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Document 1 of 1 Technology, telehealth, treatment enhancement, and selection. Author: Harwood, T. Mark 1 ; Pratt, Daniel 2 ; Beutler, Larry E. 3 ; Bongar, Bruce M. 3 ; Lenore, Samarea 4 ; Forrester, Bryan T. 4 1 Private Practice, West Chicago, IL, US [email protected] 2 Wheaton College, Wheaton, IL, US 3 Pacific Graduate School of Psychology, Palo Alto University, Palo Alto, CA, US 4 Palo Alto University, Palo Alto, CA, US ProQuest document link Abstract (English): Telehealth and other technological innovations have become increasingly more popular in the practice of psychotherapy and the training of psychotherapists. From the use of e-mail and online therapy to virtual reality (VR) technology and to patient and clinician interactive web-based systems, technology has resulted in a number of improvements, such as financial savings and time reductions. Additionally, technology has allowed clinicians to reach more people and provide potential patients with greater access to information about their presenting problem(s) and available treatments. The self-help movement in psychotherapy has also benefited from technological advances. This article will summarize some of the key developments in the field and underline some of the ethical and clinical implications of these technological applications in clinical psychology. It will briefly describe different approaches to telehealth and extract from extant research literature suggestions for future research in areas of overlap between technology and psychology. Some of these implications will be illustrated by reference to the establishment of a web-based assessment and monitoring system designed to capitalize on the strengths of telehealth procedures in facilitating improved treatment outcomes. (PsycINFO Database Record (c) 2013 APA, all rights reserved)(journal abstract) Links: Linking Service Full text: Contents
Abstract
Telehealth
Using Telehealth Technology To Replace Face-to-Face Therapy
Immersion Procedures (Virtual Environments)
Technology and Telehealth Consultation, Treatment Planning, and Monitoring
Telehealth consultation
Treatment planning and patient monitoring
Complexities of patient-treatment interactions
An Example: The STS/InnerLife System
Functional Impairment (FI)
Coping Style (CS)
Subjective Distress (SD)
Social Support (SS)
Reactance/Resistance Level (RL)
Problem Complexity/Chronicity (PCC)
Stages of Change/Readiness
Summary
Show less
Abstract Telehealth and other technological innovations have become increasingly more popular in the practice of
psychotherapy and the training of psychotherapists. From the use of e-mail and online therapy to virtual reality
(VR) technology and to patient and clinician interactive web-based systems, technology has resulted in a
number of improvements, such as financial savings and time reductions. Additionally, technology has allowed
clinicians to reach more people and provide potential patients with greater access to information about their
presenting problem(s) and available treatments. The self-help movement in psychotherapy has also benefited
from technological advances. This article will summarize some of the key developments in the field and
underline some of the ethical and clinical implications of these technological applications in clinical psychology.
It will briefly describe different approaches to telehealth and extract from extant research literature suggestions
for future research in areas of overlap between technology and psychology. Some of these implications will be
illustrated by reference to the establishment of a web-based assessment and monitoring system designed to
capitalize on the strengths of telehealth procedures in facilitating improved treatment outcomes.
Technology has developed at a rapid pace, perhaps exceeding the expectations of all but the most visionary
among us. This development continues unabated. Technology has become so ubiquitous in everyday life that
our reliance on this equipment is a necessity for functioning in all industrialized countries. Today, laptop
computers are more powerful (i.e., greater capabilities and increased speed) than the earlier “supercomputers”
that required large buildings, expanses of square footage, and great power expenditure simply to support their
use. For example, it is commonly said that today's laptop computer typically has more power than the
computers used for the Apollo missions to the moon. Given the foregoing advances and popularity that
technology enjoys, it is not surprising that technology has become a necessity in the practice of medicine and it
is becoming increasingly more important to the practice of psychotherapy.
From neurology and neuropsychology to general clinical practice, technology is evolving and developing, with
applications seemingly limited only by our imagination (L'Abate &Kaiser, in press; Newman, Erickson,
Przeworski, &Dzus, 2003; Marks, 2004). Telehealth and other forms of distance therapy are becoming more
prevalent and more accepted in spite of vocal detractors (e.g., Proudfoot, 2004). These technological
applications extend the clinician's reach to rural locations, have the potential to improve the likelihood and
magnitude of positive treatment outcomes, and make riskier practice environments (e.g., prisons) safer. As
such, we believe that more people will benefit from access to mental health treatment, the delivery of services
will be more efficient and effective, and accuracy in diagnosis, treatment planning, and ease in the tracking of
patient change trajectories is likely to improve significantly.
Telehealth
Using Telehealth Technology To Replace Face-to-Face Therapy
A primary use of telehealth programs is the general use of technology as a medium to deliver medical or
psychosocial services from a distal location as a replacement for face-to-face intervention. The mechanisms of
delivery range from the relatively straightforward use of the telephone to transmission via complex self-help
programs housed on the Internet. For illustrative purposes, in this section, we will focus on the use of
telephones and the Internet as mediums for distance therapy.
There are many practical benefits of using the telephone or the Internet for client contacts versus limiting
oneself to only face-to-face meetings (Emmelkamp, 2006); two examples are time and money. Our cultural
values and their expression in managed care programs foster a desire or need for efficiency, and many people
have grown quite comfortable with the use of technology in their everyday lives. It may be hard for any of us to
recall a day in the recent past that we went without using some type of telephone or accessing the Internet.
Concomitantly, telephone technology for the delivery of psychosocial services has been in use for decades. As
early as the 1960s the Veterans Administration (VA) developed a strong telemedicine program that rendered
favorable empirical findings (Godleski, Nieves, Darkins, &Lehmann, 2008). There are numerous benefits of
telephone use for therapy. It saves clients' travel time and costs, therapists have the ability to reach clients at a
distance (e.g., during a vacation or business travel, after a move), and therapy can be offered to clients where
no therapists are available and therapist travel is infeasible, such as in rural areas, war zones, or early on in
natural disaster relief. Therapy via the telephone allows the therapist to effectively manage clients who are less
likely to reenter an environment, such as the VA, as attempts to reenter too soon could further complicate
psychological distress due to war trauma or other psychological complications (Godleski et al., 2008; Tuerk,
Yoder, Ruggiero, Gros, &Acierno, 2010). Even the utilization of cell phone contacts as a unique supplement to
weekly meetings (e.g., check-ins for behavioral compliance and observation) improved the efficiency of patient
care.
As simple as it might seem to substitute telephonic or Internet communication for the face-to-face method of
delivering psychotherapy, doing so invokes a variety of new ethical and privacy considerations. Ensuring that
these privileged communications are not monitored by others and that all parties understand the implications of
such a treatment are exacerbated by the therapist's attenuated ability to perceive and respond to nonverbal
cues and treatment contexts. Thus, despite the practical benefits of using technology to offer distance therapy,
professionals differ in their opinions regarding the proper use of telephones and/or Internet for therapy.
Aside from personal predilections, concerns with therapist liability when patients do not improve, as well as
concerns for safety arise with distance therapy in a much different way than they do in face-to-face therapy.
Data integrity cannot be as easily ensured and neither is it as easy to confirm that patient privacy, as mandated
by HIPPA guidelines, is protected. The nature of the information available to a therapist via the telephone and
Internet requires new explorations of influence factors and the development of new regulations to govern their
use (Cartreine, Ahern, &Locke, 2010).
In comparison to e-mail or written communication, telephone technology affords one the ability to hear changes
in rate and volume of speech and the prosody of voice for emotional inflection. Some disadvantages or risks
include the cost of lengthy telephone conversations, the lack of visual information to aid understanding of and to
accurately reflect client emotional states, and the lack of visual information and physical presence of the
therapist. Many questions remain about what is required to enhance socially therapeutic processes (e.g., how
might teletherapy impact on the development of beneficial relationship factors?). The potential for a reduction in
one's ability to respond effectively and a correspondent reduced persuasive ability in an emergency (e.g.,
suicidal or violent threats), coupled with complications that surround the maintenance of confidentiality (e.g., cell
phones are not secure), are examples of problems that still require considerable effort from researchers and
ethicists. Further, there exists the possibility that the telehealth or Internet context may permit a therapist to
practice in ways that are beyond the boundaries of one's training, competence, licensure jurisdiction, or
malpractice coverage. Of particular concern with the advent of the capability to extend the psychotherapist's
role via the World Wide Web is the variation that exists among states and regions in the qualifications needed to
practice and the very definitions of psychotherapy itself. These variations result in a tangled web of
contradictory rules and practices to which the practitioner must comply. Complexities of conducting
psychotherapy across state lines include issues surrounding licensing jurisdictions, training requirements, and
proper definitions of terms such as malpractice or liability (Cartreine et al., 2010; Godleski et al., 2008).
Some of the more advanced forms of distance therapy have been introduced specifically to reduce the
handicaps imposed by a voice- (spoken or written) only interaction. These advancements involve computer
applications and videoconferencing (e.g., “skyping” technology). In this form of service delivery, clinician and
patient are able to communicate via voice-technology, much like a telephone, and view each other in real time
using computer-mounted cameras and their computer screen. Although this technology has potential for
approximating a face-to-face interaction by projecting movement with near-natural resolution, and offering a
more “human” quality to the interaction because the voice and physical presentation of each individual is
relatively well-synchronized, it seldom provides a full view of the patient. Thus, the therapist's access to the
patient's nonverbal cues is dependent on a camera that is controlled primarily by the patient. The therapist may
be unable to view important cues that are off camera. Under these conditions, the potential for negative impact
and unwarranted levels of confidence in these procedures is present.
While many of the same benefits and costs/risks exist for videoconferencing as they do for using the telephone,
there is evidence that efficacy is sufficient to offset many of these handicaps. A specific example of research
used to understand a telehealth application comes from Kolb (2009), who found that teletherapy could be
successfully used to train underserved parents on specific behavioral strategies for managing autistic children.
Likewise, researchers have examined the use of video teleconferencing in a group therapy setting and its
effects on the therapeutic relationship—the results tend to be positive (Greene et al., 2010). Efficacy of distance
technology in psychotherapy was also demonstrated in an outcome study that used telepsychotherapy to treat
panic disorder with agoraphobia (Bouchard et al., 2000). Though further research is needed for clarification, it
may simply be that the visual “presence” of the therapist made it easier to gain a healthy therapeutic alliance
and maintain therapeutic gains from relationship factors in therapy similar to face-to-face therapy.
The presence of videoconferencing may enhance a therapist's clinical ability in comparison to telephone and e-
mail delivery of psychosocial services (e.g., Godleski et al., 2008). Videoconferencing may improve the
clinician's ability to persuade suicidal clients to hospitalize themselves; however, therapists using these
telehealth procedures are likely to be unfamiliar with local resources and being still at a distance, are unable to
easily arrange patient transport to a secure environment. For example, Godleski and colleagues (2008)
observed that therapists who are unfamiliar with relevant emergency contacts and treatment locations for distal
patients may provoke discouragement in an already hopeless individual. Therapists in such situations may be
incompetent to refer when it is necessary.
As one can see, there are many practical and ethical implications for replacing face-to-face psychotherapy with
distance technologies. Both sophisticated clinical trial research and qualitative studies are needed to help us
understand the cost–benefit ratio of using distance therapy versus (or in combination with) face-to-face therapy.
We encourage disciplined reflection by clinicians on a case-by-case basis before selecting a technology for
distance therapy, or using distance therapy at all. As always, psychologists strive to do no harm, help all
patients improve, and practice only within their areas of competence (American Psychological Association, 2002
). Readers are directed to other literature for more in-depth discussion of the professional issues that should be
considered before engaging in telehealth (Barnett &Scheetz, 2003; Harwood &Pratt, in press; Koocher &Keith-
Spiegel, 2008).
Immersion Procedures (Virtual Environments)
Other high-tech approaches to reduce the limitations of conventional telehealth applications have involved the
development of innovative applications of technology that can be used within the psychotherapy session. From
simple interactive video games to more complex computer generated images, such as animated TV shows and
3-D blockbuster movies, sensory immersion (i.e., virtual) environments, sometimes identified as virtual realities
(VRs), have become commonplace. VR graphic capabilities continue to advance at a rapid rate. It is simply a
matter of time before the realism of VR is indistinguishable from real life equivalents; however, the wholesale
translation of these advancements into VR applications that are suitable for representing face-to-face
psychological treatment is more slowly developing due to the complexity of human interaction and
psychotherapy process that must be represented.
Nevertheless, VR technology is already being applied in cases where the treatment complexity is relatively low
and the required treatment process is quite straightforward. Specifically, VR environments provide a unique way
to recreate some environments in which the phobic or anxious patient can be exposed safely. Applications of
this technology are available for exposure-based extinction of anxiety symptoms in combat-related PTSD and
specific phobias (Rizzo, Rothbaum, &Graap, 2007). Virtually created clinical environments also have the
potential to be used as training platforms for psychotherapists. Beutler and Harwood, in 2004, discussed VR's
potential for improving clinical training in psychotherapy. They found this potential to be greatest for newer
therapists needing experiential learning opportunities with more difficult clinical situations, like suicidal or violent
clients posing threats, intoxicated clients, or charming clients testing the therapist's professional boundaries
(e.g., requesting personal information). The authors offered suggestions for combining these potential virtual
environments with real-time measures for appropriate trainee responses based on the latest treatment-outcome
research. With VR technology like this, fledgling therapists can be trained without the dangers that might be
associated with trainee-delivered psychotherapy to these complex problems among real clients.
For both treatment and training purposes, further research on the interactions of humans with clinical virtual
environments is needed. This research will likely require innovations that combine methodologies across
disciplines. One can envision, for example, some benefit of combining Randomized Clinical Trials (RCT) and
Aptitude Treatment Interaction (ATI) methodologies (e.g., Beutler et al., 2003) with research on Interactive
Virtual Environment (IVE) (e.g., Bailenson, Blascovich, Beall, &Loomis, 2003; Blascovich &Beall, 2010). Such
methodologies allow for the needed case-by-case evaluation of the ethical issues in VR delivery of psychosocial
services (see Harwood &Pratt, in press).
Technology and Telehealth Consultation, Treatment Planning, and Monitoring
Many of the complexities and ethical issues that attend the use of teletechnology to directly replace person-
based mental health treatments are obviated when the focus is upon using complex technologies to assist the
traditional clinician, who in turn, provides the direct service. Technology that extracts information from
databases to provide consultation, as well as that which is designed to optimize and economize patient
assessment, treatment planning, and outcome monitoring, are examples of how technology can supplement
rather than replace current treatments.
Telehealth consultation
Several research and clinical programs have been developed to use technology to reach populations that are
underserved by mental health systems through supplementing more traditional procedures. Examination of the
availability of this technology for use with underserved populations should be considered by those providing
services to further enhance access by the underserved (Kolb, 2009; Sanchez-Page, 2005). Stewart Gabel
(2010), of the New York State Office of Mental Health describes a collaborative project designed to improve
access to psychiatric services for underserved youth. This program draws from the Massachusetts Child
Psychiatry Access Project (Connor et al., 2006), the Washington State Partnership Access Line (Hilt,
McDonnell, Rockhill, Golombek, &Thompson, 2009), the University of California Davis Health System Center for
Health and Technology servicing rural northern California (Yellowless, Hilty, &Marks, 2008), and regional
programs in New York State to form a network that is connected electronically to provide ongoing consultation
and feedback. Each of these programs uses some combination of the telephone, videoconferencing, secure e-
mail, or face-to-face mediums to consult or collaborate with primary care providers in distant locations. Most
programs are funded by the state or through various grants.
Many programs that network like the foregoing example have supported their own research efforts to improve
and test these collaborative interventions. Corroborating research from external sources on the effectiveness of
such programs in general is needed. Because of the shortage of external funding, may programs are restricted
to seeking evidence of validity and benefit through small research activities. Nelson and Bui (2010), for
example, have used a case study methodology to study the impact of integrating rural mental health and
distance services through a program of systematic videoconferencing.
Compared to telehealth programs, which typically seek to replace clinicians through electronic means,
consultation and collaboration models like those described in the foregoing pose somewhat fewer ethical risks.
This reduced risk is due in part to mental health specialists working alongside general practitioners residing in
the area of the clientele. Clarification of roles and responsibilities to clients by professionals is particularly
important in collaboration situations. In addition to consultation and collaboration, incorporation of empirically
supported self-help strategies may enhance the ability of psychology to extend its reach to underserved areas (
Harwood &L'Abate, 2010).
Treatment planning and patient monitoring
Over the past 20 years, a variety of patient monitoring and outcome assessment systems have been developed,
some reliant on web-based and computer technology and some not (see Beutler, 2001). These systems, the
best known of which is the OQ-45 developed by Lambert and colleagues (Lambert et al.,1996), focus primarily
on providing outcome monitoring for insurance purposes or feedback to clinicians and patients about progress.
Lambert and colleagues have specifically inserted procedures for alerting clinicians when patients are not
progressing as rapidly as expected, with the hope that by doing so, clinicians will rethink and adjust their
therapeutic work. By and large these systems take minimal advantage of advanced technological support and
database systems, largely restricting the use of telehealth systems to the electronic administration and scoring
of fixed instruments.
A more comprehensive variation of this type of system is exemplified by the web-based, Systematic Treatment
Selection (STS/innerlife.com) system developed and updated by Beutler, Williams, and Norcross (2011). This
latter system provides a tailored and direct assessment of the patient which varies by patient response and
problem and that provides a written intake report, multiple measures of intake and outcome condition, and
tailored self-help resources. The intake report describes a cross-cutting treatment program that can guide the
therapist to optimize outcomes by fitting appropriate interventions to the particular characteristics and needs of
the patient. The heart of the system is an array of empirically derived principles that define the conditions under
which different types of interventions or therapeutic styles are most likely to exert positive effects. Patient
characteristics that are embedded within these principles are identified via a web-delivered self-report measure.
The results are scored via the web and two versions of an intake report are generated. One report is designed
as a self-help tool for the patient (via www.innerlife.com), while the other more detailed and technical report is
designed for use by the clinic or treating clinician (via www.webpsychcorp.com).
In addition, patient outcome monitoring is accomplished by tracking up to 26 symptom clusters, varied to be
consistent with patient reports, all or any of which can be reevaluated periodically by the clinician and patient. A
projected course of treatment effects are graphed based on usual or normative change for different patient
groups, and one can observe the degree to which the actual and projected change trajectories correspond. This
graph compares projected and obtained gains and can be used by the clinician to refine treatment and a
readministration of the assessment procedure can supplement these decisions.
Complexities of patient-treatment interactions
In this day of technology, it is imperative that we consider how telephonic and Internet/web-based technologies
can improve and optimize the power of mental health treatments. Though brief and, of necessity, cursory, this
review of efforts to replace or supplement traditional mental health treatment illustrates that there are benefits to
the use of various technologies and supplementing procedures in the delivery of psychotherapy. But, we
believe, we must also proceed in applying these procedures with caution in order to avoid the mistake of
oversimplifying what is required for effecting change.
To assume that “talking therapy” can be replaced by a written or verbal exchange between two disembodied
participants ignores the importance of nonverbal and subtle social cues in communication generally and
psychotherapy in particular. There are dangers that in our enthusiasm for telehealth solutions we will
oversimplify the treatment process and forget that some sources of information may go unseen and
unacknowledged by our technologies. More importantly, we must not forget that these unseen sources of
information may be critical to making positive and effective decisions. A clinician working with a suicidal patient,
for example, is aided if they know the context in which the treatment is currently taking place, the nonverbal
expressions of the patient being treated, and the resources of support that are available. It is not that nonverbal
cues and supplementary information cannot be supplied through the technology being used, but that accessing
that information may take specific planning, the development of additional technologies, and an appreciation of
its importance. In other words, it is advantageous if the clinician remains a clinician and does not become
merely a technician who services the technologies of our craft.
The STS/InnerLife system represents almost four decades of empirically supported RCT research and
development (Beutler &Clarkin, 1990; Beutler, Clarkin, &Bongar, 2000; Beutler &Harwood, 2000; Beutler et al.,
2003). In this time, it has grown in complexity as we have been forced to incorporate an ever expanding field of
knowledge into the decision trees that underwrite this procedure. Such expansion of knowledge, variables
included in decision making, and databases, make reliance on high-speed computerized technology a must.
Thus, a reiteration of some of the lessons learned during the development of the STS/InnerLife system can
serve to illustrate the importance of a broad band and open system that incorporates new knowledge as it
arises and adapts to both successful and unsuccessful efforts to apply it.
An Example: The STS/InnerLife System Originally, the STS system was intended to simply put together a brand or type of treatment with a receptive
patient. This objective is not too far removed from the current efforts to establish a list of psychotherapies for
each of various diagnostic conditions; however, in the case of the STS, it rapidly became clear that optimal
effects were unlikely to accrue in this broad band approach of fitting the model of treatment to the diagnosis of
the patient. This meant that the Randomized Control Trial (RCT) favored by medical research was replaced by
an Aptitude-by-Treatment-Interaction (ATI) research design that has become the signal feature for developing
and testing the STS/InnerLife technology. This was required in order to allow a fine-grained analysis of how
various patient predisposing dimensions interact with psychotherapeutic strategies and interventions.
Essentially, STS is a systematic eclectic patient-treatment matching model that embraces the myriad patient
change-strategies and interventions available without allegiance to any specific theory of pathology or strategy
of change.
Additionally, as research has progressed, so have the number of dimensions that are relevant for fitting a
unique set of therapy intervention to a particular patient. STS is a pure, opportunistic model of change that
employs an expanding number of patient predisposing dimensions to inform pretreatment planning and make
ongoing treatment decisions throughout the course of therapy. These variables and dimensions have been
articulated as empirically informed treatment principles and the expansion of variable and research findings
have been accompanied by a corollary expansion in the number of relevant principles that can be articulated (
Castonguay &Beutler, 2006a). The number of relevant dimensions, the knowledge of which is conducive to
optimizing treatment effect, now includes such things as: a) patient preferences for a therapist of a given type;
b) the symptoms and signs that are most dominant in the patient's complaint; c) demographic data that
correlates with certain outcomes; d) and a host of characteristics and states that predict the patient's response
to the therapist's style of intervention. There are an expanding number of the latter qualities that bear on
optimizing change, but a listing of a few whose role in the differential outcomes observed in psychotherapy will
illustrate both the complexity of treatment and the importance of patient compatibilities.
Functional Impairment (FI)
FI, a level of care principle as well as a prognostic indicator, informs the clinician of the optimal level of
treatment intensity, the preferred treatment format, and a range of effective treatment modalities that might be
used. FI has been recognized by the American Psychological Association's Division 29 (Psychotherapy) Task
Force as a participant factor (Beutler, Castonguay, &Follette, 2006; Castonguay &Beutler, 2006b), and it has
been identified by the dysphoria work group of the Task Force on Empirically Based Principles of Therapeutic
Change (Castonguay &Beutler, 2006b). Empirical support for the use of FI in treatment planning can be found in
more than 45 investigations involving a combined sample size of more than 7,700 participants from both
inpatient and outpatient settings (Harwood &Beutler, 2008).
Coping Style (CS)
CS informs the clinician of the probable value of insight-focused and symptom-focused treatment and guides
the clinician on when and how to apply strategies (i.e., differing families of interventions) that foster insight or
symptom reduction. CS has been identified as a participant factor by the Division 29 Task Force and, as
evaluated by the Division 29 or Division 12 (Clinical Psychology) Task Force, is considered an empirically
supported principle based on “a preponderance of the available evidence” (Castonguay &Beutler, 2006c, pp.
634). Empirical support for the use of CS in treatment selection comes from at least 30 investigations with an
aggregated participant sample comprised of more than 5,600 inpatients and outpatients (Harwood &Beutler,
2009).
Subjective Distress (SD)
SD provides guidance in the application of emotion-arousing techniques when distress is too low, or emotion-
reducing techniques when distress is too high. At least 11 investigations, with a combined sample size of more
than 1,250 inpatient and outpatient participants, provide empirical support for the use of SD in both pretreatment
planning and the selection of specific interventions (Harwood &Beutler, 2009).
Social Support (SS)
SS, much like FI, is a prognostic indicator, especially among patients with complex/chronic problems, and a
possible treatment goal. Moderate to high levels of healthy social support augur well for treatment success while
low levels or unhealthy social support systems indicate that the probability of success may be attenuated or that
treatment may require more time, effort, and additional resources (e.g., multiperson and multiformat to improve
likelihood of success). SS has been identified by the dysphoria work group of the Task Force on Empirically
Based Principles of Therapeutic Change as a patient prognostic indicator (Castonguay &Beutler, 2006d). At
least 37 investigations involving a combined sample comprised of more than 7,700 inpatients and outpatients
provide empirical support for SS as a patient-treatment matching dimension (Harwood &Beutler, 2009).
Reactance/Resistance Level (RL)
The patient's level of reactance or trait-like resistance guides the clinician in the proportional use of directive
versus nondirective interventions. High levels of trait reactance indicate nondirective strategies while low levels
of trait reactance indicate high or low directiveness. Due to the state aspect of reactance, decisions regarding
the directiveness of interventions depend upon the patient's current (state) reactance level; therefore, the
clinician must remain vigilant to in-session patient cues that represent real-time changes in reactance level. RL
was identified by the Division 29 Task Force as a participant factor (Castonguay &Beutler, 2006b). At least 30
investigations involving a combined sample of more than 8,000 inpatients and outpatients provide empirical
support for the use of SS in treatment planning.
Problem Complexity/Chronicity (PCC)
PCC (related to FI, SD, and SS) is a prognostic indicator. Complex and/or chronic problems suggest the need
for broad-band treatment utilizing multiperson, multiformat (e.g., group, individual), and multimodal (e.g.,
psychotropic medication) forms of intervention. PCC is directly related to length of treatment and the number of
multiperson, multimodal, and multiformat interventions brought to bear on the chief complaint. The treatment
matching dimension of PCC has received empirical support from more than 23 investigations with a combined
sample size of nearly 2,000 participants (Harwood &Beutler, 2009).
Stages of Change/Readiness
Prochaska and colleagues (Norcross, Krebs, &Prochaska, 2011) have approached the task of defining
differential treatment factors through an assessment of what kind of factors are optimal to facilitate patient
motivation or “readiness” for change. They identified five stages of readiness, ranging from precontemplative
through maintenance of change. Early stages require active therapy encouragement, the willingness to listen
and support, as well as patient motivation to explore and understand barriers to change. Later stages
progressively involve self-monitoring and practice with the most advanced stages invoking active awareness of
high-risk environments that may make one more vulnerable and active choices to maintain positive growth.
As the reader will have noted, a large body of literature exists supporting the therapeutic efficacy of various
treatment-planning dimensions in the STS/InnerLife system (e.g., Beutler et al., 2003; Beutler, Harwood,
Bertoni, &Thomann, 2006; Harwood &Beutler, 2008; Harwood &Beutler, 2009, and Harwood, Beutler, &Groth-
Marnat, 2011). Moreover, a recent meta-analysis explored the power of fitting treatments based on patient
coping style and resistance levels. Strong effect sizes were noted for the moderating effects of both patient
variables (i.e., weighted mean effect sizes of d = .55 for CS and d = .82 for RL) indicating that they served as
discrete markers for selecting and applying treatments that work (Norcross, 2011; Beutler, Harwood, Kimpara,
Verdirame, &Blau, 2011; Beutler, Harwood, Michelson, Xiaoxia, &Holiman, 2011). Finally, a recent RCT
involving comorbid patients (substance abuse with depression) examined the outcomes for prescriptive,
narrative, and cognitive therapies with respect to the contributions of interventions, the therapeutic alliance,
patient qualities, and the match between STS patient attributes and treatment elements (Beutler et al., 2003).
Results were in line with an increasing body of research literature indicating that specific interventions employed
by the therapist matters. Patient attributes (i.e., resistance/reactance, coping style, subjective distress, and
functional impairment) and good matches between patient attributes and specific interventions, therapeutic
strategies, and principles were found to be strong predictors of positive outcome. It is interesting to note that the
predictive power of these variables became greater at 6-month follow-up, accounting for more than 90% of the
variance in posttreatment outcome. The therapeutic alliance was found to be an important predictor; however, a
large portion of the variance attributable to the alliance was captured by the matching variables. In essence, a
good fit between STS patient dimensions and treatment qualities served as a powerful predictor of good
outcomes across a variety of change measures and among very complex, comorbid patients.
Summary This article has discussed the ethical and clinical implications of technological applications in psychology. We
have reviewed the relevant research literature and offered suggestions for future research in the crossroads of
technology and psychology. From general to specific, this article moved from technology and psychology, to
telehealth, to VR, and lastly to a detailed discussion of the application of STS to a computer program named
InnerLife. InnerLife provides an empirically supported and technological application of clinical decision making.
Between a determination of therapeutic need and the identification of strategies and principles of change,
InnerLife provides guidance that is increasingly fine-grained with respect to patient care and mental health
treatment.
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Address for Correspondence:
Mark T. Harwood, Private Practice, 28W641 Indian Knoll Road, West Chicago, IL 60185
Email: [email protected]
Subject: Online Therapy (major); Technology (major); Telemedicine (major); Psychotherapists; Psychotherapy; Treatment Outcomes; Classification: 3300: Health & Mental Health Treatment & Prevention Population: Human Identifier (keyword): InnerLife STS Systematic Treatment Selection patient-treatment matching psychotherapy technology telehealth treatment enhancements Author e-mail address: [email protected] Contact individual: Harwood, T. Mark, Private Practice, 28W641 Indian Knoll Road, West Chicago, 60185, US, [email protected] Publication title: Professional Psychology: Research and Practice Volume: 42 Issue: 6 Pages: 448-454 Publication date: Dec 2011 Format covered: Electronic Publisher: American Psychological Association Country of publication: United States ISBN: 1433817209 ISSN: 0735-7028 eISSN: 1939-1323 Peer reviewed: Yes Language: English Document type: Journal, Journal Article, Peer Reviewed Journal Number of references: 46 Publication history : Accepted date: 06 Oct 2011 Revised date: 06 Oct 2011; First submitted date: 03 Jun 2011 DOI: http://dx.doi.org/10.1037/a0026214 Release date: 05 Dec 2011 (PsycINFO); 05 Dec 2011 (PsycARTICLES); Correction date: 07 Oct 2013 (PsycINFO); Accession number: 2011-28096-003 ProQuest document ID: 909287512
Document URL: https://fgul.idm.oclc.org/login?url=http://search.proquest.com/docview/909287512?accountid=10868 Copyright: © American Psychological Association 2011 Database: PsycARTICLES
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- Technology, telehealth, treatment enhancement, and selection.
