Perle: Training Psychology Students for Telehealth: A Doctoral-Level Education Model
Introduction to Telehealth in Psychological Care
Definition: Telehealth, also known as telebehavioral health or telepsychology, involves using electronic information and telecommunication technologies to support:
Long-distance clinical healthcare
Patient and professional health education
Public health
Health administration (Health Resources & Services Administration, ).
Purpose: Extends and supplements traditional face-to-face (F2F) approaches for psychological care.
Technologies/Modalities: Includes:
Videoconferencing
Telephone
Email
Mobile applications (apps)
Texting
Other messaging programs
Internet-based self-help programs.
Efficacy & Effectiveness: Research generally supports the efficacy and effectiveness of various telehealth modalities for:
Assessment
Intervention
Consultation
Training
Supervision across diverse populations (Langarizadeh et al., ; Zhou et al., ).
Importance of Education:
Developing true competency requires focused education on both general knowledge and hands-on skills.
While post-doctoral continuing education exists, there is a growing call for integrating telehealth-focused education into doctoral-level graduate programs (e.g., Glueckauf et al., ; Traube et al., ).
Graduate training is a significant predictor of later practice, providing a foundational skillset (Babione, ; Cook et al., ).
Addressing Mental Health Disparities: Telehealth skills enable future providers to reach larger, underserved, or rural populations without requiring relocation.
Current Gaps: Despite its importance, detailed student-focused telehealth training opportunities (e.g., Perle, ; McCord et al., a, b) have only recently emerged, and no formal model for doctoral-level education has been disseminated.
Proposed Model: This discussion proposes a model for doctoral-level graduate education, emphasizing training at multiple stages of a student's education, adapting to their evolving abilities. It discusses:
Competencies
Initial and advanced coursework
Direct application
Supervision
Program evaluation.
Core Competencies for Telehealth Practice
Definition of "Telehealth": An umbrella term encompassing numerous modalities and approaches.
Program Responsibilities: Graduate programs must define applicable educational targets, including:
Focus on Modalities: Single (e.g., videoconferencing) or multiple (e.g., email, telephone).
Approaches: Assessment, intervention, consultation, training, and/or supervision.
Settings: Tailored education for unique adaptations required in different settings (e.g., hospitals, prisons, schools).
General Competencies (Applicable across modalities, practice types, and settings, suggested for inclusion) (e.g., Galpin et al., ; Maheu et al., ; McCord et al., a, b):
Research on efficacy and effectiveness for mental health challenges (population- and modality-specific factors).
Differences between F2F and telehealth encounters.
Care considerations and adaptations (e.g., history taking, assessment, intervention, rapport).
Ethical considerations (e.g., informed consent).
Legal factors (e.g., cross-state practice).
Safety planning.
Data security.
Technology troubleshooting.
Practice logistics (e.g., electronic health records [EHR], documenting).
Implications of culture.
Adaptations for special populations (e.g., older adults, children, disabled).
Use of tools secondary to primary practices (e.g., apps).
Supplementing General Foci: Programs should add competencies matching their specific taught topics.
Example: If videoconferencing is emphasized, additional focus on:
Room setup (lighting, camera angles).
Video-related factors (platforms, resolution, latency).
Telepresence (i.e., facilitating eye contact through video).
Twin Pillars of Education: Education of competencies should provide both:
General Didactic Knowledge: Theoretical understanding.
Applied Knowledge: Practical skills.
These two are distinct but overlapping factors essential for developing expertise.
Initial Coursework: Laying the Foundation
Student Readiness: Doctoral students often start with limited clinical knowledge, not immediately ready for advanced telehealth topics.
Introduction Strategy: Introduce telehealth in core classes to:
Expose students to the topic.
Foster critical thinking about differences between F2F and digital methodologies.
Optimal Classes: Ethics, introductory intervention courses, and introductory assessment courses (with variations based on program requirements).
Context: Present telehealth as a viable alternative or complement to F2F services.
Key Concept: Telehealth builds on F2F methods but requires specific, unique adaptations, modifications, and considerations due to the technologies involved.
Example: In an ethics course outlining a duty to warn, instructors could challenge students to consider its application across state lines with differing jurisdictional laws.
Advanced Coursework: Deepening Expertise
Necessity: Merely integrating general information into other courses is insufficient for adequate competency due to the complexity of telehealth.
Target Audience: Mid- to higher-level students who have gained basic clinical knowledge.
Course Design:
Delves deeper into history, research, methodologies, and applications of telehealth.
Incorporates didactic information, readings, applied practices, and assignments evaluating both knowledge and application.
Curriculum Foundation (Perle, ): One of the few known curricula for doctoral-level psychology students, suggesting organization around themes:
History of telehealth.
Ethics and legality of psychological practice.
Synchronous telehealth methods.
Asynchronous methods.
mHealth (mobile health).
Other strategies (e.g., video games, virtual reality).
Telemedicine.
Logistical factors.
Training and supervision.
Hands-on Learning: Augments didactic knowledge and fosters application of techniques.
Methods: In-class exercises, and if available, simulation labs with medical actors.
Benefits of Simulations: Mirror true practice in a controlled environment (Griswold-Theodorson et al., ).
Performance Grading: Can include:
Student reflections on benefits and challenges of technology usage.
Formalized tests of general knowledge.
Grading of simulated experiences using rubrics to assess applied skills.
Twofold Goals of Novel Course:
Expose students to practice-related telehealth topics to increase comfort.
Provide an opportunity to troubleshoot common challenges through monitored work.
Out-of-Class Readings: Reinforce in-class learning and foster acquisition of novel knowledge.
Sources: Textbooks, journal articles, and websites.
Textbook Limitations: No single text contains all desired information due to differing emphases; thus, chapters from multiple books are likely needed.
General Information Textbooks:
Goss et al. (): Technology in Mental Health: Applications in Practice, Supervision, and Training – Second Edition.
Campbell et al. (): A Telepsychology Casebook: Using Technology Ethically and Effectively in Your Professional Practice.
Maheu et al. (): e-Health, Telehealth, and Telemedicine: A Guide to Start-Up and Success.
Myers & Turvey (): Telemental Health: Clinical, Technical, and Administrative Foundations for Evidence-Based Practice.
Domain-Specific Textbooks (e.g., Videoconferencing):
Tuerk & Shore (): Clinical Videoconferencing In Telehealth: Program Development and Practice.
Perle (): A Mental Health Provider’s Guide to Telehealth: Providing Outpatient Videoconferencing Services.
Competency-Focused Textbook: If desired, Maheu et al. () Telebehavioral Health: Foundations in Theory and Practice for Graduate Learners can be explored.
Updates: Peer-reviewed journal articles are crucial to supplement textbooks, which can quickly become outdated.
Direct Application and Supervision: Real-World Experience
Impact of Integration: The degree to which evidence-based practices are integrated during practicum and internship influences their use post-graduation (Babione, ).
Progression: Class-based education must be applied through real-world, hands-on work.
Students should first learn and apply F2F clinical approaches as telehealth methods are advanced forms adding technology-specific considerations.
Telehealth-Specific Practicum Experiences:
Foster applicable competencies through integrating telehealth assessments, interventions, and practice logistics (e.g., appropriate documentation, troubleshooting).
Include discussions of process-related matters (e.g., rapport building, identifying rupture markers).
Gradual Difficulty: Start with least difficulty and high support (e.g., diagnostic interview via video/telephone). Progress to more complex tasks (e.g., adapting/troubleshooting assessments/interventions for digital use).
Clinical Internship: Continue telehealth education with greater independence and challenges.
Supervision: Vital for proper implementation and professional development, ideally occurring in two ways:
1. Live Supervision (see Clark, for forms):
Monitoring: Supervisor observes silently.
Monitoring with Intervening (Co-therapy model): Supervisor observes and intervenes, with student involvement increasing with development.
Bug-in-the-ear method: Supervisor provides live coaching via a one-way receiver.
"Step-out" process: Student pauses telehealth session to consult supervisor via a secondary communication method, then returns to address issues.
2. Scheduled Supervision:
Format: F2F, via technology (e.g., videoconferencing), or a hybrid approach.
Structure: One-on-one, group format, or both.
Increased Time Requirement: Supervision of student telehealth practices will likely take longer than traditional supervision.
Discussion Points:
Clinical matters of the session (assessment/treatment, rapport, successes/failures).
Technological factors (technique adaptations, successes/failures).
Integration of technology and clinical services (how technology influenced services).
Plan for the next session (clinical steps, remedying technological issues).
Recommendation: Add additional time to the supervision schedule.
Additional Benefit: Supervision allows students to become more familiar with telehealth technologies.
Opportunity to try new methods (e.g., screen sharing, different videoconferencing platforms) and troubleshoot logistics in a guided manner before patient implementation.
Program Evaluation: Ensuring Continuous Improvement
Necessity: Ongoing evaluation of student and faculty factors is required for iterative programmatic improvement.
Monitoring:
General attitudes.
Recognized strengths and limitations.
Immediate and distal training effects.
Example of Distal Effect: Are trained individuals treating underserved or rural populations more frequently than those without such training?
Evaluation Protocols:
Currently, no formalized training protocols exist to systematically evaluate student competencies.
Programs must develop their own.
Recommendation: Utilize the aforementioned telehealth competencies as evaluation targets.
Foundation for Rating System: Maheu et al. () text on graduate learner competencies can serve as a basis for creating a tailored anchored rating system.
Conclusion
Overall Message: The rapid expansion of telehealth necessitates comprehensive education to ensure ethical, legal, and safe practices.
Contribution: This discussion outlines a proposed model for implementing telehealth-specific knowledge throughout doctoral-level graduate psychology programs.
Future Directions: While further work is needed to test this model, it offers a foundational framework for programs to begin development and subsequent modification to meet their specific needs and those of their students.