Module 7: Special Populations
Special populations, as defined by the federally mandated Strengthening Career and Technical Education for the 21st Century Act (Perkins V), include:
- Individuals with disabilities
- Individuals from economically disadvantaged families, including low-income youth and adults
- Individuals preparing for nontraditional fields
- Single parents, including single pregnant women
- Out-of-workforce individuals
- Homeless individuals
- Youth who are in, or have aged out of, the foster care system
- Youth with a parent who is a member of the armed forces and is on active duty
- Individuals with other barriers to educational achievement, including individuals with limited English proficiency
Considerations for Special Populations in Telepsychology
In the context of psychotherapy and psychological practice, it is the duty of practitioners to deliver high quality and culturally competent care. Competence in working with special populations is defined as the ability of a practitioner to integrate into their interventions, services, and conceptualizations elements of diversity that may impact the client and therapy progress (Fuertes & Ponterotto, 2003).
Special considerations should be taken for vulnerable populations and their needs over telehealth.
- Practitioners and telepsychology providers should be cognizant of and address the experiences of clients from special populations.
- These special considerations can be built on foundational diverse and multicultural counseling competence.
- Telepsychology practitioners should develop systems of patient-centered and integrated care that responds to the unique needs of diverse areas and populations. (McCord et al., 2020).
Practitioners should also exert reasonable effort to be aware of any shortages of social support and/or resources for their clients in underserved areas. Furthermore, providers should also seek to understand the impact of the stigmatization of marginalized groups on their clients, as well as the impact of local policies and legislation on attitudes towards minoritized groups (e.g. legislation regarding the rights of disabled populations, policies and services for youth in foster care, etc.). Providers may also engage their clients in appropriate conversation about their experiences and how these experiences may contribute to any presenting concerns (McCord et al., 2020).
Trey Armstrong, Ph.D., Licensed Psychologist and Louise Bonneau, LMSW developed the following Guiding Principles to telepsychology services for Clients and Examiners with Disabilities:
Your role is to enable equal access to service as opposed to doing things or making the process error-free for the individual. Resist the urge to do everything for them because they have a disability. Accommodation makes sense and keeps the individual in an active role. For context, family members and friends can be overly helpful or helpful in an unhelpful way, so you want to lean towards autonomy and respect.
They are a person with a disability, they are not wholly defined by it. Talk to your clients and examiners about what language they want used in reference to them and their disability. Use the terminology that makes them comfortable, not what makes you feel comfortable. You should also not assume that since someone has a physical disability then they also have a mental disability/IDD. For instance, you should not talk to someone like a 2-year old just because they are in a wheelchair.
One way to help build the therapeutic alliance is to be more descriptive when describing the counseling environment, the process of psychotherapy, and how you envision it going. Be mindful of your language and terminology (i.e., avoiding psychojargon) to better accommodate IDD for instance.
Helpful to have needed materials (manipulatives, forms, telehealth equipment) be in the same place every time.
Society at large as well as systems and social environments these clients exist in are not built for people with disabilities and can be invalidating—both overtly and covertly. From this, you may also find yourself in an advocacy role at times.
The telepsychology needs of child cases may be different from adult cases, and practitioners should do their best to adjust their telehealth care in the context of the children they are providing services to (American Psychological Association, 2020). A few important considerations for child cases include but are not limited to:
- The development of an understanding of telepsychology in child patients. Thus, the telehealth setup and services should also be explained to the client in a developmentally appropriate manner
- Difficulties establishing the same rapport as providers may be able to through in-person sessions. Stories, toys, and technologies are all possible tools for establishing rapport with the child to foster that strong patient-provider relationship even over telecommunications
- Keeping children, especially young children, engaged in the telehealth session. This may be done through switching activities or the use of interactive technology
- Awareness of the potential for child abuse and neglect. While noticing these signs can be more difficult than normal over telehealth, practitioners should still develop an awareness of the possibility
- Children with disabilities, medical needs, language barriers, from low income homes, and more may require adaptations to treatment
- E.g. a child without reliable internet may not be able to use videoconferencing to receive services, but they may be able to continue therapy by phone
- A child with autism may benefit from recreating the routines of in-person care as closely as possible
- A child with disabilities may require special therapies or supports
- Usage of appropriate screening methods to determine telepsychology fit. Environmental factors such as the ability of the family to create and maintain an optimal testing and service environment should also be considered
(American Psychological Association, 2020).
Populations with Disabilities – Hearing and Vision Impairments
Practitioners must ensure they are providing equal access to all patients during the provision of telepsychology services. Patients with sight, hearing, or neurological impairments may face difficulties when it comes to receiving psychological care through online services. Accessibility and communication are great mediators of outcomes for these populations (Wright, 2020).
There are auxiliary aids and services that can be utilized to enhance and improve the interactions between telepsychology practitioners and patients with specialized needs. Practitioners should remember to engage with their client when deciding which modality is most effective for communicating, as the patient will likely have their own preferences and know best what is most effective for them.
Furthermore, privacy and security should be of the utmost priority when it comes to telepsychology visits.
Some technologies that can be utilized to provide accessible services to those with visual or hearing impairments are:
- Video remote interpreting: A form of sign language that allows a deaf or hard of hearing patient to communicate via videoconferencing instead of live, on-site interpreting. Videoconferencing equipment is used at both locations (provider and patient).
- Assistive technology: Devices or equipment that can improve a patient’s Activities of Daily Living (ADLs) and enhance their ability to communicate.
- Closed captioning: The use of subtitles displayed on a television, video screen, iPhone or other visual display to provide interpretive information.
- Three-way video conferencing: Provider, patient, interpreter
- Telecommunications relay service: Operators facilitate telephone calls between deaf and/or blind patients and providers (Wright, 2020).
Pandemic consideration-Clear face masks: Protective masks that are transparent so that the patient can read lips and observe facial expressions. The patient can also wear these.
Armstrong and Bonneau (2021) recommend the following actions that clinicians can take to accommodate their clients with a disability:
- Visually impaired- Be descriptive in terms of what environment they are in, that you are in, and how eye contact typically looks with clients. Audio cues and ensuring high quality audio can help.
- Hearing impaired- Ensure that the client can see the interpreter and you at the same time. This can usually be accomplished by turning off Speaker view (one speaker at a time) and having all video feeds shown at once. Remember that all communication in the session must be interpreted by the interpreter and relayed to the client. If the interpreter needs to talk directly, they will identify themselves first. Expect for these sessions to be longer, and it’s okay to go a bit slower in therapy if needed. Best practice regarding documentation is to include the interpreter as an identified participant in the session, the interpreter agency (if used), and the interpreter’s license number. For those hard of hearing, understand that lipreading may play a major role in how they understand and comprehend others. This has the potential to be diminished over telehealth, so it can help to talk slower and make sure your video quality is high. When adjusting your voice for hard of hearing clients, it’s helpful to ask what specific changes could help (i.e., higher volume, adjusting your rate, high versus low pitch, etc.).
- Physical disabilities- It is helpful to have a sit-stand desk at the station that allows for the height to be easily adjusted to accommodate different kinds of wheelchairs as well as allow for eye contact levels to be adjusted if needed.
- Consider velcroing any needed materials (e.g., TV remotes) to the desk to ensure consistency; this is more important in a videoconference-type telehealth setting (e.g., VA setting) than using a desktop, which can utilize accessibility software. Be mindful that the telehealth equipment used is accessible regarding fine motor control and dexterity issues (e.g., wireless mouse receivers can be tricky to plug in, phones should be positioned within reach).
- For telehealth services provided through hub and spoke or through agencies/organizations (as opposed to direct-to-consumer), there should be accessible paths, doors, and restrooms as well as handicap accessible public transportation options to the clinical setting. Many barriers/factors that impact underserved clients such as transportation issues, lower SES, underinsured, rural-residing can be amplified for individuals who also have a disability.
- Helpful to take the perspective of the client. This is particularly important for clients with visual impairment. When directing the client, use orientation heuristics (e.g., clock position: the mouse is typically at your 3 o’clock, the monitor is dead center at 12, and with the webcam position, you are looking at about 1 o’clock). Helpful to, as best as you can control, have a consistent path to and from things. Be sure to reorient if furniture is rearranged or if using a different room/environment than they’re familiar with. Principle to keep in mind with visually impaired clients is pathing. The shortest or quickest way to something is not the best way if it is unfamiliar to them. Paths that involve a small number of turns or are more straightforward even if they are longer are preferred.
Safety and Privacy of Special Populations
Safety is an essential component of care delivery, especially for special cases and vulnerable populations (Cowan et al., 2019).
- In the case of child and adolescent populations, for example, while access to telepsychology does involve a baseline increase in access to mental health services, underserved youth may have difficulties accessing care due to limited or unreliable access to the internet and technology
Furthermore, safety and privacy in telepsychology is important to consider within the context of special cases. This is especially true for the provision of telepsychology care for youth and adolescents, as these individuals may be in the same physical space as others while care is being delivered. Confidentiality should be discussed with the client and with their caregivers through an informed consent process, and practitioners should do what is reasonably appropriate to ensure the privacy and confidentiality of their clients and/or patients.
In more serious cases, workflows and risk mitigation tools should also be carefully considered if a practitioner notices that their client may be presenting with escalating safety concerns. Think of the following situations:
- An older adult who lives alone in an apartment may describe suicidal ideation while on a telepsychology call and the phone line suddenly cuts off during the session
- A child who is left alone during the middle of a session for a significant amount of time
- A teenager displaying self-injurious behaviors during a video session
- A client experiencing a seizure event in session
- A situation in which a minor with a history of trauma suffered from a caregiver is receiving telepsychology services in the home where the caregiver is present. This results in not only safety and access concerns for the minor, but also behavioral concerns that must be considered in context
In all of these cases, practitioners should identify the appropriate risk management practices and operational workflows to ensure the safety of their patients to the best of their abilities. Ensuring the availability of a trusted caregiver to help mitigate risk in youth receiving telepsychology services may be considered; leveraging care coordination, agency supports, and emergency services may also be considered; and practitioners should work to develop an understanding of their client’s familial resources and similar supports, especially for more vulnerable and disadvantaged populations (Li & Childs, 2021).
Examiners/Therapists with Disabilities
Armstrong and Bonneau (2021) outlined recommendations for those with disabilities who will provide the psychological services:
1. Imperative that you self-reflect and know what specifically you are willing to disclose to your clients and what you are not. To help establish a strong alliance early on, consider disclosing initially about yourself and your disability along with considerations that you want the client to be aware of in your work (e.g., I can’t really recognize people when I’m shopping, so if you run into me and I don’t say anything, I’m not trying to ignore you).
2. Imperative for you to communicate your needs and what accommodations will help you be successful to your organization, agency, or employer.
3. Imperative for supervisors/agencies to make training decisions alongside their examiners with disabilities. Closed-door meetings regarding accommodating examiners should be avoided as well as unilateral decision-making. This takes away autonomy from the person. While the outcomes may be the same, the examiner with a disability should be aware of the potential burden placed on them in certain situations and retain their choice in the matter. Additional burden should be mitigated through discussion and accommodation as well as compromise.
4. One factor that can affect both agencies and examiners with disabilities is stigma. Agencies should be mindful of greater societal and cultural views/messages surrounding individuals with disabilities. It is also imperative that agencies are familiar with the basics of the Americans with Disabilities Act of 1990 (ADA) law and its protections. They should also be fluent with the difference between equality and equity. Treating everyone equally may not be helpful and can be harmful at worst. This is similar to therapists saying, “I don’t see race”, “I’m colorblind.” In that it diminishes the unique challenges faced by individuals (often put on them by society at large and the majority).
5. Stigma can also be internalized by individuals with disabilities. They may feel shame or guilt around asking for help. The greater context of having a disability is the potential to worry constantly about being a burden on others, whether this is rational and justified or not. Individuals with disabilities should know their rights (i.e., be well versed in ADA law and protections) and prepare to assert themselves in order to be successful.
- APA Telehealth Continuing Education Resources: apa.org/ed/ce/telehealth
- APA’s racism, bias, and discrimination resources: https://www.apa.org/topics/racism-bias-discriminationAmericans with Disabilities Act: ADA.gov
- National Association of School Psychologists: nasponline.org
- National Consortium of Telehealth Resource Centers: telehealthresourcecenter.org
- TBHI’s Americans With Disabilities Act (ADA) Policy: telehealth.org/ADA
American Psychological Association (2020). Connecting with children and adolescents via telehealth during COVID-19. http://www.apa.org/topics/covid-19/telehealth-children
Banks G. G., Butcher C. (2020). Telehealth testing with children: Important factors to consider. American Psychological Association. https://www.apaservices.org/practice/legal/technology/telehealth-testing-children-covid-19
Cowan, K. E., McKean, A. J., Gentry, M. T., & Hilty, D. M. (2019). Barriers to use of telepsychiatry: clinicians as gatekeepers. In Mayo Clinic Proceedings, 94(12) pp. 2510-2523.
Fuertes, J. N. (2012). Multicultural counseling and psychotherapy. In E. M. Altmaier & J. C. Hansen (Eds.), The Oxford handbook of counseling psychology, pp. 570–588.
McCord, C., Bernhard, P., Walsh, M., Rosner, C., & Console, K. (2020). A consolidated model for telepsychology practice. Journal of Clinical Psychology, 76(6), 1060-1082.