The Future of Clinical Training in Psychology: How Technology Matters

Steven R. Thorp, Ph.D.

Aims of Presentation

Discuss how technology is shaping psychological services so that clinical training can provide relevant knowledge and skills

Focus of presentation is on assessment and treatment issues that can be discussed in supervision settings

Context

Clinical trainees live in a multimedia world, with many competing demands for attention

Static lectures and supervision will miss opportunities provided by new technologies

Clinical training should include discussions of technology and utilize the technology to enhance training

Possibilities for Enhanced Clinical Training

Interactive Webinars and Live Meetings (at a distance)

In slide presentations to students, true integration of diagrams and charts, measures, videos, and websites in discussions of important clinical issues (e.g., skills training, suicide assessment, gifts from clients, aggressive clients, etc.)

Portable video recording and viewing of psychotherapy sessions for optimal supervision

Supervision topics may be less relevant by the next session: “Bug in the ear” and “bug in the eye” techniques allow for immediate feedback

Telepsychology

Telepsychology refers to psychological services provided using communication technology

Examples: Conducting assessments or providing psychoeducation or psychotherapy skills by telephone, recording devices, video conferencing, interactive monitoring equipment, personal data assistants, or computers

Provides increased access to care

Videoconferencing Psychotherapy1

1Backhaus, Agha, Maglione, Repp, Ross, Zuest, Rice-Thorp, Lohr, & Thorp (in press)

Systematic review found 65 articles on videoconferencing psychotherapy (VCP)

VCP is feasible, has been used in a variety of therapeutic formats and with diverse populations, has good user satisfaction, and has similar clinical outcomes to traditional face-to-face psychotherapy

VCP Grants

• Two studies comparing modalities of one-on-one psychotherapies for PTSD (in person vs. videoconferencing)

– 143 Veterans received prolonged exposure therapy (Department of Defense; Thorp, PI)

– 208 Veterans received cognitive processing therapy (VA; Thorp and Agha, Co-PIs)

• Are outcomes as good? Is satisfaction as good for clients and therapists? Is therapeutic alliance as good?

Locations

Therapist Site (Mission Valley)

Remote Site (La Jolla)

Two Telemedicine Grants

Lessons Learned About Videoconferencing Psychotherapy (So Far)1

1Thorp, Fidler, Moreno, Floto, & Agha (in press).

Monitoring and Equipment

Using digital recorders and video players and training in their use

Cameras and digital video recording

Paperwork and fax machines

Thorp et al. (in press).

Other Logistical Issues

Visual artifacts: Frozen image, “ghost” images, tracer images, poor resolution (especially with regard to facial features); Lighting and background

Audio: Delay, echo, or mechanical sounds

Sitting close (cameras) and eye contact

Movement off screen (heavy chairs help)

“Dropped” calls

Thorp et al. (in press).

Potential Pros and Cons of VCP

• Potential Pros: • At a distance from contagious diseases• At a distance from intimidating clients• Easier to stop sessions on time• Implied authority of “being on TV”

• Potential Cons:• Harder to read emotions (e.g., sniffling due to

sadness or cold symptoms)• Can’t see all of client (e.g., fidgeting hands;

wheelchair)• Cannot touch (e.g., shake hands) or smell

clients or offer them a tissue

Thorp et al. (in press).

Satisfaction

Some therapists and clients had difficulty with the audio delays and video artifacts

Several therapists and clients reported that they were surprised how quickly they became comfortable with VCP

Some therapists and clients reported preferring VCP to in-person therapy

Thorp et al. (in press).

VCP Grants Summary

These projects test a newer technology to demonstrate whether it can improve access to care for veterans

Although the technology holds promise, there are several issues to consider before beginning treatment in this modality

Psychological Services by Computer:Assessments

Examples: Self-reports, SCID, MMPI, neuropsychological batteries

Eliminates data entry, administration errors (e.g., in timing or remembering rules), reduces data transfer errors, automated scoring of scales (and subscales), ease of visual displays for clients and trainees, ease of transfer for statistical analyses

Psychological Services by Computer: Interventions: Utility

Joseph Weizenbaum and ELIZA

Some have praised computers as therapeutic, as they have good memories and can be nonthreatening, patient, and consistent

Computers have since been used for counseling, hypnosis, biofeedback, psychoeducation, and it has been called “the perfect marriage” for some aspects of cognitive and behavioral treatments (e.g., teaching common errors in thinking)

Will never replace human interactions, but, like self-help books, can augment the treatments we provide

Psychological Services by Computer: Interventions: Examples

Cognitive Skills Training (e.g., learning, memory, reaction time, discrimination tasks, switching tasks)

Training in Cognitive Restructuring and Behavioral Activation

Attention Training

Virtual Reality and Therapeutic Video Games

Online “Chat” Therapy

Psychological Services by Smart Phone Applications

Portable: Can be used by active duty military in the field; emergency personnel; clients who have limited mobility or who are in institutions far from specialists; actigraphy

Example: PTSD Coach1: Information on PTSD and treatments; Tools for screening and tracking symptoms; Convenient, easy-to-use skills to help manage symptoms; Direct links to support and help

1Created by the VA's National Center for PTSD and the DoD’s National Center for Telehealth and Technology.

PTSD Coach Screenshots

Email and Social Media

Email is used increasingly in primary care settings for appointment management and dialogue: Potentially useful form of communication in psychological treatment

Social Media (Facebook, MySpace, Twitter) offer good opportunities for psychoeducation and behavioral activation for clients

Both require precise clarification about therapist availability and confidentiality

Issues to Consider

VHA Telepsychology Workgroup1 requested that 11 issues be addressed

by the APA/ASPPB/APAIT Telepsychology Task Force Guidelines:

Client Safety

Home-Based Telepsychology Services

Information Security

Jurisdictional Issues

Third Party Reimbursement

Appropriate Clients

Therapeutic Relationship

Cost-Effectiveness

Clinical Outcomes

Ethical Principles

Training and Licensure Requirements

1Thorp (Chair), Acierno, Morland, Smith, & Tuerk (2011)

Older Adults are the Future

Aging population and some aging-specific issues (e.g., comfort with technology, vision and hearing difficulties, limitations to mobility and transportation) suggest importance of research

Some small studies have suggested that using remote technologies has worked well for conducting assessments, treatments, and care management with older adults

Discussion

Many different modalities for services, but increasingly false dichotomies between computers, smart phones, videoconferencing, etc.: These functions are becoming truly integrated

Many of these technologies will augment traditional services rather than replace them

Excellent opportunities to use technology to optimize training

Many issues to consider when providing technology to students for psychological services, but there are many helpful resources (articles, books, Internet)

Thank You!