Why have psychologists been slow to adopt telehealth?

Medicare Benefits Schedule (MBS) data indicated a low uptake of telehealth psychology (audio or videoconferencing consultations) prior to COVID-19. Back in 2004, researchers reported a relative lag in the uptake of videoconferencing technology by Australian psychologists, arguing that psychologists were wary of the technology and had little exposure to it (Rees & Haythornthwaite, 2004). More than a decade later, it was again noted that psychologists were slow to incorporate telehealth technology (Richardson & Simpson, 2015). The rapid expansion of telehealth psychology in response to COVID-19 has been a significant adjustment for psychologists and clients alike.

Despite the 2017 expansion of the Better Access to Mental Health Care Initiative (Better Access) to include telehealth psychology services for rural and remote Australians (Department of Health, 2018), uptake among psychologists remained low. Medicare data for 2019 showed telehealth psychology accounted for only 0.22 per cent of Better Access consultations provided by a psychologist that lasted at least 50 minutes (Australian Government Services Australia, 2020). This suggests the lack of client reimbursement prior to 2017 was not the sole barrier to telehealth psychology uptake. Indeed, a recent Australian study found that some psychologists were completely unaware of the Medicare telehealth psychology initiative for rural and remote clients (Knott, Habota, & Mallan, 2020).

With the outbreak of COVID-19, subsidised telehealth psychology expanded to include videoconferencing and telephone consultations, for all psychological services under Medicare, regardless of location (Department of Health, 2020). Medicare data for April 2020, after the introduction of COVID-19 items show that telehealth psychology (telephone and videoconferencing) accounted for 52.08% of Medicare consultations provided by a psychologist and lasting at least 50 minutes (See Table 2; Australian Government Services Australia, 2020). The COVID-19 expansion of telehealth psychology represents an unprecedented opportunity to improve our understanding of the barriers and facilitators to the effective use of telehealth psychology in Australia.

Clinicians report numerous barriers to the use of telehealth psychology, despite considerable evidence in support of the modality. Clinicians are more likely than clients to express reluctance toward telehealth, and are therefore considered the “most significant initial gatekeepers” to its widespread uptake (Cowan, McKean, Gentry, & Hilty, 2019, p. 2519).

Telehealth barriers and facilitators

Access to services

Telehealth psychology can make an important contribution to overcoming inequalities in access to psychological services. This is most obviously related to improving the availability of services in rural and remote areas, yet the modality is also advantageous for client groups experiencing difficulties leaving the home (e.g., clients with agoraphobia, stigmatised groups).

Other broad advantages also include an enhanced capacity for clients to choose a clinician with specific expertise, reduced time waiting for an appointment, less time off work to attend the appointment, and increased flexibility in appointment time and location.

Efficacy of telehealth

Clinicians often report concerns related to the efficacy of telehealth psychology. This is despite high-quality experimental evidence demonstrating the efficacy of videoconferencing and telephone therapy (Fletcher et al., 2018; Varker, Brand, Ward, Terhaag, & Phelps, 2019). Systematic reviews examining the efficacy of telehealth psychology compared to in-person treatment report equivalent outcomes for depression, anxiety, physical health issues, addiction, eating disorders and post-traumatic stress disorder (PTSD) (Backhaus et al., 2012; Hilty et al., 2013). This finding extends across child, adolescent and adult client groups, and across cultural groups (Hilty et al., 2013).

The evidence-base for telehealth psychology continues to expand, with recent studies supporting the use of telehealth psychology for issues including veteran and civilian PTSD, obesity management, parenting and adolescent obsessive compulsive disorder (Glassman et al., 2019; Lewis, Huang, Hassmén, Welvaert, & Pumpa, 2019; Ngai, Wong, Chung, Leung, & Tarrant, 2019; Turner et al., 2014).

Therapeutic alliance

Clinicians also hold negative perceptions of the quality of the therapeutic alliance in telehealth consultations, and tend to rate it more negatively than clients (Lopez, Schwenk, Schneck, Griffin, & Mishkind, 2019). Clinicians report concerns with establishing rapport, communicating empathy, conversation flow and the perception that telehealth is impersonal (Brooks, Turvey, & Augusterfer, 2013; Connolly, Miller, Lindsay, & Bauer, 2020). Non-users of telehealth psychology report finding the modality uncomfortable, and clinician discomfort is increased in sessions involving risk disclosure, and high levels of emotion and countertransference (Knott et al., 2020; Richardson, Reid, & Dziurawiec, 2015). Many clinicians also lament the loss of non-verbal cues, for example, the ability to detect crying, fidgeting, alcohol use and issues with client hygiene (Connolly et al., 2020).

There is, however, consistent evidence of comparable patient reported satisfaction and therapeutic alliance between in-person and telehealth psychology consultations (Jenkins-Guarnieri, Pruitt, Luxton, & Johnson, 2015; Lopez et al., 2019). One small Australian controlled trial compared videoconferencing and in-person CBT and found equivalent retention, therapeutic alliance, patient satisfaction and treatment outcomes (Stubbings, Rees, Roberts, & Kane, 2013). Further, some clients find the online setting less intimidating, and prefer the additional personal space and control it provides (Simpson & Reid, 2014a). Client satisfaction is also shown to persist even when technological disruptions occur during session (Richardson et al., 2015).

Ethical concerns and risk management

The lack of clear ethical and professional guidance for telehealth psychology is considered a significant barrier to clinician uptake (Simpson & Reid, 2014b). There have long been calls for concrete Australian guidelines surrounding the appropriate videoconferencing platform, practice documentation, and standards for ethically compliant telehealth psychology (Rees & Haythornthwaite, 2004; Richardson & Simpson, 2015). International studies show that ambiguous professional and ethical guidelines lead to uncertainty among clinicians regarding their professional obligations, particularly in relation to client privacy, security and risk management (Glueckauf et al., 2018; Perle et al., 2013).

Indeed, it is suggested that risk management may be the most anxiety-inducing aspect of telehealth psychology among clinicians (Cowan et al., 2019). While risk can be managed through careful planning and the development of emergency procedures, clinicians appear to lack confidence surrounding how to do this (Glueckauf et al., 2018). Fortunately, the need to expand the use of telehealth psychology in response to COVID-19 has resulted in a rapid expansion in guidelines and resources to support the use of telehealth psychology (e.g., bit.ly/2MoMwwc).

Administrative, practical and technical barriers

Numerous administrative, practical and technical barriers to telehealth psychology use have also been identified. Administrative difficulties include poor communication and low prioritisation from clinical leaders of telehealth processes, difficulties with client recruitment and a lack of support staff and appropriate equipment (Adler, Pritchett, Kauth, & Nadorff, 2014).

Practical barriers include changes in booking and documentation processes, and managing online client records (Brooks et al., 2013). Technological difficulties, such as poor internet connection and audio-visual quality, are commonly reported clinician barriers to the broader use of telehealth psychology. Numerous practice management programs have adapted recently in response to COVID-19 to reduce the administrative, practical and technical burden associated with telehealth psychology.

Training

Clinicians report inadequate training in conducting telehealth psychology (Knott et al., 2020). In one US study, few clinicians (21%) reported receiving sufficient training, yet the majority (75%) indicated greater willingness to use telehealth psychology with additional training (Perle et al., 2013). An Australian study explored the outcomes of a pilot telehealth psychology program by postgraduate psychology students and delivered to rural clients (Simpson, Rochford, Livingstone, English, & Austin, 2014). The authors concluded ‘hands-on training’ was essential for the success of telehealth psychology, and should cover technological skills, adaptation of therapeutic techniques to the online setting and exposure to the telehealth psychology evidence-base (Simpson et al., 2014). Incorporating telehealth psychology into postgraduate training programs is also considered key in enabling clinicians to navigate the ethical complexities of telehealth consultations (Glueckauf et al., 2018)

The future of telehealth

Clinician barriers to telehealth psychology include negative perceptions of efficacy and therapeutic alliance, uncertainty surrounding ethical obligations, high-perceived practical burden and inadequate training. And yet research demonstrates that the efficacy, alliance and client satisfaction is often equivalent to in-person treatment. The introduction of improved guidelines, resources and professional development opportunities – particularly in light of COVID-19 – may further address clinician concerns. Therefore, telehealth psychology has the potential to meet the ever increasing need for accessible, high-quality psychological care, both during the COVID-19 pandemic and beyond.

There are important gaps in our understanding of psychologists’ experience of telehealth psychology. We are researching psychologists’ perceptions of telehealth, whether they are using telehealth technology, and how they are adjusting to the transition to telehealth in response to COVID-19. For information about participating in this study visit bit.ly/2YYWrOW

The corresponding author can be contacted at [email protected]