Telehealth in Clinical Psychology:
Challenges and Future Directions

Henry A. Willis, M.A.
University of North Carolina at Chapel Hill

I am a doctoral candidate from the University of North Carolina at Chapel Hill, and a current psychology intern at Montefiore Medical Center/Albert Einstein College of Medicine. My dissertation, defended just a few months before the start of the COVID-19 pandemic, explored culturally adapting mobile-health (mHealth) and telehealth technologies for use among African American youth and young adults. At the time of my defense, the widespread use of telehealth and mHealth in clinical psychology seemed like a far-off reality. Yet, in light of the COVID-19 pandemic, the field was forced to immediately adapt to telehealth, and mental health professionals experienced a sudden, mass migration to delivering services online. Despite my own foundation and passion for telehealth, I still found that utilizing technology to deliver psychological services to be a jarring experience. Though some aspects of delivering psychological services via telehealth seemed straightforward, both my research and personal experiences have exposed the challenges that face clinicians and student therapists, especially when we treat those from vulnerable populations (i.e., people of color, those from low-income backgrounds, etc.). In this perspective, I discuss challenges that may arise when utilizing telehealth as a student clinician, considerations for using telehealth with vulnerable populations, and potential future directions for telehealth and mHealth.

1. Possible Challenges of Utilizing Telehealth as a Student

Delivering psychotherapy via telehealth has its many advantages (i.e., reaching clients that may have transportation challenges, who may live in rural areas, etc.) but as a student, I’ve found that I was often faced with many practical challenges that impeded early attempts to deliver services effectively. The first challenge is access to working devices and effective internet. Faculty members and supervisors may assume that students have access to a camera-enabled mobile device and high-speed internet due to our status as graduate students, but delivering psychotherapy via telehealth often requires additional resources. For instance, even if one has the necessary “hardware” (i.e., a computer with a working camera and microphone), there can sometimes be difficulties with devices being able to effectively handle the various programs required for telehealth (i.e., Zoom, Microsoft Teams, etc.). Initially, I often found that my home internet was not “fast enough” to handle telehealth sessions, and this is often a challenge for students who do not live alone and may have others utilizing the same internet/WiFi. This can be distressing to student therapists as it leads to constant disconnections or visual/audio difficulties that impacts our ability to deliver services effectively. Moreover, student therapists may not have the resources to create an environment that is conducive to delivering treatment. For instance, students who are parents, live with family members or roommates, and/or who have limited space within their homes are at a particular disadvantage. 

Lack of access to reliable hardware and internet may disproportionately impact graduate students who are from low-income backgrounds and/or already feeling financially strained by their graduate student stipend. As students, in order to grapple with these challenges, it is important that training programs provide additional resources that allow us to effectively conduct telehealth sessions (i.e., funding for mobile-devices/computers, reimbursement for high-speed internet services, etc.). Even if student clinicians have the necessary equipment to conduct psychotherapy via telehealth, our clients may need additional support to engage in telehealth effectively. Often times, I found myself in the dual role of being both a clinician and an IT specialist. For students beginning telehealth, it is important to realize that some session time may be spent helping clients connect to telehealth platforms and/or troubleshoot technological issues. This is stressful for both the student clinician and the client, as either may have varying knowledge of technology and software platforms. Again, this is a situation in which it is important that institutions and training programs provide ample resources, trainings, and support for graduate students to help them feel competent when navigating potential technological issues/difficulties. 

In the “virtual” therapy room, a host of other issues may arise. First, given that sessions occur outside of the clinic, there is an increased chance that session content is overheard, either by others in the client’s home, or by others in the clinician’s home. Some solutions exist, such as the use of headphones, but do not entirely ameliorate the difficulty in ensuring confidentiality when therapy takes place virtually. Moreover, during sessions, I often found it harder to navigate leading and facilitating group therapy sessions as it’s easier for clients to talk over each other over Zoom. I also had  to become more comfortable “talking over” or interjecting more forcefully during sessions with more talkative clients. In video sessions, it may also be more difficult to pick up on non-verbal cues that we might notice during in-person sessions, such as eye contact, fidgeting, etc. 

Additionally, environments outside of the traditional clinical setting are expectedly more chaotic. As a student therapist, I had to become adjusted to being more comfortable with unexpected intrusions, such as loud noises from cars or neighbors, unexpected visitors, and even package deliveries. Our clients are also navigating similar intrusions and unexpected distractions while in virtual psychotherapy. These experiences may impact rapport with our clients and our own perceived effectiveness as clinicians. For example, technical difficulties (i.e., becoming disconnected or frozen) or intrusions may interrupt a client during a particularly emotional or difficult exchange. This inevitably will frustrate both the clinician and the client, and may impact how the client perceives treatment or the clinician. While navigating this, I’ve found that first, cultivating a heightened sense of empathy and self-compassion for myself has helped to deal with the stress of these challenges. Moreover, discussing these potential intrusions/distractions with clients at the beginning of telehealth sessions helps to reduce the distress that occurs when these intrusions inevitably occur. The transition to telehealth and these new challenges also highlighted an increased need for supervisors to begin to take into account how to help students navigate the many issues raised above, and the unique challenges that arise when delivering mental health services via telehealth.

Finally, the biggest challenge I faced when transitioning to telehealth is an increased difficulty to “be present” while in sessions. As I highlighted earlier, a host of intrusions that would not normally occur in a clinical setting increases the risk that both the therapist and client become distracted. Even just being on a computer or mobile device increases the chance that one is distracted by incoming emails, messages, or calls. For those students beginning telehealth, some “best practices” include: closing/silencing mail and message applications, putting your device on “do not disturb”, and communicating any potential interruptions that may occur on your end to the client (i.e., the potential that the session is interrupted by a pet, children, or other factor). Clients should also be made aware and agree to follow these “best practices” to the extent possible. In the end, being transparent with clients about the many challenges we face when engaging in telehealth, being flexible, and applying empathy to both ourselves and our clients, can reduce anxiety related to delivering psychotherapy via telehealth.

2. Telehealth with Vulnerable Populations

Despite my passion for telehealth and mHealth, my research and clinical experiences have highlighted how telehealth is not a silver bullet in terms of resolving disparities in access to or utilization of mental health services. Simply put, existing disparities, especially in marginalized communities, will impact how people engage in tele-mental health treatments. For example, finding safe, private, and secure locations to have therapy is already challenging given the impact COVID-19 has had on several facets of life (adults working full-time from home, children attending school virtually from home, etc.). Unsurprisingly, finding these spaces is even more challenging for those from low-income backgrounds and/or those who may be in urban areas/small households. For clinicians, this means we have to be open to being flexible on where psychotherapy takes place. In my most recent experiences, it’s not uncommon for clients to attend sessions from a car, a park bench, a closet, or even a bathroom. It is also important to realize that those from low-income backgrounds may lack access to working devices, high-speed internet, and/or may not feel comfortable navigating the various software platforms we use for therapy. It’s important for clinicians and supervisors to assess these factors with clients and also be able to help the client find resources in the community that may help them resolve these barriers. 

When engaging in telehealth with vulnerable and often underserved populations, it is also important to realize that traditional systemic barriers to treatment do not magically go away because of telehealth. In fact, these obstacles may just impact telehealth in more complex ways. For example, access to childcare is often a barrier to treatment engagement among marginalized groups. Though telehealth means that now families can engage in treatment from home, lack of access to childcare during telehealth sessions can impact parents’ ability to engage in therapy, especially when there is only one caregiver in the home with multiple children. Similarly, existing disparities in equitable access to resources and other determinants of health outcomes (i.e., food, housing, employment, adequate insurance, etc.) have been exacerbated by the COVID-19 pandemic, and disproportionately affect vulnerable populations such as people of color, those from low-income and/or rural backgrounds, individuals with disabilities, and more. These stressors impact the psychological well-being of clients from these backgrounds, and are undoubtedly more stressful or debilitating during this crisis. Healthcare systems and training programs should take on the responsibility of making effective telehealth services more accessible during (and after) this pandemic for these populations.

Finally, it is also necessary to acknowledge the ongoing racial violence against African Americans and the ensuing protests occurring across the country. This, in combination with individuals quarantining and spending more time at home and online, means that there is an increased risk for African Americans and those from other racial-ethnic minority groups to be exposed to the traumatic effects of viewing videos of such violence and unrest online or in the media. My prior research highlighted how exposure to traumatic videos online that portray African American men being shot by police are linked to higher levels of posttraumatic stress and depressive symptoms for African American and Latinx youth (Tynes, Willis, Stewart, & Hamilton, 2019). This increased exposure to online traumatic videos, in combination with stress related to the pandemic, highlights the increased need for culturally-relevant tele-mental health services. Unfortunately, these at-risk communities may also have reduced access to traditional sources of support that contribute to resilience due to the pandemic and quarantine, such as community and family events, religious activities, and social support. Clinicians should address this during telehealth sessions by providing safe, affirming spaces for client’s to process and develop coping strategies to navigate these race-related stressors, while also helping the client find ways to access culturally-relevant support and affirming spaces that exist online. Because of this, culturally-informed clinical training becomes even more vital, as clinicians and supervisors should be prepared to have these race-related discussions during the course of treatment.

3. Future Directions for Telehealth and mHealth

As we continue to utilize telehealth and face the challenges that accompany this delivery method, there is a sense among many that this may become the “new normal” in mental healthcare. As we move forward, despite the many advantages of telehealth, there are many ways these interventions can be improved. Primarily, I believe that the field should strive to integrate telehealth services with mHealth (i.e., the use of smartphone/mobile technology to deliver telehealth) technologies, which could bolster treatment accessibility and engagement, especially among underserved populations. For instance, mHealth applications have the ability to help clients manage appointments and remain engaged in therapy (i.e., mobile devices can deliver text-based appointment reminders/notifications). It may increase homework compliance and accessibility by providing on-demand access to digital resources such as worksheets and psychoeducational readings and videos. mHealth technologies can also help clinicians track clients’ symptoms and response to treatment, as well as improve communication between clients and therapists by providing opportunities to text via secure application messaging in-between sessions. In the end, although telehealth and mHealth aren’t silver bullets for resolving existing barriers to treatment, over time, they have the potential to help clinicians increase access to effective mental health treatments, especially to those from underserved communities.

4. Conclusion: Special Considerations for
Clinical Students of Color

The COVID-19 pandemic, in addition to the concurrent racial violence and injustices, have presented many challenges for students of color. I’ve heard varying experiences from peers about, and have personally struggled with, how to best navigate clinical training during these times. As a Black clinical psychology student, this is even more distressing in that so often, the world around me and the events that are happening have immediate and devastating effects on myself, my family, friends, and community. During this period, I have found it most helpful to engage in self-care, while seeking out safe spaces with advisors and fellow students who identify with my experiences. Most importantly, navigating this time with awareness and acceptance that things are difficult has increased my own self-compassion. 

Academia often forces us into a bubble that can sometimes feel separate from the world going on around us. This isolating effect is also compounded by the pandemic and the need to quarantine in an effort to keep those that we care about safe. As we continue to move forward in our clinical training, I hope students of color can continue to find safe ways to cultivate resilience and thrive during this difficult time. As institutions and training programs begin to provide support to graduate students that help them navigate the many changes to our education/training that COVID-19 has prompted (i.e., the switch to telehealth and virtual classes, etc.), I hope that special considerations and culturally-informed support for clinical students of color is also made a priority. 

Reference

Tynes, B. M., Willis, H. A., Stewart, A. M., & Hamilton, M. W. (2019). Race-Related Traumatic Events Online and Mental Health Among Adolescents of Color. Journal of Adolescent Health, 65(3), 371–377. https://doi.org/10.1016/j.jadohealth.2019.03.006

About the Author

Henry Willis is a doctoral candidate in the Clinical Psychology program at the University of North Carolina at Chapel Hill. His current interests include exploring the relationship between online and offline racial discrimination and mental health outcomes, understanding sociocultural protective factors (i.e., racial identity) and how they impact psychopathology (i.e., obsessive-compulsive disorder) within African Americans, creating cultural adaptations of evidence-based treatments, and utilizing mobile-health technology to increase access to mental health treatments for underserved populations. He is currently completing his predoctoral clinical internship at the Albert Einstein College of Medicine/Montefiore Medical Center in the Bronx, New York.