to ask questions and hear about alternative courses of action, as appropriate
	Psychologists uphold professional standards of conduct, as they are aware of other applicable laws of informed consent and are subject to other relevant considerations, including contractual obligations, ethical standards, and legislation	Patients have the right to refuse or withdraw participation at any time
Consent-related risks	The psychologist must include information about the risks related to providing psychology services in formats other than face-to-face interactions. For example, the psychologist may not have the benefit of viewing some of the patient's body language and non-verbal cues, which could affect the professional opinion
Disclosure to the patients	The psychologist's name, work address, area of practice, and training/education, as applicable
	Registration with the regulatory body where the client is located (Saudi Commission for Health Specialties)
	Registration with any professional body such as Saudi professional psychology associations or any other professional psychology organizations
	Participation of other care providers
	Risks and benefits of participating or not participating in telepsychology services
	Any potential conflicts of interest

Cultural competency and patient-centeredness

Providing a psychological intervention that offers culturally competent services is important to delivering responsive psychological care in telepsychology [9], [29]. Due to cultural norms and help-seeking beliefs, patients could not access mental health services [30]. Allowing patients to access telepsychology services from their homes would likely increase access and the acceptance of seeking help from a psychologist by reducing the stigma associated with appearing in mental health clinics [25].

The emergence of cultural competency as central to healthcare is not new, but its essential factor in facilitating patient-centeredness care could be new. Cultural and societal constraints must be included in the telepsychology policy and guideline [9]. The compatibility of telepsychology with cultural ethics and rules, human culture, and traditional beliefs were stated as barriers and challenges in telepsychology services [18].

Establishing telepsychology services to provide seamless models of service could help with the delivery of psychological services for remote and rural clients during COVID-19. Such telepsychology will involve integrating services to provide high-quality service to all patients, in either cities or rural areas [25].

Telepsychology might lead to an interesting discussion about “How can telepsychology and patient-centeredness transfer from the idea stage to the practice stage in Saudi Arabia?” The establishment of telepsychology and patient-centeredness guidelines might pave the way to a replication of the theory about telepsychology and patient-centeredness in the field of practice, leading to a bridged gap between healthcare professionals and mental health patients [31].

Therapeutic approach in telepsychology

A vast amount of literature has been written about ethical and logistical guidelines, and the advantages and disadvantages of telepsychology services, while little to no attention has been paid to subjects related to telepsychological therapeutic boundaries [32].

Telepsychology services will probably encounter novel boundary issues that are unlikely to arise in traditional face-to-face clinics. Psychologists should consider which telepsychology therapeutic approach and services could benefit from the flexibility that remote care offers, and how to maintain appropriate boundaries in telepsychology settings to prevent harm and optimize interventions gains [24]. Psychological responses should be based on existing health services, available local support, and the psych-socio-cultural environment. Interventions during COVID-19 may be delivered through several health services (Table 5 ), including telepsychology services [33].

Table 5.

Telepsychology sample of psychological responses based on existing health services.

Before a day-a-week
Call the patient 2–7 days in advance
Check the patient's medical record for risks for psychological problems and current psychological statistics during COVID-19
Urgent cases receive priority appointments. Have a judgment of providing PFA for those in need with fast track
Review the telepsychology process with the patient and obtain recorded consent or through email
If the patient refuses to participate in telepsychology visits, offer other services
Provide the patient with this message for only the first telepsychology session: not all psychological problems are clinically suitable for telepsychology services. Your psychologist will first hear from you; then the telepsychology will be activated, or the psychologist may recommend alternative services for specific issues
Connect
Check the patient's medical record for current psychological statistics with COVID-19 and pre-existing psychological conditions
See the patient via Zoom, FaceTime, Skype, Google Duo, or telephone (need official approval from the telepsychology providers)
Call the patient 20–30 minutes before the appointment and confirm the telepsychology protocols
Confirm that you are talking to the right person before you start, and especially before giving out any information
Introduce everyone who is present, including those who may not be visible on camera
Confirm the patient's location (highly recommended that it be in-home)
Caregivers may be present, but it must be known who is in the telepsychology sessions
See the full details about this step in Table 3
Apply an appropriate psychological intervention such as iCBT
Communicate
Check on the need for an emergency protocol. If yes: (Where are you? Is the space private and safe? Can anyone hear you? Can anyone barge in?)
Inform the patient about the risks and benefits of telepsychology sessions, including limited diagnostic assessment capabilities
Make a single visual impression: well-appearing, no acute distress
Explore the patient's psychological ideas and concerns, the main question that needs to be clarified, and the goal of this telepsychology session, and agree on a problem list
Listen more and speak less – active listening, convey respect for their concerns and beliefs, build trust, ask open questions, and avoid jargon and information overload
Apply proper psychological assessments, such as those for anxiety, depression, social concerns, spiritual concerns, loneliness, etc.
Provide routine psychological support and services as appropriate
Conclude
The reduction of information, such as the lack of non-verbal cues, may lead to important information being missed. Thus, summarizing the most important information and key results are important
Summarise outcomes by identifying the key results
For running case: confirm that the follow-up will be through telepsychology
Inform the patient and parents/caregivers that the next appointment will be sent by patient services to their mobile, for example
Ask if the patient has any further questions
For discharged: discuss the discharge plan. Confirm that the telepsychology is closed
Thank everyone and ask for evaluation forms to be filled in and returned (this is recommended)
Close the telepsychology
Follow-up
A follow-up message with a standardized, easy-to-read tip sheet could be emailed to the patient to reiterate psychological instructions discussed via telepsychology services
This time is an opportunity for obtaining patients’ feedback about the telepsychology services, which will help to improve the quality of psychological services provided through this approach
Documentation
Prepare documentation as usual. It is recommended to use virtual visit language
Add the following notes, mainly for telepsychology
Documentation requirements specifically for telepsychology
This session was provided using telemedicine (video visit, phone visit)
Actual location of client
Location of provider
Names of people in the session and their relationship
Informed consent specifically for telepsychology was obtained

Crisis psychology is recommended to provide multiple levels of telepsychology interventions within COVID-19. These levels align with a spectrum of psychosocial conditions that are represented in gradual steps, ranging from embedding social and cultural considerations into telepsychology services to providing specific services for patients with more severe psychological conditions. For example, for patients who are experiencing symptoms of anxiety and depression during COVID-19, strategies such as psychological first aid and brief cognitive behavioural therapy and relaxation training should be considered.

Psychological First Aid (PFA)

PFA is a simple method that focuses on psychological techniques that can be used to help reduce distress in a time of fear, anxiety, and uncertainty. PFA must be provided in a private setting that facilitates confidentiality and safety. Key features of PFA include being supportive but non-intrusive, recognising that people have the right to accept or reject help or support. PFA also includes active listening but without requiring patients to speak if they do not feel comfortable doing so (Table 6 ). It offers comfort and well-being, as well as supports calmness during crisis times such as COVID-19 [34], [35].

Table 6.

Psychological recommendations during COVID-19.

Follow WHO and Saudi MOH health agency recommendations (knowledge, recognition)	Normalizing your feeling: understand that stress and fear are normal in unknown situations (self-awareness)
Practice social distancing during COVID-19, but stay in touch emotionally and online with closed-in people. This will feed the human connection we all need to thrive daily (practice)	Limit exposure to COVID-19 news, as too much information can trigger anxiety disorders (awareness and action)
Avoid confusing the solitude of preventive confinement with abandonment, rejection, or helplessness (self-awareness)	Tell someone when you experience symptoms of sadness or anxiety (connected)
Pay attention to your own needs, feelings, and thoughts. Monitor psychological conditions such as irritability, anger, and aggression, and ask yourself why (Link)	Stigma: avoid discriminating against or blaming groups or individuals for the contamination process (Link)
Maintain adequate sleep, nutrition, and exercise patterns (action: lifestyle behaviours)	Practise positive psychology techniques such as gratitude at regular times throughout the day (practice)
Be aware of the collective impact of your behaviour (awareness)
Be aware of the impact of social actions on stopping or decelerating COVID-19 (awareness)
Avoid disseminating information from unofficial sources (awareness)

Offering support or PFA during COVID-19
Things to say and do	Things to NOT say or do
Listen more than you speak to identify concerns	Interrupt someone who is speaking
Ask gently probing questions	Judge what they have or haven’t done, or how they are feeling
Use open-ended questions: when, where, what, who	Say, “You shouldn’t feel that way,” or “You should feel lucky you survived.”
Let them know that you are listening; say, for example, “hmmmm…”	Pressure others to speak if they do not want to speak
Allow for silence. Be patient and calm	Ask why this or that
Allow for the processing and venting of emotions	Use technical terminology
Acknowledge feelings and understanding of events	Talk about yourself or tell them someone else's story or experiences
Normalize emotions and reactions	Give false promises or false reassurances
Provide information about COVID-19. Be truthful about what you don’t know. This is a new virus that we are all learning about	Act as if you (as the psychologist) must solve all the patient's problems for them
Listen to individuals’ options and help them make choices
Ensure confidentiality unless issues mentioned affect the safety of the individual or others

Normalizing anxiety and other psychological symptoms during COVID-19: PFA phrases for empathy and some key psychosocial tips

In this condition with COVID-19, your reaction is quite natural…

I understand your concerns, and most people are facing similar doubts…

It is very natural to have some stress or to be angry or upset

I completely understand that you are feeling this way…

Perhaps we could discuss possible solutions…

Holistic approach: what has helped you in the past in such situations?… Psycho-socio-spiritual approach, have much to contribute and help in these times… pray and read Quran, for example

If the patient needs more than psychological first aid: I am concerned about you, and I would like to refer you to someone who can help you…

Internet-Based Cognitive Behavioural Therapy (iCBT)

Another example here of telepsychology interventions is iCBT, with particular emphasis on its use in light of COVID-19. iCBT was recommended as an evidence-based intervention. For example, mental health services in China during the COVID-19 outbreak applied online psychological self-help intervention systems, including iCBT [7]. In fact, some studies propose that iCBT can be as effective as face-to-face CBT [36]. A psychologist must discover how to adapt iCBT for remote delivery and telepsychology in order to address the consequences of COVID-19 [37] and to decrease loneliness and improve mental well-being [38]. In Saudi Arabia and Middle Eastern countries, iCBT could be observed as more accepted culturally and psychologically by those who exhibit a stigma and show a high level of avoidance and withdrawal from social interaction, social phobia, or some other cultural issues related to mental health needs [9].

Conclusion and recommendation

There is a clear need for a telepsychology multidisciplinary group under the umbrella of the NHIC, which would bring together people from clinical and IT, policy backgrounds, and others who are active in telehealth in general and telepsychology in particular. Such a group could facilitate the development of an online website or mobile apps that offer resources for those who are interested in developing telepsychology services, thereby raising the awareness of the potential of telepsychology across the health service in Saudi Arabia.

The development of a telepsychology policy that deals with any national emergency responses must be constructed on the evidence that telemedicine in general and telepsychology in particular is becoming a major factor of our health system [39].

Psychological associations and societies in Saudi Arabia and other Arabic communities should welcome and support the establishment of new telepsychology guidelines for conducting ethical and professional services.

COVID-19 has broadly transferred the focus of psychological practicum sites for the foreseeable future. Accordingly, training programs may be moved to consider the inclusion of training related to disasters and telepsychology services [40].

Telepsychology should not be excluded based on disability, age (children and old), cultural barriers, or any type of difficulty. Professional modification should be established to enable all to be engaged and benefit from telepsychology, acknowledging that it will not be possible for all [6].

Finally, telepsychology services are ideal for mitigating the overcrowding of hospitals and preventing additional unnecessary human exposures, as well as promoting the delivery of high-quality care during COVID-19 [41], This service is emerging as an effective and sustainable solution for prevention and treatment to contain the spread of COVID-19. Telepsychology must no longer be considered a luxury option or emergency and temporary response. Rather, it is recommended that telepsychology services should be considered as a part of a proactive governance model to secure a continuity of care for patients suffering from mental health, for whom care cannot be postponed during national emergencies [42].

Discussion: overcomes the barriers and turning the challenging to opportunity

Health professional experts found that telemedicine played a fundamental role in controlling the COVID-19 pandemic in several parts of the world [43]. Telemedicine for mental health during the COVID-19 pandemic was documented as being practically feasible and suitable for providing essential and professional services and support for patients, family members, the community in general, and health professionals [44]. For greater benefits in the long-term, it was recommended that telemedicine be implemented proactively rather than reactively, as in the case of the COVID-19 pandemic, to help with everyday healthcare services and in emergency crises [39].

About seven months have passed since COVID-19 became known among the Saudi community. Since then, health professionals have learned much about COVID-19 and have made progress in combating the virus. Additionally, a group of researchers in Saudi Arabia aimed to turn the threat and challenge of COVID-19 into an opportunity for greater support for local mental health services by establishing a telepsychology guideline. For the first time, telemedicine in general, and telepsychology in particular, were in the spotlight due to COVID-19 care and its related psychological and mental health services. However, health professionals faced a lack of clear guidelines and official pathways to providing such services. During the lockdown, they had to offer health services without sufficient training. Telemedicine may be provided by any accredited health professional in Saudi Arabi within either the public or private sector.

The existing telemedicine literature, not only in Saudi Arabia but also in Arabic and Middle Eastern countries, does not supply any clinical or practical documents such as guidelines, whether legal and regulatory, or privacy- and policy-related [45]. Rather the literature provides a form of description and perspective related to patients’ and physician's knowledge, attitude, barriers, and challenges in adopting telemedicine. Some previous studies [18], [19], [46], [47] highlighted the situation regarding telemedicine in Saudi Arabia and confirmed that although many healthcare organizations are using communication technologies to improve healthcare quality, there was no organized effort to establish national protocols and guidelines to provide professional telemedicine services. Such a case could be generalized for the telemedicine situation in Arabic countries and most Middle Eastern countries.

Although many telemedicine programs in Arabic countries have been launched since the 1990s, the efforts that were taken in their utilization have been insufficient [45]. The task force concluded, after a full discussion, that healthcare professionals, and psychologists in particular, could regard telepsychology as an essential element of patient-centred care, which will overcome several cultural and mental health barriers in terms of providing everyday healthcare services. The entire guideline was reviewed and then updated with several topics and mended again accordingly. A recent Saudi study [45] recommended allocating proper funding and a sufficient annual budget to establish telemedicine in Saudi Arabia, considering the financial factor as one of the main barriers. From the other financial side, the study encouraged policymakers to invest in telemedicine and indicated that these services could achieve cost savings without compromising the quality of patient management [48]. Another consideration here is related to the legal and regulatory barrier to the use of telemedicine in Saudi Arabia. This includes establishing guidelines and formulating policies and standards for the adoption of telemedicine in Saudi Arabia [45], [49].

In a recent Arabic study, the cultural element was considered the greatest barrier – even more than technical issues – to the adoption of telemedicine in Arabic countries [50]. In several studies on the use of telemedicine in Arabic countries, religious and cultural issues were found to affect communities’ willingness to accept telemedicine. At times, no efforts were made to bridge this essential gap [45].

Religious factors have not been regarded as a barrier to telemedicine in previous Arabic studies [50]. However, Western mental health standards and guidelines, applied to services in Islamic cultures, are somewhat limited in terms of absorbing the community norms and values and could be irrelevant and counter-indicated [9], [51]. One typical example here regards the preference of female patients in Arabic cultures to be diagnosed in a culturally sensitive manner that, accordingly, cannot be done when they are alone behind a closed door with a male, even in a professional setting [9]. Female patients also prefer to cover up their bodies – mainly, the face and hair – in the company of male doctors and to uncover only the part that must be examined [9], [50].

Interestingly, during mental health clinics, Saudi female patients may feel safer and more secure talking about especially embarrassing issues when behind the veil, to protect their identity, especially if they are confident that most health professionals will not ask them to reveal their faces in adherence to Islamic legislation [9]. Does telepsychology, as a distance therapy, provide the same safe and secure environment for our patients? This is a very good question that must be answered.

As has been mentioned above, telepsychology could pave the way toward allowing mental health patients to access professional services from their homes, which in turn could reduce the stigma and other cultural and religious issues linked to appearing in mental health clinics. These cultural and religious issues, which could be regarded as an advantage for mental health telepsychology services, have not yet been investigated. This is an area recommended for future research.

Limitation

This is not a therapeutic protocol for telepsychology services. Rather, it is a guideline for COVID-19 telepsychology services that is prepared to support psychologists and healthcare providers in decision-making that is consistent with the best scientific evidence-based practice and clinical consensus. The ultimate clinical judgement regarding patient psychological services and the therapeutic approaches must be made by the professional psychologist, taking into consideration the assessed needs, strengths, weaknesses, and preferences of each patient as well as available resources.

Human and animal rights

The authors declare that the work described has not involved experimentation on humans or animals.

Informed consent and patient details

The authors declare that this report does not contain any personal information that could lead to the identification of the patient(s) and/or volunteers.

Disclosure of interest

The authors declare that they have no competing interest.

Funding

This work did not receive any grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

All authors attest that they meet the current International Committee of Medical Journal Editors (ICMJE) criteria for Authorship.