Thursday, December 12, 2013

Telepsychology Update

C. Munro Cullum, PhD, ABPP
C. Munro Cullum, PhD, ABPP
C. Munro Cullum, PhD, ABPP
Professor of Psychiatry and Neurology & Neurotherapeutics
The University of Texas Southwestern Medical Center
Dallas, TX

This is an adapted version of an article by Dr. Cullum that appeared in the Texas Psychologist, Fall 2013.
Telemedicine or telehealth technology is spreading rapidly and promises to become increasingly prominent in the future of healthcare worldwide.  Telehealth programs are growing rapidly in the U.S., particularly since the technology has become more available and less expensive.  At least four professional journals now focus on telehealth and telemedicine, and the literature has seen a tremendous increase in “tele-“ based publications in the last decade.  Programs in telestroke, teleradiology, teledermatology, and telerehabilition are among the most commoly reported, although telepsychiatry, telepsychology, and telemental health references have seen a three- to four-fold increase in the past decade, now with over 200 such references in the PubMed database.  The VA system has made wide use of telehealth services through its various outreach clinics, and Medicare’s announcement in 2012 that tele-based services (albeit with some restrictions) will be covered has also helped to increase awareness and availability of distance-based healthcare services.  Numerous companies now offer practitioners assistance with information, technology setup and monitoring of telehealth-based services.
The evidence base supporting the provision of mental health services using electronic means continues to grow (e.g. see Myers and Turvey, 2013, for a comprehensive review).  For example, there is now good support for many of our standard psychological services (particularly therapies) being provided via video teleconference.  Provider- and patient-satisfaction ratings with telemental health have consistently been high, suggesting good receptivity and acceptability.  Although it may take some getting used to seeing your patient or doctor over a monitor rather than in person, adaptation is usually realized quickly, and a majority of patients and providers find it to be an “acceptable” means of service provision in many cases.  Most individuals prefer in-person interactions even if they have to travel a few hours, but distance and time are often cited as determining factors for consumers in terms of selecting telehealth-based services.  Data regarding outcome efficacy in various telemental health interventions is somewhat more limited, although research suggests similar results when compared to tradition in-person therapeutic interactions for most studies.  Most of the literature in this area has been conducted in adult and underserved populations, however, with less known about efficacy of telemental health interventions in children.

Application of telehealth technology to the provision of mental health services requires a number of adaptations and special considerations (e.g. see Grosch et al., 2011).  In terms of informed consent, clients must be made aware of the special circumstances that exist or may arise in the remote provision of clinical services.  This includes the fact that their confidential information (visual and verbal) is being shared across a distance via electronic transmission. This raises the possibility of inadvertent compromise of confidentiality in various ways, and implications for HIPAA also must be considered.  For example, there is ongoing debate about the level of security offered by various popular internet-based videoconference applications (i.e., which ones are truly HIPAA compliant?).  This merits careful exploration before services are offered, and clients must be informed of the additional potential risks of loss of confidentiality when using electronic transmission of information.  Other questions that arise include:  Is the transmission of data (i.e., the entire interaction during the session) fully encrypted?  Is it in fact HIPAA compliant just because the vendor indicates so?  Are there appropriate safeguards in place, such as firewalls, etc.?  Who might have access to the information? Are third-parties involved in the process (e.g. IT personnel), and if so, what is their role and access to data?  Depending upon the far-end set-up, what is the possibility of a third-party wandering into the area where the client is being seen?  What is the likelihood of interruptions in that setting? If any data are being stored as part of the process, this must be disclosed and appropriately safeguarded.  

The provision of mental health services using distance technology also requires that the provider be competent in this mode of intervention. Continuing education to support training in this specialized application of services is encouraged, even as preliminary guidelines are developed by the American Psychological Association and American Telemedicine Association (e.g. see their respective websites for information).  Practical issues must also be addressed, including preparedness for potential emergencies during distance-based interactions.  Appropriate review of procedures with clients should be conducted, in addition to consideration being given to staff availability at the far end, appropriate training in emergency situations, and IT personnel availability in the event of equipment failure should be considered.

From a diagnostic interviewing standpoint, psychological interviews appear as valid when conducted via videoteleconference as in-person, although less information exists with respect to the validity of psychological or neuropsychological assessments administered in this fashion.  Preliminary studies of videoteleconference-based neuropsychological assessment have been promising in terms of patient satisfaction (e.g. see Parikh et al., 2013) as well as validity of the measures that have been studied to date, although many tests have not been studied in this environment.  Our research group has demonstrated the comparability of video teleconference-based and traditional in-person administration of neuropsychological tests using a brief battery of generally language-based instruments that are commonly used in dementia evaluations (Cullum et al., 2006). This has included tests of attention, naming, verbal fluency, verbal memory, and visuoconstructional ability that required little to no modification of standard test instructions.  We have also experimented with other tasks that require the use of manipulable test materials, but such tasks require the availability of equipment for the remote client as well as alteration in instructions and in some cases, administration procedures.  Our results are also limited to tests studied to date, although a list of many tests used under video teleconference conditions can be found in Cullum and Grosch (2013). If significant modifications to procedures are required for the administration of some tests, for example, this must be noted, and the potential impact upon traditional scoring and interpretation must be understood.  As such, more research needs to be done to ensure the validity of our procedures administered remotely, as some tests may require modified instructions, procedures, and/or norms, and these factors must be considered by clinicians conducting this work.

As noted above, Medicare and some insurance companies have approved reimbursement for telemedicine-based mental health services, although it is incumbent upon clinicians to verify local provider procedures along these lines, as many payors are yet to get on board with reimbursement despite good headway being made by the American Telemedicine Association.  A related issue in the provision of distance-based services is that of licensure, since many states require that the provider be licensed not only in her or his own state, but also in the state where the client is located.  

As telehealth technology continues its rapid growth, opportunities for psychologists’ services will expand.  Familiarity and training with these technologies, including advantages, limitations, and evidence-based support for various procedures and services, will become increasingly important for psychologists.  Fortunately, many of our services are amenable to the telehealth environment, and with appropriate education and experience, we should be in a good position to help drive and participate in the provision of behavioral health and mental health services using telehealth technologies within our changing healthcare environment.


Cullum, C.M. & Grosch, M.G. (2013). Teleneuropsychology. In K. Myers & C. Turvey (Eds.), Telemental health: Clinical, technical and administrative foundations for evidence-based practice. Elsevier (pp 275-294).

Grosch, M.C., Gottlieb, M.C., & Cullum, C.M. (2011). Initial practice recommendations for teleneuropsychology. The Clinical Neuropsycholgist, 25, 1119-1133. 

Myers, K., & Turvey, C.L. (2013).  Telemental Health: Clinical, technical and administrative foundations for evidence-based practice.  Elsevier. 

Parikh, M., Grosch, M.C., Graham, L.L., Hynan, L.S., Weiner, M.F., & Cullum, C.M. (2013). Consumer acceptability of brief videoconference-based neuropsychological assessment in older individuals with and without cognitive impairment.  The Clinical Neuropsychologist, 27,5, 808-817.  

Monday, July 15, 2013

Positive Applied Neuropsychology

Robert Bilder, Ph.D., ABPP/CN
Robert Bilder, Ph.D., ABPP/CN, is speaking about Positive Applied Neuropsychology as part of the SCN program at the upcoming meeting of the American Psychological Association, on Wednesday 7/31/2013 from 1000am to 1050am in Convention Center Room 304B. 

The discipline of clinical neuropsychology is at a cross-roads, confronting an array of options to redefine its parameters, and without any option to turn back.  The forces propelling this shift have been brewing for decades.  First, assessment of brain structure and function for both clinical and research purposes continues to migrate to novel technologies. Neuroimaging already has displaced neuropsychology’s role in structural lesion localization, and now is providing the lion’s share of new information about functional localization and network mapping.  Computerized neuropsychological assessment continues to make steady inroads as evidenced by the introduction of iPad systems for conventional testing, and the proliferation of other products including computerized and Internet-based assessment systems.  Second, health care reform is changing every facet of clinical service delivery in the United States, and neuropsychology is among the services that may be most affected.  Our professional societies, including notably the Society for Clinical Neuropsychology (SCN; APA Division 40), have inaugurated efforts to keep us up to date and help us navigate the shifting sands of new systems that aim to manage health care costs, including accountable care organizations.  The Affordable Care Act further mandated electronic medical records that are increasingly facilitating the aggregation of medical test results and the evaluation of health care expenses and allocation of services following evidence-based models.  Third, treatments are increasingly being delivered by the lowest-cost providers, which are in some cases electronic.  It is hard to compete with a computer if it can execute an assessment or administer a therapy, and while currently available systems have their limitations, the day is coming when humans will be more important in designing but probably not in administering assessments and treatments.  What path should clinical neuropsychology follow to forge its own future?  Some answers include efforts, already underway, to increase our shared evidence-bases and collaborate on a grand scale (see Bilder, 2011).  For other answers we need to look further into the future.

I faced this challenge a few years ago when asked to speak about the “Next Wave” in brain research, to a smart lay audience (see TEDx San Diego talk here).   I first thought the talk might cover advances in genetics, genomics, and brain-related phenotyping, before realizing that the allotted 12 minutes would be gone before I could finish defining the word “phenotype.”  I had just read Ray Kurzweil’s book – “The Singularity is Near” – foretelling the implications of a future in which nonbiological intelligence will supersede all biological intelligence (if you are curious, Ray predicts this will happen in 2029, so stay healthy to live forever in the post-singularity era).  But what intrigued me the most was our inevitable progress towards a point when we will know enough about how the brain works to use it differently, and by design, enabling Personal Brain Management and entering the next stage of human evolution (for more, see this).  I started teaching courses in PBM at UCLA, and then was lucky to be involved in our new Healthy Campus Initiative, specifically to focus on how to enhance mind, brain, and spirit and promote creative achievement among our students, staff, and faculty (see   As we have developed this initiative, I increasingly have come to believe that there is enormous opportunity for our discipline to pursue Positive Applied Neuropsychology, and that this will be an important path for clinical neuropsychology as we travel further into the 21st century.  A recent volume defines positive neuropsychology as a field that “… incorporates positive psychology principles and aims to promote cognitive health through various means…” (Randolph,  2013).   I believe an even broader definition may be warranted, extending beyond cognitive health, to consider any method to promote well-being that leverages knowledge about the brain.

How does Positive Applied Neuropsychology (PAN) differ from the rest of positive psychology?  A strength and a weakness of positive psychology is that it does not necessarily consider the brain mechanisms underlying beneficial effects of its practices.  The strength is that it is not limited by current knowledge about the brain.  It is absolutely reasonable to select positive psychology treatments without knowing anything about the brain systems that are involved.   In contrast, a PAN intervention should be informed by our understanding of the brain systems that mediate its effects, so in theory PAN will lead to the design of treatments that would never have been developed if we did not know about the relevant brain systems, and that may be more specific and effective because we do know the relevant brain mechanisms. 

So what do we have today?  Not much yet, reflecting the current relative lack of detailed knowledge about the specific mechanisms of action in the brain for any treatment of any disorder.  Consider for example, how little we know about the ultimate mechanisms of action of antidepressant or antipsychotic drugs.  But this knowledge is burgeoning.  Its rate of growth is so fast, and interest is so strong, that there may well be many novel practices available within the next decade.  Consider the growth of mindfulness meditation practices, a now classic positive psychology intervention that has yielded substantial benefits to its practitioners despite our ignorance of the brain systems that are involved in its effects.  But now we are learning how mindfulness impacts both brain structure and function, and it is conceivable that future tools will promote specific prescriptions for practices that either more narrowly focus or diffusely broaden attention to achieve desired outcomes. Perhaps such practices will be augmented by EEG neurofeedback using inexpensive consumer-grade headsets, or transcranial direct current stimulators.  It is now difficult to go on line (or even turn on the TV) without seeing advertising for diverse “brain training” systems.  Cognitive exercise regimens that focus on promoting neuroplastic changes within key brain systems may become as routine as is training dedicated to muscle groups (and to this end, we have opened at UCLA a new “brain gym” to help familiarize our university community with the relevant tools).  For us “boomers” it appears this brain fitness market may have a long way to go before it is saturated.

What is our role as members of the SCN in the next wave of positive applied neuropsychology?  First, our unique training and expertise is required to determine what paths will be the most fruitful for development.  What cognitive training procedures (if any) are truly effective?  Do any of these procedures lead to generalization?  What evidence would be necessary to support more widespread application of neurofeedback?  Can we augment meditation practices to enhance capacity for focused attention or anxiety-reducing broadening of attention?  Second, we must provide a counterweight to the commercial forces that already are attempting to capitalize on these ideas before they are proven.   SCN members need to provide well-informed opinions about the merits – and lack thereof – of applications already in widespread use.  Finally, we must champion consideration of the ethical considerations that attend to this brave new world that involves brain-altering practices.   What do you recommend to your baby-boomer patients who wonder if they should have personal genetic testing to learn their APO-E genotype, get a positron emission tomograph, or get neuropsychological testing to learn if they are “at increased risk” for Alzheimer’s disease?  How do we help parents navigate the increasingly dizzying maze of choices being offered for attentional problems (medication, neurofeedback, working memory exercises), particularly for kids who do not satisfy criteria for a syndrome like attention-deficit/hyperactivity disorder?  What are the components of a regimen that supports long-term cognitive and emotional health?  We all know this must go beyond “cognitive exercise,” but exactly what components of physical, psychological, social, emotional, and spiritual practices should we be recommending as practitioners of the healthy brain sciences?  These questions already are prominent in many of our clinical practices and in the coming years we can expect this emphasis to increase.  The time is at hand for us to establish best practices and to anticipate a future that will further blur the lines between health optimization and clinical care.  We are in a unique position to advise the public and other stakeholders how to harness new knowledge about the brain to help us advance the values we possess as individuals and share as a society.


Bilder, R. M. (2011). Neuropsychology 3.0: Evidence-based science and practice. Journal of the International Neuropsychology Society, 17(1), 7-13.

Bilder, R. M. (2010, Nov). Personal Brain Management, from TEDx San Diego "The Next Wave."

Bilder, R. M. (2012, July). Huffington Post Blog on Personal Brain Management.

Randolph, J. J. (Ed.).  Positive neuropsychology: Evidence-based perspectives on promoting cognitive health. 10.1007/978-1-4614-6605-5_2.  Springer Science+Business Media, New York, 2013. [quote from location 146; Kindle edition].