Running head: FUTURE OF TELEPSYCHOLOGY TITLE PAGE 1
Future of Telepsychology, Telehealth, and Various
Technologies in Psychological Research and Practice
Marlene M. Maheu
Myron L. Pulier
Joseph P. McMenamin
Les Posen
FUTURE OF TELEPSYCHOLOGY 2
Abstract
It is increasingly urgent for psychologists to confront the difficult questions raised by the way
that information and communication technologies are altering not only health care, but the
human experience worldwide. Whether psychologists embrace or resist aspects of technology,
they should: recognize how advanced technologies are changing the way we communicate and
process information, anticipate needed growth, and prepare to meet ensuing challenges to
professional psychology. Exponential growth of technology is enabling new mental health
services, extending existing ones, and augmenting options available to individuals for self-
monitoring and decision-making, both with and without professional involvement. Professional
organizations can help retain psychology’s leadership position by promulgating more specific
guidelines and policy for science, practice and education. Protection of clients already requires
new legal and regulatory initiatives for licensure, referrals, client education, privacy, screening,
assessment, record-keeping, reimbursement and self-help product development. Protections for
psychologists require new risk management procedures and adaptations by malpractice carriers
as multidisciplinary teams evolve within and beyond health care into new public and private
sector arenas. Key technologies that presage future trends include video teleconferencing,
"smart" mobile devices, cloud computing, virtual worlds, virtual reality and electronic games.
Predicting change and adapting psychology accordingly will enable psychologists to future-proof
their workplaces. Equipping future generations of psychologists and patients to collaborate more
successfully in all potential growth areas requires educators and trainers to increase their focus
on technology in graduate education, training and supervision.
Keywords: telemental health, mhealth, online therapy, malpractice insurance,
reimbursement, licensure
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Future of Telepsychology, Telehealth, and Various Technologies
in Psychological Research and Practice
Two potent forces—the technological expansion of health care delivery and heightened
consumer expectations—present psychologists with the imperative to efficiently and ethically
leverage new tools and systems to enhance practice, research, education, training and policy.
Despite individual psychologists choosing to adopt or resist the profound changes in delivery of
and demand for behavioral healthcare services, administrators, clinicians and their professional
organizations should recognize the nature, advantages and dangers inherent in the changes,
anticipate how technology will continue to transform practice and prepare for the expected
opportunities and challenges.
Information and communication technology (ICT) in health care has given rise to the term
telemental health to describe telehealth activities focused on behavioral health care (Baker,
2011). Telehealth itself encompasses not only direct provision of professional care to remote and
home-bound clients such as by video teleconferencing, but also administrative, back-office and
continuing educational activities mediated by technologies, websites and smart device “apps”
that help client access trustworthy ICT resources, electronic diaries, telephoned reminders and
self-monitoring tools—technologies that can readily supplement traditional services for patients
who come in for in-person treatment, and that can provide valuable assistance to populations
worldwide who will never obtain direct care.
Recognizing the Role of Technology in Professional Psychology
Telemental health extends beyond psychological disorders, problems of living and self-
development to take on such psychological aspects of general health care as adherence to
treatment plans, lifestyle issues and preventive care. In these ways, ICT is altering the medical
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ecosystem and supporting wider participation of psychologists in all of health care, both medical
and non-medical. Non-health-related aspects of psychology also are poised for rapid expansion.
In "traditional" practice of clinical psychology, ICT can facilitate working with other treating
professionals (such as a patient's primary care physician, psychiatrist, social worker and, indeed,
non-professional carers) as a team (Siebdrat, Hoegl, & Ernst, 2009). Beyond this currently
common "split treatment" model, increased attention to the psychological aspects of general
health care can be expected as accountable care organizations (ACOs) focus on cost containment
(Rozensky, 2011) and put greater emphasis on collaborative management of the most expensive
chronic illnesses (Von Korff, Gruman, Schaefer, Curry, & Wagner, 1997). ACOs are
associations of providers that assume responsibility for the cost, quality and care of a group of
people covered under federal health care programs (Devore & Champion, 2011) as codified by
law (Patent Protection and Affordable Care Act, 2010). These new entities deploy "medical
home" and other patient-centered approaches, emphasize preventive care through
multidisciplinary teams that may include mental health professionals and employ electronic
clinical records and other ICT tools (Beacham, Kinman, Harris, & Masters, 2012; Tew, Klaus, &
Oslin, 2010). Psychologists can not only participate in ACOs, but may be best suited to optimize
team interactions within such entities (Siebdrat, Hoegl, & Ernst, 2009) and to support
communications with family and patient to encourage self-management (Wagner, et al., 2001)
and their use of Internet-based support resources (Paul, et al., 2011).
With the psychotechnologies (those technologies particularly useful for delivery of mental
health care), psychologists can attract new clients, perform screening, assessment and various
kinds of therapy (Holländare, Andersson, & Engström, 2010) and offer a range of services
beyond what was formerly practical or even possible.
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Benefits of the psychotechnologies in complementing traditional mental health services
have long been substantiated (Maheu, Pulier, Wilhelm, McMenamin, & Brown-Connoly, 2004),
allowing psychologists to ethically conduct clinical assessments and therapy wholly or in part by
telephone, email, videoconferencing and websites (Donker, van Straten, Marks, & Cuijpers,
2009). When conducted in carefully controlled settings, highly successful outcomes have been
documented. For instance, in a in a study of 98,000 mental health patients, hospitalization
utilization was decreased by an average of 25% between 2006 and 2010 when telemental health
services were delivered with remote videoconferencing (Godleski, Darkins, & Peters, 2012).
Telepsychology offers opportunities for adequately prepared professional psychologists to
not only increase their effectiveness, but also broaden their range of services and enrich their
practices (Eonta et al., 2011; Glueckauf, Pickett, Ketterson, Loomis, & Rozensky, 2003; Greene
et al., 2010). However, telepsychology also calls for innovation in graduate training; continuing
education; guidelines from professional associations; and for new approaches in insurance
coverage, regulation of professional activity and applicable law (Eby, Chin, Rollock, Schwartz,
& Worrel, 2011). Regulation of telepsychology is expanding (Gilbert, 1999; Health Insurance
Portability and Accountability Act, 1996). Reimbursement is becoming available, particularly for
Medicare and Medicaid services (Davidson & Santorelli, 2009). Telepsychologists are needed in
a variety of institutional settings including correctional facilities, schools, hospitals, the military
and particularly in nursing homes (Maheu et al., 2004), where the mandatory reduction of
antipsychotic medications will require behavioral interventions (Centers for Medicare and
Medicaid Services, 2012).
Telemental health is increasingly consumer-driven to an extent that is outrunning
professional readiness and opening opportunities for non-professionals to displace psychologists
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in supplying counseling. The International Telecommunication Union (2012) estimates that 87%
of people on our planet already had cell phone subscriptions by mid-2011. Even rural Americans
will soon have access to online video and other high-speed services (National Broadband Plan,
2010). The psychotechnologies are profoundly altering consumers' communication about
psychological issues with both peers and professionals, and how people seek and acquire
knowledge in this area (Beckner, Howard, Vella, & Mohr, 2010; Neil, Batterham, Christensen,
Bennett, & Griffiths, 2009). Consumers increasingly expect to be able to contact professionals by
email and text messaging. The health industry, including insurers and even pharmaceutical firms,
are steadily responding to patients' demand for information (PwC Health Research Institute,
2011).
Research and Technology
Technology does not bring unalloyed good news for psychologists. Patients sometimes
prefer telephone and Internet-based interactions above in-person meetings with psychologists
(Mohr et al., 2010), even though the quality of psychology resources directly available to
consumers is inconsistent (Klein, et al., 2010). Using technology, primary care physicians may
achieve outcomes comparable to those of psychotherapists (Shandley et al., 2008). Consumers
can independently access certain fully automated psychological tests and other interventions
online (Andrews, Cuijpers, Craske, McEvoy, & Titov, 2010), but effectiveness and standardized,
ethical administration generally need far more attention. There is thus a great need for higher-
quality research (Hailey, Roine, & Ohinmaa, 2008; Whitten, Johannessen, Soerensen, Gammon,
& Mackert, 2007), particularly in evidence-based methods for bringing treatment safely into the
"unsupervised" setting of patients' homes (Luxton, Sirotin, & Mishkind, 2010).
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That 9.8% of responding practitioners already use weekly email for clinical services
(Jacobsen & Kohout, 2010) raises questions about practitioner training and assessment of clinical
competence. Severe penalties exacted by licensing authorities for online violations of
professionalism highlight the need to promote training to increase understanding and self-
monitoring of practitioners' Internet-communications with patients (Greysen, Chretien, Kind,
Young, & Gross, 2012). What are the repercussions of using platforms such as Skype™,
Facebook™, Twitter™ or other Internet platforms without adequate training (Cretien, Azar, &
Kind, 2011)? Can these or similarly easy-to-access platforms be used more safely? To what
extent will their availability and power enable non-professionals to draw consumers away from
receiving proper, ethically-delivered care? How can the psychology profession respond to such
divergent yet pressing challenges?
With psychology research institutions at the forefront of understanding both normal and
abnormal human behavior, human factors, marketing and consumer behavior, in addition to ever-
growing specialties in psychotherapy, psychology is in prime position not only to shepherd the
change of technology adoption for all health care, but to lead other health professions in the
journey. More specifically, as scientist practitioners, psychologists are in an optimal position to
consider evidence-based data and integrate them with technology. For one thing, research is
showing how improvements in user interface and in system capabilities can overcome reluctance
by patients and clinicians to adopt ICT more widely (Krist & Woolf, 2011).
Gordon Paul (1967) called for optimal fit among patient, problem and intervention. As
technological options increase, it is becoming more imperative for psychologists to add their
selections of best technology to Paul's list (Glueckauf & Lustria, 2008; Harwood et al., 2011;
Maheu, et al., 2004).
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Furthermore, technology is bringing consumers greater options outside of traditional
mental health care that might better meet their access needs because of cost, location, time of
day, language, social class, educational level, available social support and other circumstances…
specifically services available in their hip pockets, through a mobile device. With teens already
preferring to communicate via social media and texting, it is reasonable to question whether, in
the next decade, in-person treatment will remain the primary mode of intervention (Fox, 2010).
Psychologists clearly need to identify and become familiar with alternative methods and services
to remain relevant and viable in the marketplace.
Anticipating the Future of Telepsychology
Consumers are embracing the unfettered flow of communication using whichever device is
near at hand. This development points to the need for psychologists to be trained in the risks and
benefits of an ever-growing variety of telecommunication tools (Schwartz & Lonborg, 2011). A
client can move smoothly from a supportive conversation on the telephone with a family member
in the morning; to an in-person therapy session with a therapist; to a crystallizing insight sent via
text messaging to a friend; to tracking with a smartphone-based, self-help "app" (i.e., application
or program) entry later that same day; and to further integrating lighthearted commentary on a
social networking website later that evening. A well-motivated individual might then also find a
self-help article or receive one from a supportive spouse, friend or family member for further
discussion the next day. Indeed free, Internet-based communication sources, psycho-education
and social media platforms will take over many of the current basic and support functions served
by psychologists, who, one hopes, will be available to understand and skillfully guide clients in
using the most appropriate resources, and possibly help clients tailor technology to their specific
needs.
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How can we anticipate which technologies are likely to become prominent in mental health
care delivery in the near future? The technologies most prone to rapid adoption are those that
allow us to enable, extend, augment and connect (Posen, 2011), as their built-in intelligence
facilitates completion of complex tasks with minimal demand for understanding how they work.
Once in widespread use, such tools become models for other technologies to follow (Kiplinger,
2010; Norman, 2011). It is increasingly important, then, for clinicians and administrators to
anticipate and plan effectively for future trends by understanding each of these aspects. With
these aspects in mind, we can predict that in addition to increased use of video teleconferencing,
the technologies most likely to be central in the telemental health are mobile devices, cloud
computing, virtual worlds, virtual reality and gaming.
Mobile Devices
The smartphone and tablet or pad computer devices best embody the attributes compelling
consumer acceptance of ICT and point to the tools psychologists and their clients will employ
over the next few years (Chen, 2011). Despite the "technological divide" associated with sex,
age, race, religion, physical challenges, political affiliation, wealth, education and location, these
handheld computers are quickly replacing cellular phones in general use. Many psychology-
specific applications or "apps" are available for researchers, practitioners, students and
consumers (Luxton, McCann, Bush, Mishkind, & Reger, 2011; Maheu & Pulier, in press.).
Enabling lets people accomplish what their bodies alone cannot. Smartphones enable
conversations with several people simultaneously, almost anywhere and at any time.
Psychologists can far better maintain continuity with clients, assess and respond to urgent
situations, quickly consult with colleagues and access professional literature when using such
psychotechnologies.
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Mobile smart devices extend people's ability to capture sounds and pictures and transmit
them for others to witness and share. They can guide and convey patients' symptom reports and
diary entries and will soon routinely monitor activity levels and psychophysiological values.
They can augment perception by explaining and commenting on what their GPS (global
positioning satellite) components, microphones and cameras detect in users' environments, in
order to enhance orientation, understanding and decision-making (Hainich, 2009; HeartMath,
2011). A smart device's clock enables personalized reminders such as to take medication,
practice a physical or mental exercise, break out of an obsessive trend or relax. Sensors can
sharpen patients' awareness of their emotional states and can support biofeedback training at
locations and times where it may be maximally effective, rather than only in a therapy office.
Beyond talking with one person at a distance, the mobile devices connect users with
"social media" such as Facebook and Twitter that provide personal multimedia scrapbooks and
virtual billboards that can be viewed by large numbers of strangers (Shirky, 2008) as well as
access at any time to peer support groups of all sorts (Griffiths, Calear, & Banfield, 2009). For
some, such communication has been their only escape from marked social isolation, while for
others it may be removing them from more-intimate contact. In either case social media are
already profoundly affecting how people relate to each other, and will continue to grow as an
essential ingredient of therapeutic intervention.
Smartphones and tablet devices will sweep away concerns some psychologists have about
using personal computers. These devices, though simple in appearance, offer exceptional power
and diversity of applications, and reduce the downtime and extra privacy challenges of accessing
third party technical support. Psychologists will routinely conduct not only therapy but also
clinical assessments at a distance, write up clinical data, back everything up and securely share it
FUTURE OF TELEPSYCHOLOGY 11
across devices and locations from their offices via cloud computers (see below) even when
thousands of miles from their offices (Miller, 2009).
Some vendors already claim their smartphone videoconferencing devices are "HIPAA-
compliant," meeting standards for privacy (e.g., O’Grady, 2011). Such secure communication
can support variations on evidence-based practices such as exposure therapies. Better than
handing out pamphlets, or recommending books and websites, clinicians can supply patient
education materials to be accessed on mobile devices and, especially for anxiety and depression,
evidence-based treatment programs and exercises (Barak, Klein, & Proudfoot, 2009). Solutions
currently exist to accept debit and credit card payments for clinical services (Schropfer, 2010).
Electronic wallets will be available in the near future, making payment easier and quicker.
Beyond speech recognition for dictation, smart devices can already recognize the meaning
of spoken questions and seek answers from specialized databases (Sung, 2011), enabling
psychologists to search clinical records and research publications "on the fly" or to find other
psychologists who have made similar queries, thus creating new opportunities not only for
collaborative work but also for discussion of current clinical issues or making referrals. The
cameras and microphones in smartphones and tablets support multi-person videoconferencing
that can be used for discussion with peers, senior clinicians and leaders in various fields to assist
psychologists in training, special-skill development and even telesupervision.
The adoption of smart devices by psychologists and clients will allow for variations on old
themes. Psychological test vendors will offer more of their assessment tools, modified and
normed for computer administration (e.g., Digital library, 2011). Internet connections will make
scoring much easier and more reliable, so that tailored reports will be available immediately after
clients submit their data. Such assessments will also be inexpensive and housed in sensor-based
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technology and software. They will permeate the consumer market, making clients able to use
smart devices equipped with biosensors to measure, explain and intervene with individually-
tailored therapies that appear on mobile phones in response to cardiovascular signals as piloted
with Intel's Mobile Heart Health project (Morris & Guilak, 2009). Various home-based and
wearable computers are also in development to assist psychologists develop interventions that
will be available at the moment of need, rather than practiced then left in the therapy office
(Morris, this issue).
Already, even clients with the lowest-quality equipment and electronic communication
linkage can take advantage of symptom diaries, reminders and situation-relevant advice features
available via ordinary cell phones. Even very low-end "user-friendly" telecommunication can
augment traditional rehabilitation psychology services for individuals and families burdened with
chronic conditions (Dollinger & Chwalisz, 2011; Dorstyn, Mathias, & Denson, 2011; Forducey
et al., 2003).
Blogging and personal websites give psychologists a voice outside of mainstream peer
reviewed publications to express their ideas and creativity, something long suggested by
psychologists to their clients (Pennebaker, 1997). Barriers to publishing books, articles and
multimedia presentations will continue to crumble, allowing psychologists to reach new
audiences and to initiate lively discussions of their work online, as well as to create new risks
from disseminating inaccurate or ill-advised information. Consumers with combinations of
symptoms will not only be able to find each other in support networks, but also to communicate
securely and share technology-accumulated data to contrast and compare symptom patterns.
Cloud Computing
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An emerging technology that will enhance the impact of mobile smart devices on
telepsychology is cloud computing. Consumers already use such distant coordinated arrays of
computers for storage, data processing and other services beyond what is available on their
personal computers, to give their mobile devices capabilities comparable to desktop computers
and to yoke all their ICT devices at home, at work and on the go into an integrated array. Free
Web-based email services such as Gmail and Yahoo! and photograph managing services such as
Picasa™ use cloud technology. Apple, Inc. users already keep the music, ebooks, videos and
movies they purchase on the iStore cloud. In place of Microsoft Office™ on one's desktop
machine, Microsoft Web Apps™ make document processing and data storage available on a
cloud to any Internet-connected device. Rather than purchase, install, configure and upgrade
programs, users now just lease a few milliseconds of data processing when needed, paying only
for what they use, and sharing with hundreds of thousands of other subscribers the cost of highly
sophisticated speech-processing (e.g., dictation) and statistical programs. For health care
professionals, the cloud will make Bayesian-based diagnosis and clinical decision-support
affordable, and pair these services with top-quality security.
The cloud model already facilitates communicating with a patient and family between in-
person sessions, anytime, anywhere and using whatever devices are convenient or relevant at the
moment. The cloud model also promotes an "ecological" perspective that facilitates integration
of professional interventions with other activities involved in the patient's health, fitness,
lifestyle, education, social function and general adaptation.
In the future, a clinician's cloud service can have clients' smart devices acting as virtual
personal computers, dedicated to each client's mental health care. Though appearing like
machines with which the patient is otherwise familiar, such "appliances" will accept ordinary
FUTURE OF TELEPSYCHOLOGY 14
email, will be far less vulnerable to attack by viruses or hacking, and, when appropriate, will
limit retrieval of Web pages to those approved by the clinician (or some reliable authority) as
providing trustworthy information and advice. This could markedly reduce the risk of theft of
sensitive information accomplished via "social engineering," which would be the greatest
residual vulnerability after implementation of a sound cloud strategy. The virtual computer
would be activated only after the patient and clinician have reliably authenticated their identities.
All communication would be strongly encrypted, and after a therapy session or other dialog ends,
the virtual computer would remain available to pick up where the patient left off using other
healthcare resources. Even if a patient's real devices are infested with viruses, and if Internet
access is via a public WiFi hotspot it could be possible for her smartphone or personal computer
to function as a virtual computer safely.
Reliability of a cloud-based system is already excellent. Cloud computing offers automatic
backup and expert maintenance of equipment so that the core service is unlikely to lose data or to
malfunction. If one of a user's devices fails, or the Internet connection goes down, it is easy to
substitute another device or connection, perhaps at a friend's or at a public library.
While security and unauthorized access to sensitive private information is a particular
concern when transmitting and storing data remotely, cloud computing actually can ensure
greater safety because the costs of maintaining highly sophisticated protection that is well
beyond the capability even of large health care organizations are amortized among the large
customer base of cloud service providers. The fact that major financial institutions are adopting
cloud technologies attests to the security of this resource when correctly implemented. Health
care administrators should be aware of the special security and ethical issues and should learn
how to operate their ICT systems properly in ongoing collaboration with carefully selected cloud
FUTURE OF TELEPSYCHOLOGY 15
providers (Devereaux & Gottlieb, in press). All these considerations suggest the cloud
arrangement will become dominant in very few years.
Virtual Worlds, Virtual Reality and Gaming
Over the next five-years, gaming, virtual reality and virtual worlds are likely to gain
prominence in mental healthcare. Gaming apps for smartphones are proliferating rapidly
(Koekkoek, 2011). For the next generation of clients, who often play electronic games for hours
each day, game formats may be preferred for home-based clinical as well as self-help
interventions across a range of mental health issues (Lenhart, Lewis, & Rainie, 2011).
Techniques in gaming design are currently successfully adapted to deliver virtual exposure
sessions for veterans returning from war (Rizzo et al., 2011a). Patients experience a sense of
immersion in what appeals to the senses as one's actual environment with which one interacts in
real time so that one's responses and decisions seem to have immediate consequences. There are
clinical applications of virtual reality for common anxiety conditions with results approximating
those of in vivo exposure programs (Rothbaum et al., 2006). There are also effective Internet-
based self-paced programs set in virtual worlds (Moore, Wiederhold, Widerhold, & Riva, 2002).
Consumer-grade virtual world technologies have become readily available. As one example, in a
virtual world groups can meet and interact online, with individuals depicted as animated
characters ("avatars") behind which consumers maintain anonymity (Hoch et al., 2012).
As avatars improve in convincingly replicating human facial and bodily movement they
will be used not only for gaming, but also to "populate" psycho-educational environments that
support treatment resistant populations such as returning war veterans who need but refuse
mental health care (Bush, Bosmajian, Fairall, McCann, & Ciulla, 2011; Rizzo et al., 2011b).
Telepsychology Law, Regulation and Reimbursement
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In addition to educated guesses about where technology will lead, psychologists may
anticipate where governance is headed. Licensing authorities are, of course, expected to protect
the public from dangerous or inadequately trained care providers, but the fact that practitioners
are increasingly treating clients at considerable distance, usually "below the radar" of authorities,
raises new issues. Characteristic of telehealth, the "collapse" of distance, requires revision of
licensure to both help control and ease cross-jurisdictional practice (American Telemedicine
Association, 2011). Aside from the Nurse Licensure Compact (Puskin & Tipping, 2010), adopted
by only 24 U. S. states, there is no inter-state portability arrangement. The closest approximation
for psychology is that advanced by the Association of State and Provincial Psychology Boards
(ASPPB), which offers licensure mobility solutions for psychologists. Out of these efforts, is the
likely emergence of a national license for the several health professions as seen in Australia,
perhaps limited to inter-state electronic services or permitting a “consulting exception.”
National (or international) licensure could coordinate standards, yet retain a sovereign
state's ability to monitor practice, and dispense discipline to clinicians engaged in egregious
behavior. Protection of the public may also call for requiring clinicians to demonstrate
acquisition and maintenance of competence with at least some psychotechnologies and their
optimal methods.
Today, every cell phone can be a medical device, but the U. S. Food and Drug
Administration (FDA) is ill-equipped to deal with communications issues and the Federal
Communications Commission is a relative stranger to health care. Hence the proposal by the
Institute of Medicine (IOM) to create a new agency to regulate "mobile health" is also likely to
bear fruit as technology increasingly permeates the healthcare landscape (Committee on Patient
Safety and Health Information Technology, 2012). Any such new agency may face resistance
FUTURE OF TELEPSYCHOLOGY 17
from the incumbents (See, e.g., Food and Drug Administration, 2011). Psychology and other
professions will have to appropriately influence the precise mission, powers and composition of
such an agency in the interests of itself and its consumers.
Privacy will remain a challenging problem, as technology transfers information and
resulting power to consumers through social media and mobile devices. Although HIPAA,
HITECH (Health Information Technology for Economic and Clinical Health Act, 2009) and
analogous state statutes give government ample authority to police providers’ privacy practices,
the plaintiffs’ bar will become increasingly active in seeking money damages in tort. Providers
will need to stay abreast of technological developments improving the privacy, security and
accuracy of their communications, and evaluate ethical and practice guidelines for informed
consent and minimizing the extra patient risk inherent in treatment at a distance. The average
clinician working at a distance will also need to better understand and manage access to local
resources and emergency backup teams. As the psychotechnologies change the standard of care
(such as by requiring certain distance care capabilities) and as reports of untoward events appear,
malpractice carriers will develop new approaches, perhaps offering discounts on premiums for
clinicians who have received special training in use of the psychotechnologies.
Third party reimbursement for telepsychology has been inhibited, perhaps by tight budgets,
fear of abuse, or ignorance, but has been available from Medicare and Medicaid in rural areas.
More general relaxation of restrictions on reimbursement will probably occur first in those
federal programs, where data suggest that telepsychology is cost-effective care for management
of chronic problems. Reimbursement for psychological interventions will also increasingly
involve disease management. Even without direct third party action, Accountable Care
Organizations (ACOs) may choose to deploy psychologists for the management of costly
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physical conditions. Because of their expertise in designing and implementing assessment and
interventions for future health maintenance, psychologists may have much to offer chronic care
and primary care practices through "health homes" designed to help contain healthcare costs.
Psychologists will be in good position to benefit from expansion in technology-related research
to meet the increasing demand for more accountability and responsiveness to outcome measures.
Patients themselves are already willing to bear the cost of distance care online. This is
consistent with the growing emphasis on patient-centered care, and will circumvent obstacles
that the public increasingly sees as intolerable. However, clients have been turning to—and
directly paying for—life coaches and other professionals who practice online, many of whom are
inadequately trained for telemental health care and are unlicensed to practice in areas they
service publically without regulation. What impact this trend will have on psychologists' practice
is unclear, but the issue demands discussion.
Preparing Practice and Policy for the Future
As the psychotechnologies proliferate, so will increasingly complex issues. How will
psychologists resist the inherent temptations of increased access, greater convenience, decreased
costs, lack of an evidence base and lack of training to combat the lure of an ever-increasing array
of gadgets available for service delivery? How do different technologies change interactions
among consumers or with their psychologists about health, mental health and life-skills? Which
competencies will the psychologist of the 21st Century need to possess for email, instant- or text-
messaging, chat room groups, video, virtual worlds or virtual reality (Maheu & McMenamin, in
press)? How much practitioner training and/or supervision is sufficient before embarking on
professional services with any single new technology? Evidence of practitioner errors in
judgment in their online behaviors is beginning to mount, such as outright profanity, boundary
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infractions and other questionable behaviors (Cretienet al., 2011). Solving such issues by trial-
and-error is sometimes warranted, but often unacceptably risky to clients. Such errors may create
legal and ethical vulnerabilities for the clinician. Evidence-based data leading to professionally
promulgated practice guidelines, themselves subject to continuing revision because of
accelerating technological evolution, will soon assume paramount importance (Maheu &
McMenamin, in press.).
The psychologist of the near future will be called upon to render services based on
relatively minimal and increasingly inadequate scientific knowledge, training or legal guidance
and protection. Psychologists (e.g., Belar, 1998; Glueckauf et al., 2003; Glueckauf & Lustria,
2008, Maheu et al., 2004; Maheu, Whitten, & Allen, 2001) have discussed the need for
psychologist training in the delivery of telehealth at the graduate and postgraduate levels, in self-
assessment and in continuing education regarding the complexities of intake, record-keeping,
direct care, referrals, and emergencies in an effective and legally and ethically appropriate
manner as technology continues to expand in all directions. Graduate psychology training should
take a proactive approach to promoting psychology's inclusion in the general health care system
(Reid-Arndt, Stucky, Cheak-Zamora, DeLeon, & Frank, 2010) as well as other areas of business,
commerce and the arts.
Administrators should prepare themselves to be able to organize their information systems,
task assignments, lines of responsibility, contracting procedures, financial arrangements and
monitoring activities to optimize safety, cost-efficiency, clinician competence, user satisfaction
and other aspects of telemental health within their domains. In particular they should learn how
to use cloud computing resources safely and how to instill safe use of ICT among clients as well
as clinicians for the sake both of clinical outcome and risk management.
FUTURE OF TELEPSYCHOLOGY 20
Professional associations should provide specific guidelines for using psychotechnologies
as they emerge, particularized for various clinical populations, conditions and circumstances;
identify and set standards for required competencies not only in clinical training programs, but
also in education, science, and policy. This oversight is also needed to assist regulatory bodies,
third party payers and insurers to devise approaches, rules and procedures that reduce risk to
patients yet support psychologists to advance the profession in systematic, safe and ethical
manners consistent with efficient work flows and successful outcomes. Clear evidence-based
guidelines, regulations and administrative norms for psychologists will enable collaboration with
ITC developers to proceed with greater confidence in creating new products and services that are
most likely to be effective, accepted, reimbursable and profitable.
What will be the role of future psychologists? Psychologists currently are at a crossroads.
Their future depends on the speed with which they organize to make themselves more relevant in
the current technological marketplace. To date, their involvement with ICT lags that of other
healthcare disciplines (Maheu et al., 2001; Maheu et al., 2004) as well as non-healthcare groups
online. Each individual psychologist needs to decide whether, when and how to leverage
technology. Similarly, each professional association and organization needs to decide whether to
allocate needed resources to shepherd technology adoption or take a back seat to other
disciplines.
FUTURE OF TELEPSYCHOLOGY 21
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