Cover Story

More psychologists are using telehealth to deliver behavioral services, but they're far from trading in their brick-and-mortar buildings for virtual offices.

Psychologists do of course use the telephone for long-distance sessions and consulting with colleagues. But providing therapy over a two-way audio and video link and even e-mailing patients remains rare.

Videoconferencing and Internet technology hasn't caught on yet, psychologists say, for two reasons. For one, the current technology isn't able to support face-to-face discussions with high-quality images--the kind that many psychologists believe are essential to providing good therapy.

But perhaps more importantly, practitioners are apprehensive about embracing a mode of therapy that's been so little studied.

"We continue to lack basic information about how and under what conditions telecommunications-mediated services lead to positive psychological and health-care outcomes," says Robert L. Glueckauf, PhD, director of the Center for Research on Telehealth and Healthcare Communications at the University of Florida, Gainesville.

The jury is still out on which technologies are best for delivering which types of services. "Unfortunately, there remains a paucity of empirical data that assesses the efficacy and feasibility of telehealth capabilities for clinical applications," says Leigh W. Jerome, PhD, a clinical psychologist and behavioral telehealth research scientist in Kailua, Hawaii.

The lack of such data, however, won't curb the telecommunications industry from developing affordable, high-quality distance technology, which could be available in two to five years, experts say. To be prepared for the day that technology hits the streets, an APA work group is recommending that the association advocate for large-scale, multi-site telehealth studies that will show what works, under what conditions and for which patients.

"You don't want the technology to drive the service," says Russ Newman, PhD, JD, APA's executive director for practice. "You want the service to drive the technology."

The research so far

To date, most studies on telehealth have focused on patient and provider satisfaction with the technology rather than the effectiveness of the technology in delivering services. These studies usually have small sample sizes and they rarely include randomized clinical trials. Information about the cost-effectiveness of telehealth services is also limited.

One reason for the paucity of data on telehealth's effectiveness is the lack of federal funding to support telehealth research. "The government's been more focused on developing the telecommunication infrastructure to provide the services rather than finding out if the services work," says Glueckauf of Florida.

One important question is understanding how videoconferencing affects different disorders, says Beth Hudnall Stamm, PhD, a research associate professor at the Institute of Rural Health Studies at Idaho State University and a member of APA's Committee on Rural Health. For instance, she says, paranoid schizophrenics who believe television can influence their thoughts may not be good candidates for services provided through videoconferencing. However, children with attention-deficit hyperactivity disorder appear to respond well to behavioral interventions provided by videoconferencing because they're often fascinated with television.

Increasing the studies on telehealth's effectiveness is a top priority for the Work Group on Professional Practice Issues in Telehealth, created in 1997 by APA's Board of Professional Affairs to study the potential impact of telehealth on psychology. In addition, the Technology Applications Advisory Group of APA's Board of Directors is charged with addressing overall policy for APA in terms of how the technology should be used in the association's activities as well as within the profession. And APA's Council of Representatives discussed telehealth at its February meeting.

Meanwhile, the telehealth work group recently recommended that APA advocate that the federal government fund large-scale, multi-site telehealth studies that would compare the cost and effectiveness of telehealth interventions delivered by speakerphone, videoconferencing and e-mail.

The work group also indicated that telehealth research would be helpful in the following areas:

  • The differential effects of various telehealth interventions among clinical populations.

  • The effect telehealth has on therapeutic relationships.

  • Whether providers and consumers find telehealth interventions accessible and desirable.

  • How socioeconomic status, ethnicity, culture, geographic location, age and gender affect a patient's access to and acceptance of telehealth.

  • How to most effectively educate consumers and providers in the use of telehealth.

"Substantial, quality research is needed in order to address the real impact of psychology applications using telehealth technologies," says Antoinette Anker, PhD, work group chair and a private practitioner in Denver. "Without such research, it's difficult to fully comprehend the impact of technology tools on psychology."

Future research

Meanwhile, a handful of psychologists has begun several important telehealth studies. One is Leigh W. Jerome, PhD, a member of the APA telehealth work group and a behavioral telehealth research scientist with the Pacific e-Health Innovation Center/Project AKAMAI, a congressionally mandated, Department of Defense medical research and development project sponsored by Tripler Army Medical Center in Hawaii. It's one of the largest and most comprehensive research centers in the world, with an annual budget of $20 million and projects ranging from surgical to behavioral interventions, says Jerome.

Jerome is exploring the effectiveness of using low-end telehealth technology to provide clinical services at a distance to deployed military personnel who would not otherwise have access to care. The research seeks to establish the minimum technological requirements and skill sets needed for psychological interventions ranging from family therapy to neuropsychological assessements.

In a separate effort, Glueckauf is conducting the only controlled study to date that compares the effectiveness of a behavioral intervention for rural teens with epilepsy when it's delivered by audio-video link, speakerphone and face-to-face meetings. Preliminary findings suggest that psychotherapy delivered by audio-video link and speakerphone is just as effective as face-to-face therapy, he says.

Glueckauf and colleagues at the University of Florida are also assessing whether follow-up sessions delivered through videoconferencing lead to better outcomes than those obtained from standard treatment for veterans with neurological disabilities. They hope to recruit about 150 veterans to participate in this study.

In another study, Glueckauf and Samuel Sears, PhD, are comparing whether rural, primary-care patients who self-report depression symptoms have better outcomes when they receive standard medical care, standard care plus a brief cognitive-behavioral therapy intervention provided by videoconferencing or standard care and a brief intervention provided by speakerphone. They expect about 30 primary-care patients to participate in this pilot study. Preliminary results for both studies should be available next April.

Research on telehealth is also being conducted by the Veterans Administration, DOD and Bureau of Prisons (BOP). BOP has partnered with DOD and the Department of Justice to evaluate the benefits of using telehealth to provide behavioral treatments to inmates rather than transporting them to specialists, which can be costly for security reasons. Preliminary data from a study led by clinical psychologist Philip Magaletta, PhD, show that telehealth offers psychologists and inmates the dual advantage of secure custody and increased access to care.

These studies reflect a movement within the health-care market to provide preventive intervention services in the home, says Glueckauf.

"In the next 10 to 15 years, more and more health care will be delivered through the Internet and in the home environment and easily accessible settings," he says. "Telehealth is likely to at least partially replace health care as we know it today."

Further Reading

  • Advances in telepsychology/telehealth. (2000). Professional Psychology: Research and Practice, 31 (2).

  • Jerome, L., DeLeon, P. & James, L., Gedney, J. (2000.) The coming of age of telecommunications in psychological research and practice. American Psychologist, 55 (2).

  • Reed, G., McLaughlin, C. & Milholland, K. (in press). Ten interdisciplinary principles for professional practice in telehealth: Implications for psychology. Professional Psychology: Research and Practice.

  • Glueckauf, R., Whitton, J. & Nickelson, D. (in press). Telehealth: The new frontier in rehabilitation and healthcare. In M.J. Scherer (Ed.), Assistive technology and rehabilitation Psychology: Shaping an alliance. Washington, D.C.: American Psychological Association.