Role of Technology in Clinical Psychology Research Paper

At a more mundane level, no doctoral student or clinical psychologist working in an academic institution in the 1960s and 1970s can forget using typewriters to write multiple drafts of dissertations, professional papers, and research articles, relying on hand calculators to compute most statistical analyses, or, eventually, lugging IBM cards to mainframe computers for more prodigious analyses. What has changed, of course, is the sophistication of the available technology and its widespread availability to working psychologists, as well as to the public.

The advent of the widespread adoption of technology by clinical psychology came with the personal computer in the 1980s and proliferated with universal access to the Internet in the following decade. There were, of course, a few clinicians who made noteworthy use of mainframe computers in clinical practice long before this time. The earliest software program that could be used for a computer and a person to engage in a therapeutic discussion using ordinary language was created by Joseph Weizenbaum at MIT in 1966 and dubbed ELIZA. Intended more as an experiment in artificial intelligence than as an attempt to devise a talking therapist, ELIZA could answer questions. The first part of Weizenbaum’s program extracted information from material typed into it by the patient; the second part used a script that formulated an appropriate reply. The computer program might be viewed as a primitive Rogerian therapist, kind, nonjudgmental, and simplistic, but realistic enough that people would “forget” that they were interacting with a machine. Another experiment in creating a software program that could conduct psychotherapy was initiated by William Colby at about the same time (Colby, Watt, & Gilbert, 1966).Although Colby and his colleagues hoped that their program might eventually serve as a low-cost provider of psychotherapy in hospitals and mental health centers but expressed reservations about its efficacy, Weizenbaum retained considerable misgivings about the ethics of using a computer to substitute for a respectful, caring human being as a psychotherapist (Bloom, 1992).

Technology Usage by Clinical Psychologists

In many ways it is a shame that the computer entered the psychology field as a psychotherapist, since that is among the mostdifficultandcontroversialactivitiesthatitmightperform (Bloom, 1992). With the exception of a few adventurous psychologists, there appears to be a significant lag between the advent of technology in everyday life and the use of technology by the practicing clinical psychologist. According to Kemenoff (1999), the primary use of computers in clinical practiceappearstobeforadministrativeandclericalpurposes. McMinn, Buchanan, Ellens, and Ryan (1999) recently conducted a survey of 420 American Psychological Association (APA) members in clinical practice (out of 1,000 possible respondents) regarding their use of and attitudes toward the implementation of technology to assist their office practices. McMinn et al. divided technological advances into three tiers based on level of advancement. The first wave consists of tools for keeping records and maintaining an office more efficiently and includes devices such as fax machines, photocopiers, and computerized software for billing purposes. The second wave refers to current tools that directly affect patient care, such as computer applications of test administration and interpretation, and adjunctive computerized educational programs to increase self-esteem or reduce drug and alcohol use. The third wave represents more emerging technologies, such as videoconferencing and using virtual reality programs for overcoming phobias. The authors were surprised to find that computer usage in office practice had not increased appreciably since a comparable survey by Farrell (1989) a decade earlier. A majority of respondents employed computers to assist in patient billing, but only a minority used computers fairly or very often for test scoring (26%), test interpretation (20%), maintaining patient records (22%), and more esoteric applications such as teleconferencing for psychotherapy (.2%) or virtual reality for treating anxiety disorders (.2%). By far the most common “technological” practices were consulting with colleagues on the telephone (95%) and providing crisis intervention on the telephone (96%).

The lag in adopting available technological tools to assist in clinical practice is accompanied by—or perhaps affected by— the respondents’ concerns about the ethics of such behavior. Significant numbers of psychologists were concerned about the confidentiality implications of, for instance, using the computer to store patient records or a fax machine to forward confidential records. Providing direct clinical services on the Internet seemed fraught with ethical concerns, as did providing regular psychotherapy on the telephone (although adjunctive telephone therapy, as in crisis intervention or screening, seemed to be acceptable). A majority of psychologists (60%) thought that the adoption of therapy via computer was probably unethical, an opinion seemingly based not only on confidentiality considerations but also on “reticence to embrace technologies that usurp or supplant the therapeutic relationship” (p. 169). In short, third-wave technologies raised the most concerns, and second-wave technologies raised more concerns than first-wave technologies.The unfamiliar is suspect.

One might argue that change in the field of psychology proceeds at a glacial pace, but one cannot apply that argument to the availability of technology that promises (or threatens) to impact current practice in the field. The real hazard in writing this research paper is that the content will become obsolete upon the date of publication. Thus, we are more interested in exploring the issues than in reviewing available software and hardware. The fact is that all sorts of technological gadgets and programs are becoming available for streamlining the office practice of clinical psychology, ranging from computerized billing programs to automated test scoring systems to hi-tech relaxation chairs. Rather than describing the kinds of products that can currently be found in a good mail-order catalog from a respectable mental health vendor, we will focus on what seems to be most germane to the practice of clinical psychology and divide the paper into three broad areas: (a) technology in the education and training of clinical psychologists, (b) technology in supervision and consultation, and (c) technology in psychological assessment and treatment.

Technology in Education and Training

In a recent invited address to theAPA, Diane Halpern, winner of anAward for Distinguished Career Contributions to Education and Training in Psychology, noted that changing the university is like changing a cemetery: You don’t get help from the inhabitants (Halpern, 1998). Nonetheless, with or without the sanction and blessing of faculty and students, technologymediated instruction has taken the university by storm.

The history of computer-assisted instruction, first attempted using time-sharing computers in the 1960s, has been clearly described by Linda Harisim and her colleagues (Harasim, Hiltz, Teles, & Turoff, 1995). Communication took place over dumb terminals connected to mainframe computers or dial-up telephone lines. In 1969, the U.S. government experimented with dedicated telephone lines for data exchange by constructing the Advanced Research Projects Agency Network (ARPANET) to connect researchers with remote computer centers to share resources. It was not long before these researchers wanted to exchange messages with one another about their projects. The electronic mail (e-mail) function was born and became immensely popular. Other communication networks (e.g., USENET, BITNET, CSNET) followed, still predominantly connecting researchers and scientists. Eventually, the Internet, a global network of networks, supplanted these individual efforts.

Murray Turoff is given credit for designing the first computer conferencing system in 1970 (Hiltz & Turoff, 1978). Today there are many conferencing systems available that support not only the discussion feature but other, more sophisticated features as well, including personal messaging and audio and video capability. Bulletin boards, common spaces for posting messages over the computer, were developed in the late 1970s (Sterling, 1992) but did not proliferate until a decade later. Both of these functions are at the heart of the implementation of computer networks for training and education.

Computer conferencing systems were applied tocourse activity in higher education in the 1980s and remain a prominent feature of online education today. According to Harasim (1998), there are three major applications of computer conferencing technology in education: (a) as the primary teaching mechanism for one or more courses, (b) as an enhancement to traditional face-to-face courses, and (c) as a forum for discussions and information exchange with peers and experts and a means of accessing online resources. All of these variants have found their way into the training of clinical psychologists.

The use of the Internet has been well integrated into higher education at the present time and augurs to increase. Almost every institution of higher learning has incorporated some aspects of the new technology into its curriculum delivery system. Most universities and training institutions of clinical psychologists still rely on traditional methods of face-to-face education, and there is doubt among many that computer networks can replace the personal touch in training students in the more interpersonal skills of the psychologist. Most institutions use computer networks as an adjunct to more traditional classroom experiences. Some assignments or the occasional course might be offered online, where discussion can run more freely and library resources are more available. In other schools the online environment is fully integrated into the curriculum and plays a major role in the delivery of education.

The Fielding Institute, Union Institute, Walden University, and Saybrook Institute are among the few major graduate institutions that have, for several decades, been training students who are dispersed from one another and from the institution itself to become clinical psychologists. They represent what has historically been known as “distance education.” According to the U.S. Congress forTechnologyAssessment, distance education refers to “linking of a teacher and students in several geographic locations via technology that allows for interaction” (Daniel & Stevens, 1998, p. 162). However, many distance learning institutions that have come to adopt a strong online presence were functioning prior to the Internet by relying upon individually directed study, mail, the telephone, and/or infrequent residential sessions for contact between students and instructors.They usually established a distance education model in order to provide an educational opportunity for a group of geographically dispersed students, such as midlife, midcareer professionals who could not easily give up their family and work responsibilities in order to move to a campus-based institution for a lengthy period of time.

It is important to clarify that there is a difference between distance education and computer-networked education. Adherence to a distributed model of training does not necessarily imply the adoption of an online teaching environment. Distance education flourished long before the advent of the personal computer (Maehl, 2000). Distance education institutions have not necessarily embraced online learning, but when they have done so, the transition to a communication-based technology has often gone more smoothly because of the overlap of values and skills required to succeed in the setting.

More recent entrants into the online education field include Capella University, which offers a totally online degree program in clinical psychology; theAmerican Schools of Professional Psychology, which is developing an online presence throughArgosy Online, started in 1999; and the University of Phoenix, which offers a host of academic programs and continuing education courses online. The Fielding Institute, which has the only distributed APA-accredited PhD program in clinical psychology, uses a blended model, which relies on a combination of distance activities and residential activities. Students come together for national and regional sessions with faculty and one another and participate in face-to-face seminars, colloquia, and other learning activities at those times. They also participate in monthly residential “cluster groups” led by core faculty who are distributed throughout the United States. The computer augments the educational experience rather than defining it. Students and faculty communicate regularly via e-mail (an increasingly common practice in more traditional schools as well), access bulletin boards for course and institutional information, deliberate online in faculty and committee meetings, and have the option of taking or offering several of their courses online.

Fielding’s approach to incorporating online coursework into the clinical psychology curriculum is illustrative of creative efforts currently being conducted by many other academic institutions. By and large, courses are offered as asynchronous online seminars, although students have the opportunity to select face-to-face seminars and tutorial options to taking courses online. The asynchronous format has the advantage of allowing students to participate in a class whenever and wherever they wish, within the time constraints and requirements of a particular course. It is also true that various faculty are experimenting with real-time teaching aids, including chat rooms and audio and visual displays. Each “class” is limited to about eight students, so there is ample opportunity for online discussion. Students post assignments and papers on an electronic forum and respond to one another’s work with both critical feedback and motivational support. Over time a clear set of norms has developed in order to maximize the use of the electronic medium for academic coursework. The norms include clear deadlines for work, the types of messages that are appropriate and inappropriate, the number of log-ons required per week, and the role of the instructor in terms of facilitation, modeling, and structuring boundaries (Stevens-Long & Crowell, 2002).

Learning Outcomes of Online Education

At this point in time, there are no definitive outcome data that allow us to argue for the superiority of online learning to classroom learning. There are some studies accumulating that find online classes, that is, courses that use computer networking as the university classroom, to be at least as effective in producing learning outcomes, as measured by exam scores and student feedback, as the traditional classroom. One recent study reported better examination performance from students taking a web-based introductory psychology course than those taking a traditional lecture course and attributed the findings to the fact that online sections force students to interact with the course material (Maki, Maki, Patterson, & Whittaker, 2000).

There is also an emerging literature on the dynamics of online groups and how they are similar to and different from face-to-face work groups or therapy groups (see, for example, Sproul & Kiesler, 1991). One consistent advantage of online groups is that the lack of social and visual cues that characterize the asynchronous learning environment helps to level the playing field for students: quiet and reserved students in traditional classes are often equal participants in online classes; gender and ethnicity diminish as concerns of engagement. Moreover, evidence suggests not only that students learn the course content as well as they do in traditional classrooms, but that a significant amount of metalearning takes place. Students learn how to communicate in writing, how to give and receive feedback sensitively and effectively, how to manage time and collaborate, and how group dynamics evolve over the course of time.

As universities and training institutions scramble to keep up with the onslaught of Internet-based distance education, there are scant data available to offer guidance to what works and what does not work. A recent report produced by The Institute for Higher Education Policy, funded by the National Education Association (2000), offers benchmarks for success. The following ingredients are distilled from those that were determined to be essential for quality education over the Internet:

• A reliable, optimally fail-safe technology delivery system with a well-supported and maintained centralized infrastructure.
• Clear guidelines and faculty-student agreement regarding times for completion of assignments and faculty response, including timely, constructive feedback to students.
• The development, design, and delivery of courses based on clear guidelines regarding minimal standards, with the selection of technology used to deliver the course content determined by desired learning outcomes.
• Courses designed to require students to demonstrate the skills of analysis, synthesis, and evaluation and the methods of effective research.
• Facilitated interaction among students and between students and faculty.
• Students prepared to participate on the basis of selfmotivation, commitment, and access to the technology requirements.
• Student access to electronic libraries on the Internet and training to obtain the necessary information.
• Student and faculty access to adequate technical assistance and training prior to and during the courses.

Pedagogy

Electronic teaching developed from advances in communication technology, not from innovative changes in pedagogy (Stevens-Long & Crowell, 2002). This fact has profound implications for identifying a suitable place for technology in the training and education of clinical psychologists. Generally speaking, educational institutions that experiment with the incorporation of sophisticated technology into their training programs do so within the context of their dominant pedagogical principles and historical attitudes toward education.

When that pedagogy relies upon the authoritative expertise of the instructor, who disseminates knowledge and information to relatively passive students using lectures supported by audiovisual aids, that same pedagogy is transposed to the electronic environment. In that context, instructional materials would be presented to the student online in the form of lecturettes (either in real time or in archived video form), which the student downloads and provides evidence of absorbing through the completion of exams or papers. These measures of competence might take the form of responding to a set of exam questions on a website or writing a term paper and submitting it to the professor by e-mail. The professor evaluates the material, perhaps provides some feedback, and the student receives a grade in the course. Thus, reliance on a prevailing educational paradigm in the guise of computermediated coursework means that face-to-face instructional practices (and distance learning by correspondence) are now being replicated in a new medium. However, this may not be the best and most effective use of the online environment.

In one study, 176 teachers were surveyed regarding differences and similarities between teaching online using computer networks and teaching in the traditional classroom (Harasim & Yung, 1993). Ninety percent of the respondents articulated the following kinds of differences characteristic of the online experience:

• The teacher becomes a facilitator and mentor.
• Students become active participants in discussion.
• Students and faculty have more access to resources.
• Students become increasingly independent.
• Students develop more equal learning opportunities with significantly more group interactions.
• Learning and teaching become more collaborative.
• Teachers and students operate more as equals with less hierarchy.
• Students have more time to reflect on ideas and exchange ideas.

Such statements suggest that computer-mediated communication technology has the potential to radically alter the graduate training experience. We would argue that to take full advantage of the opportunities of communication technology for training purposes implies significant shifts in thinking about educational pedagogy. Michael Schrage (1990) suggests that we need to shift our thinking from viewing technology as a means of managing information to regarding technology as a medium of relationships. As Schrage puts it, “Technology is really a medium for creating productive environments” (p. 67). Technologies can be effective if they are designed to empower students’engagement with the learning process and collaboration. Computer networks lend themselves well to the training of clinical psychologists, moving students beyond simply assimilating information to engaging in a “community of practice” (Brown & Duguid, 2000). This is what accreditation agencies refer to as “professional socialization,” an enculturation process that extends beyond the warranting or credentialing function of psychology training programs.

Implications for the Future

It appears that networked learning needs to be part of a larger strategy to reconceptualize education and build learning organizations and a knowledge society (Senge, 2000). The status of the university as the core training site for clinical psychologists is threatened by the possibility of creating an international university without walls enabled by communication-mediated technology. The debate about the future form and function of the university promises to be ferocious (Noam, 1995; Tehranian, 1996). Building training programs to grow tomorrow’s psychologists and meet the continuing education needs of today’s psychologists will require principled design that focuses on collaboration rather than competition; reflective thinking (Schon, 1987); and active self-directed learning that includes creative, real-world problem-solving.

Cynthia Belar, chief of APA’s Education Directorate (1998), has recently noted that psychology seems to be slipping behind other disciplines in the adoption of telecommunication and computer-based learning programs. The trick is to determine what aspects of clinical training can be automated and which require extensive faculty time and attention. For instance, there is no reason why certain core courses, those that stipulate a standard curriculum, cannot be offered on CD-ROM and other self-paced learning programs that studentscanmasterindividually(oringroups).Thiscouldextend to the core clinical service curriculum as well, perhaps including interviewing skills, mental status exams, test administration, and some intervention principles. Belar suggests adding a virtual reality component to training graduate students in skill development in assessment and intervention. In this way, the public is protected from inexperienced therapists and assessors who are low on the learning curve. It may also mean that there will be greater cooperation among institutions and training programs, which might share programs easily, because space and time would cease to be mitigating factors.

In sum, we agree with Dede’s (2000) futuristic vision of a gradual erosion of the distinction between distance education and classroom-based education to a model that negotiates a balance between the two approaches based on the particular subject matter, group of students, and learning objectives. It will be an ongoing challenge to design effective learning environments that are responsive to the changing face of educational institutions, as training programs seek to respond appropriately to a clientele that is demanding increasing flexibility due to issues of work, age, geography, and experience. Thus, we will need to know how each interactive medium shapes the cognitive, affective, and social interactions of participants.

Technology in Supervision and Consultation

A number of individuals and institutions have explored the application of computer technology to supervising or training clinical psychology students or mental health practitioners in clinical skill acquisition. One is a software tutoring system for helping develop entry-level family therapy skills called The Therapist Education and Supervision System (TESS; R. C. Smith, 1996). Another is a self-instructional, videobased package that has been successfully used to teach basic clinical interviewing skills, including the ability to ask openended questions, paraphrase content, reflect feelings, and engage in confrontation (Carter, 1997).

A time-honored supervision and training method, the group case presentation, has been modified using computer software (Homrich, 1997). Group Support Systems (GSS), a computerized method of facilitating work-group tasks, was used to structure the psychotherapy case presentations and was compared with a more traditional format. The discussions using GSS yielded higher levels of participation, greater trainee satisfaction,ahigherlevelofperceivedqualityofinteraction,and superior learning.

Janoff and Schoenholtz-Read (1999) have introduced web-based collaboration into the clinical training and supervision of clinical psychology students. The core components of their group psychotherapy training model include theory presentations, experiential work on group leadership facilitation, and clinical case consultations. They blend face-to-face meetings between students and faculty supervisors with online posting of documents and threaded conversations on a discussion forum.

Telehealth

The introduction of online supervision of graduate students within a psychology training program is but part of a larger domain, called telehealth, which supports a variety of healthrelated activities, including providing psychological and medical supervision and consultation at a distance. One recent source defines telehealth as “the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision, education and information across distance” (Nickelson, 1998, p. 527).

The number of papers associated with telehealth has grown rapidly over the last decade, as has the number of telehealth programs. The first telehealth program opened at the University of Nebraska in 1959. In 1994, there were 17 telehealth programs; by 1995, there were 50 (Telemedicine Information Exchange, 2000). Since 1995, mental health has become one of the most important telehealth applications, with a variety of activities, including use of websites, telephones, e-mail, online videoconferencing, store and forward applications, virtual reality, and information transmission from peripherals and tests (Jerome et al., 2000; Rothchild, 1999; Stamm, 1998, 2000). The role of psychologists in this emerging and varied market has yet to be determined (Jerome et al., 2000; Stamm, 1998).

Supervision and consultation are common and can include activities such as specialists supervising generalists, doctorallevel psychologists supervising midlevel or paraprofessional caregivers, supervision for licensure, and peer-to-peer supervision to prevent burnout and vicarious or secondary trauma (Stamm, 1999).An extension of supervision and consultation is professional-to-professional consultation, in which the primary care provider introduces the patient to an expert at a distant location. As patients become more comfortable with the technology and, particularly, with the provider at the remote location, there is a decreasing need for two professionals. For example, a teacher or principal in a rural school might initiate the relationship between his or her student and a distant school psychologist. As the student gains confidence in the relationship, he or she may meet directly with the remote professional with only modest technical assistance to begin and end the session.

Telehealth is increasingly common in correctional settings, linking inmates with their families to improve family function and to speed reintegration into the community (Magaletta, Fagan,&Ax,1998).Similarly,telehealthisusedwithfamilies who are separated by institutionalization for serious mental illnesses (Stamm, 1998). Telehealth also supports the mental health of caregivers, by reducing the effects of isolation, such as burnout and compassion fatigue, and restoring competency and positive control (Stamm, 1999; Terry, 1999).

Because of reductions in cost and technological difficulty, the choice to participate in a telehealth system can be made by small organizations, by individual providers, and even by consumers. This allows patients to play an ever-expanding role in selecting their own health care.

Telehealth distributes control for care to a larger circle of people than has heretofore been common. At the same time, there is a digital divide that augments health disparities. Income is a major predictor of accessing the Internet (National Telecommunications and Information Administration, 1999), and the divide between rich and poor is increasing in severity: the gap between the highest and lowest income widened 29% between 1997 and 1999. Whites are more likely to have Internet access than any other racial group, and urban areas are more likely to have access than rural areas (National Telecommunications and Information Administration, 1999).

Models of Training and Supervision

Binder (1999) has argued persuasively that interactive computer technology can significantly alter and improve training and supervision in therapy technique. He distinguishes between “declarative knowledge” and “procedural knowledge.” Declarative knowledge relates to how therapists employ “working models” to organize clinical information and ascribe meaning to it, draw on clinical data from previous and current experiences, and use theoretical concepts to organize the data. Beginning therapists have relatively unformed, primitive working models; over time, new information and conceptual knowledge become integrated with previous experiences. Declarative knowledge becomes transformed as the novice eventually becomes an expert. Historically, according to Binder, students obtain declarative therapeutic knowledge through course work and direct supervision, in which the supervisor offers suggestions and points out missed opportunities and poor decision-making from clinical sessions that have already taken place. Increasingly, therapy treatment manuals are available to help students acquire declarative knowledge in more precise ways.

However, how does an inexperienced clinical psychologist learn when and how to implement theories and concepts of practice? One does not learn to ride a bicycle by reading and talking about it! This is where procedural knowledge comes in, the application of declarative knowledge to real-work situations, what Donald Schon (1987) described as “knowing-inaction.”As Binder (1999) puts it, “The competent practitioner is capable of constructing a working model of a problem situation that effectively guides problem-solving behavior” (p.711). Whereas declarative knowledge may be learned from didactic experiences, including progressively sophisticated treatment manuals, procedural knowledge requires the active involvement of the learner, who is exposed to a “prearranged sequence of progressively more complex clinical problems, knowledge and methods” (p. 715). Supervision based on therapy audiotapes or videotapes does not afford this level of controlled learning. However, the simulation of real clinical experiences, based on structured sequences of events, can now be captured using interactive, multimedia computer technology, providing the student with guided interactive practice with immediate feedback.

At this point in time, developments are under way to improve this technology. Engen, Finken, Luschei, and Kenney (1994) and Maple (as cited in McMinn, 1998) have designed interactive videodisks that offer psychology students choice points during simulated psychotherapy sessions. Each choice point invites an action and an outcome, which can be used for learning purposes. So-called expert system-based, computerassisted training programs (ESCATs) are also proliferating. They draw on artificial intelligence technology to model the decision-making processes of experts within specialty fields. Thus, the Rorschach Trainer (McMinn & Scanish, 1996) helps students learn Exner’s Comprehensive System for scoring the Rorschach on their own, and an ESCAT designed by Todd (1996) helps students learn how to diagnose eating disorders.

Technology and Research Training

We would be remiss not to include some commentary regarding technological developments in research training and application as pertaining to the practice of clinical psychology. In this context we will briefly describe four general applications of computer-enhanced communication to research activities, as opposed to more technical advancements in measurement technology and data analysis. First, research training, as part of the curriculum, can also take place over the Internet. One pertinent example is the online teaching of statistics, a content area that requires a great deal of individual tutoring and practice. Many statistics texts now come with software for acquiring mastery of data analysis concepts and applications, and there are sophisticated training programs available through vendors such as SPSS and SYSTAT. These programs typically take a modular approach and include exposure to concepts and provide problem-solving experience with detailed feedback until the student meets the criteria for competence. Saba and Hodges (2002) regularly teach a popular graduate-level course in statistics to clinical psychology students online. It is a multimodal approach that includes group discussion, individualized exercises, and a chat room in which students can see, work on, and confer about statistical problems while receiving real-time consultation and feedback from the instructor. Other examples of teaching statistics online can be found in Harasim et al. (1995).

Second, psychologists are now engaged in trying to understand the impact of technology on human behavior and attitudes. Consequently, there is a growing literature on the influence of cyberspace on personality (Pratt, 1995). Moreover, the Internet is quickly becoming a viable new laboratory for experimentation and a wonderful environment for studying psychological concepts such as collaboration, aggression, leadership, friendship, romance, and group behavior (Wallace, 1999).

Third, we are all aware that the research dissertation (and, for that matter, much of university-based research) has historically been oriented around obtaining data from undergraduate psychology students at the university that the student researcher is attending. Research in clinical psychology cries out for real-world application, and the opportunity to capitalize on computer-based communication methods is notable. It now becomes much easier for psychologists in different parts of the world to collaborate on research projects not only by communicating via e-mail but also by instantaneously sharing data and research records with one another. Multisite research becomes convenient and economical, a particular benefit for researchers without access to major funding or alternative resources. Faculty and students in different areas can each collect data on the same phenomenon and readily share their findings, thus claiming a truly representative and heterogeneous sample. The Internet also becomes a viable means of data collection. Participants who share a particular characteristic or interest can be sought and accessed through listservs, news groups, chat rooms, or search engines. The same scales or surveys can be distributed readily to many more people than can practically be reached face-to-face, and responses can be simply—and anonymously—returned and data downloaded and analyzed automatically by the researcher. In effect, the Internet becomes an entry point for global access to a mother lode of rich and diverse real-world research data. This fact has not been lost on the American Psychological Society, which maintains a listing of Web-based studies on its home page (Jerome et al., 2000).

Finally, the world of electronic publishing is exploding. Within the profession of clinical psychology, it becomes increasingly possible to disseminate papers and articles to peers and students using the Internet. Jerome et al. (2000) have recently discussed how technological changes are affecting the editorial review process of psychology journals. Electronic journals are still in their infancy but are certain to multiply in the near future. Martin Seligman, former APA president and highly regarded spokesperson for clinical psychology, led the way in 1998 by inaugurating the publication of the electronic journal Prevention and Treatment under his editorship.

Technology in Psychological Assessment and Treatment

Public Use of the Internet for Education and Psychotherapy

The Internet is currently being used by the public to obtain counseling and psychotherapy both in self-help form and from licensed professionals. As of 1999 there were over 28,000 newsgroups on the Internet (Fink, 1999), and many of these have a focus of sharing and responding to specific types of psychological problems. There are online groups for every conceivable type of shared interest or problem, ranging from infertility to financial setbacks.

Virtual support groups have multiplied by the ease at which they can be created using listservs. The popularity of many of these online support groups is astounding. This should come as no surprise because the market for self-help books and videotapes has been huge for many years and online groups can be viewed as a more technological iteration of the same need.As might be anticipated from self-help groups, responses are uneven in quality, often validating, but not necessarily wise or insightful.

People who might not otherwise seek treatment or possess accurate knowledge regarding mental health issues now have a wealth of information and access to resources readily available. Search engines are a rapid vehicle for locating useful information and dialogue on health promotion and health maintenance.Widespread access to information, which is what the Internet offers, can help demystify psychology, which for many remains an esoteric discipline. For others the possibility of revealing deep secrets online seems safe, since the home computer coupled to the Internet allows the opportunity to hide in anonymity. In this regard, there is empirical evidence available to suggest that there is therapeutic value in personal, diarylike writing about traumatic events and personal frustrations (Pennebaker & Beall, 1986; Pennebaker, Colder, & Sharp, 1990).

One can also be concerned about the limitations of nonprofessional help for serious mental disorders. There is reason to believe that vulnerable people do express suicidality in cyberspace (Baume, Rolfe, & Clinton, 1998) and suicidologists are concerned about the so-called Werther effect, which refers to the potential for distressed individuals to become suicidal through social learning, contagion, imitation, or suggestion, processes that can easily be facilitated by electronic newsgroups.

Some professionals have noted that many consumers are using contacts with anonymous others on the Web as surrogates for significant others in daily life. It is quite easy to construct a “virtual community” in cyberspace. How do these communities function like psychotherapy, and, more importantly, are they a threat to the professional practice of psychotherapy? Moreover, if they are, what negatives arise from the threat, and what might that threat produce that is positive?

It could be said that we have been here before. The advent of the telephone certainly made it possible to be connected to others at great distance. However, there are differences. Miller and Gergen (1998) have noted eight of them:

1. The Internet allows for immediate contact with large numbers of individuals who share a specific problem.
2. Numbers of contacts and geographical distance do not influence the cost, which is low.
3. Bulletin boards and e-mail provide the option of asynchronous communication, allowing ample time for reflection and reply. Telephones do not.
4. It is elementary to maintain a written record of online communications.
5. The lack of social markers, such as age, gender, ethnicity, and physical appearance, reduces the risk of prejudice in communications.
6. The sheer scope of the Internet allows for a wide array of opinions from individuals from very different walks in life.
7. The medium offers anonymity.
8. Communications tend to be two-way, and recipients of help can easily shift into the role of helpers.

Miller and Gergen (1998) conceived an elegant study of tracking conversations across one Internet discussion group (chat room) for a period of 11 months to explore the similarity between the conversations that take place online with those more characteristic of traditional psychotherapy.As an exemplar they chose a discussion group on suicide from an Issues in Mental Health forum. They divided the discourse among participants into five domains: (a) help-seeking interchanges, (b) informative interchanges, (c) supportive interchanges, (d) growth-promoting interchanges, and (e) punitive interchanges. They discovered that punitive interchanges were rare, informative interchanges were moderately available, and supportive interchanges were very common. Participants provided sympathy and encouragement, validated one another’s experiences, offered helpful (and nonhelpful) advice, and even asked provocative questions. However, they rarely provided the interpretations, reflections, reframing, and metacommentary that we associate with experienced psychotherapists. Thus, the authors concluded that Internet discussion groups are useful for helping others help themselves and have therapeutic potential, but that the field of professional psychotherapy is probably safe from this competition because it promises to offer a level of reflective understanding rarely seen in cyberspace self-help groups.They suggest that the real challenge ahead for clinical psychology is how to effectively combine the power of the Internet with what we have traditionally been trained to do face-to-face.

Professional Use of the Internet

Russ Newman (2000), executive director of theAPA, recently declared in the Monitor on Psychology that

We have an opportunity to be a preeminent profession within the Internet culture . . . the question is not simply whether health services should be delivered via the Internet, but rather what services under what conditions can be effectively delivered through the Internet or other telecommunications technologies. (p. 24)

Professional mental health workers, including psychologists, have discovered the Internet as a business opportunity. The first for-profit psychological practice that is administered by professionals on the Internet goes by the name Shrink-Link (Binik, Cantor, Ochs, & Meana, 1997). A standard procedure is for clients to post questions online to an expert panel and receive an e-mail response within 24–72 hours, together with a bill for services. There is even a Directory of Internet Psychotherapists (Ainsworth, 1997) who practice what is commonly called “cybertherapy.” Fee setting is innovative because session time takes on a whole new meaning in cyberspace. Thus, charges either accrue per minute of response time ($1.50–$2.00 a minute is typical) or per e-mail ($20.00–$25.00; Fink, 1999). Patients approach therapists online for either single interactions, in the same way that they might write Dear Abby, or multiple contact. Is this psychotherapy? Probably not in terms of how most psychologists define the term, but reports suggest that customer satisfaction is high (Fink, 1999), and it is accessible to individuals who have physical disabilities or who live in remote areas.

It seems evident that there will be an increasingly creative use of the Internet to provide psychological services in the near future. Online group psychotherapy (Colon, 1999) and crisis intervention (Wilson & Lester, 1998) are just two recent innovations. This growth will be accompanied by the need to resolve concerns raised by the professional community, such as concerns about confidentiality (Pope & Vetter, 1992) and cross-jurisdictional licensing and accountability. Fundamentally, should the provider of care be licensed in the state where the care originates or the state to which the care goes? (Nickelson, 1998)

Koocher and Morray (2000) surveyed state attorney generals regarding the delivery of mental health services via telemetry and discovered no established standards across the states. Rural states are more advanced than their urban counterparts. Koocher and Morray predict increasing regulatory and legal precedent and recommend that psychologists (a) assess their competency in providing care through the medium, (b) consult with their professional liability insurance carrier, (c) seek consultation from their colleagues, (d) provide patients written emergency procedure information, (e) inform clients of the standard limitations and cautions regarding mental health care as well as potential risks to privacy due to the technology used, and (f) clearly inform patients what types of services can be offered.

Computer-Assisted Assessment

Most applications of computers in clinical assessment are in the areas of computerized assisted interviewing or in psychological test administration, scoring, and interpretation. This discussion is limited to initial assessment in general practice. The interested reader can find excellent and relatively recent revues of computer applications in neuropsychological assessment (Kane & Kay, 1997) and behavioral medicine (Werner, 1995). In addition, edited volumes are available on adaptive testing (Drasgow & Oslo-Buchanan, 1999) and behavioral health care management (Trabin, 1996).

Computerized interviewing began at the University of Wisconsin. A group of researchers experimented with using computers to collect medical history information directly from patients(Slack,Hicks,Reed,&VanCura,1966).Althoughthis was labeled “interviewing,” it amounted to programming a computer to administer a questionnaire. The branching logic capabilities of the computer permitted questions to be presented contingent upon the responses to previous questions. This was possible only to a very limited degree with pencil and paper. The enthusiasm for this research found its way into taking psychiatric histories (Greist, Klein, & Van Cura, 1973; Maultsby & Slack, 1971). Others attempted to collect and report more comprehensive descriptive data such as patient problem lists (D. R. Fowler, Finkelstein, Penk, Bell, & Itzig, 1987) and psychosocial histories (Giannetti, 1987).

In the early 1970s most clinicians had little or no knowledge of computers. Many resisted the very idea that computers might be used to collect data directly from patients. They viewed computers as a dehumanizing hazard when applied to any aspect of patient care. The early studies on computer-administered interviews served to establish their credibility. The majority of patients enjoyed responding to computeradministered questionnaires and frequently preferred them to clinician interviews (e.g., Angle, Ellinwood, Hay, Johnsen, & Hay, 1977; Card et al., 1974; Lucas, 1977; Lucas, Mullin, Luna, & McInroy, 1977), and the agreement between information collected by computer and clinical interview was very high (Carr, Ghosh, &Ancill, 1983; Grady & Ephross, 1977).

Other computer applications were based upon a formalization of the clinical diagnostic interview. Clinicians would conduct an interview by following a structured interview schedule and record their observations on rating scales and checklists. Presumably, a structured interview process could yield more complete and reliable data than an informal interview. The data were then input into a computerized decision-tree program that would make DSM-II diagnostic classifications. An early example was the Current and Past Psychopathology Scales (CAPPS; Endicott & Spitzer, 1972). The CAPPS data were processed by a computer algorithm (DIAGNO-II; Spitzer & Endicott, 1969) to yield one or more DSM-II diagnoses. The authors found that computer diagnoses agreed with clinicians’ diagnoses as well as clinicians agreed with each (Fleiss, Spitzer, Cohen, & Endicott, 1972).

A number of other computerized structured diagnostic interviews have been developed. These include the Diagnostic Interview Schedule (DIS; Robins, Helzer, Croughan, & Ratcliff, 1981), DTREE (First, Williams, & Spitzer, 1989), Structured Clinical Interview for DSM-IIIR (SCID; Spitzer, Williams, Gibbon, & First, 1990) and its successor versions, and the Composite International Diagnostic Interview (CIDI; World Health Organization, 1993). The DIS, CIDI, and SCID havebothclinician-administeredandpatientself-administered capabilities.

Parallel with these developments, the computer was being applied to the administration, scoring, and interpretation of psychological tests. The first interpretive program was the Mayo Clinic MMPI (Rome et al., 1962). This application, intended for psychological screening of medical patients, produced a brief list of likely symptoms or characteristics. A number of other researchers were working on more comprehensive interpretive systems at that time (e.g., R. D. Fowler, 1980). Commercial services for MMPI mail-in scoring and interpretation emerged in the late 1960s and early 1970s. The introduction of the microcomputer permitted practitioners to have office-based testing systems (Johnson, Giannetti, & Williams, 1978). These computers were still very expensive, and the available software was limited.

The introduction of the desktop personal computer changed everything. Computer-assisted testing became industrialized rather rapidly as new and existing assessment companies entered the field. The number of available computerized self-report tests increased geometrically. Scoring and interpretive aids for clinician-administered intellectual and projective tests soon followed. Today, the clinician can select from a wide array of products.

Computer-based diagnostic interview programs vary in their coverage of diagnostic classifications, and none of them cover all possible diagnoses. The reliability and validity of these interviews have been evaluated in several studies (e.g., Dreesen & Arntz, 1998; Peters & Andrews, 1995; Rosenman, Korter, & Levings, 1997). Diagnostic agreement varies substantially by diagnostic category. If there is an advantage to this approach in clinical practice, it would be in the structured and reliable collection of data. The advantage does not lie in diagnostic accuracy.

There is little doubt that computerized administration and scoring of psychological tests is more convenient, faster, less expensive, and less error prone than conventional administration and hand scoring. It is also advantageous to have data electronically stored for other analyses. Studies mentioned earlier established that most patients do not object to interacting with a computer and many enjoy the process. Once we get beyond these basic findings, however, matters become decidedly more ambiguous.

Moreland (1987) observed that most assessment tools available for computer administration were developed for conventional administration: “Therefore, as a practical matter, one must be concerned that factors indigenous to computerized administration, but irrelevant to the purposes of the test, may alter test performance” (p. 32). He also noted that that there had been little research on this matter. Fifteen years later, Butcher, Perry, and Atlis (2000) reviewed available studies on the equivalence of booklet and computer administered tests. They found a substantial number of studies on the MMPI/MMPI-2, including one meta-analysis of 14 studies (Finger & Ones, 1999). They concluded that the two methods of administration are psychometrically equivalent. However, they found very few studies on tests other than the MMPI, and some of those did show differences between administration methods. Another review (Schulenberg & Yutrzenka, 1999) presents good evidence for the equivalence of conventional and computerized versions of the Beck Depression Inventory. For any other tests that were developed and normed based upon conventional administration, one cannot assume that scores obtained from a computer-administered version are equivalent to the original version.

Even with the MMPI and the BDI, for which group statistics on equivalency are good, the practitioner should be aware that other factors could conceivably affect the results for individuals. Schulenberg and Yutrzenka (1999) have argued that recent studies indicate computer aversion can have an effect on scores on measures of negative affect. Spinhoven, Labbe, and Rombouts (1993) asked 343 patients admitted to an outpatient clinic to volunteer for computerized assessment, and 186 refused. Those who refused tended to be older, female, less educated, and less experienced with computers than those who volunteered. Those who completed the computerized assessment tended to rate the experience positively. Even within this group, sex, age, education level, and computer experience correlated with attitudes toward the use of computers.

Beyond administration and scoring, many programs are on the market that provide computer-based test interpretations (CBTI) for, primarily, tests of personality. Evaluating the validity of CBTIs is a very complex matter. Snyder (2000) summarized many of the issues. The validity of the instrument itself and the availability and quality of clinical correlate information limit the validity of any interpretation, whether it is generated by a computer or an individual clinician. The decision rules used to generate narrative statements are almost always proprietary and, hence, cannot be examined as part of any study. The sample in any given study is likely to trigger only a subset of the available narrative statements in the CBTI pool. Evaluation of the statements can vary from global judgments about the entire report, to comments on subsections of the report or individual statements.

Moreland’s (1987) review concluded that CBTI research had produced mixed but generally positive results and was well worth pursuing further.Amore recent review of CBTI research (Butcher et al., 2000) presents a grand total of four additional CBTI studies in the 13 years since Moreland’s review. Our search discovered one additional study on the Millon Adolescent Personality Inventory (Rubenzer, 1992) and one on the WISC-R (Tsemberis, Miller, & Gartner, 1996). Taken together, these newer studies would not alter Moreland’s original conclusions. Despite their popularity, there are no adequately validated CBTIs. The validities of CBTIs are essentially unknown, and apparently there has been very little interest in conducting validation studies.

A recent departure from the traditional CBTI approach attempts to tie assessment more closely to treatment planning. It is a computer program designed to implement Beutler and Clarkin’s(1990)SystematicTreatmentSelection(STS)model. The software has a variety of features, including projection of treatment course based on similar patients in its database, graphs of the patient’s relative standing on assessed variables, assessment of probable risk, and a list of the most pressing problems. The distinguishing feature is the assessment of patient characteristics that have been empirically shown to predict differential responses to different interventions (Beutler & Harwood, 2000), permitting the clinician to select treatment strategies tailored to the individual patient.

The four patient characteristics currently assessed using the STS Clinician Rating Form (Fisher, Beutler, & Williams, 1999) are level of functional impairment; characteristic ways of coping with stress, particularly externalization and impulsivity; traitlike levels of interpersonal resistance to external influence; and current level of distress. As an example of the implications for treatment selection, patients who cope with stress by internalizing responsibility and blaming themselves respond better to insight-oriented treatments. Patients who cope by externalizing blame, by acting out, or by avoidance respond better to behaviorally oriented treatments (Fisher et al., 1999). The output identifies the patient’s likely coping style and lists suggestions for interventions suitable to that style.

Computer-Assisted Psychotherapy

DeWeaver (1983) described the microcomputers available in the early 1980s and the ways they might contribute to an independent psychotherapy practice. Today many computer-assisted educational programs exist to prevent alcohol and drug abuse, increase responsible sexual behavior, prevent delinquent behavior, enhance self-esteem, modify self-destructive lifestyles, and reduce disruptive classroom behavior (Bloom, 1992). Professional software programs are increasingly available to address specific psychopathologies.An example is Student Bodies, a self-help eating disorder prevention treatment that includes a multimedia program and a computer-mediated discussion group (Winzelberg, 1998). Another program is designed for treating posttraumatic stress and pathological grief through the Internet (Lange et al., 2000).

Most computer-assisted therapy applications are automated versions of traditional cognitive behavioral therapy techniques used to address specific problems of anxiety, affective disorders, sexual dysfunction, and habit control. They range from those intended for use by clinicians as adjuncts to treatment to applications that are more self-help-based and intended to extend services to primary care settings or to persons who are reluctant or unable to seek professional assistance. Examples are a self-directed graduated exposure treatment program for phobics (Ghosh, Marks, & Carr, 1988); a computer-assisted vicarious exposure treatment program (K. L. Smith, Kirkby, Montgomery, & Daniels, 1997); an individualized program for dysfunctional beliefs and automatic thoughts in mild to moderate depression (Selmi, Klein, Greist, Sorrell, & Erdman, 1990); a weight loss program using behavior therapy with a palmtop computer offering treatment regimes, feedback, and reinforcement (Burnett, Tayloy, & Agras, 1985); a behavioral self-control program for problem drinkers (Hester & Delaney, 1997); use of a palmtop computer for self-monitoring and reinforcement in the treatment of panic disorder (M. G. Newman, Kenardy, Herman, & Taylor, 1997); and a couples therapy program for sexual dysfunctions called Sexpert that simulates therapeutic dialogue and responds differentially to a client’s input (Binik et al., 1997).All of these programs have provided some evidence to suggest that they can be effective with regard to clinical outcomes and useful at least as adjuncts to traditional interventions. They have the further virtue of saving valuable therapist time.

One of the limitations of the older generation of computerassisted treatment programs is their “one form fits all” approach. Recent programs offer individualized treatment and are more sensitive to specific client goals and circumstances. Although the examples above are automated techniques applied to specific problems, the Therapeutic Learning Program (TLP; Gould, 1990) is intended to help patients identify and solve their own problems. The application is grounded in Gould’s theory of adult development. It is a short-term, goaloriented approach in which the computer program assists the patient in defining problems, identifying actions that will address the problems, and dealing with conflicts and irrational thoughts about engaging in those actions.After a session with the computer, the patient receives a printout and interacts with the therapist in an individual or group session (Gould, 1996). A randomized controlled study comparing TLPassisted therapy groups to traditional cognitive-behavioral stress reduction groups found them equally effective in reducing depression and anxiety, but the TLP groups used one-third toone-halflessofthetherapist’stime(Dolezal-Wood,Belar,& Snibbe, 1998).

The most cutting-edge software treatment programs make use of virtual reality technology to produce a perceptual world that captures the patient’s experiences and responds to the patient’s actions. Virtual reality (VR) therapy operates under the principle of providing the patient with the illusion that an experience that is computer-mediated is not mediated but direct (Fink, 1999). Where control is an important therapeutic issue, such as in phobias, VR software typically enables the user to exercise control in terms of the rate and extent of exposure to feared objects and situations. Virtual reality equipment usually consists of a head-mounted visual display with earphones that is connected to a computer. The computer generates the audio and visual stimuli to produce simulations of feared or unknown situations. The therapist can experience what the patient is experiencing and can speak with the patient through a microphone. The patient “moves” through the environment by a sensor that tracks head position and orientation. The position of other parts of the body can be tracked as well so that, for example, the patient’s hand movements interact with objects in the simulation.

An early desensitization of phobias program using VR was instituted at Clark University in 1992 to study the fear of flying (Williford, Hodges, North, & North, 1993). The most commonly simulated environments are still associated with phobias, and the treatments employ some form of graduated exposure therapy. For a statement of the theoretical rationale for its use and examples of applications, see Rothbaum and Hodges (1999). The two available controlled studies of VR are both for agoraphobia and used wait list controls (North, North, & Coble, 1998; Rothbaum, Hodges, & Kooper, 1997). Although the findings are quite positive, there have been no studies to date directly comparing the effectiveness of VR exposure to imaginal or in vivo exposure.

Virtual reality therapy offers numerous advantages for the practice of psychotherapy. Exposure therapy can be conducted without the time involved in leaving the therapist’s office, and it reduces the risk of harm or public embarrassment to the patient.The therapist has more precise control of exposure stimuli. It is more convenient than in vivo exposure and more realistic than imaginal exposure. It can be used in situations in which in vivo exposure is quite expensive (fear of flying) or impossible (combat-related posttraumatic stress disorder).

There are a couple of disadvantages to the use of virtual reality therapy. One is the financial cost involved, since computer programs and head-mounted displays can cost several thousand dollars. However, as with most of the new technology, these costs will surely come down in the near future. Second, some individuals complain of dizziness and nausea when they participate in VR (Regan & Price, 1994).

Although the initial VR work was on anxiety disorders, there have been attempts to apply VR technology to the treatment of eating disorders (Riva, Bacchetta, Baruffi, Rinaldi, & Molinari, 1998) and impotence (Optale et al., 1998). Virtual reality has the potential to simulate the social, as well as the physical, environment (Glance, Durlach, Barnett, & Aviles, 1996). Social simulations would permit the therapist to accompany the patient into current and past situations, interacting with simulated people significant in the patient’s life to assist the patient in solving problems or mastering skills. The technology necessary for such applications is still in its infancy.

A more sophisticated form of VR, called augmented reality, refers to the manipulation of environments to enhance rather than replace the physical world (Fink, 1999). The patient, for instance, might project his or her image into a crowded football stadium or experience dental treatment minus the pain of the actual scene. An extension of this technology is the creation of virtual reality communities on the Internet. These are called Multi-User Dimensions (MUDs), and although they could theoretically be used for therapy purposes they typically have no such explicit purpose. There is no reason, for instance, that a therapist could not “accompany” a patient into a MUD and encourage the patient to experiment with new behaviors in the virtual environment.

Summary and Future Directions

There is reason to believe that the resistance to computers may come more from therapists than patients (Ben-Porath & Butcher, 1986). After all, although computer-programmed clinicians may lack nonverbal skills, they are apt to remain polite and friendly; never become angry, bored, or fatigued; and tend to be relatively inexpensive in comparison to their human counterparts (Bloom, 1992). Clinical psychologists, on the other hand, often have an aversion to computer technology because they fear its dehumanizing implications. Moreover, clinicians express deep reservations about adopting computerassisted interventions with patients. Not surprisingly, these reservations are more common among psychodynamically oriented psychologists than among cognitive-behavioral psychologists or family systems–oriented psychologists. This is probably because the latter models place less emphasis on therapist-patient relationship issues within the therapy session and anticipate new behaviors to occur primarily outside of the session (Bloom, 1992). It is also timely to note that the brief, focused therapy models of a cognitive-behavioral persuasion that so far lend themselves more to computerized applications are precisely the types of therapy that managed care providers tend to appreciate. One might predict the development and adoption of computer-assisted interventions to find a receptive home in this environment.

Dobson and Khatri (2000) exemplify both the enthusiasm and the apprehension of psychologists regarding the proliferation of computerized approaches to psychotherapy. On the one hand, they note, manualized therapies are probably the most easily modified for computer delivery, and that will most certainly take place very soon. On the other hand, we need to remind ourselves that acquiring information is not the same as gaining knowledge, and gaining knowledge is not the same as having wisdom. Cognitive therapists are already vulnerable to criticism of being overly mechanical and minimizing the human relationship factor in psychotherapy. The acquisition of greater competence via the electronic medium always runs the risk of further de-emphasizing skill training in human interactions. The risk is that, with the widespread implementation of computerized treatment, time and money will be targeted to the training of students in computer skills rather than in the ability to construct effective personal interactions.

Technological advancements in the field of clinical psychology are now sufficiently developed to make them practical for use by most educators, researchers, and practitioners. The pressing issues today are less related to the development of technology per se than they are to the fit between the technology and the human aspects of service delivery. It is critical to remember that, as clinical mental health professionals, our value as academicians and caregivers rests on our commitment to psychological knowledge and human service, not on our skills as technologists. Technology is a far-sighted tool, but a near-sighted master.

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