Stanford University To Kill a Mockingbird Discussion Carry out a triple reading on some piece of art. This can be a song, painting, movie, or any other cul

Stanford University To Kill a Mockingbird Discussion Carry out a triple reading on some piece of art. This can be a song, painting, movie, or any other cultural creation. Be sure to note the aesthetic, political, and racial properties of the form. Once you have done that, explain how the artwork reflects a white, racist, or antiracist aesthetic. Professional Psychology: Research and Practice
2014, Vol. 45, No. 1, 27–35
In the public domain
DOI: 10.1037/a0034547
Best Practices for Remote Psychological Assessment via
Telehealth Technologies
David D. Luxton
Larry D. Pruitt and Janyce E. Osenbach
National Center for Telehealth & Technology, Tacoma,
Washington and University of Washington School of Medicine
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 psychological 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
treatment progress and outcomes. The use of telehealth technologies 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-andforward) 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 of multimedia content
(i.e., pictures, videos, sounds, etc.), computer adaptive testing
techniques, and automatic scoring and interpretation algorithms
(see Barak & Buchanan, 2004). The Internet can also be used for
VTC by using personal computers (PCs) and off-the-shelf webcams, 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 techniques 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 psychological assessments when administered via those technologies.
Practitioners also need to know whether a given measure or
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 component of telemental health (TMH) practice and is necessary for
diagnostics, screening, symptom monitoring, and evaluations of
DAVID D. LUXTON 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 Medicine in Seattle. His research and writing are focused in the areas of military
psychological health, telehealth, and technology-based treatments.
LARRY D. PRUITT 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 development of treatments for anxiety and mood related conditions.
JANYCE E. OSENBACH 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.
THE 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.
CORRESPONDENCE 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: ddluxton@uw.edu or david.d.luxton.civ@mail.mil
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LUXTON, PRUITT, AND OSENBACH
28
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 treatment services (i.e., diagnostic and symptom assessment), the principles and procedures that we discuss are pertinent to other remote
assessment and testing applications including neuropsychological/
cognitive testing, forensic risk assessment, and occupational testing.
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 relevant information regarding hygiene as well as the use of alcohol
or other substances. Body posture, facial expressions, body language (e.g., foot tapping, hand wringing), as well as nonverbal
emotional responses such as facial flushing, tearing up, and direction of eye-gaze, also provide important information. The observation 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 prohibit 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 physically distant (Grady & Melcer, 2005). Also, in the case of homebased 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 perceived 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 applications, 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 environmental conditions for standardized administration are not altered 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 unavailable or limited, it may also be necessary to ask additional questions
to improve the accuracy of the assessment. For example, if administering 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 (see Cullum, 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 Personality 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 assessment 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 (Buchanan, Johnson & Goldberg, 2005; Reips, 2000).
ASSESSMENT
Technology Issues
There are several technical issues associated with the use of telehealth technologies that may influence the quality of telehealth-based
assessments. Eye gaze angle is the angle between 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 monitors 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, however, 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 available 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 problems 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 information 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 bandwidth requirements for TMH (see American Telemedicine Association, 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.
29
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 clinical 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 malfunctions 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, rescheduling the session, or conducting it with an alternative medium (e.g., over the phone) if necessary.
It is also important to consider potential cognitive and/or sensory 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 viewing computer monitors) should also be evaluated before and during
the assessment process, especially during lengthy assessment sessions.
User Acceptance
Generally, the validity of any psychological assessment is modulated 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 example, Modai et al. (2006) reported that patients and providers are
generally satisfied with VTC and that regular use of VTC improves the overall degree of satisfaction with this medium. A
review by Richardson, Frueh, Grubaugh, Egede, & Elhai (2009)
showed that there are high levels of user satisfaction and acceptance 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 (see Hilty, Nesbitt, Kuenneth, Cruz, & Hales,
2007; Simpson, Bell, Knox, & Britton, 2005). These benefits may
be especially important when considering the need for multiple
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LUXTON, PRUITT, AND OSENBACH
visits for some psychological assessments (i.e., initial interview,
assessment battery administration, and feedback/treatment planning).
Technological issues may also play an important part in the
acceptability of telehealth-based assessments as well as rappor…
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