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TELEPSYCHOTHERAPY: THE BRIDGE TO CONTINUITY IN CARE AND MENTAL HEALTH SERVICES IN COVID-19 AND POST COVID ERA
SMRITI JOSHI
Lead Psychologist, Wysa.io
Researchers Murray and Lopez had shared projections in 1996 which suggested that the health burden due to mental disorders will record a 15% increase by 2020 (Murray and Lopez 1996). The pandemic that has now brought our world to a standstill in 2020, was not even imagined or its repercussions included in these projections or predictions made till date. Almost 2.6 billion people are in a state of enforced lockdown across the globe (Van Hoof, 2020).
Following WHO (2020) guidelines around social isolation, which is being looked at as one of the key ways to prevent the spread of this deadly virus, people have lost access to many services, activities and even medical facilities as outpatient departments have been shut down or restricted to only emergencies. People with existing mental health conditions and those struggling with psychological distress arising from fear and anxiety of their loved ones or themselves being infected by COVID-19, feel lost and helpless. The need for social distancing has also led healthcare providers including mental health service providers like psychologists and counsellors to suffer economic losses and feel guilty about not being able to assist their clients as they would have done in pre-COVID-19 times. There already exists a huge gap between service providers and end users in India, as 70% of the population live in rural areas with limited access to mental health services (Murthy & Ramaprasad, 2010).
It seems like people across the globe are grieving for losing how we were living just before COVID-19 struck. The uncertainty and lack of a road map is keeping people in a hyper vigilant mode, constantly scanning for threat and losing their “here and now”. Some themes that stood out in conversations with Wysa, an emotionally intelligent chat box and with therapists on their online therapy platform, were feelings of collective grief: a sense of invisible loss, loss of safety, loss of routine/connection with outside world/loss of not being able to do things that gave them joy, because of quarantine or other restrictions, loss of job or fear of it, losing a loved one to COVID-19 or because their loved one is a frontline COVID-19 worker.( Becky et. al, 2020). It is being called the world's largest psychological experiment and everyone is in the experimental group (Van Hoof, 2020).
Various Indian organisations that provide mental health services and training like the National Institute of Mental Health and Neuro Sciences (NIMHANS) and the professional body for clinical psychologists- Indian Association of Clinical Psychologists (IACP) and their various state chapters, in coordination with government-run mental health programmes, are trying their best to provide crisis intervention helplines for general public. To make sure that these crisis helplines are able to offer the intended support, these organisations have also framed guidelines and are providing online training via webinars to help the fraternity members make this shift from in-person sessions to be volunteers for these telecounselling helplines. But most of this shift has been triggered by the COVID-19 and there still are concerns about how to deliver telecounselling or telepsychotherapy in an ethically and legally safe way.
The purpose of this article is to highlight the need for telepsychotherapy not just as a bridge to continue providing mental health support during these times of social distancing and lockdowns but also as an independent field for delivering mental health services. This paper also takes a courageous attempt at suggesting national level recommendations to help this field deepen its roots in our country and discuss ethical challenges and solutions to these challenges that will not only help in delivering tele psychotherapy legally and ethically in these times of the pandemic, but even beyond.
Telepsychotherapy- Why now?
The concern is not limited to only COVID-19, but the pandemic is a public mental health crisis as well. Considering the barriers posed by the need for social (read, physical) distancing, tele-psychotherapy seems like a viable option to not only manage the mental health impact of the pandemic and economic crisis, but also offer preventative solutions that help with building resilience skills, especially in view of the Pre-COVID-19 research which already indicated that by 2030 depression will be the leading cause of disease burden globally (Becky et.al, 2020).
According to Inter Agency Standing Committee report (IASC,2020), the current need is to not only cater to those already suffering from mental health disorders or those at high risk due to (a) a history of previous emotional problems, and (b) exposure to severe stressors during the pandemic, but to also prepare oneself to meet the second wave of mental health problems one may see in the latter half of 2020. This may also include people with stressors like severe life-threatening illnesses, death of loved ones, severe financial hardships and economic losses (e.g., due to social distancing), stressful experiences during quarantine (e.g. severe symptoms combined with absence of contact with friends or loved ones) and burn-out from caregiving, especially healthcare providers or members of our own fraternity. To meet these needs, we need to assess cost-and-time saving, easily available resources with both clients and mental health service providers so that both parties are able to reach out and be available for psychotherapy/counselling sessions. Mobile phones or other electronic devices and the internet then becomes the most common and reliable resource to form this bridge between the mental health service providers and the clients.
This is where Telepsychotherapy or telecounselling service comes in as a great alternative to in-person sessions. Lee (1998), president of American Counselling Association said in one of his speeches, “…to think that clients in the new century would not expect to access Internet counselling services is probably foolish and short-sighted on our part”. Telepsychotherapy or telecounselling is defined as, ‘the process of interacting with a licensed psychotherapist/qualified counsellor online in ongoing conversations over time when the client and therapist are in separate or remote locations and utilize electronic means to communicate with each other’ (Bloom 1998). The electronic means of communication could be text-based chat, audio, or video, both for scheduling sessions and for provision of psychotherapy and also used in a blended way. Online therapy/counselling services could be delivered to and received by individuals or as a group (Amulya, 2020). Modalities for offering these services can be differentiated in terms of Time of service delivery—whether an intervention is delivered in ‘‘real-time’’ (synchronously) like live video or audio or text-based chat, or is delayed (asynchronously) like email or web- based self-help programmes.
Online counselling or therapy, can be the first step for many in their journey towards mental health services for clients previously unwilling to seek treatment (Heinlen, Welfel, Richmond & Rak, 2003; Rummell & Joyce, 2010). These online services can offer additional support for existing in-person therapy (Wodarski & Frimpong, 2013).
This pandemic has now brought up new realisations around helpfulness of offering mental health service, especially bringing teletherapy and telecounselling to the forefront as this is one way to provide crisis support, especially when most states in India are still under enforced lock down or people who have tested positive are in self-quarantine. There has been a rise in demand for online therapy/counselling since the past 2-3 months. Wysa has witnessed a 77% increase in new users during February to March 2020, as compared to the same period in 2019. Also, the number of clients who referred to the term COVID-19 during Wysa Coach/Therapist sessions increased week-on-week during March 2020, from 5% in the first week to 60% in the fourth week (Becky et.al 2020).
Perspectives on Support for Growth of Telepsychotherapy in India
One cannot emphasise enough on the role that government and policy makers play in managing any disaster - man made or natural or a health crisis like COVID-19. Any number of hotlines or outreach work may not have the desired impact, as social distancing may be a barrier, especially in reaching out to those in remote areas or containment zones. Conventional telemedicine is offered in India for quite a few years by ISRO and the Apollo Telemedicine Networking Foundation, which have served more than 100 hospitals, provided training and have also helped set up telemedicine delivery centres in disaster/crisis locations during catastrophic times (Ganapathy & Ravindra, 2009). We can try to replicate similar models of telepsychotherapy/ counselling services during these critical times. Video conferencing seems to be a suitable modality to deliver mental health services to rural areas in our country as it can easily help bridge geographical distances and break educational and technical literacy barriers assumed to be present in the rural population (Joshi, 2017).
Allocation of funds for bringing in telepsychotherapy health facilities within existing clinical settings like primary healthcare centres or private healthcare providers in remote areas is one way to reach the maximum people during this public mental health crisis (Manickam, 2020). Insurance providers should be encouraged to provide insurance support to clients accessing mental health support via telepsychotherapy facilities to encourage providers and clients to use these platforms.
Steps to ensure smooth transition: Potential Challenges and Solutions
Imagine sitting in one’s own office or a room in one’s house, using one’s phone or laptop to connect with a client who is seeking therapy for a mental health concern. It may seem like a mockery of what one has learnt about the relevance of the physical setting of a therapy room. It does challenge the traditional way of providing or receiving empathetic therapeutic support in the presence of one’s therapist or counsellor, where the therapist can observe verbal and non-verbal cues and offer appropriate tools/strategies to the client. How does one ensure that the standards of care and ethics that are followed in in-person sessions are followed even when client and therapist are not in the same room? Will the therapeutic alliance be as effective as in-person therapy? Research studying efficacy and therapeutic alliance on various online modalities like audio and video based sessions revealed that clients reported experiencing good working alliance and close contact with the therapist and also felt that therapy received was more customised suiting their needs, helping them improve the understanding of their condition (Egede et al., 2016). Poletti et.al., (2020) reviewed 18 studies on telepsychotherapy and results revealed that even though therapists and general public may be skeptical about providing or receiving therapy via video-based sessions, it has been found to be a trustworthy alternative and efficient in treating mental health disorders like anxiety, depression and post-traumatic stress disorder.
With such research backing telepsychotherapy, these services are quickly gaining popularity in India as well, and currently, even the most sceptic providers have to make this shift catalysed by COVID-19, as it seems to be the only alternative available.
To help with a smooth transition it would help to go over these challenges listed below and potential solutions to these challenges.
Providers and clients may find it hard to adjust to this sudden, almost forced shift towards adopting this new way of providing or receiving services. For some therapists the novelty and perceived ease in offering service via these modalities can make them reach most of their clients. Assessing client suitability is based on
a. Severity of pathology or crisis the client is facing.
b. Technological literacy and accessibility to the internet and devices supporting the modality via which you wish to offer telepsychotherapy sessions.
c. A safe space, especially for the client to help them feel safe and reassured, is important to avoid turning this experience into an unpleasant, uncomfortable one for both sides.
d. It is best to first offer this to those clients with whom a good therapeutic alliance has already been formed to facilitate a smooth transition. Any gaps noticed in one’s work with these clients can then be filled in during work with new clients- so plan this transition in a phased manner.
2. Informed Consent and Record keeping
Informed consent and documentation of professional work as well as session records, records of financial transactions, and crisis scenarios and steps taken is as essential for telepsychotherapy/telecounselling practice as it is for in-person sessions. It is important to communicate with the client in writing, about the modality and process of interaction, the potential benefits and risks of online therapy (e.g. specific confidentiality issues, data security), crisis management process etc., fee for different modalities and what would happen in case of missed sessions from either side related to telepsychotherapy must be understood by the client. If telepsychotherapy sessions are being offered as a temporary measure to clients (e.g. during the COVID-19 pandemic or any other scenario), then this must be explicitly stated and discussed with the client and consent obtained for the same.
3. Competence
As psychologists prepare themselves to make this shift, they should:
a) Remember to provide these services within the boundaries of their skills learnt from their training and supervised work experience and what is defined in their scope of work by their professional or licensing body (Chenneville & Schwartz-Mette, 2020, Manickam, 2020).
b) Share available evidence of one’s competence or skills advertised on a website or any other space, say social media. This could include proof of identity, qualifications, relevant experience (including experience in providing online services) and membership in any official registers/licensing boards and any relevant statutory body.
c) In India, as of now, telepsychotherapy is not a part of any post graduate curriculum. Even though a lot of basic competencies and skills for offering psychotherapy via tele-modalities would remain the same, there are some unique skills and knowledge needed to offer services via this modality. For example, it is mandatory that psychologists train themselves in skills to foster a good working alliance in the absence of visual cues, or learn how to deal with communication breakdown if the session gets disrupted. Professional consultation/supervision with experts in e-mental health and undertaking continuing professional development courses targeted towards such skills is recommended. Some institutions offering courses in telecounselling/telepsychotherapy are:
a. Tele Behavioural Health Institute https://telehealth.org/
b. Online therapy Institute https://www.onlinetherapyinstitute.com/
c. https://www.zurinstitute.com/course/certificate-in-telemental-health/
4. Crisis Management:
Discuss crisis management procedures during the intake process itself- like, what if a client reaches out to the provider/helpline during off-hours and if during a crisis the therapist may break the confidentiality clause to fulfil the duty of informing authorities to provide appropriate help.
a. Collaborate with clients to help them build a local support network.
b. Misunderstanding can happen due to technical glitches or reading too much or too little from cues available about the client via tele-modalities. Make sure you have discussed ways to deal with these potential misunderstandings to ensure a good therapeutic alliance.
c. Monitor all clients throughout telepsychotherapy to see if they need to be referred for in-person work or emergency services.
d. Establish in-person clinical support for clients in their geographic location.
e. Have relevant emergency phone numbers on hand during each session.
f. Last, but not the least, maintain your session notes, share them with clients and also record all communication around any crisis event/plan made and referrals made and ensure that this data is safe and protected in your devices.
5. Need for Guidelines/Regulating body:
Absence of clear policies and guidelines about the delivery of telepsychotherapy can be one of the major challenges that can make clients or therapists feel wary of using this modality. NIMHANS (2020) and IACP (2020) guidelines for telepsychology and telecounselling were framed just in time to help professionals feel comfortable and confident in initiating telepsychotherapy practice. Remember, the key is to maintain the same ethics and professional standards of care and practice that are required in an in-person practice. Reach out to your supervisors/professional bodies for clarity in times of doubt and keep referring to any relevant acts like the mental health act or data privacy act applicable in your jurisdiction.
6. Burn out
Being in a helping profession can make a therapist or counsellor vulnerable to vicarious trauma and compassion fatigue, in addition to facing one’s own fears or anxieties about this pandemic. As a result, therapists might struggle to accomplish adequately their professional duties towards telepsychotherapy. Seeking supervision from a designated supervisor or one’s peers to discuss not just difficult cases but also emotional challenges that one would be feeling as an occupational hazard due to exposure to other people’s pain or from self-doubt about one’s ability to help people in the best way, would be a very helpful strategy to manage burnt out. Referring clients to other mental health professionals, for instance, those clients whose concerns lie outside your professional boundaries, or, if you feel there’s a client who might benefit more from speaking to a counselling psychologist or psychiatric social worker, would be very helpful in managing one’s case load. Having time for self-care plus self-reflection on a daily basis could help a lot with managing feelings of fatigue and burn out.
Conclusion
The benefits of telepsychotherapy surpass its limitations, especially during the current pandemic. Studies on telepsychotherapy reveal the advantage as: increased care access, enhanced efficiency, reduced stigma, ability to bypass diagnosis-specific obstacles to treatment such as when social anxiety prevents a patient from leaving the house (Aboujaoude, Salame & Naim, 2015). Tele-psychotherapy practice and research investigating objective and subjective experiences of illness, suffering, altruism, dedication, what is working or not working in terms of treatments and treatment modalities would be precious to help both psychologists and the clients to sail through these difficult times together. There is a need to closely monitor this upcoming field and treat the current guidelines as working guidelines and update them to include any specific steps to take when addressing our multicultural and diverse population. It is also important that telepsychotherapy or telecounselling is offered as a specialization or a part of the post graduate courses in psychology/counselling as this indeed is one of the specialised fields and an early exposure to it will help with well-researched, improved list of skills and competencies specifically required for offering psychotherapy via various tele modalities.
References
Aboujaoude, E., Salame, W., & Naim, L. (2015). Telemental health: A status update. World psychiatry: official journal of the World Psychiatric Association (WPA), 14(2), 223–230. https://doi.org/10.1002/wps.20218
Amulya, D. S. L. (2020). An experiment with online group counseling during COVID-19. In L. S. S. Manickam (Ed.), COVID-19 pandemic: Challenges and responses of psychologists from India (pp. 182-197). Thiruvananthapuram: The Editor.
Becky, et al. (2020). Early warning signs of a mental health tsunami: Initial data insights from digital services providers during COVID-19 (Preprint). 10.2196/preprints.19903.
Bloom, J. W. (1998). The ethical practice of Web Counseling. British journal of guidance and counselling, 26(1), 53-59.
Chenneville, T., & Schwartz-Mette, R. (2020, May 21). Ethical Considerations for Psychologists in the Time of COVID-19. American psychologist. Advance online publication. http://dx.doi.org/10.1037/amp0000661
Egede, L. E., Acierno, R., Knapp, R. G., Walker, R. J., Payne, E. H., & Frueh, B. C. (2016). Psychotherapy for Depression in Older Veterans Via Telemedicine: Effect on Quality of Life, Satisfaction, Treatment Credibility, and Service Delivery Perception. The Journal of clinical psychiatry, 77(12), 1704-1711.
Elke, H. V. (2020). This is the psychological side of the COVID-19 pandemic we were ignoring. Retrieved from https://www.weforum.org/agenda/2020/04/this-is-the-psychological-side-of-the-COVID-19-pandemic-that-were-ignoring
Ganapathy, K. & Ravindra, A. (2009). Telemedicine in India: The Apollo story. Telemedicine Journal of E Health, 15(6):576‐585. doi:10.1089/tmj.2009.0066.
Indian Association of Clinical Psychologists. (2020). Tele-counselling Instructions during COVID 19 for volunteers. Retrieved from http://iacp.in/wp-content/uploads/2020/04/Tele- counselling-Instructions-April-7.pdf
Inter-Agency Standing Committee. (2020, March 4). Interim briefing note addressing mental health and psychosocial aspects of COVID-19 outbreak (developed by the IASC's reference group on mental health and psychosocial support). https://www.who.int/docs/default-source/searo/whe/coronavirus19/iasc-interim-briefing-note-on-COVID-19-outbreak-sl-e.pdf?sfvrsn=a5bbbab4_0
Joshi, S. (2017). Online Psychotherapy: Current Status and Future Prospects. In A. Shukla & A. Dubey (Eds.) Mental Health: Psycho-Social Perspectives (Volume:4 Therapeutic Applications) (pp 164-192). Delhi: Concept publication.
Lee, C. (1998). Counseling and the challenges of cyberspace. Counseling Today, 40(10).
Murray, C. J., Lopez, A. D., & World Health Organization. (1996). The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020: summary. World Health Organization.
Manickam, L.S.S. (2020). COVID-19 Pandemic: A time for prudent and ethical action. In L. S. S. Manickam (Ed.), COVID-19 pandemic: Challenges and responses of psychologists from India (pp.218-228). Thiruvananthapuram: The Editor.
Murthy, S. K., & Ramaprasad, D. (2010). Family Burden and Rehabilitation Need of Beneficiaries of a Rural Mental Health Camp in a Southern State of India. International Journal of Psychosocial Rehabilitation, 15(2). 5–1.
National Institute of Mental Health and Neuro-Sciences. (2020). Guidelines for tele-psychotherapy services. Retrieved from http://nimhans.ac.in/wp-content/uploads/2020/04/Guidelines-for-Telepsychotherapy-Services-17.4.2020.pdf
Poletti, B., Tagini, S., Brugnera, A., Parolin, L., Pievani, L., Ferrucci, R., ... & Silani, V. (2020). Telepsychotherapy: a leaflet for psychotherapists in the age of COVID-19. A review of the evidence. Counselling Psychology Quarterly, 1-16.
Wodarski, J.S., & Frimpong, J. (2013). Application of E-Therapy Programs to the Social Work Practice. Journal of Human Behavior in the Social Environment. 23 (1), 29-36. Doi: 10.1080/10911359.2013.737290.
WHO. (2020, April 29). https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public