Telehealth
Telehealth is likely to become a significant part of the future of health care. Although terms such as online therapy and cybertherapy are sometimes used interchangeably, the broadest term to describe the full-range of mental health services that can be provided using telecommunication technology is behavioral telehealth. Telehealth is the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision, education, and information across distance. Behavioral telehealth is simply the application of the same technology to provide behavioral health service. Telehealth includes the delivery of mental health services via the Internet but also includes telephone, television, video, and fax. There is a convergence of functions and hardware in the telecommunications field. Videoconferencing, for example, can be conducted over the Internet using cameras connected to computers, or the data can be sent over telephone lines, or over a closed proprietary Intranet.
The U.S. government already heavily invests in telehealth-over 20 billion dollars in 2000 (mostly in the military). Congress specifically included funding for $200 million per year for telemedicine reimbursement in Medicare. (Unfortunately, many government projects use the less inclusive term telemedicine to describe this expanding field.) There are telehealth programs in nearly all of the states and provinces of the United States and Canada.
The first telehealth projects date back 40 years ago when, in 1959, the University of Nebraska School of Medicine began experimenting with a closed-circuit television link to provide psychiatric and other health services between the Nebraska Psychiatric Institute and Norfolk State Hospital. Through the 1970s, with federal financial and technical assistance, a number of rural projects were developed that relied on satellites or dedicated video connections to supply mental health services. In the late 1980s, military and correctional institutions began experimenting with telehealth systems.
However, these were small scale attempts. Many feel telehealth is about to take off as a means of delivering professional service:
This most recent attempt to bring telehealth service delivery into mainstream health care service delivery is fundamentally different from prior attempts. Although barriers and challenges to the adoption of telehealth have been discussed since its inception, only in the last few years has a solid consensus emerged as to what those barriers are and just how they should be addressed. That consensus, coupled with consumer and commercial demand for affordable telecommunications technology, has spurred health care communications and other manufacturers to develop affordable, user-friendly systems. Finally, legislators, seeing affordable technological options, hearing consensus around both barriers and solutions, and receiving requests from undeserved constituents that the government help implement such solutions, have begun to act to ensure that telehealth technology becomes a significant part of the continuing evolution of health care.
Kathleen M. Kirby, Patrick H. Hardesty and David W. Nickelson, Telehealth and the Evolving Health Care System: Strategic Opportunities for Professional Psychology, Professional Psychology: Research and Practice, December 1998 Vol. 29, No. 6, 527-535
REQUIRED QUIZ ITEM: 20
Telemedicine
According to Marlene Maheau, Ph.D., in Telehealth-Call to Action,
For our specific purposes as psychologists, telemedicine will revolve around a) telephone b) videoconferencing c) e-mail d) fax.
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Terminology
Which term is the most inclusive for describing online and telecommunication assisted delivery of services a) cybertherapy b) online therapy c) behavioral telehealth d) Internet-based psychotherapy
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Online Therapy
The first attempt to use the Internet for delivery of therapy actually dates back to 1972 at a demonstration of a psychotherapy session between computers at Stanford and UCLA. The earliest known organized service to provide mental health advice online is
Ask Uncle Ezra
a free service offered to students of Cornell University in Ithaca, NY (named for Ezra Cornell, the University's founder) which has been in continuous operation since September, 1986.
Fee-based mental health services offered to the public began to appear on the Internet in mid-1995. Most were of the "mental health advice" type, offering to answer one question for a small fee. David Sommers, Ph.D. was the first to establish a fee-based Internet service which which was based on establishing long-term, ongoing helping relationships, communicating only via the Internet. From 1995 through 1998, Sommers worked with over 300 persons in his online practice, spanning the globe from the Arctic Circle to Kuwait. Sommers employed Internet technologies for e-therapy, primarily e-mail with encryption but also real-time chat and videoconferencing. He no longer delivers service over the Internet.
Another early explorer of online therapy was Ed Needham, M.S., who established his "Cyberpsych" IRC chat service in August 1995, and was the first to focus exclusively on e-therapy interaction via real-time chat. He worked with 44 persons from 1995 to 1998. Although he too has discontinued his online practice, he has left his Cyberpsych site up describing this work.
Martha Ainsworth maintains a web site that describes what services online therapists offer, ranging from e-mailed answers to questions to 2-way video, and she also runs credentials checks to make sure they have the licenses and degrees they claim.
 Metanoia Directory of Internet Psychotherapists
She reports that in the fall of 1995, when she first did a search, she found 12 e-therapists practicing on the Internet. By May 1999 her database had grown to include over 250 private-practice websites where e-therapists offer services, and the new e-clinic represent collectively nearly 700 more e-therapists. And the number is growing.
Terri Powell conducted a survey study of therapists listed in the Metanoia Directory of Internet Psychotherapists. While a small sample of 13 limits generalizability, she summarized her findings as follows:
Providers of online mental health services are likely to be seasoned professionals attached to colleges and universities...This survey found that the average online counselor is a 48 year old male and a psychologist with 15 years of traditional clinical practice experience. He's been in online practice for almost 2 years and calls his service "advice giving." When you visit his website, you'll find that he uses some sort of encryption software to protect your anonymity. In order to reduce fraud and exploitation, his credentials have been authenticated. Our composite counselor thinks the availability of online mental health services increases clients' access to mental health professionals, especially clients living in remote areas or suffering from disabilities.
Online Counseling: A Profile and Descriptive Analysis by Terri Powell
Despite the increasing numbers, use of the Internet to provide psychotherapy is controversial. Even most therapists who deliver services via the Internet do not claim that what they are doing is psychotherapy. Most clearly state that the exchanges are educational rather than therapeutic in nature. Traditional psychotherapy does not seem to be part of the online offer of mental health services. Yet there is little doubt that many people have been helped, some profoundly, by interacting with mental health professionals over the Internet. Martha Ainsworth's commitment to furthering online therapy by managing a web site devoted to this subject (Metanoia discussed earlier) is based on her personal e-mail based online therapy which lasted 2 years without ever seeing or talking to her therapist.
I would compare it to keeping a journal in that every day when I wrote him an e-mail I explored my thoughts and feelings in great depth. But usually when you keep a journal it doesn't talk back to you. He challenged me. The fact that we communicated by e-mail, I think, made me feel like he was inside my head and present in my life.
Online Therapy--Not Yet
She has reviewed the key issues surrounding the provision of mental health services over the Internet including ethics, confidentiality, legality, and effectiveness on her site
Metanoia ABC'S of "Internet Therapy"
John Grohol, PsyD, has been a leading proponent of what is increasingly being called e-therapy. He has published a series of articles on best practices in the field.
He is chief operating officer of HelpHorizons that offers e-therapy adhering to the standards evolving among mental health professionals involved in exploring the potential of this approach. The site also contains information about e-therapy developments.
REQUIRED QUIZ ITEM: 22
Telehealth Target
In Dr. Grohol's Definition & Scope of e-therapy, the one technology that is part of both traditional and e-therapy interventions is: a) e-mail b) videoconferencing c) telephone d) chat
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Another example of online therapy is
Eating Disorder Recovery Online
Jeanne Rust, a licensed therapist, offers both individual and group therapy by e-mail and phone.
 Cyberpsych: Mental Health on the Internet This is a RealPlayer recording of a roundtable discussion covering the spectrum of online mental health issues including online therapy with:
 John Grohol,PsyD researcher and a founder of HelpHorizons.com
Russ Newman,PhD clinical psychologist, attorney and executive director for professional practice for the American Psychological Association
Gregg Bloche,,MD attorney, psychiatrist, professor and co-director of the Georgetown/Johns Hopkins Joint Program in Law and Public Health
Richard Sansbury,PhD Internet psychotherapist who has also practiced traditional therapy for more than 20 years
Martha Ainsworth Web consultant reads excerpts from her own on-line therapy.
As an example, click on the site
Eating Disorder Recovery Online
Jeanne Rust, a licensed therapist, offers both individual and group therapy by e-mail and phone.
REQUIRED QUIZ ITEM: 23
Delivery Modalities
Which of these telecommunication modalities is being actively explored as a vehicle for delivery of mental health services: a) telephone b) videoconferencing c) e-mail d) all of the above
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Online Virtual Reality Therapy
Virtual Reality Exposure involves exposing the patient to a virtual environment containing the feared stimulus in place of taking the patient into a real environment or having the patient imagine the stimulus. A team of therapists and computer scientists developed a treatment for fear of heights (acrophobia) that was shown to be very effective in reducing acrophobic subjects' anxiety and avoidance of heights, and in improving attitudes toward heights. You can see some of the graphics they created for this treatment and learn more about the research on this approach at the Emory/Georgia Tech Biotechnology Research Center site.
Virtual Reality Exposure Therapy
The developers note that this virtual reality approach is particularly amenable to telehealth:
Virtual reality exposure therapy is appropriate for networked delivery of clinical psychology and psychiatry services to remote locations. Since the patient is receiving therapy within a virtual environment, the clinician conducting the therapy session could be present physically or participate via computer networks from a remote location.
Underway are projects to simulate PTSD-related experiences of Viet Nam veterans for a desensitization program.
REQUIRED QUIZ ITEM: 24
Virtual Reality Therapy
In Immersed in a Virtual World, the authors state that,
Virtual environments differ from traditional displays in that computer graphics and various display and input technologies are integrated to give the user a )a cathartic experience b) an unlearning experience c) sense of presence or immersion d) contact with repressed memories.
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Virtual Reality Therapy
In Immersed in a Virtual World , virtual reality (VR) includes ...
a) graphics,
b) sounds,
c) tactile stimuli,
d) all of the above.
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Rural Mental Health
One major application of telehealth involves the provision of services to people living in rural, remote, and even wilderness areas. The National Institute on Disability and Rehabilitation Research (NIDRR) funded a project to evaluate the impact of "issue-specific video counseling" on the psychosocial and educational functioning of rural teens with epilepsy and their parents, which is described in this online article:
 Home-Based, Video Counseling for Families of Rural Teens with Epilepsy: Program Rationale and Objectives by Robert Glueckauf, Jeff Whitton, Janet Kain, Susan Vogelgesang, Mike Hudson, and Jeff Baxter
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Telehealth targets
Which population has not been targeted for telehealth based interventions: a) seniors b) psychoanalytic patients c) disabled d) rural dwellers
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Ethical and Legal Issues in Telehealth
The ethical status of telehealth is now being reviewed by many professional organizations. For example, the Ethics Committee of the American Psychological Association issued a statement in 1995 and revised it in 1997 indicating that the APA Code of Conduct "has no rules prohibiting such services". The statement highlights issues of confidentiality and adhering to state licensure regulations in the provision of such services. A special committee is preparing a more comprehensive examination of the implications of telehealth for the practice of psychology.
Services by Telephone, Teleconferencing, and Internet
Concerns include the fear that it will be impossible to ensure confidentiality on the Internet and worry that therapists working by computer may not be able to monitor patients closely enough or intervene quickly in a crisis such as a suicide attempt.
The International Society for Mental Health Online (ISMHO) was formed in 1997 to promote the understanding, use and development of online communication, information and technology for the international mental health community. After considerable discussion and debate, they published
Suggested Principles for the Online Provision of Mental Health Services
Their guidelines address many issues that apply to all forms of therapy but have a unique application to online modes of delivery, such as
1. Informed consent
Potential benefits
Potential risks
Alternatives
Safeguards
2. Boundaries of competence
Ensuring competence in clinical topics
Ensuring competence in online delivery of therapy
3. Requirements to practice
Conformity with state practice guidelines
Then some guidelines have been developed to address specific ethical issues in online delivery of therapy.
Structure of the online services
Turnaround time
Privacy of the counselor (The therapist's right not to have email or other communications disseminated.)
Other ethical guidelines for online therapy have also been published including:
Guidelines for the Clinical Use of Electronic Mail with Patients
Kane Beverly, Sands Daniel Z. Journal of the American Medical Informatics Association. 1998; 5: 104-111.
Standards for the Ethical Practice of WebCounseling
National Board for Certified Counselors
Ethical Standards for internet On-line Counseling
American Counseling Association
But state regulations vary from state to state, and by virtue of state-based licensing system for mental health professionals, guidelines developed in one state would only apply to therapists licensed in that state. The patchwork of licensing regulations has functioned as an impediment to dissemination of telehealth initiatives. In California, the Telemedicine Act of 1996, while mandating some forms of payment for telemedicine, does restrict the provision of mental health services to patients within the state boundary.
REQUIRED QUIZ ITEM: 27
State Regulations
State regulations on telehealth a) are uniform in all 50 states b) apply only to mental health professionals residing in that state c) vary from state to state d) b and c
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Online Resources on Telehealth
Online Web Forums
The Behavior Net site hosts an ongoing web forum led by Leonard Holmes,PhD which explores these issues:
BehaviorNet: Online Clinical Work
John Suler,PhD also hosts a Psychology of Cyberspace web forum on BehaviorNet. John Suler,PhD. also has a web site on the Psychology of Cyberspace which includes a section on Psychotherapy and Clinical Work in Cyberspace.
Mailing List
ISMHO maintains a mailing list with discussion about current issues and events in the delivery of online mental health services.
Organizations
Two telehealth organizations address behavioral telehealth.
The American Association of Telemedicine Service Providers has established an interdisciplinary working group on mental health.
The American Telemedicine Association does not have a specific mental health committee but addresses behavioral telehealth issues in some of its standing committees.
Online Articles
There have been many articles in the popular media on online therapy, and an increasingly popular name for this approach is e-therapy.
E-Therapy: History and Survey
Another review of online therapy is in the article,
Internet therapy and self help groups - the pros and cons
by Storm A. King,PhD & Danielle Moreggi
TelehealthNet has links to many online resources and telehealth professionals, including a free online newsletter Telehealth News which covers the latest developments, projects, and resources in the utilization of telecommunication and information technology in healthcare.
Fictional Account of Therapy in 2005
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