Enhancing Patient Access to Specialized Clinical Psychology Services through Direct-To-Patient Telehealth

The COVID-19 pandemic demonstrated the feasibility and benefit of widespread direct-to-patient telehealth delivery, which ultimately guaranteed its continuity long after the public health emergency ended. Although significant health disparities and the “digital divide” persist, the advent of telehealth helped address some important barriers to access in underserved regions where specialized care is often unavailable to patients unable to travel long distances. Perhaps unsurprisingly, an entire behavioral telehealth industry sprang up during and since the pandemic, with most companies providing general psychotherapy, counseling, and/or psychiatric medication management. While psychology specialists have also continued to provide telehealth services, there seems to be wide variation across providers, institutions, specialties, and services in terms of whether and when patients are required to return to in-office visits. This lack of consistency exposes some patients who had been relying on telehealth services to the same barriers that existed for them prior to the pandemic. For example, individuals with cognitive impairment, intractable epilepsy, or functional neurological symptom disorders often have their driver’s licenses revoked for personal and public safety and may not be able to rely on caregivers for transportation to scheduled in-office appointments. Similarly, individuals requiring psychological evaluations for solid organ transplant listing frequently live hours from their transplant center and have severe medical symptoms that make traveling difficult.

The literature on telehealth provision of specialty psychology services is sparse to date. Some data, albeit limited, demonstrate the effectiveness of telehealth delivery of neuropsychological assessment and behavioral interventions for functional neurological disorders. There is also some preliminary support for asynchronous, online interventions for specific clinical health needs, such as chronic pain, but these do not address individual patient needs and therefore often need to be supplemented by synchronous appointments with an expert. There is much more robust empirical support for synchronous psychotherapy for general mental health conditions, demonstrating that there are no significant differences in clinical outcomes when compared with in-person psychotherapy for a wide range of general mental health conditions. There is good reason to assume that specialty psychology services conducted via direct-to-patient telehealth can be provided with the same high level of quality as those delivered in-office. In line with evidence-based practice in psychology (EBPP), defined as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences,” there is a strong case for expanding telehealth for specialty psychology services when practical and no clinical contraindications are evident. This can happen while also conducting further research to fully understand the optimal use of telehealth in specialty psychology and its limitations.

The primary goal of advocating for telehealth expansion of specialized psychology services is, of course, to expand patient access to a scarce resource. A secondary benefit, however, may be an increase in the number of psychologists who pursue specialized training and board certification. The competent, wide-spread practice of telehealth facilitated by the Psychological Interjurisdictional Compact (PSYPACT) creates greater opportunity for psychologists who do not permanently live near academic health centers to offer specialized care to patients they would not otherwise be able to serve due to geographic distance and lack of affiliation with a specific health system. It also would allow specialists bound by restrictive covenants of former employers to continue serving patients in need of their unique expertise and skillset through other programs and institutions without having to relocate for new employment. By the same token, academic health systems struggling to recruit psychology specialists will likely attract greater numbers of highly-qualified applicants by advertising fully remote, telehealth positions for clinical psychology specialists. Given that many didactics, administrative meetings, and other academic activities have continued to be conducted via videoconference platforms (e.g., Microsoft Teams, Zoom), remote specialists can actively and seamlessly participate in training programs and engage productively with their departments, thereby contributing meaningfully to the non-clinical activities of academic health centers as well. Unfortunately, as of the time of this publication, very few fully remote psychologist positions in academic health centers are posted on psycCareers and other job boards.

To be clear, telehealth is not appropriate for every clinical service, every patient, or even every psychology specialist. There will always be a need for in-person care, integrated multidisciplinary teams, and face-to-face interaction with learners and colleagues in healthcare settings. However, the benefits of telehealth can and should be further embraced by psychology specialists and academic health centers in the service of patients who might otherwise be unable to engage in the type and level of care they can uniquely provide. Advocacy efforts at local, state, and national levels like those that psychologists and APA engaged in during the pandemic must continue to promote expanded insurance coverage and reimbursement for behavioral telehealth services. In addition, formalized training in behavioral telehealth should be incorporated into psychology internship and postdoctoral fellowship specialty rotations so that future psychologists understand the nuances of telehealth delivery with the specific populations they will be serving.