Over the past four decades, computer technology has improved exponentially while cost has decreased. Personal computers (PCs) are more sophisticated, and PC-based programming languages are powerful yet relatively easy to use. Technological applications to health psychology practice are considerable in number and scope. As managed care places new demands on health care service provision, it is essential for health psychologists to capitalize on emerging technologies to facilitate efficient practice. However, these new developments require sensitivity to emerging ethical issues as new ethical guidelines and principles are developed, and as new state and federal policies affect health psychology practice.
This overview considers how recent technological developments affect the practice of health psychology with respect to administration, clinical practice, and training. First addressed is the use of developing technology (such as electronic media) for administrative activities. Then the clinical application of computers to therapy (e.g., online forums of counseling via the Internet, telehealth) and computer-assisted assessment (administration, scoring, and interpreting tests with computers and computer software) are reviewed. Finally, computer-assisted training of health psychologists (e-learning, online supervision, virtual practicum using the Internet or satellite technology) is addressed, concluding with a review of professional organization responses to emerging technologies.
A Brief History
Computer-based applications in psychology-related professions began in the 1960s, with computer-based test interpretation. During the 1970s, researchers expanded computer-assisted testing capabilities to include administration, scoring, and interpretation of psychological tests, and their use increased over time. With less success than its assessment-based counterparts, computer-assisted psychotherapy also began in the 1960s, evolving into various types of computer-assisted therapies including professional consultation programs, client therapeutic learning programs, and online therapy. New and powerful PC technology increases efficiency and productivity and can replace mundane pencil-and-paper tasks in health psychology practice. However, health psychologists need to consider the assets and limitations of technological applications before implementing them.
As computer technology is infused into health psychology practice, the use of paper, typewriter, and pen may be replaced by fax machines, Internet capabilities, wireless satellite networks, and personal digital assistants (also available in cellular phone combinations). Cell phones, e-mail, and fax technologies are commonplace.
Health psychologists are cautioned not to send confidential data through these technologies without appropriate precautions, if at all. To implement these technologies, health psychologists need to carefully apply existing standards of ethical practice to these emerging technologies, as well as consider emerging issues unique to these new tools. The American Psychological Association’s (APA) Ethical Principles of Psychologists and Code of Conduct (1992; revised 2002) requires that psychologists “maintain appropriate confidentiality in creating, storing, accessing, transferring, and disposing of records under their control, whether these are written, automated, or in any other medium” (Section 5.04).
Personal computer systems comprise hardware and software. Hardware is electrical and mechanical equipment, such as the central processing unit in the chassis of the computer, monitors, printers, and various peripheral devices. Software is programming code that directs the hardware to run various applications, such as word processors for creating text documents, spreadsheets for numerical record keeping, databases for file records, combinations or suites of similar applications, and previously mentioned assessment and therapeutic programs.
Hardware that stores electronic media includes internal hard drives; floppy disk drives; compact disk drives; ZIP and JAZ drives, which are similar to floppy disk technology; and servers with large data storage drives for a network of computers. Hardware can be safeguarded with mechanical lock and key, but once turned on, such systems are vulnerable unless protected by security software that requires a password to access to the system. Health psychologists can use a server to manage a network of computers (e.g., a local area network), which can be accessed by others over telephone lines. Systems can be designed with the appropriate safeguards and security protocols to maintain confidentiality.
The Health Insurance Portability and Accountability Act is a federal statute related to the management of electronic data in health psychology and allied health settings. Signed into law in August 1996, it was designed to protect Americans from losing their health insurance when they changed jobs or residences. The act also set up consistent standards for transmitting electronic health care claims, storing information, and protecting an individual’s privacy. The Department of Health and Human Services set up a deadline of April 14, 2003, for professionals to standardize their practices in line with the privacy rule requirements of the act. As with all new legislation, regulatory standards are evolving as the new law is implemented, so health psychologists need to check with their professional associations for updates.
Virtual psychotherapy programs are therapeutic software products marketed to operate without therapist assistance. In general, such technology has yet to be widely implemented; further research is needed to evaluate its effectiveness. Educational programs have experienced the most success. Career counseling often involves information provision, which is ideal for computer-assisted venues. Computerized career counseling benefits clients who are highly motivated and goal directed. However, clients with less-clear goals and less motivation for independence may benefit less.
Cognitive retraining therapy occurs in rehabilitation settings, where computer programs can implement repetitive exercises to enhance cognitive functioning, including alertness, attention, concentration, fine-motor skills, memory, and certain language abilities (e.g., spelling, reading, and word finding). Therapeutic computer programs have also been developed to assist people dealing with AIDS, drug and alcohol abuse, obesity, burn pain, personal distress, sexual dysfunction, smoking cessation, depression, phobias, violent offenders, and stress (Peterson, 2003).
As computer technology progresses, so will computer-assisted therapies. Researchers will need to compare the outcomes of real-life service modalities and computer-assisted ones, determine what factors contribute to effective therapy, and evaluate client safety issues (e.g., the tendency to accept computer-generated data at face value). Although cost savings, convenience, and independent use are benefits associated with such technology, health psychologists need to be aware of potential negligence in its use. As malpractice suits are litigated, resulting laws, codes, and standards will evolve.
Online Forums Of Therapy
Online forums of psychology-related service provision use the Internet, a product of computer networks originally used by the U.S. military to communicate with education, government, and business institutions working on military projects. The World Wide Web (WWW) consists of computer servers and graphical interfaces connected to the Internet, which exchange audio, visual, and text-based information. Online forums have been described a number of ways in the psychological literature: psychotherapy in cyberspace, counseling on the information highway, behavioral telehealth, cybercounseling, telepsychology, WebCounseling, and, simply, counseling over the Internet.
Online forums in counseling and psychology have taken several forms. Intranet, or closed Internet systems, permit virtual psychotherapy with a controlled audience. Therapeutic consultants can provide services through Internet chat rooms. Bulletin board systems can be organized around a topic of interest, moderated or unmoderated, where people can read postings or add their own. Internet relay chat allows two people to correspond in real time. Computer conferencing allows groups of individuals to converse simultaneously through text.
Telehealth services provide access to health information and services remotely. Such services have recently gained government support. Health care providers are eligible for Medicare reimbursements equal to coverage for office visits for telehealth services to rural areas determined by the federal government to have shortage of health professionals. The APAs Board of Professional Affairs has allocated resources since 1997 to consider the ethical implications of telepsychology, and articulated and disseminated information regarding its relationship to telehealth and telemedicine.
Many states have developed legislation related to online counseling-related services. One issue of concern is how credentialing is managed across jurisdictions (e.g., someone in New York providing services to Illinois). Outcomes of malpractice lawsuits involving behavioral telehealth will dictate case law. Koocher and Morray (2000) provided some useful precautions in using this new technology.
Sampson and his associates (1997) accurately predicted the development of an information highway where cable service carriers will combine efforts with telephone services, allowing access to the Internet and the WWW through television cable networks. They predicted such technology could be used to advertise online counseling services and provide real-time video conferencing for clients to shop for potential therapists and for therapists to screen clients. Their predictions were accurate, as psychology services increasingly occur over Web and other telehealth modalities, providing access to consumers in remote areas or who are unable to travel.
Computer-assisted assessment includes automated administration, scoring, and interpreting of personality tests, cognitive tests, and structured interviews. Such technology has experienced widespread use. Computer-assisted testing also advanced the use of adaptive or tailored testing, which allows the examinee’s responses to determine which subsequent items are to be administered, reducing the number of items necessary, providing more difficult items for higher-ability examinees, and more achievable, less discouraging items for lower-ability examinees.
Storing and retrieving test data can be more reliable with computer applications than traditional means, minimizing human error. However, as with computer-assisted therapy applications, reliability of computer-assisted assessment relies on the health psychologist using it. A computer cannot observe the examinee during testing, nor interpret a test score in light of environmental stimuli, distracters, or arousal level of the client during assessment. Neuropsychological testing in particular relies on a stimulus-response complexity that is difficult to duplicate with current computer technology.
The Standards for Educational and Psychological Testing (American Education Research Association, American Psychological Association, National Council on Measurement in Education, 1999) address computer-based testing in general, the development of computer-administered tests, the use of computer-generated test interpretations, and the implementation of computer adaptive testing. To use test norms established on paper-and-pencil versions, the computerized version must be psychometrically equivalent.
The Internet can be used to train psychologists through distance learning and remote supervision. In supervision, email can be used to share professional ideas and information with supervisees in remote and distant areas. Removing the face-to-face interaction between supervisor and supervisee may limit the data to which supervisors may respond (e.g., body language, reaction to constructive criticism). However, with the development of satellite and computer technology that allows real-time video and audio interaction, these limitations can be minimized.
Distance learning can use television, radio, and satellite broadcasting in place of in vivo course instruction. HTML programming (a programming language for Web pages) capabilities and multimedia presentation of written material and high-quality graphics can be used by educators to make learning interactive and interesting. Curriculum can be delivered in a synchronous (real-time) scheduled presentation of online streaming video or in an asynchronous mode (e.g., the Blackboard or WebCT systems), where students can interact with the system as time allows. Combinations of the two modalities can be used for multimodal interactive curriculum. As with remote supervision, distance learning is useful to persons in remote areas, for students with limited mobility, and for professionals with busy schedules or economic limitations.
Health psychologists involved with distance learning initiatives need to be concerned about program integrity and continuity. An in vivo course may not translate well to a distance-learning format. Research is necessary to compare the effects of technology on traditional learning paradigms.
Response To Emerging Technologies
In response to the emerging technologies reviewed, counseling and psychology-related professional organizations have begun to address new standards of practice, and legislators have developed new statutes as case law presents. Practicing health psychologists should remain aware of developing information as they employ new technologies. Useful sources of such information are listed in Table 1.
This entry addressed emerging technologies in health psychology service provision and the ethical issues related to their implementation. The human element in health psychology remains essential to effective practice, with technology facilitating psychologists’ efforts to provide efficient and effective interventions to the people whom they serve.