Running head: FUTURE OF TELEPSYCHOLOGY TITLE PAGE 1 ...

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


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


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.


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


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).


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).


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.


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.


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


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


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


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


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


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


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


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


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


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.


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.


References

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