The Complexities of E-TherapyPrior to beginning work on this discussion, please watch the Virtual Clinic (Links to an external site.)Links to an external site. video and review the Guidelines for the

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The Complexities of E-Therapy

Prior to beginning work on this discussion, please watch the

Virtual Clinic  (Links to an external site.)Links to an external site.

video and review the Guidelines for the Practice of Telepsychology (2013). Be sure to also read Baker and Bufka (2011), “Preparing for the Telehealth World: Navigating Legal, Regulatory, Reimbursement, and Ethical Issues in an Electronic Age,” Harris and Younggren (2011), “Risk Management in the Digital World,” Luxton et al. (2014), “Best Practices for Remote Psychological Assessment Via Telehealth Technologies,” and Gros et al. (2013), “Delivery of Evidence-Based Psychotherapy via Video Telehealth” articles.

In your initial post, provide an evaluation of the efficacy of using telehealth with mild, moderate, and severe mental health disorders. As part of your evaluation, assess the integration of evidence-based practices into the telehealth trend in psychotherapy. Consider the population, specialty, and treatment preferences you identified in the Week One

Creating a Specialist Website

interactive assignment, and assess the appropriateness of using telephone, text-based, virtual clinics, and/or video telehealth given your client focus, specialty, and treatment preference(s). Analyze ethical and professional issues you might encounter and explain the risks and benefits of using these delivery methods with your identified treatment population.

Attached is the articles, I also tried attaching the video. The assignment from week one creating a website is also attached for this. Needs to be done in APA style and two and half pages. I went ahead and attached all the references for the articles and video.

Arnott, I. (Producer). (2009).

Virtual clinic

(Links to an external site.)Links to an external site.

[Video file]. Retrieved from

Baker, D. C., & Bufka, L. F. (2011).

Preparing for the telehealth world: Navigating legal, regulatory, reimbursement, and ethical issues in an electronic age


Professional Psychology: Research and Practice, 42

(6), 405-411. doi:10.1037/a0025037

Gros, D. F., Morland, L. A., Greene, C. J., Acierno, R., Strachan, M., Egede, L. E., … & Frueh, B. C. (2013).

Delivery of evidence-based psychotherapy via video telehealth


Journal of Psychopathology and Behavioral Assessment, 35

(4), 506. doi:10.1007/s10862-013-9363-4

Harris, E., & Younggren, J. N. (2011).

Risk management in the digital world


Professional Psychology: Research and Practice, 42

(6), 412-418. doi:10.1037/a0025139

Joint Task Force for the Development of Telepsychology Guidelines for Psychologists. (2013).

Guidelines for the practice of telepsychology


American Psychologist, 68

(9), 791-800. doi:10.1037/a0035001

Luxton, D. D., Pruitt, L. D., & Osenbach, J. E. (2014).

Best practices for remote psychological assessment via telehealth technologies


Professional Psychology: Research and Practice, 45

(1), 27-35. doi:10.1037/a0034547

The Complexities of E-TherapyPrior to beginning work on this discussion, please watch the Virtual Clinic (Links to an external site.)Links to an external site. video and review the Guidelines for the
Delivery of Evidence-Based Psychotherapy via Video Telehealth Daniel F. Gros &Leslie A. Morland &Carolyn J. Greene & Ron Acierno &Martha Strachan &Leonard E. Egede & Peter W. Tuerk &Hugh Myrick &B. Christopher Frueh Published online: 7 July 2013 # Springer Science+Business Media New York (outside the USA) 2013 AbstractThere has been increasing interest in using video telehealth to deliver evidence-based psychotherapies (EBPs). Telehealth may have numerous advantages over standard in- person care, including decreasing patients’and providers’ costs and increasing system coverage area. However, little is known regarding the effectiveness of EBPs via video telehealth. This review had two goals, including a review of the existing literature and ongoing research on using video telehealth technologies to deliver EBPs as well as an informal survey of telehealth experts to discuss the special consider- ations and challenges present in adapting practices to video telehealth. Together, findings suggest that telehealth practicescould represent an important component of the future of psychotherapy and clinical practice, especially in dissemina- tion and implementation of EBPs in traditionally underserved areas and populations. KeywordsPsychotherapy. Evidence-based. Telehealth. Telemental health. Telepsychology. Telepsychiatry Introduction Over the past decade, interest in using technology to improve access to mental health services has grown. One such venue is the incorporation of telehealth into treatment options, which involves the use of video telecommunication technol- ogy to provide assessment and treatment to patients (Frueh et al.2000; Monnier et al.2003; Richardson et al.2009). In general, research demonstrates that telehealth services may have numerous advantages over standard in-person care, such as decreasing patients’and providers’costs (e.g., transportation costs, travel time, missed work) and increas- ing system coverage area to providers (Dunn et al.2000; Trott and Blignault1998). Investigations of these proce- dures in numerous settings and populations exist and in- clude research on participants in rural areas (Brown1998; Grady and Melcer2005), older adults in community- dwellings (Poon et al.2005), ethnoracial minorities (Shore et al.2007), participants adjudicated by the courts (Zaylor et al.2000), and veteran populations (Dunn et al. 2000; Frueh et al.2007). In a past review of the research on telehealth, Richardson et al. (2009) concluded that several significant areas of investi- gation still are needed. In particular, emphasis was placed on evidence supporting the use of telehealth services to provide evidence-based psychotherapy (EBPs) for specific mental health disorders and comparable effectiveness research on telehealth D. F. Gros :R. Acierno :M. Strachan :L. E. Egede :P. W. Tuerk : H. Myrick Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA D. F. Gros :R. Acierno :M. Strachan :L. E. Egede :P. W. Tuerk : H. Myrick Medical University of South Carolina, Charleston, SC, USA L. A. Morland National Center for PTSD – Pacific Islands Division, Department of Veterans Affairs Pacific Islands Healthcare System, Honolulu, HI, USA C. J. Greene Center for Health Care Evaluation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, USA B. C. Frueh University of Hawaii, Hilo, HI, USA B. C. Frueh The Menninger Clinic, Houston, TX, USA D. F. Gros (*) Mental Health Service 116, Ralph H. Johnson VAMC, 109 Bee Street, Charleston, SC 29401, USA e-mail: [email protected] J Psychopathol Behav Assess (2013) 35:506–521 DOI 10.1007/s10862-013-9363-4 practices across various underserved groups. In general, EBPs are defined by meeting each of the following criteria: 1) treat- ment has been compared to a control/comparison treatment; 2) treatment has demonstrated statistically significantly different outcome from the control/comparison treatment; 3) two or more randomized controlled trials (RCTs) demonstrate the efficacy of the treatment; 4) studies of the treatment involve multiple re- search teams; 5) patient samples are well specified within these studies; and, 6) treatment manuals were used to guide treatment within these studies (Chambless and Ollendick2001;Kazdin 2006). Though additional research is needed, there has been tremendous growth in research on telehealth practices over the past several years, leading to a better understanding of the use andcompatibilityoftelehealthandEBPs. Current Review In contrast to previous reviews that have included a wide range of telehealth modalities (e.g., telephone, internet and email, virtual reality simulators, and videoconferencing) and mental health procedures (e.g., diagnostic assessment, symp- tom tracking, medication management, supportive psycho- therapy, and EBPs) (Frueh et al.2000; Monnier et al.2003; Richardson et al.2009), the current review focused its atten- tion on the rapidly growing literature on the delivery of EBPs via telehealth to provide a critical presentation and interpre- tation of the existing literature, as well as identifying limita- tions and areas of further development. There were two goals of the present article. First, a review of literature on the use of video telehealth technologies to deliver EBPs to child and adult participants was provided. The review was limited to video telehealth technologies due to the current direction of the field to move beyond other, outdated formats (e.g., tele- phone). These video telehealth technologies included any devices used to deliver EBPs by a professional provider in real time over a video link. In general, video telehealth studies involve stand-alone videoconference systems (i.e., video monitor with mounted video camera and telecommu- nication connection) set up in mental health clinics in local and remote sites, with a fax machine was used to exchange treatment handouts and questionnaires. The review, orga- nized by commonly treated psychiatric disorders (e.g., anx- iety disorders, depressive symptoms and suicidality, eating disorders, and addictive behaviors), highlighted recent ad- vances that have taken place over the past several years in the field of telehealth. Second, consensus opinions from an in- formal survey of American telehealth experts were presented to discuss special considerations and challenges in using telehealth in clinical and research settings, difficulties with telehealth technologies, and difficulties in system-wide ap- plications of telehealth. Experts included many of the leading names in both clinical and research applications of telehealth and EBPs over the past decade in the United States.Review of Recent Research on Evidence-Based Psychotherapy via Video Telehealth Empirical articles related to the delivery of EBPs via video telehealth were identified through database searches using PsycINFO, Medline, and GoogleScholar. Searches involved pairings of therapy terms (therapy, psychotherapy, or counseling) with telehealth terms (telehealth, telemental health, telepsychology, telepsychiatry, or telemedicine). In addition, reference searches were completed within past review articles on general telehealth applications and prac- tices (Frueh et al.2000; Grady et al.2011; Monnier et al. 2003; Richardson et al.2009; Yellowlees et al.2010). Three specific criteria were necessary for study inclusion. First, the study must have included the use of video telehealth in the delivery of the primary intervention. Studies that included alternative types of telehealth (e.g., telephone, internet text/applications, and virtual reality) and/or were limited to only partial telehealth treatment (e.g., primary face-to-face component followed by telehealth component) were exclud- ed. Second, the study must have included a targeted and diagnosed psychiatric disorder. Studies that targeted general symptoms or clusters of symptoms (e.g., undiagnosed depression and/or using cutscores on a specific measure to approximate depression) were excluded. Third, the study must have included an EBP for the targeted psy- chiatric disorder. Although the criteria for EBPs (listed earlier) was not strictly followed, as study treatment manuals and their specific evidence-base were not inves- tigated separated, treatment studies incorporated into the review included treatments with detailed descriptions and terminology consistent with available EBPs (e.g., cogni- tive behavioral therapy [CBT] for panic disorder with situational and interoceptive exposures). Studies that in- cluded general counseling, vague descriptions of struc- tured therapy, and/or non-EBPs (e.g., long-term psycho- dynamic psychotherapy for depression) were excluded. These articles are summarized in Table1. Research on Video Telehealth by Disorder Groups Anxiety Disorders and Related ConditionsThe first pub- lished research on the delivery of an EBP via video telehealth was on panic disorder with agoraphobia (PD) (Bouchard et al.2000). The initial study involved 8 participants with PD from a remote, rural town in an open trial (i.e., study design lacked a comparison group) of CBT for PD delivered via telehealth to a rural clinic from a local clinic in an urban area. Bouchard et al. (2000) noted that PD was selected for the study due to the disorder’s association with severe avoid- ance (e.g., long distance trips) and related poor outcomes in participants needing to commute from remote areas (e.g., poor attendance and high discontinuation rates). J Psychopathol Behav Assess (2013) 35:506–521507 Table 1Selected characteristics of completed studies identified by review Study Target disorder EBP Results Groups (Sample size) (randomization)Sessions (format) Bakke et al. (2001) Bulimia nervosa CBT for bulimia nervosa (individual) a Abstinence from binge eating and purging for last 4 weeks of treatment and 1-month follow-up visit. Telehealth (n=2) Bouchard et al. (2000) Panic disorder CBT for panic disorder 12 sessions (individual)Significant pre- to post-treatment improvements in panic symptoms, trait anxiety, and global impairment. Telehealth (n=8) Bouchard et al. (2004) Panic disorder CBT for panic disorder Significant pre- to post-treatment improvements in panic symptoms, state and trait anxiety, depression, and global impairment. Telehealth demonstrated significantly greater reductions in panic frequency than in-person. No other differences between the two groups. Telehealth (n= 11) 12 sessions (individual) In-person (n= 10) (non-randomized) Carlson et al. (2012) Tobacco use disorder Smoking cessation Continuous abstinence rates in about 25 % of intent-to-treat samples. No differences between the two groups. Telehealth (n= 184) 8 session (group) In-person (n= 370) (non-randomized) Cowain (2001) Panic disorder CBT for panic disorder Pre- to post-treatment symptom reductions in depression and anxiety scales. Telehealth (n= 1) 12 sessions (individual) Frueh et al. (2005) Alcohol abuse/dependence Relapse prevention Abstinence in 13 of 14 treatment completers. High patient satisfaction and treatment credibility and good session attendance. Telehealth (n= 18) 8 sessions (group) Frueh et al. (2007) PTSD CBT for PTSD No treatment improvements demonstrated in either group. Similar reports of satisfaction in both groups. Telehealth (n= 17) 14 session (group) In-person (n= 21) (randomized) Germain et al. (2009) PTSD CBT for PTSD Pre- to post-treatment reductions in PTSD symptoms in both groups. No differences between treatment groups. Telehealth (n= 16) 16–25 sessions (individual) In-person (n= 32) (non-randomized) Goldfield and Boachie (2003)Anorexia nervosa Family therapy Improved closeness with family and significant post-treatment weight gain. Telehealth (n= 1) 8 sessions (family) Griffiths et al. (2006) Mood & anxiety disorders CBT for specific disorders Pre- to post-treatment improvements in depression and anxiety scores. Telehealth (n= 15) 6–8 sessions (individual) Gros et al. (2011b) Acute suicidality Crisis management Safe and effective intervention and coordination of care to address acute suicidality. Telehealth (n = 1) 1 session (individual) Gros et al. (2011c) PTSD Exposure therapy Pre- to post-treatment improvements in PTSD, depression, anxiety, stress, and impairment. In-person group demonstrated larger improvements in PTSD and depression than telehealth. Telehealth (n= 62) 12 sessions (individual) In-person (n= 27) (non-randomized) Hassija and Gray (2009)PTSD Exposure therapy Pre- to post-treatment improvements in PTSD symptoms and maintained to 4-month follow-up. Telehealth (n= 1) 7 sessions (individual) Himle et al. (2006) OCD Exposure with response preventionPre- to post-treatment improvements in OCD symptoms and work and social adjustment scores. Telehealth (n=3) 12 sessions (individual) Himle et al. (2012) Childhood tic disorders Comprehensive behavioral intervention for ticsSignificant pre- to post-treatment improvements in tic behaviors. Strong ratings for acceptability and therapist- client alliance. No differences between treatment groups. Telehealth (n= 10) 8 sessions (individual) In-person (n=8) (randomized) King et al. (2009) Illicit drug users Relapse prevention Pre- to post-treatment improvements in abstinence and return to less-intensive care. No differences between treatment groups. Telehealth (n= 20) 12 sessions (group) In-person (n= 17) (randomized) Mitchell et al. (2008) Bulimia nervosa CBT for bulimia nervosa Pre- to post-treatment reductions in binge eating, purging, and depression in both groups. In-person reported significantly less purging at follow-up than telehealth group. Majority of other outcome measures were comparable across groups. Telehealth (n= 62) 20 sessions (individual) In-person (n= 66) (randomized) 508J Psychopathol Behav Assess (2013) 35:506–521 Statistically significant pre- to post-treatment improvements were found on all clinical outcome measures, including panic frequency, panic apprehension, self-efficacy, trait anx- iety, disability, and panic and agoraphobia scale scores. Telehealth procedures were well received by participants, as demonstrated by high scores on a working alliance ques- tionnaire and participants’open feedback. Similar small open trials and case studies have been completed for CBT for PD (Cowain2001), CBT for social phobia (Pelletier 2003), and exposure with response prevention for obsessive compulsive disorder (OCD; Himle et al.2006). Each of these studies evidenced similarly positive pre- to post-treatment symptom reductions, therapeutic alliance, and patient satisfac- tion with telehealth. Of interest, Cowain (2001)notedafew technological (e.g., transmission speed over slow modem,inability to transmit printed materials, sound echoing) and therapeutic (e.g., inability to provide in-person support during in-session exposure exercises) issues that may have reduced the quality of the therapeutic relationship and effectiveness of the telehealth intervention; however, an in-person control group was not included to test this hypothesis. As a follow-up investigation of their initial findings, Bouchard et al. (2004) completed a second study of CBT for PD with a larger sample and an in-person control condi- tion. The study involved 21 participants with PD, with 11 participants in the telehealth treatment and 10 participants in the in-person control condition. The study did not involve random assignment; rather, participants completed treatment based on their geographic location such that treatment was delivered to participants at the remote site via telehealth and Table 1(continued) Study Target disorder EBP Results Groups (Sample size) (randomization)Sessions (format) Morland et al. (2004) PTSD Coping skills intervention Similar information retention and patient and clinician satisfaction ratings in both groups. Higher attrition rates in in-person group. Telehealth (n= 9) 8 sessions (group) In-person (n=8) (randomized) Morland et al. (2010) PTSD CBT for anger management Pre- to post-treatment improvements in anger symptoms. No differences between treatment groups in symptom or process variables. Telehealth (n= 61) 12 sessions (group) In-person (n= 64) (randomized) Morland et al. (2011) PTSD Cognitive processing therapy Pre- to post-treatment improvements in PTSD symptoms. No differences between treatment groups. Telehealth (n= 6) 12 sessions (group) In-person (n=7) (randomized) Nelson et al. (2003) Childhood depression CBT for childhood depression Pre- to post-treatment reductions in depression scores and an 82 % remission rate for depression diagnoses. Telehealth demonstrated a greater decrease in depressive symptoms over time than in-person. No other group differences found. Telehealth (n= 14) 8 sessions (family) In-person (n= 14) (randomized) Oakes et al. (2008) Problematic gambling Exposure therapy Pre- to post-treatment improvements in gambling behavior, anxiety, depression, and work and social adjustment. Telehealth (n= 1) 6 sessions (individual) Pelletier (2003) Social phobia CBT for social phobia Pre- to post-treatment clinically significant symptom on social anxiety scales demonstrated in 4 of 5 patients. Telehealth (n= 5) 12 sessions (individual) Simpson et al. (2003) Eating disorders CBT for eating disorders Pre- to post-treatment reductions in binge eating and compensatory behaviors and improvements in eating behaviors. Telehealth (n= 12) 12-20 sessions (individual) Strachan et al. (2012a) PTSD Behavioral activation and therapeutic exposurePre- to post-treatment improvements in PTSD, anxiety, and depression. No differences between treatment groups. Telehealth (n= 18) 8 sessions (individual) In-person (n= 13) (randomized) Tuerk et al. (2010b) PTSD Prolonged exposure Pre- to post-treatment improvements in symptoms of PTSD and depression. No differences between treatment groups. Telehealth (n= 12) 1–21 sessions (individual) In-person (n = 35) (non-randomized) CBTcognitive behavioral therapy,PTSDposttraumatic stress disorder,OCDobsessive compulsive disorder anumber of sessions of psychotherapy was not reported J Psychopathol Behav Assess (2013) 35:506–521509 to participants at the local site in-person. Both treatment groups evidenced significant pre- to post-treatment improve- ments in all measures of panic, anxiety, depression, and impairment. Only one group difference was found between the effectiveness of the two treatment conditions. Telehealth participants demonstrated a greater reduction in panic fre- quency than in-person participants; however, the interpreta- tion of these findings is limited by the small sample size and lack of randomization. Although not typically considered an anxiety disorder, childhood tic disorder shares many characteristics with an anxiety disorder (i.e., OCD) and has been considered for incorporation into the obsessive-compulsive spectrum disor- ders (Phillips et al.2010). Thus, a recent study of Comprehensive Behavioral Intervention for Tics(CBIT) for childhood tic disorder delivered via telehealth also was in- cluded in this section (Himle et al.2012). The study involved 20 children (ages 8–17) randomly assigned to either an in- person treatment at a local clinic or telehealth treatment at a remote clinic. The CBIT involved 8-sessions administered across 10 weeks, with primary components of psychoeducation, habit reversal training, function-based as- sessment and intervention, and relaxation training. Both treatment groups demonstrated significant pre- to post- treatment improvements across symptom and impairment measures as well as high acceptability ratings. No group differences were reported. The authors noted initial concerns that CBIT would perform less well via telehealth due to greater provider difficulties in observing, detecting, and dis- criminating discreet episodes of often subtle, rapid tics due to technological limitations; however, this hypothesis was not supported in the findings. Several preliminary conclusions can be drawn from these initial studies on the use of video telehealth to deliver EBPs for the anxiety disorders and related conditions. First, despite the limitations of small samples and largely non-randomized treatment conditions, EBPs were delivered effectively across studies and across disorders. Initial concerns listed by many authors focusing on the potential negative influence of telehealth technology on assessment (e.g., in-session track- ing of tic behaviors) and therapeutic practices (e.g., in- session interoceptive exposures) were not supported by the treatment outcome findings. In addition, although logistic concerns may be present for other in-session therapeutic practices in the telehealth treatment conditions (e.g., in- session situational exposures to elevators), these concerns were not mentioned by the authors and did not appear to influence outcomes. In addition, the findings for therapeutic alliance and acceptability of telehealth practices were con- sistently high and similar across telehealth and in-person modalities. Together, these findings suggest that telehealth technology should be considered as a viable option in the treatment of the anxiety disorders, especially when in-persontreatment may be difficult due to geographic location and/or individual disorder-related situational avoidance (e.g., driv- ing, waiting rooms, or hospitals). Depressive Symptoms and SuicidalityEBPs via video telehealth have been studied in both children (Nelson et al. 2003) and adults (Griffiths et al.2006) with major depressive disorder (MDD). Nelson et al. (2003) completed the first RCT of an EBP comparing telehealth and in-person prac- tices. Their study involved 28 participant families with school age children (ages 8–14) with MDD. Participant families were randomized to eight weekly sessions of CBT for MDD, delivered either via telehealth or in-person within the same facility. Both groups demonstrated significant pre- to post-symptom reduction in symptoms of depression, in- cluding an 82 % remission rate that was found across the total sample. The telehealth group evidenced a significantly faster rate of decline in symptoms of depression than the in- person group. No group differences were found in session attendance or treatment attrition. Telehealth participant fam- ilies endorsed high satisfaction with the treatment and re- ported preferring telehealth services to in-person practices, despite occasional technological issues (e.g., rebooting equipment [10 % of appointments], using the telephone [3 % of appointments] or rescheduling appointments [2 % of appointments]) due to technological problems). The au- thors offered two interpretations for the group differences in rate of decline in symptoms. First, the authors hypothesized that the novelty of the telehealth treatment may have caused participants to feel“special”and therefore maximized the impact of treatment. The second interpretation was that the finding was a chance variation, as the finding was inconsistent across the outcome measures. However, regardless of the interpretation, these findings provided initial support for the potential success and acceptance of telehealth administered CBT for depression, despite infrequent technological difficul- ties in the telehealth equipment. Griffiths et al. (2006) completed an open trial of CBT for participants with depression and/or anxiety disorders via telehealth. The study involved 15 participants, including six patients with MDD, three with generalized anxiety dis- order, three with PD, and three with mixed anxiety and depressive disorder, that completed 6 to 8 sessions of a CBT tailored to their specific disorder via telehealth. Although the primary CBT intervention was provided via video telehealth to a remote clinic, in-person case managers were available to provide emotional support following every treatment session. Participants evidenced significant pre- to post-treatment improvements in symptoms of anxiety and depression. Both participants and providers reported accep- tance of telehealth procedures and only a few technical problems were reported (e.g., telephone was used once when video link failed). 510J Psychopathol Behav Assess (2013) 35:506–521 One of the most frequent concerns cited for telehealth services for the treatment of depression is patient safety and suicidality due to distance between therapists, patients, and emergency services (Godleski et al.2008; Mitchell et al. 2008). Although there is research supporting the use of telehealth for assessment purposes (Jong2004), literature on crisis management for acute suicidality is limited in part, due to the low base rate of the phenomena. Recently, Gros et al. (2011b) presented a case study of a participant with comorbid posttraumatic stress disorder (PTSD) and MDD enrolled in a large scale RCT of exposure therapy for PTSD delivered via telehealth (Gros et al.2011a). In contrast to studies reviewed earlier, this study involved the use of home-based telehealth (i.e., delivering services from local clinic directly into partici- pant’s home). The authors detailed the steps taken to address this participant’s needs when acute suicidality arose, including: 1) enlisting a second provider for consultation and coordina- tion with local services (e.g., emergency personnel and care facility), 2) establishing a safety plan with the participant, including plans if the telehealth connection was lost, 3) arrang- ing hospitalization with participant’s local emergency person- nel and transportation, and 4) arranging participant’s transfer to provider’s treatment facility. The case study demonstrated that video telehealth, in combination with telephone services, could be used both to provide safe crisis management and to coordi- nate emergency service. The authors also suggested that telehealth services may in fact provide several benefits above in-person treatments, as patients who might otherwise fail to attend a clinic for treatment that is far away because they are suicidal or very depressed with neurovegetative symptoms may be more likely to participate in telehealth; therefore, clinicians have a better opportunity to intervene and help suicidal patients. Together, these studies on EBPs delivered via telehealth for depression provide initial support for the potential effective- ness of the treatment as well as the safety of these practices with patients with suicidality. Similar to the findings for the anxiety disorder, the studies demonstrated roughly equivalent symptom outcomes and treatment satisfaction across both telehealth and in-person treatment conditions. In fact, al- though requiring further evaluation and replication, improved symptom decline was noted in the telehealth condition in Nelson et al. (2003), suggesting promising findings for these symptoms/treatments. Unlike potential concerns noted in treatment of anxiety disorders (e.g., in-session assessment and treatment practices), EBPs for depression may be even better suited for treatment via telehealth due to less depen- dence on in-session behavioral techniques (e.g., between- session behavioral activation practices for depression versus within-session situational exposures for social phobia), and therefore may pose less of an obstacle for telehealth providers. Eating DisordersThe initial research on CBT delivered via telehealth for bulimia nervosa (BN) and anorexia hasfocused on case studies and small open trials. The methods and technology involved in these studies were very similar to the studies presented earlier, including providing EBPs via telehealth from a local clinic to a remote site. In each study, telehealth participants demonstrated significant pre- to post- treatment improvements, including reduced binge and purge behaviors in participants with BN (Bakke et al.2001; Simpson et al.2003) and significant weight gain in partici- pants with anorexia (Goldfield and Boachie2003). In addi- tion, telehealth was generally well accepted and satisfying across studies, with only infrequent problems noted (e.g., video clarity and jerkiness, delayed audio). Following small open trials, Mitchell et al. (2008) complet- ed a large RCT of CBT for BN comparing telehealth and in- person treatment conditions. The study involved 128 partici- pants with BN receiving 20 sessions of CBT for BN via either telehealth delivered from a local clinic to remote clinics or in- person delivered at the remote clinics. Both treatment groups demonstrated significant pre- to post-treatment improvements in abstinence rates for binge eating and purging. Unlike the majority of telehealth studies for other disorders/treatments, several group differences were identified at follow-up assess- ments. The in-person group reported significantly lower levels for binge eating and purging as well as less purging frequency at 12-month follow-up than the telehealth group. The in-person group also demonstrated significantly greater reductions in eating concerns, shape concerns, and symptoms of depression in comparison to the telehealth group. Study therapists were initially more concerned about using telehealth for CBT than participants, but these concerns reduced with time. Several logistical and practical considerations also were noted when using telehealth to deliver CBT, including problems with light- ing and privacy at the remote sites, difficulty with exchanging homework assignments and other handouts between sites, and concerns regarding the management of suicidality. There are several preliminary implications of the telehealth findings for the eating disorders that merit further discussion. Although limited to a single study with an in-person compar- ison group (Mitchell et al.2008), this literature suggested that there may be different treatment effects for telehealth and in- person conditions, with less purging frequency identified in the BN in-person group at follow-up. Unfortunately, Mitchell and colleagues provided little interpretation of these group differences and focused their discussion primarily on the general effectiveness and logistic concerns of providing CBT for BN via telehealth. The general logistic concerns, not necessarily observed in the study, included lighting and monitor/camera placement issues, reimbursement issues with third party payers, transmission of assessment and homework documents over fax machines, and safety concerns regarding potential suicidality. However, it’s unclear whether any of these concerns would have influenced the treatment findings for the telehealth condition. J Psychopathol Behav Assess (2013) 35:506–521511 Upon review of CBT for the eating disorders (Fairburn et al.2008), there may be a vital treatment component that would be difficult to complete via telehealth: in-session weighing. Weekly in-session weighing is included in most CBT protocols for the eating disorders and is both a required and anxiety-provoking practice. In fact, Fairburn et al. (2008) described weekly in-session weighing as“one of the most valuable new elements of the treatment.”The authors continued that,“this view is shared by many patients, who report at the end of treatment that regular in-session weighing in collaboration with the therapist was extremely helpful (p. 591–592).”Although weekly weighing was not mentioned in Mitchell et al. (2008), it is feasible to assume that it was omitted from the telehealth condition due to likely participant resistance and logistic concerns (e.g., participant needing to move the camera to view their recorded weight). Future research is needed on the telehealth treatment for the eating disorders to determine the reliability of group differ- ences between telehealth and in-person conditions as well as the potential influence of presence or absence of specific treatment components in the telehealth treatment (e.g., week- ly in-session weighing). Addictive BehaviorsGiven the complexity of addictive dis- orders and their treatments, literature on EBPs delivered via telehealth for these disorders is limited. The first study on the topic involved an open trial of an 8-session group relapse prevention therapy delivered via telehealth from a remote site to a local clinic to veteran participants with alcohol abuse and dependence (Frueh et al.2005). The findings demonstrated abstinence in 13 of 14 treatment completers during the 4-week treatment. High participant satisfaction, treatment credibility, and participant attendance were also found for the telehealth treatment. A second study involved a case study of a 6-session exposure therapy for problem gambling via telehealth from a local clinic to a remote site that demonstrated prolonged re- ductions in gambling behaviors, in addition to decreased symptoms of depression and anxiety over a 4-year follow-up period (Oakes et al.2008). A third study involved a RCT of group relapse prevention therapy delivered either via home- based telehealth or in-person at a local clinic to 37 illicit drug users in a methadone maintenance treatment program (King et al.2009). Similar treatment response was shown in both groups, as evidenced by abstinence and return to less intensive treatments. Interestingly, participants expressed a preference for the telehealth treatment due to improved convenience and confidentiality. More recently, Carlson et al. (2012) completed a study of smoking cessation treatment delivered via telehealth and in- person at local and remote clinics. Although the study did not involve randomization, the sample sizes for the groups were quite large (telehealthn= 184; in-personn= 370). The treat- ment involved an 8-session smoking cessation group.Reasonable treatment response was demonstrated in both groups (25 % continuous abstinence rates) and no group differences were reported. Together with the earlier telehealth studies (Frueh et al. 2005; King et al.2009), there is initial support for the use of telehealth technology to deliver limited individual and group treatments for addictive behaviors (e.g., post-treatment sup- port of recovery and smoking cessation). No group treatment differences in clinical outcomes were observed between the telehealth and in-person treatment groups, but with potential benefits in convenience and confidentiality noted for telehealth. Although not specifically detailed in any of these studies, these positive findings are reported despite the need of potential in-person assessment (e.g., breathalyzers and urine drug screens) and safety procedures (e.g., managing acute intoxication). Additional research is needed on more severe substance use disorders and their related treatments and on how best to incorporate the application of in-person assessment and safety procedures. Studies with randomized group assignment also are needed with these disorders. Posttraumatic Stress DisorderPTSD has received the most attention in the literature, due in large part from efforts by the Department of Veterans Affairs (VA) and Department of Defense (DoD). Initial studies of PTSD and EBPs via telehealth focused on testing the feasibility of these practices (Morland et al.2004; Frueh et al.2007). Both of these initial studies involved RCTs of CBT group interventions for vet- erans with PTSD and focused more on process variables (e.g., attendance, retention, satisfaction) than on clinical out- comes (e.g., reduced symptoms of PTSD, depression, anger). More specifically, Morland et al. (2004 ) randomly assigned participants with PTSD to an 8-week PTSD coping skills group delivered via telehealth or in-person within the same facilities. No differences were observed in participant satis- faction, clinician satisfaction, or participant retention be- tween the two groups. Similarly, Frueh et al. (2007) random- ly assigned participants with PTSD to 14-session CBT de- livered via telehealth or in-person within the same facility. Once again, no differences were demonstrated in participant treatment satisfaction, attendance, or rates of discontinuation between the two groups. Together, these studies demonstrat- ed no differences in process variables between telehealth and in-person treatment groups, thus providing preliminary sup- port for the feasibility of using telehealth to administer EBPs to participants with PTSD. More recently, studies have focused on the delivery of individual exposure therapy (Germain et al.2009; Gros et al. 2011c; Strachan et al.2012a; Tuerk et al.2010b), group cognitive processing therapy (Morland et al.2011), and group CBT for anger management (Morland et al.2010)to participants with PTSD via telehealth. These studies can be broken down into two groups. First, several studies involved 512J Psychopathol Behav Assess (2013) 35:506–521 non-randomized group assignment into either telehealth to a remote site or in-person at the local clinic (Germain et al. 2009; Gros et al.2011c; Tuerk et al.2010b). The second group of studies involved randomized group assignment into either telehealth or in-person condition within the same facilities (Morland et al.2011; Strachan et al.2012a). Together, each of the randomized and non-randomized trials reported comparable significant symptom reductions in clin- ical outcomes across groups with one exception. Gros et al. (2011c) demonstrated larger improvements in the symptoms of PTSD and depression through in-person delivery com- pared to telehealth. Although participants were not random- ized to condition, Gros et al. (2011c) included a much larger telehealth sample (n= 62) than each of the other studies involving exposure therapy (ns < 19). Both Germain et al. (2009) and Tuerk et al. (2010b) found similar differences in group effect sizes, but were underpowered to detect these differences due to small sample sizes. However, Gros and colleagues interpreted this difference as being due to higher- than-expected effects in the in-person conditions across stud- ies (i.e., effect sizes were nearly twice as large as the pub- lished averages for in-person exposure therapy), rather than any concerns regarding the effects in the telehealth condi- tions (i.e., effect sizes were largely consistent with published averages for in-person exposure therapy). The authors also repeatedly noted the lack of randomization as a potential contributing factor to the observed differences (e.g., partici- pants in the telehealth group were recruited from more rural settings than the participants in the in-person group). One large scale RCT has been completed in participants with PTSD and was focused on group CBT for anger man- agement (Morland et al.2010). The study involved 125 vet- eran participants with PTSD randomized into 12-session group treatment conditions delivered either via telehealth or in-person within the same facilities. The study found signifi- cant pre- to post-treatment reductions in anger symptoms in both groups. No group differences were detected in any of the clinical (anger and PTSD symptoms) or process variables (attrition, adherence, satisfaction, and expectancy). However, although therapeutic alliance with therapists was high in both conditions, alliance was significantly higher among partici- pants in the in-person condition. Interestingly, alliance and cohesion within and among the group members was compa- rable in both conditions (Greene et al.2010). The conclusions that can be drawn from the initial studies on PTSD treatments via telehealth are mixed, in part due to the large number of studies in this area. Although each of the studies demonstrated pre- to post-treatment symptom reduc- tions in the telehealth conditions, three of the studies involv- ing exposure therapy for PTSD also demonstrated larger effect sizes in the in-person treatment conditions (Germain et al.2009; Gros et al.2011c; Tuerk et al.2010b), with roughly equivalent effect sizes across conditions in oneadditional study (Strachan et al.2012a). These findings are in contrast with non-exposure-based treatments that demon- strated similar outcomes across treatment conditions (Morland et al.2010,2011). Similar to the hypotheses noted earlier for other disorders (e.g., eating disorders), these find- ings suggest that there may be specific treatment techniques that are unique to exposure therapy and potentially less effective via telehealth presentation. In contrast to situational exposures that are common in other treatments for anxiety disorders with similar telehealth and in-person outcomes (e.g., panic disorder; Bouchard et al.2000,2004), imaginal exposures are more common in PTSD treatments and may contribute to the identified group differences. Additional research that incorporates randomization is needed, especial- ly in terms of studies involving exposure-based treatments. Ongoing Research on Evidence-Based Psychotherapy via Video Telehealth As noted earlier, the VA and DoD have been driving forces behind recent developments of EBPs delivered via telehealth. In addition to many of the aforementioned studies that were com- pleted within a VA setting (Gros et al. 2011b,c; Frueh et al. 2005,2007; Morland et al.2004,2010,2011;Strachanetal. 2012a; Tuerk et al.2010b), several large RCTs of EBPs via telehealth are currently underway. These studies include telehealth versus in-person RCTs forBehavioral Activation Therapy for Depressionfor older Veterans with depression (Egede et al.2009), behavioral activation and therapeutic expo- sure for active duty and retired service members with PTSD (Gros et al.2011a),Prolonged Exposurefor veterans with PTSD (Strachan et al.2012b), and groupCognitive Processing Therapyfor veterans with PTSD (Morland et al.2009). In contrast to the majority of the previous studies reviewed earlier, each of the ongoing studies incorporates a non-inferiority design with large sample sizes (Ns ~ 200). A non-inferiority approach is particularly well-suited for telehealth research, as non-inferiority designs involve a one-sided test that can be used to determine if a novel intervention or delivery modality (e.g., EBP delivered via telehealth technology) does not significantly differ from a standard intervention/modality (e.g., EBP delivered in- person; Greene et al.2008). Non-inferiority designs and standard superiority trials differ in several fundamental ways. Most importantly, in contrast to the null hypothesis of superiority trials stating that there is no true difference between the interventions, the null hypothesis in non- inferiority designs is that the novel intervention is inferior to the standard intervention by at least a pre-specified amount (Greene et al.2008). The alternative hypothesis in non-inferiority designs is that the novel intervention is infe- rior to the standard intervention by less than the pre-specified J Psychopathol Behav Assess (2013) 35:506–521513 amount. With the exception of one study (Morland et al. 2010), the existing studies on telehealth have relied on su- periority designs, suggesting that an improved understand- ing of the potential differences (or lack thereof) between telehealth and in-person practices could be gained through the application of non-inferiority designs. Descriptions of Ongoing Studies Egede et al. (2009) involves an ongoing four-year RCT on the comparative effectiveness of an EBP for MDD delivered via telehealth and in-person. The proposed sample includes 224 male and female older adults (age 60 or older) that will be randomly assigned to either the home-based telehealth condition delivered via an analogue videophone (n= 112) or in-person treatment condition at a local clinic (n= 112). The treatment will be 8 sessions ofBehavioral Activation Therapy for Depression, which generally involves teaching participants to monitor their mood and daily activities with the goal of increasing pleasant, reinforcing activities and reducing unpleasant events (Lejuez et al.2001). Outcome measures will include clinical outcomes (e.g., depression and social functioning), process variables (e.g., satisfaction and attendance), and economic outcomes (e.g., costs and re- source use). The primary goal of the study is to demonstrate comparable effectiveness between telehealth and in-person behavioral activation for MDD in this high risk, underserved population to inform and improve implementation efforts, especially in rural settings. Gros et al. (2011a) and Strachan et al. (2012a) both involve the delivery of exposure-based EBPs to veteran participants with PTSD via telehealth and in-person. The two studies have very overlapping methodology and are being conducted by the same research team. In both studies, large samples of consenting veterans (targetedNs > 200) will be recruited and randomized into the two treatment condi- tions. The telehealth conditions in these studies involves primarily home-based telehealth via an internet-based instant video service or, at the participant’s discretion, an analogue videophone. The primary difference between the studies is the type of treatment provided. Gros et al. (2011a) uses an 8- session exposure-based treatment,Behavioral Activation and Therapeutic Exposure, that contains behavioral activa- tion, situational exposures, and imaginal exposures (Gros et al.2012). In contrast, Strachan et al. (2012b) uses 9- to 12-session ofProlonged Exposurepsychotherapy, one of the primary EBPs designed for PTSD (Foa et al.2007). The primary goal of these studies is to investigate the compara- tive effectiveness of exposure-based EBPs for PTSD deliv- ered via home-based telehealth and in-person, to inform and expand the delivery of these services to active duty and retired military service members. Outcome measures include clinical outcomes (e.g., PTSD, depression and socialfunctioning), process variables (e.g., satisfaction and atten- dance), and economic outcomes (e.g., costs and resource use). The preliminary findings of Gros et al. (2011a) have been published and demonstrated similar outcomes for the two treatment conditions (Strachan et al.2012a). A fourth ongoing telehealth investigation is being investi- gated by Morland et al. (2009). This study seeks to recruit 126 veteran participants with PTSD and randomly assign them to either telehealth or in-person across four clinic settings. The treatment involved 12-sessions of groupCognitive Processing Therapy(Resick2001). Outcome measures include clinical outcomes (e.g., PTSD, anger, and social functioning), process variables (e.g., satisfaction and attendance), and economic outcomes (e.g., costs and resource use). The preliminary find- ings of Morland et al. (2009)havebeenpublishedanddem- onstrated similar outcomes for the two treatment conditions (Morland et al.2011). Together, these four ongoing studies on the delivery of EBPs via telehealth technology are likely to address many of the outstanding questions in the telehealth literature. First, each of these studies incorporates large samples of participants, ran- domization into treatment groups, and non-inferiority designs. As reviewed earlier, the majority of previous studies have been limited to smaller samples, lacking comparison groups and/or randomization into groups, and included superiority designs. Second, each of these studies includes clinical outcomes, as well as process and economic outcomes. Although support for equivalent clinical outcomes are of high importance, evidence of beneficial process and economic outcomes (e.g., telehealth appointments are better attended and/or telehealth appointments aremore cost effective) is also needed to further promote the incorporation of and transi- tion to delivering EBPs via telehealth. Process and econom- ic variables have not been thoroughly investigated as of yet in the telehealth literature. Unfortunately, these ongoing studies are limited to two highly overlapping disorders (i.e., PTSD and MDD; Gros et al.2010), and are unlikely to directly inform EBPs for substance use, eating disorders, or other non-depressive/non-anxiety disorders. However, if consistent findings are demonstrated across these four rig- orous studies, it should increase confidence that similar findings will be observed in other disorders as well. Consensus of Experts in Clinical and Research Applications of Video Telehealth Overview In order to better understand potential challenges associated with clinical and research applications of EBPs via telehealth, an informal survey of telehealth experts was completed. A survey approach of experts was selected to accompany the 514J Psychopathol Behav Assess (2013) 35:506–521 research review earlier to provide multiple perspectives on a wide range of topics within the delivery of EBPs via telehealth as well as assess and discuss many related topics that may not garner sufficient attention in research articles. The presenta- tion of the survey results is intended for both researchers and clinicians interested in the delivery of EBPs via telehealth. Eight American experts were contacted via email to par- ticipate in the informal survey. These experts were selected based on their contribution to the research on telehealth, with a particular focus on the delivery of EBPs via telehealth. More specifically, the experts selected have experience with large-scale research projects on telehealth, including many previous and ongoing studies described earlier, as well as large-scale clinical initiatives, including state-wide programs within private and public hospital systems and multi-state programs within the VA. Together, the group of experts have received 9 federally-funded grants to complete telehealth studies and published 29 manuscripts on telehealth research. Experts were asked to type in their answers in an informal survey and return the survey over email correspondence. The survey contained 7 questions regarding the expert’s personal background with telehealth research (e.g., ongoing projects/initiatives, publications, and funded grants) as well as the expert’s opinions on the clinical, research, technology, and systems issues related to uses telehealth to deliver EBPs. Experts also were asked their opinions regarding the future directions of telehealth as they related to clinical and research practices. No experts declined to participate in the survey. A summary of the experts responses is presented next. The content was organized by the questions in the survey (major headings) and specific areas of content/feedback pro- vided by the experts (subheadings). Supporting findings from telehealth research and practice articles was incorpo- rated when available. Clinical Applications By and large, experts agreed that EBPs delivered via telehealth provide very similar clinical outcomes to those provided in-person. This finding supports the majority of the research reviewed earlier, demonstrating similar outcomes for telehealth and in-person treatments. However, most experts acknowledged that minor alterations to standard in-person practices are needed to adjust EBPs to telehealth. These alterations include logistical coordination at provider and patient sites, initial patient and provider orientation to telehealth technologies, and adjusting in-session assess- ments and psychotherapeutic practices to be compatible with telehealth. Each of these recommended alterations is discussed in detail next. Treatment Site ConsiderationsTelehealth involves two treat- ment sites, with only one site directly controlled by treatmentproviders. Thus, experts emphasized how providers of telehealth must coordinate the setup and maintenance of the second treatment site with either local support staff (e.g., providing treatment at a rural clinic) or patients (e.g., home-based telehealth). Several considerations are needed to allow for smooth treatment delivery on both ends. First, technological problem-solving was highlighted as a major concern and potential obstacle to providing telehealth. Personnel familiar with internet services and telehealth tech- nologies should be available at both sites, whether it is a stand-alone videoconference system at a local clinic or a home laptop with videoconferencing software. Experts rec- ommended that audio and video settings should be inspected prior to each session and backup procedures should be in place if technologies fail (e.g., backup telephone). Second, identification of appropriate treatment rooms also raised several concerns, particularly as they relate to home-based telehealth practices. Patients receiving home-based telehealth must have a quiet, private location free from distractions (e.g., children walking into room for attention from parent/patient) in which to conduct their therapy sessions. These rooms should be spacious enough to allow for practice of various in-session exercises (e.g., interoceptive exposures for PD). Third, the patient location should to have access to a fax machine or computer with a printer to allow for transfer of assessment (e.g., self-report questionnaires) and treatment documents (e.g., session handouts and homework assign- ments). If this is not possible, providers should plan accord- ingly and mail documents to the clinic and/or patient’shome. Assessment measures also can be read and answered aloud. Fourth, providers must acquire contact information for appro- priate emergency services in the patient’s locality prior to the first session (e.g., emergency dispatcher, police department, local hospitals, local mental health facilities). Having emer- gency contact information readily available has been shown to be vital in managing suicidality via telehealth (Gros et al. 2011b). Communication Style AdjustmentsDue to limitations of telehealth technologies, several adjustments to communica- tion styles on the part of both patients and providers were recommended by experts. An initial orientation at the begin- ning of treatment is recommended to address these adjust- ments early in the treatment process. For example, a slower rate of speech and polite turn-taking are needed in order to reduce communication difficulties as many telehealth tech- nologies only allow speakers on one side or the other to speak at a time. Body language and hand gestures may also be difficult to interpret when smaller screen sizes are used, suggesting that these behaviors should be augmented or replaced when possible by more direct questions and an- swers from patients and providers. Although most experts agreed that these limitations are minor and easy to adjust to J Psychopathol Behav Assess (2013) 35:506–521515 within the first session or two of telehealth, patient and provider hesitation and resistance to telehealth should be assessed throughout the treatment process. In rare cases, patients have refused treatment via telehealth due to dissat- isfaction with technology and communication style. Also, in rare cases, some providers have expressed dissatisfaction with these procedures, as there are initial feelings that telehealth services are inferior and more time-intensive than traditional in-person practices, despite empirical evidence to the contrary (e.g., Mitchell et al.2008). Treatment Protocol AdjustmentsExperts also recommended that adjustments may be needed in treatment protocols them- selves, due to limitations of telehealth and geographic dis- tance from patients. Although these adjustments vary by disorder and treatment approach and do not appear to typi- cally influence the effectiveness of treatment, they must be acknowledged and incorporated into telehealth practices. For example, providers’use of self-report questionnaires, treat- ment handouts, and in-session examples (e.g., figures presented on dry erase board) may be limited due to telehealth technologies. Thus, thorough preparation and faxing or mailing of materials prior to session is recom- mended. Alternatively, these materials also could be digi- tized and collected online. Additional materials (e.g., in- session imaginal exposure audio recordings) may need to be mailed immediately aftersession completion (Tuerk et al.2010b). In-session situational (e.g., riding an elevator) and interoceptive (e.g., walking up stairs) exposures also may be limited in telehealth treatment and may need to be completed between sessions via homework assignments or during additional face-to-face appointments when possible; however, continued technological advances may address this limitation overtime with portable telehealth equipment (e.g., smart phones). Other limitations include reduced ability to identify acute intoxication (e.g., smell of alcohol, pupil size) or conduct unplanned drug testing in patients with substance use. Research Applications In many ways, telehealth treatment practices are ideal for research. As noted earlier, telehealth treatments require thor- ough preparation of equipment, protocols, and treatment materials, as is typical of most well-planned research. However, experts noted several difficulties in completing treatment studies involving telehealth, including obtaining informed consent from participants, completing lengthy as- sessment batteries, and selecting telehealth equipment. Each of these difficulties is detailed next. Informed ConsentConsent of eligible participants was noted as a significant obstacle to research by experts. Due torequirements by institutional review boards and research and development committees, consent forms are generally completed in-person in most treatment outcome studies. This policy is focused on participant protection regarding confi- dential full disclosure and understanding of the consent pro- cedures and related study. However, this policy also may result in additional burden on participants through required travel and may limit the usability of telehealth in any study population located a significant distance from the research team (e.g., deployed active service members). Although these policies may change as telehealth practices become more widely used and accepted, currently, the in-person consent requirement may limit the impact and generalizabil- ity of research on EBPs delivered via telehealth (Oliver et al. 2010). Assessment ProceduresRelated to the clinical limitations of telehealth, the administration of lengthy assessment batteries frequently is completed in-person in telehealth research (e.g., Gros et al.2011a; Morland et al.2009,2010). Although brief weekly self-report measures have been completed via telehealth in some studies (e.g., Gros et al.2011c; Tuerk et al.2010b), experts reported several reasons as to why research groups have chosen in-person delivery for lengthy assessments. First, assessment batteries generally are com- plicated. Researchers may need to be present to walk partic- ipants through the instructions and various forms and ad- dress participants’questions during the administration. Second, due to the time commitment involved in these as- sessments, communication difficulties via telehealth are like- ly and could result in the repetition of items and measures, in addition to the potential for lost data. Third, non-paper-and- pencil self-report measures may be difficult to administer via telehealth, including lengthy interviews, neuropsychological testing, behavioral assessments, and psychophysiological indices. However, use of single and/or multiple in-person assessments may limit research and related benefits of telehealth practices, as not all participants are available to travel to complete said assessments (e.g., participants with transportation difficulties, participants in geographically iso- lated areas, participants that are deployed active duty service members). Thorough planning and consideration of assessment-related concerns should be used when selecting assessment measures for telehealth research, with specific types (e.g., brief self-report) being more compatible with telehealth practices than others. Alternatively, these mate- rials could be digitized and collected online, pending approv- al by research governing bodies (e.g., institutional review board). Research Information TechnologyExperts also reported that the selection of telehealth equipment and treatment location may present a challenge in telehealth research. In the 516J Psychopathol Behav Assess (2013) 35:506–521 majority of previous research, telehealth services were from urban to rural clinics using stand-alone telehealth hardware. However, in newer studies of home-based telehealth (Gros et al.2011a,b), several different technologies have been used, including videophones, tablets and smartphones with built-in video calling services, and laptop and desktop com- puters via internet-based videoconferencing software. Selection of equipment depends largely on participant re- sources (e.g., traditional landline phone access vs. high speed internet access vs. none of the above or home com- puter access vs. smartphone/tablet access vs. none of the above). In these situations, researchers may have to be either very selective in their study inclusion criteria or provide hardware to their participants for the duration of the study. These options can be problematic in terms of generalizability of the findings and costly to the funding agency. Technology Considerations According to experts, technology involved in providing EBPs via telehealth also may pose several concerns to pro- viders and researchers alike. In many of the studies described earlier (Griffiths et al.2006; Nelson et al.2003), telehealth procedures were completed via slow modem speeds (e.g., 128kbit/s), presenting numerous challenges due to audio and visual delays and disruptions. Although technologies and high-speed internet access have improved over the years, several technology-related challenges for telehealth remain, including issues with patient and clinician trainings, band- width, and encryption. Each of these challenges is detailed next. Trainings for Participants and ProvidersDue to potential difficulties navigating telehealth equipment and related soft- ware, experts recommended the employment of a pretreat- ment telehealth orientation session for both participants and providers, as noted in several of the ongoing telehealth studies (Egede et al.2009; Morland et al.2009). Orientation sessions may involve reviewing the operation of telehealth equipment (e.g., turning on, making calls, adjusting camera) and trouble- shooting problems (e.g., checking power supply and internet connection). Home-based telehealth may require additional trainings, including instruction on how to install and navigate the necessary telehealth software in addition to basic computer skills for computer-naïve participants. With telehealth techno- logical disruptions reported in a large number of studies, experts suggested that a quick orientation to telehealth equip- ment could reduce the number of encountered problems and improve troubleshooting on both ends of communication. Access ConsiderationsBandwidth was identified by experts as another technological challenge related to delivering EBPs via telehealth. As telehealth technologies may be mostuseful in treating patients in geographically-isolated areas (e.g., rural settings), issues related to poor bandwidth be- come more relevant due to the historical digital divide be- tween urban and rural settings and their access to computers and high speed internet (Rains2008; Wilson et al.2003). This issue is particularly concerning for home-based telehealth practices. Although a survey of ongoing research on home-based telehealth reported 90 % of participants with Internet access (Gros et al.2011a), much smaller numbers have been reported in nationally-representative studies of rural internet access (60 % dial-up and 40 % high speed broadband; Rains2008; Ruggiero et al.2011). Unfortunately, lower inter- net speeds are associated with increased audio and video de- lays and increased chances of lost connections. Together with these findings, experts suggested that telehealth services should be offered through the patient’spersonalcomputer via home-based telehealth when high-speed broadband is available as well as to community mental health clinics with more reliable and available bandwidth. Confidentiality and Data SecurityEncryption settings are another set of obstacles identified by experts in the delivery of EBPs via telehealth. As patient privacy and confidentiality are of utmost importance, secure encryption settings are recommended for telehealth practices. However, higher levels of encryption typically require more resources, resulting in potential reductions in connection speed and increased delays in audio and video signals. This presents a difficult balance between security and ability to provide adequate telehealth services. Fortunately, as technologies advance, experts were hopeful that newer developments in encryption software will require fewer resources and cause fewer connection problems. Healthcare Systems As the delivery of EBPs via telehealth is a novel approach to delivering treatments to traditionally underserved popu- lations, experts highlighted to need of agencies to develop new policies to support these practices. Although several changes have been made over the years, there still are several obstacles to large scale implementation of EBPs via telehealth at a systems level. Some of these obstacles include communication and sharing of resources between urban and rural facilities, coordination of within facility services between clinical practice and technological sup- port, reimbursement schedules by third-party payers, and licensing and credentialing policies. These issues were frequently listed as the most difficult to manage among the experts. Resource Allocations In telehealth practices between established clinics, resources must be shared in order to J Psychopathol Behav Assess (2013) 35:506–521517 provide reliable services. These resources include protected office space at the regional clinic for telehealth equipment, support staff to escort patients to the telehealth office and deliver and fax paperwork from telehealth patients to pro- viders, and qualified staff to manage emergency proce- dures. In addition, coordinated scheduling and communi- cation systems are needed to manage patient scheduling and cancelations, as both sites need to be aware of all appoint- ments. Experts highlighted that these resources may be limited and difficult to negotiate between local and telehealth providers. In this case, system-level support and a general cultural shift to implement changes to incorporate and support telehealth practices are needed (Tuerk et al. 2010a). Care CoordinationIn addition to coordination between sites, experts noted that coordination between various sys- tems and departments within sites also may be needed. Due to clinical, technological, and privacy concerns discussed earlier, staff from mental health, information technology, and management from one or more sites may be needed to coordinate the implementation of telehealth services. As is the case in any larger setting with complicated bureaucracies, coordination could be particularly difficult and time- consuming and risk the effectiveness of the services. Once again, top-down initiatives with managerial support may be needed to promote the growth of these services and their wide-scale implementation in some settings. Licensing and CredentialingExperts also highlighted the importance of licensing and credentialing as another potential system-wide obstacle to telehealth practices. In a recent re- views of the telehealth policy (Chamberlin2010; Herbert et al. 2012), authors noted that although there are no federal laws or regulations governing telehealth practices, 22 states have enacted telehealth laws (only three specifically include psychologists/psychotherapy). For example, California re- quires written and verbal consent for services involving inter- active video, audio, or data communications (Chamberlin 2010). In addition, eight state psychology licensing boards have issued specific rules and policies for telehealth practices, with many others currently in the process of developing their own policies. In general, these policies have focused on pa- tient protections (i.e., ensuring confidentiality and written consent) and practicing psychology across state lines. Chamberlin (2010) also advised that malpractice providers might have specific rules and regulations regarding telehealth practices. Although these regulations ultimately will aid in continued development and acceptance of telehealth practices, the current rapidly changing environment may discourage future providers and agencies from incorporating telehealth into their own practice, in addition to reducing the utility of telehealth if services are limited within state lines.ReimbursementOn a related topic, experts reported that the reimbursement of telehealth practices by third-party payers remains largely underdeveloped. Many insurance companies do not reimburse for treatments delivered via telehealth or have specific rules or restrictions. For example, Medicare reimburses telehealth at the same rate as in-person practices, including reimbursing staff at the satellite office to support the patient. However, specific criteria must be met for this reimbursement by Medicare, including: 1) patients must be located in a non-metropolitan statistical area, 2) treatment must be provided in a qualifying facility and accompanied by a qualified staff person, and 3) procedures must be approved for telehealth (e.g., individual psychotherapy). Although these practices support office-to-office telehealth, experts noted that there is no mechanism to obtain reimbursement for most home-based telehealth practices. Although some large agencies have adapted their billing practices for telehealth (e.g., Veterans Health Administration), the adop- tion of telehealth practices likely will be slow in non-VA settings until reimbursement of telehealth treatments is wide- ly adopted. Experts suggested that it is likely that home- based telehealth practices could become the preferred meth- od by third-party payers over time due to its potentially reduced costs as compared to clinic-to-clinic practices. Discussion The purpose of the present paper was to review existing literature and ongoing research on the delivery of EBPs via telehealth technologies for each psychiatric disorder, including anxiety disorders, depressive symptoms and suicidality, eating disorders, and addictive behaviors. In addition, the paper also included a consensus opinion of American experts in the field of telehealth in order to identify current challenges related to clinical and re- search practices, technology, and systems that may im- pede the wide-scale implementation of telehealth as they apply to the United States. Review Findings The present research on EBPs via telehealth includes prelim- inary supporting evidence for a wide range of diagnoses and treatment approaches. Across studies, telehealth technolo- gies were found to provide roughly equivalent clinical out- comes (i.e., reductions in symptoms of PTSD, depression, and anxiety, binge and purge behaviors, abstinence from drugs and alcohol) and process variables (i.e., attrition, ad- herence, satisfaction, expectancy) as traditional in-person treatments. The majority of studies involved telehealth prac- tices between two outpatient clinical settings; however, 518J Psychopathol Behav Assess (2013) 35:506–521 preliminary support also was found for telehealth practices delivered directly into the home (Gros et al.2011b; Strachan et al.2012a). Although differences between telehealth and in-person were reported in some studies (Bouchard et al. 2004; Gros et al.2011c; Mitchell et al.2008), these differ- ences were generally small and not consistent across all measures, studies, and/or disorders. Additional research is needed on specific treatment practices that may be difficult to complete via telehealth, especially in disorders where group differences were identified (e.g., imaginal exposures for PTSD and in-session weighing for eating disorders). Together, these findings provide a foundation for further utilization and implementation of EBPs via telehealth in addition to continued investigation of these practices. The telehealth literature still has several limitations. Of the 26 total studies, only 9 were RCTs. In addition, only 4 studies had reasonably sized samples in the telehealth con- dition (Ns > 30). Although some of these concerns likely will be addressed soon by large-scale ongoing RCTs (Egede et al. 2009; Gros et al.2011a; Morland et al.2009; Strachan et al. 2012b), the majority of ongoing studies are focused on PTSD due to targeted populations and related priorities of large funding agencies (e.g., VA and DoD). More research is needed on nearly every disorder, with the exception of PTSD. In addition, the focus of the current literature is primarily on clinical outcomes (e.g., symptoms and impair- ment), rather than costs and process variables (e.g., atten- dance, attrition, satisfaction). As clinical outcomes have been shown to be roughly consistent across telehealth and in-person conditions, more research is needed to understand potential differences between these modalities, especially in areas in which telehealth practices may be more beneficial than in-person practices. Consensus of Experts The informal survey of telehealth experts revealed a set of obstacles in clinical and research practices, technology, and systems related to the delivery of EBPs via telehealth. Clinical procedures require more pre-treatment preparation to coordi- nate sites and orient both patients and providers to telehealth technologies (e.g., troubleshooting disruptions) and treatment procedures (e.g., faxing treatment handouts). Slight changes also may be needed to treatment protocols, as providers are unable to assist in-person during in-session practices. Research practices require additional attention to consenting techniques, assessment procedures, and the selection of equipment for home-based telehealth projects. Technological considerations include adjusting to low bandwidth and maximizing encryp- tion and privacy settings. From a healthcare systems perspec- tive, top-down initiatives and system-wide managerial support may be needed to coordinate multiple treatment sites and multiple agencies responsible for implementing telehealth. Inaddition, third-party payers and federal and state regulatory agencies may be limiting initial growth of the delivery of EBPs via telehealth due to strict reimbursement and practice policies. Despite these obstacles, the delivery of EBPs via telehealth has demonstrated continued growth across both clinical and research settings. For the most part, many of the concerns identified likely will decrease as telehealth prac- tices gain in popularity and as the potential benefits of telehealth are better recognized (e.g., decreasing patients’ and providers’costs and increasing system coverage area to providers). For example, recent advances in technology has allowed telehealth practices to evolve from heavily hardware-based applications (e.g., standalone video phones and videoconferencing equipment) to software applications available via home computers with videoconfencing pro- grams. In addition, advances in technology also have allowed for a safer and more secure environment via im- proved encryption and privacy settings. Although slight changes to clinical (e.g., in-session exercises, transferring of materials) and research (e.g., consent, assessment) prac- tices likely will remain needed, these changes have not prevented continued growth in the delivery of EBPs via telehealth, nor have they resulted in detectable differences in the effectiveness of most treatments in the literature. Future Directions Over the coming years, the delivery of EBPs via telehealth likely will increase dramatically. This growth could take place in several areas. Telehealth practices could increase from the limited number of existing outreach clinics to outpatient clinics in every community; therefore, drastically reducing geographic barriers to EBPs. Telehealth practice also could continue to expand in home-based applications, both with the home computer and other related technologies, such as tablets and smart phones. These expansions in ser- vice would allow for many changes in how and where telehealth treatments are completed. For example, telehealth via mobile devices could improve in-session practices by allowing patients contact with their provider during behav- ioral activation and/or exposure practices in the moment (e.g., riding public transportation). In addition, expanding the reach of telehealth practices to all areas could allow for improved access to EBPs for high risk populations that previously had limited access to providers (e.g., active com- bat zones, recent disaster areas). Additionally, beyond apply- ing existing EBPs via telehealth, the treatment modality opens up possibilities for new EPBs to be developed to specifically take advantage of natural/home ecologies in the treatment process (Tuerk et al.2010a). And of course, each one of these new developments needs to be accompa- nied by thorough investigation from the telehealth research community. J Psychopathol Behav Assess (2013) 35:506–521519 Conclusions The delivery of EBPs via video telehealth could be a major component in the future of psychotherapy and clinical prac- tice. These services have received preliminary support in the literature for clinical effectiveness, cost effectiveness, patient and provider acceptance, and safety, with additional large- scale ongoing non-inferiority studies (Egede et al.2009; Gros et al.2011a; Morland et al.2009; Strachan et al. 2012b). Although many obstacles have been identified dur- ing initial development and investigation of these practices, most of these concerns likely will improve with increased acceptability of telehealth technologies among patients, pro- viders, and administrators. 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J Psychopathol Behav Assess (2013) 35:506–521521 R epro duce d w ith p erm is sio n o f th e c o pyrig ht o w ner. F urth er r e pro ductio n p ro hib ite d w ith out p erm is sio n.
The Complexities of E-TherapyPrior to beginning work on this discussion, please watch the Virtual Clinic (Links to an external site.)Links to an external site. video and review the Guidelines for the
Best Practices for Remote Psychological Assessment via Telehealth Technologies David D. Luxton National Center for Telehealth & Technology, Tacoma, Washington and University of Washington School of Medicine Larry D. Pruitt and Janyce E. Osenbach National Center for Telehealth & Technology, Tacoma, Washington The use and capabilities of telehealth technologies to conduct psychological assessments remotely are expanding. Clinical practitioners and researchers need to be aware of what influences the psychometric properties of telehealth-based assessments to assure optimal and competent assessments. The purpose of this review is to discuss the specific factors that influence the validity and reliability of remote psychological assessments and to provide best practices recommendations. Specific factors discussed include the lack of physical presence, technological issues, patient and provider acceptance of and comfort with technology, and procedural issues. Psychometric data regarding telehealth-based psycho- logical assessment and limitations to these data, as well as cultural, ethical, and safety considerations are discussed. The information presented is applicable to all mental health professionals who conduct psychological assessment with telehealth technologies. Keywords:psychological assessment, telehealth, telemental health, video-conferencing, mobile devices The use of telehealth technologies in psychological practice has steadily increased over the last decade and their use is expected to grow substantially in the years ahead (American Psychological Association, 2010a;Maheu, Pulier, McMenamin, & Posen, 2012). Psychological assessment is an integral com- ponent of telemental health (TMH) practice and is necessary for diagnostics, screening, symptom monitoring, and evaluations oftreatment progress and outcomes. The use of telehealth tech- nologies to conduct psychological assessments from afar can provide convenience, reduce costs (e.g., travel avoidance), and enable access to assessment services when they are otherwise unavailable. There are many technologies available to clinicians who are engaged in TMH practice. These include traditional telephones and video-teleconferencing (VTC) equipment for synchronous (real-time) communication as well as asynchronous (store-and- forward) technologies such as fax or email to send and receive assessment materials. The Internet is also used to administer psychological tests and measures remotely on web pages. Internet-based testing and assessments can make use of technology-enhancements such as the use ofmultimedia content (i.e., pictures, videos, sounds, etc.), computer adaptive testing techniques, and automatic scoring and interpretation algorithms (seeBarak & Buchanan, 2004). The Internet can also be used for VTC by using personal computers (PCs) and off-the-shelf web- cams, which may be an affordable and highly accessible option for home-based TMH (Luxton, 2013a). More recently, smart mobile devices (i.e., smartphones and tablets) have emerged as a way to conduct psychological assessments. Assessment measures can now be in the form of an application or “app” on mobile devices or accessed via Internet connectivity. Traditional interview tech- niques conducted via VTC using webcams on PCs or mobile devices themselves may be augmented with electronic measures completed on the device with data uploaded to clinicians for review (Luxton, McCann, Bush, Mishkind, & Reger, 2011). Given the numerous available telehealth technologies and their increasing use, practitioners who use them need to be cognizant of the factors that influence the psychometric properties of psycho- logical assessments when administered via those technologies. Practitioners also need to know whether a given measure or DAVID D. L UXTON is a licensed clinical psychologist who received his PhD in clinical psychology from the University of Kansas. He is a Research Psychologist and Program Manager at National Center for Telehealth & Technology (T2) and an Affiliate Associate Professor of Psychiatry and Behavioral Sciences at the University of the Washington School of Med- icine in Seattle. His research and writing are focused in the areas of military psychological health, telehealth, and technology-based treatments. L ARRY D. P RUITT is a licensed clinical psychologist who received his PhD from the University of Nevada, Reno. He is a Research Psychologist with the National Center for Telehealth & Technology (T2). His research and writings are concentrated in the areas of telemental health and the devel- opment of treatments for anxiety and mood related conditions. J ANYCE E. O SENBACH received her PhD in Psychometrics from Fordham University. She is currently a Research Psychologist with the National Center for Telehealth & Technology. Her previous research publications examined the risk factor profiles of posttraumatic stress disorder (PTSD) and how those with PTSD interact with the law. Her current interest is on the influence of mobile technology to induce behavioral change. T HE VIEWS EXPRESSED are those of the authors and do not reflect the official policy or position of the Department of Defense of the U.S. Government. C ORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to David D. Luxton, National Center for Telehealth & Technology (T2), Defense Centers of Excellence (DCoE) for Psychological Health & Traumatic Brain Injury, 9933 West Hayes Street, Joint Base Lewis-McChord, WA 98431. E-mail:[email protected] Professional Psychology: Research and PracticeIn the public domain 2014, Vol. 45, No. 1, 27–35DOI:10.1037/a0034547 27 assessment technique is appropriate for use and they need to be familiar with the proper administration procedures in order to assure competent and ethical practice. Our purpose with this article is therefore to review the specific issues that influence the validity and reliability of telehealth-based assessments and to provide best practice recommendations for practitioners. Although we focus primarily on psychological assessment and evaluation during treat- ment services (i.e., diagnostic and symptom assessment), the prin- ciples and procedures that we discuss are pertinent to other remote assessment and testing applications including neuropsychological/ cognitive testing, forensic risk assessment, and occupational test- ing. Reliability and Validity Considerations and Recommendations Remote Physical Presence and Setting The primary and most obvious difference between telehealth and in-person assessment is the fact that the patient is not in the same room as the clinician. The lack of in-person presence may influence how information is assessed as well as what can be assessed. Nonverbal information is useful for determining the patient’s emotional state and, in some cases, risk behaviors. For example, olfactory sensory information can provide clinically rel- evant information regarding hygiene as well as the use of alcohol or other substances. Body posture, facial expressions, body lan- guage (e.g., foot tapping, hand wringing), as well as nonverbal emotional responses such as facial flushing, tearing up, and direc- tion of eye-gaze, also provide important information. The obser- vation of psychomotor and other medical symptoms are also important to observe during psychological assessments. Further, the observation of how an examinee approaches a test or measure may be critical for making an accurate assessment. The lack of physical presence, however, may limit the range of information available or how it can be observed. VTC assessments may be influenced by camera angle, screen size, room characteristics, or other technical factors (e.g., network bandwidth issues) that pro- hibit the observation of all behaviors. Further, the lack of physical presence in itself may influence a patient’s clinical presentation. For example, patients who are socially anxious may underreport symptom severity when they are assessed remotely because the fear-evoking stimulus (i.e., the presence of the assessor) is phys- ically distant (Grady & Melcer, 2005). Also, in the case of home- based assessments, symptoms of panic disorder, agoraphobia, or the hyper-arousal symptom cluster of PTSD may be less salient because the patient is able to avoid situations that may be per- ceived as threatening, such as driving to a clinic or being around strangers in a busy waiting room. To help assure the validity and reliability of remote assessment, it is first necessary to make sure that the environmental conditions at the remote location are conducive to the assessment procedures. The location of the room for the assessment session should assure comfort and privacy. The assessment space should be large enough for the patient to feel comfortable in and assessments that involve groups and family interviews will require a space that is large enough to accommodate multiple people and, for some applica- tions, may require a table and other supplies (Kramer, Ayers,Mishkind, & Norem, 2011). In the case of home-based assessment, the presence of roommates, family members, pets, unexpected phone calls, or other distractions may disrupt the assessment process. It is therefore important for the practitioner to work with the patient to plan for and schedule sessions during a time that is free of potential disruptions. These considerations are particularly important for home-based assessments because the practitioner will have less control of the environment than they may have in an office setting. Given the potential limits of what and how information can be collected during remote assessments, it may be appropriate to modify typical in-person assessment procedures. However, careful review of the instructions or administration manuals for measures and tests should be conducted to assure that procedures or envi- ronmental conditions for standardized administration are not al- tered in a way that threatens the reliability and validity of the assessment. In the case of VTC-based assessment, it may be necessary to ask a patient to hold a paper-and-pencil assessment (e.g., self-report measures or therapy homework) up to the video camera for viewing or to use larger handwriting because of small screen size or poor image quality. In addition, it may be helpful to ask the patient to read their responses out loud in scenarios where synchronous video is not used or when the connection quality is inadequate. When nonverbal information is useful but is unavail- able or limited, it may also be necessary to ask additional questions to improve the accuracy of the assessment. For example, if admin- istering the Hamilton Rating Scale for Depression (Hamilton, 1967), it may be appropriate to ask the patient to self-report symptoms of psychomotor retardation and agitation with specific follow-up questions such as “Do you have problems sitting still for more than a minute or two” or “Do you move more slowly than your coworkers?”. It is important to note that the procedures for some assessments may not lend themselves to remote administration without physical presence. For example, the Wechsler Adult Intelligence Scale (WAIS-IV;Wechsler, 2008) involves hands-on interaction, such as administration of the Block Design, Matrix Reasoning, and Visual Puzzles subtests from the Perceptual Reasoning Index, which would be inappropriate and impractical to administer via VTC. In some cases, however, it may be feasible to administer assessments remotely, such as cognitive function testing (seeCul- lum, Weiner, Gehrmann, & Hynan, 2006), whereby an on-site staff member administers the assessment and then shares the results with a remote clinician who scores and interprets them. Also, some assessment instruments, such as the Minnesota Multiphasic Per- sonality Inventory (MMPI)-2 or WAIS-IV, should be physically safeguarded (not made openly available to the public) to assure the validity of future administrations. It is therefore important for the practitioner to consider whether remote administration of assess- ment materials presents a risk to the integrity of the instrument (e.g., by patients being able to print items at home or share them via the Internet, etc.). Practitioners should also consider whether there is an increased risk for dishonest responses (e.g., responses obtained from the Internet or someone else taking the assessment) because control over the testing environment is reduced (Bu- chanan, Johnson & Goldberg, 2005;Reips, 2000). 28 LUXTON, PRUITT, AND OSENBACH Technology Issues There are several technical issues associated with the use of tele- health technologies that may influence the quality of telehealth-based assessments. Eye gaze angle is the anglebetween the eye and the camera and the eye and the center of the display (Tam, Cafazzo, Seto, Salenieks, & Rossos, 2007). A potential problem when using VTC technology is that users often make eye contact with the image of the person on the screen rather than with the camera (Chen, 2002)—a phenomenon that gives the appearance that one person is looking down or away from the other person. Eye contact between a patient and a clinician is important because it provides visual cues to which the participants can respond (Grayson & Monk, 2003;Tam et al., 2007). Eye contact is also a source of clinical information that is useful for determining the presence of psychological states or particular disorders (e.g., autistic disorder). Interpretation of facial expressions and affect may be difficult when eye contact is misleading, and eye gaze angle may also influence satisfaction with using VTC (Tam et al., 2007). Cameras should be positioned in a way that allows the images of both parties to appear straight-on and centered in their respective mon- itors so that both appear to speak eye-to-eye with each other (Kramer et al., 2011).Tam et al. (2007)pointed out that improved eye contact can be realized by increasing the horizontal distance of participants from the videoconferencing unit. Sometimes, how- ever, patients may shift position during a session, or the camera may be accidently be shifted from the optimal angle. It may therefore be necessary to ask the patient to make adjustments. It is also recommended to check-in with the patient to make sure they can see and hear clearly. The “picture in picture” function avail- able on many VTC devices can be used to ensure that the provider is clearly in frame as well. Network connection quality is another important factor that can influence assessment capabilities and quality. Connection prob- lems can be caused by a variety of factors such as low quality equipment, an overloaded computer (e.g., too many programs running at one time), inadequate bandwidth, and user inexperience with VTC (Hyler, Gangure, & Batchelder, 2005;Jones, Johnston, Reboussin, & McCall, 2001;Luxton, Mishkind, Crumpton, Ayers, & Mysliwiec, 2012).Jones et al. (2001)found that inadequate audio quality can influence the ability to accurately gather infor- mation from the patient. For example, the observation of vocal properties (e.g., shakiness, inflection, and tone), as well as whether an individual may be crying, can be an important source of information regarding emotional states, and a low-quality audio connection may inhibit observation of this information. It is also important to consider that technological issues (e.g., bandwidth limitations, signal drop-outs, etc.) may influence how well the patient understands the clinician (not just how well the clinician understands the patient). It is therefore a best practice to test the quality of the connection at the beginning of the assessment session and to check in with the patient from time to time to make sure the connection quality is still adequate. Although there is some guidance available regarding minimum recommended band- width requirements for TMH (seeAmerican Telemedicine Asso- ciation, 2009), what is or is not adequate in any given application will depend on a variety of factors, including requirements for the type of assessment, environmental conditions, and the technology itself.Potential distractions caused by use of technology (e.g., web cam, personal computer, microphone, mobile device, etc.) may also introduce threats to the validity and reliability of remote psychological assessments. For example, when conducting a clin- ical assessment interview over a web cam, the patient may become distracted by inconsistent connections, error messages, or other technical anomalies (Germain, Marchand, Bouchard, Drouin, & Guay, 2009;Yoshino et al., 2001). Furthermore, technical mal- functions during telehealth sessions may become a source of frustration for patients (Luxton, Mishkind, et al., 2012;Luxton, Sirotin, & Mishkind., 2010). Persistent technical malfunctions that occur before or during remote assessment sessions may therefore influence motivation, agreeableness, and adherence to assessment procedures. It is thus important to have a plan to resolve technical malfunctions by expeditiously troubleshooting the problem, re- scheduling the session, or conducting it with an alternative me- dium (e.g., over the phone) if necessary. It is also important to consider potential cognitive and/or sen- sory deficits that patients may have that could impair their ability to use telehealth technology. Technological aides (e.g., headsets, screen magnification devices, speech to text translation software, etc.) or the involvement of family members or other care givers that can assist may be appropriate. Possible fatigue or physical discomfort caused by technology use (e.g., eye strain when view- ing computer monitors) should also be evaluated before and during the assessment process, especially during lengthy assessment ses- sions. User Acceptance Generally, the validity of any psychological assessment is mod- ulated by the degree to which the person being assessed accepts (i.e., is willing to participate in) the context of a given assessment including the setting and manner in which the assessment is conducted (Cronbach, 1970;Elhai, Sweet, Guidotti Breting, & Kaloupek, 2012). An individual’s acceptance of a particular type of assessment is a multifaceted construct that depends on an individual’s physical and emotional state, motivation, attention, personality, and temperament. Poor acceptance has been cited as a factor that reduces compliance and the motivation to engage in mental health assessments (Rogers, 2001). Inadequate acceptance of TMH by either the patient or practitioner can therefore be expected to have a negative influence on the validity and reliability of psychological assessments. Several reviews that discuss overall acceptance and satisfaction with TMH provide insight into the factors that may influence acceptance of telehealth-based psychological assessments. For ex- ample,Modai et al. (2006)reported that patients and providers are generally satisfied with VTC and that regular use of VTC im- proves the overall degree of satisfaction with this medium. A review byRichardson, Frueh, Grubaugh, Egede, & Elhai (2009) showed that there are high levels of user satisfaction and accep- tance with TMH across diverse clinical populations and services. In particular, the benefits of reduced travel time, wait times, and lost work time, as well as greater sense of personal control over sessions were specifically associated with higher satisfaction among patients (seeHilty, Nesbitt, Kuenneth, Cruz, & Hales, 2007;Simpson, Bell, Knox, & Britton, 2005). These benefits may be especially important when considering the need for multiple 29 ASSESSMENT visits for some psychological assessments (i.e., initial interview, assessment battery administration, and feedback/treatment plan- ning). Technological issues may also play an important part in the acceptability of telehealth-based assessments as well as rapport between the patient and practitioner (Glueck, 2013). A review by Backhaus et al. (2012)found that patient acceptability of VTC is generally on par with the acceptability of face-to-face contact, although the most common areas of dissatisfaction were associated with technical difficulties that interrupted sessions. In particular, problems with establishing a connection, connection speed, sound echo/feedback, and inability to transmit written material (e.g., a thought journal or activity log) in a way that allowed both the patient and the therapist to review it together were noted (Cowain, 2001;Folen, James, Earles, & Andrasik, 2001).Hyler, Gangure, and Batchelder (2005)found that both patients and providers preferred in-person assessment when compared to low-bandwidth VTC assessment, especially when detailed observation of patients was necessary; however, when high-bandwidth VTC was avail- able, this method was preferred over in-person assessments. Also, the loss or distortion of nonverbal behavior and other patient characteristics may also negatively impact a clinician’s acceptabil- ity of telehealth-based assessments (Grady & Melcer, 2005). So- lutions to these technology-based issues are available (e.g., faster Internet speeds, head sets, adjunct technology such as fax/docu- ment scanner) but come with financial costs that may limit feasi- bility. Overall, it is important for practitioners to consider that the factors that may influence the acceptability of telehealth-based psychological assessments may not be consistent across all assess- ment sessions or settings. Cultural Considerations As with in-person psychological assessment and testing, prac- titioners and researchers who make use of telehealth technologies must attend to a broad range of cultural factors, including the patient’s age, technological familiarity, and culture-specific norms to assure valid and reliable assessments. For example, the remote physical presence inherent in TMH may create a barrier that reduces a patient’s engagement in the assessment process, espe- cially among members of cultures or groups that emphasize inter- personal connectedness or that rely heavily on nonverbal interac- tions (Nieves & Stack, 2007;Savin, Glueck, Chardavoyne, Yager, & Novins, 2011). An essential component of this is the provider’s ability to make use of whatever nonverbal communication is available. This is a skill that is essential when working with groups where the symptoms of mental illness may be minimized or stigmatized (e.g., Asian and Asian American populations, military populations;Yeung, Hails, Chang, Trinh, & Fava, 2011). Also, patients that are less comfortable or have less experience with technology, such as elderly or severely impoverished populations, may display a more drastic discrepancy between in-person and VTC assessments (Rohland, Saleh, Rohrer, & Romitti, 2000). When working with specific populations, the provision of TMH services, including psychological assessment, should be tailored to the needs, resources, and technological infrastructure of the local community (Brooks, Spargo, Yellowlees, O’Neill, & Shore, 2013). Preliminary work suggests that the customization of TMH to the needs and features of the group that is being served has thepotential to enhance access to psychological services within tradi- tionally underserved populations (Dwight-Johnson et al., 2011). Shore et al. (2008)have also demonstrated that structured assess- ments provided via VTC were as acceptable as in-person assess- ments among an American Indian population and that the VTC use did not influence ratings of the perceived usability of the assess- ment, patient/provider interaction, or overall satisfaction. Also, individual backgrounds may present a strong contextualinfluence on whether and how technology is used (Brooks, Spargo,Yellowlees, O’Neill, & Shore, 2013). It is therefore important for practitioners to be sensitive to the capabilities and preferences of patients during TMH assessments and also recognize that telehealth-based assess- ments may not be appropriate for all individuals. The provision of a brief questionnaire or interview survey to evaluate previous experiences and preferences regarding technology may be helpful. Ethical, Privacy, and Safety Considerations Attention to general ethical principles, such as those specified in theEthical Principles of Psychologists and Code of Conduct (American Psychological Association, 2010b), is necessary during psychological practice whether it is conducted in-person or re- motely. Standard 9, Assessment, specifically addresses standards for psychological assessment and these too apply to all forms and mediums of psychological assessment. There are, however, aspects of telehealth-based assessments that require additional thought in order to assure ethical practice and optimal assessments. For example, it would be inappropriate practice to select, develop, or modify assessment instruments or alter procedures for remote administration without evidence of sufficient scientific validation or the appropriate disclosure of limitations. It is therefore neces- sary for practitioners to be familiar with what measures or tech- niques are supported by the scientific literature before using them. Moreover, the assurance of patient confidentiality is an example of ethical practice that may influence the validity and reliability of psychological assessments. If a patient does not feel that their privacy is respected and valued by practitioners, the patient may be less willing to disclose information (Rogers, 2001). Both physical and electronic safeguards should be used to assure confidentiality during remote psychological assessments. For ex- ample, people may speak louder when using telehealth technology than when in-person and electronic speakers may amplify sound significantly. Thus, audio should only be loud enough at each end so that both the patient and practitioner can be easily heard but not so loud that the TMH session can be overheard by people outside the room (Kramer et al., 2011). In the case of home-based TMH assessments, practitioners should assess whether the patient has any extra concerns about their privacy (i.e., whether family mem- bers or others may overhear the assessment session). Practitioners conducting psychological assessments with tele- health technology also need to be cognizant of the applicability of the Health Insurance Portability and Accountability Act, the Health Information Technology for Economic and Clinical Health Act, applicable state law, and local privacy and security require- ments. The American Telemedicine Association provides specific practice standards and guidelines regarding this topic (American Telemedicine Association, 2009,2013). Appropriate disclosure of safeguards and potential risks associated with privacy and elec- tronic data should be addressed during the informed consent pro- 30 LUXTON, PRUITT, AND OSENBACH cess. As pointed out byMaheu and McMenamin (2013)however, the informed consent process or an agreement with patients may not be adequate in all situations, in all states, or in foreign coun- tries. Moreover, the diversity in the types of technologies, network infrastructures, and procedures for their use requires careful review of data security risks and requirements (seeKramer, Mishkind, Luxton, & Shore, 2013;Luxton, Kayl, & Mishkind, 2012). Whether or not a particular technology platform or application meets standards for security and privacy of data can be compli- cated by complex issues such as whether and how digital data is stored on commercial servers, manufacturer agreements regarding ownership of transmitted data, and other potential technical risks to data security and privacy. Consultation with applicable legal or regulatory offices, information technology system administrators, equipment and software manufacturers, and other experienced experts in the field may be necessary when selecting telehealth platforms or when uncertainties regarding particular applications exist. It is also important to consider the safety of the patient during TMH assessment sessions and to have a safety plan in place (Luxton, O’Brien, McCann, & Mishkind, 2012). A principal con- cern involves what to do if a patient becomes distressed or has a medical emergency during a remote assessment session. Safety plans should include procedures for contacting emergency services in the patient’s locale, alternate contact methods in case the syn- chronous telehealth connection is lost (e.g., backup phone contact), and plans for resolving technical problems (American Telemedi- cine Association, 2013;Luxton, O’Brien et al., 2012). The iden- tification and involvement of a local collaborator, such as a family member or friend of the patient that can assist with on-site tech- nical problems or provide support to a patient during emergency situations should be considered (American Telemedicine Associ- ation, 2013;Gros, Veronee, Strachan, Ruggerio, & Acierno, 2011; Luxton, O’Brien et al., 2012). The use of a collateral person, as well as overall telehealth assessment procedures, risks, and bene- fits should be addressed during the informed consent process. Patients with a history of adverse reactions during treatment (e.g., severe panic attacks), or those who are at high risk of harm to self or others (e.g., family members in the case of home-based TMH), may not be appropriate candidates for telehealth services provided to clinically unsupervised settings (Luxton, O’Brien et al., 2012). These issues should also be considered when conduct- ing remote assessments, especially when providing assessment results. As noted byPope (1992), the form of assessment results and the process of presenting them may influence how patients interpret their meaning. Given these concerns, it is important to consider whether providing assessment results remotely via tele- health technologies is appropriate for any given patient. Prior to engaging in remote assessments, review of the patient’s history and potential risks, assessment of available technologies and the patient’s familiarity with them, as well as discussion of preferences regarding engaging in remote assessments are recommended. Al- ternative options (e.g., in-person) may be necessary if patients are not appropriate candidates for telehealth-based services due to safety concerns, clinical contraindications, technological barriers, or personal preferences (Luxton, O’Brien, et al., 2012;Luxton, Sirotin, & Mishkind, 2010). Selecting Assessment Measures: Psychometric Considerations It is important for practitioners to consider that even if an assessment tool has been shown to be valid and reliable in the original paper form or in one particular modality (i.e., in-person interview or computer-based administration) it does not necessar- ily mean that the measure or tool will be valid or reliable when conducted remotely via telehealth technologies. Moreover, even if there is empirical support for the use of a particular measure in one telehealth technology medium, such as on an Internet web page, it does not necessarily mean that it will be valid or reliable when transferred to another medium, such as a mobile device. The differences in the physical format of these mediums and proce- dures for use may influence the psychometric properties of mea- sures administered through them. As mentioned previously in this article, it is necessary for practitioners to be familiar with the available scientific literature regarding a measure or technique’s appropriateness for use. Several published reviews provide useful information regarding the validity and reliability of remote psychological assessment via various telehealth technologies. For example,Hyler et al. (2005) conducted a review and meta-analysis that included 14 studies that compared telepsychiatry to in-person psychiatric assessments. Five studies used objective assessment measures, two studies used subjective measures (i.e., satisfaction measures), and seven studies used a combination of objective assessment measures and subjec- tive measures. The Brief Psychiatric Rating Scale (Overall & Gorham, 1962) was the most common assessment instrument. The meta-analysis results indicated that objective telepsychiatry assess- ments were similar to in-person assessments in regard to diagnosis or symptoms assessment. The Telemental Health Standards and Guidelines Working Group (Grady et al., 2011) also conducted a review of published data regarding the psychometric properties of remote telehealth-based psychological assessment. They noted several studies that have examined psychological assessment via clinical interviews or psychiatric interviews based on the Struc- tured Clinical Interview for DSM Disorders (SCID;Spitzer, Wil- liams, Gibbon, & First, 1990). Two studies (Ruskin et al., 1998; Shore, Savin, Orton, Beals, & Manson, 2007) demonstrated high reliability in the administration of the SCID. Comparability be- tween face-to-face and VTC is also demonstrated for the Hamilton Depression Rating Scale for depression (Kobak, 2004;Kobak, Williams, & Engelhardt, 2008).Backhaus and colleagues (2012) conducted a systematic review of the research on psychotherapy using VTC and reported that 69% of the 42 studies that they reviewed used a well-accepted psychometrically validated (in- person) standardized measure for treatment outcomes. Of these, the most common assessment (24% of the 42 studies) was the Beck Depression Inventory (BDI-II;Beck, Steer, & Brown, 1996). Grady et al. also noted that there are not any psychometric data available regarding projective testing over VTC. Grady et al. also noted evidence that demonstrates the feasibility of remote neuropsychological assessment (Hildebrand, Chow, Williams, Nelson, & Wass, 2004;Saligari et al., 2002) and com- parability of scores between remote and in-person assessment (Cullum et al., 2006;Loh, Donaldson, Flicker, Maher, & Gold- swain, 2007), as well as some research that has demonstrated differences on test scores (Ball, Tyrrel, & Long, 1999;Loh et al., 31 ASSESSMENT 2004;Montani et al., 1996). Cognitive assessments that have been examined and validated include the cognitive section of the Cam- bridge Mental Disorders of the Elderly Examination (Ball & Puffett, 1998), the Mini-Mental State Examination (Grob, Wein- trau, Sayles, Raskin, & Ruskin, 2001), the National Adult Reading Test, and the Adult Memory and Information Processing Battery (Tschirch, Walker, & Calvacca, 2006). The development of new norms has been recommended so that the thresholds used for impairment are valid when compared with face-to-face adminis- tration (Grady et al., 2011;Kirkwood, Peck, & Bennie, 2000). Evidence of equivalence as well as differences between Internet-based questionnaire assessments and paper-and-pencil ad- ministrations of standardized measures has also been reported in the literature (Barak & English, 2002;Barak, Hen, Boniel-Nissim, & Shapira, 2008;Buchanan, 2002;Naglieri et al., 2004). For example, evaluation of online versions of BDI-II have shown that psychometric properties differ across testing modalities of psycho- metrically validated assessments, even when comparisons are made between equivalent samples, and that online BDI-II scores tended to be higher (Glaze & Cox, 1991;Peterson, Johannsson, & Carlsson, 1996;Schulenberg & Yutrzenka, 1999). Also, some evaluations of personality inventories administered online have shown differences in item loadings compared to paper-and-pencil versions (Buchanan, 2001;Buchanan, Johnson, & Goldberg, 2005). These differences may be due to the lessened impact of social desirability, an increase of self-disclosure in online assess- ment, or as the result of the technology-based presentation itself (Buchanan, 2003). In sum, the literature base regarding the psychometric properties of telehealth-based assessments is growing; however, there are gaps in the literature that practitioners should consider when selecting particular assessment instruments and mediums. In par- ticular, the vast majority of available measures and assessment tools are based on norms that were established by employing traditional in-person procedures. The reevaluation of these tools with diverse populations, clinical presentations, and telehealth mediums is necessary to assure the validity of assessments con- ducted via telehealth technologies. It is critical for practitioners to be cognizant of assessment measure limitations and to appropri- ately disclose and document them in their practice. Keeping up with the scientific literature as well as publications by organiza- tions such as the APA and American Telemedicine Association is recommended. Discussion The validity and reliability of psychological assessments con- ducted via telehealth technology is influenced by factors that are both common to in-person assessment and unique to telehealth- based assessments. Although the psychometric characteristics and standardized procedures of traditional in-person psychological as- sessments provide useful information about how they may trans- late to other mediums, practitioners would be remiss to simply assume equivalency between in-person and remote administration of psychological assessments. It is therefore important for practi- tioners who already use or are considering the use of telehealth technologies to be familiar with these factors and to use appropri- ate administration techniques when conducting remote psycholog- ical assessments. It is feasible to assure reliable and valid remotepsychological assessments with appropriate knowledge, prepara- tion, and practice. The use of telehealth technologies for remote psychological assessment has several benefits for both patients and practitio- ners. For example, telehealth-based assessments allow practi- tioners to conveniently monitor symptoms and other health variables betweenin-person or telehealth treatment sessions. Fur- ther, telehealth-based psychological assessment may improve care satisfaction and overall health outcomes by providing services that are specialized for the patient’s needs. In particular, telehealth technologies may provide access to clinical specialty assessments (e.g., neuropsychological assessments) that are not available in the patient’s locale. Telehealth-based psychological assessment may also increase access to services among patients who speak differ- ent languages. For example, a non-English speaking patient could engage in mental health assessment and treatment with a clinician who speaks their native language, regardless of physical location, which may minimize potential misunderstanding and misdiagnosis of a patient’s symptom report (Yeung et al., 2011). This would also be true for the use of American Sign Language and would remove the need for a third-party translator who may unintentionally change the meaning of a communication during the translation process. The use of telehealth technologies also allows patients to connect with providers that are trained in specialized assessments and who also have experience working with particular cultural groups (e.g., military culture, the elderly, specific ethnic groups, etc.). Current and emerging technologies not only allow remote ad- ministration of traditional assessments but may also offer new or improved capabilities and methods of assessment. In particular, the growing field of mobile device apps has created opportunities for self-care assessments and symptom screening that were not pos- sible just a decade ago (Luxton, McCann et al., 2011). Assessment apps on smartphones and tablet PCs can also be useful for mea- suring the dynamic characteristics of a person. For instance, sub- jective mood or anxiety levels can be tracked in real-time and data from bio-feedback equipment can be tracked and analyzed re- motely. The small size and touch screen features of smartphones and tablet PC devices are factors that may influence the psycho- metric characteristics of assessments provided on these devices. Preliminary data, however, have suggested that these devices may be a feasible platform for assessments that is comparable to paper- and-pencil and computer-based assessments (Bush, Skopp, Smo- lenski, Crumpton & Fairall, in press). More research is needed, however, regarding the psychometric properties of psychological assessments administered via mobile devices. Assessments conducted with computer-simulated virtual reality environments are another emerging capability (Holloway & Reger, 2012;Parsons, Silva, Pair, & Rizzo, 2008;Riva, Wiederhold, & Molinari, 1998). Assessments can be built into the virtual envi- ronment so that measures appear virtually while a patient is in the virtual environment or to simulate real-world conditions that are useful for the assessment of particular variables. For example, virtual environments have been tested as a way to create environ- mental or social cues for assessment of emotional and behavioral responses among patients being treated for addiction or anxiety related behaviors (seeBordnick, Carter, & Traylor, 2011). The application of artificial intelligence technologies to conduct clini- cal interviews, psychological assessments, and evaluations is also 32 LUXTON, PRUITT, AND OSENBACH a promising area (Luxton, 2013b). Virtual intelligent agents capa- ble of human-like social interaction can be designed to conduct clinical interviews, analyze results, and provide feedback to pa- tients. These types of systems have already been developed for clinical training and some treatment services (DeAngelis, 2012; Parsons, Kenny, et al., 2008). Artificial intelligence-enabled tech- nologies that use advanced sensing and language processing ca- pabilities are also being developed to assess physiological and psychological variables. These advances in technology have the potential to increase the reliability and validity of psychological assessment, improve clinical care, and reduce costs for both pa- tients and practitioners. In conclusion, the use of telehealth technologies provide an opportunity for psychologists and other health care professionals to expand the capabilities of their practice, provide quality ser- vices, and meet the health care needs of care seekers. The in- creased user demand for technology as well as the continued growth of TMH services will push the need for telehealth-based psychological assessments. 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The Complexities of E-TherapyPrior to beginning work on this discussion, please watch the Virtual Clinic (Links to an external site.)Links to an external site. video and review the Guidelines for the
Running head: CREATING SPECIALIZED WEBSITE 0 Creating Specialized Website Heather Yant PSY 650 Introduction to Clinical and Counseling PsychologyAdam Quinn 8/9/18 Creating Specialized Website Name, Photo, and Credentials:  Photo: Name: Heather Yant, Ph.D., Address: 8960 US-19 Pittsburgh, Allegheny County 15237 USA Cell No: (310)-909, 0121, Email: [email protected] Person Degree: Doctors of psychology (Ph.D.) Clinical Psychology License: I am a licensed clinical Psychiatric Membership: I am a proud member of: – Society of Clinical Psychology, Gained my specialty certification in 2014. Other division membership certification include:- The American Psychological Association(APA) The American Board of Professional Psychology(ABPP) Association for Applied Sport Psychology Personal statements I have wide experience in the field of clinical psychologist since I graduated with doctorate honors in the Capella University. I have served several mental hospitals including Coalinga state Hospital and Napa state hospital specialized in treatment. Still, I have been widely involved in the community affair in helping those with mental issues by providing psychiatric medical attention. Through the experience I gained in serving several mental hospitals and be actively involved in community affair I, therefore, seek to invite all interested parties to my clinic. In the clinic, we provide consultation services:- Community psychology consultation Family consultation services. The clinic still offers psychological assessments for children, adolescent, and adults in the following areas for example:- learning disability in children Attention deficits Evaluation of mental disorders Substance and addiction assessments and other areas. The clinic still provides a wide range of clinical counseling and treatments in children, adults, and adolescents in the following option:- Parenting and family issues Divorce, eating disorder, stress management, and anxiety management Drug and alcohol problem addiction recovery Aging and Other areas involving family therapy, group, couples, children, and the community. My Psychiatric clinic offers services that are dear to the community and to my potential client as outlined above. The potential clients include individual with the issues discussed in the three categories of services we offer in the clinic. The clinic will serve both adults and young children with mental disorders. The reason to choose this field is in order to make sure my community can afford psychological services and solve issues which have been ignored in the society. Specialties: I specialize in Depression, Relationship issue, Assessments Treatment Preferences The psychological theoretical orientation applicable in my personal approach of treatments and assessment include: Adlerian Psychotherapy Emotional Freedom Techniques Gestalt Therapy Jungian Psychotherapy Positive Psychotherapy The modalities will be Applicable to Couple, Groups and Family Client Focus:  I will serve client based in California which is composed of majority white Caucasian, African American, and Latinos. I fluently speak in pure English. Confidentiality Limitations: The information about assessments and evaluation of client disorder will always remain confidential and no one can reveal that information without the consent of the client. Children consent will be offered by the guardian or parents. Reference Heatherington, L., Messer, S. B., Angus, L., Strauman, T. J., Friedlander, M. L., & Kolden, G. G. (2012). The narrowing of theoretical orientations in clinical psychology doctoral training. Clinical Psychology: Science and Practice, 19(4), 364-374. American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57(12), 1060-1073. Neimeyer, G. J., Taylor, J. M., Wear, D. M., & Buyukgoze-Kavas, A. (2011). How special are the specialties? Workplace settings in counseling and clinical psychology in the United States. Counselling Psychology Quarterly, 24(1), 43-53.

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