mHealth for Mental HealthIntegrating Smartphone Technology

mHealth for Mental Health:
Integrating Smartphone Technology in Behavioral Healthcare
David D. Luxton, Russell A. McCann, Nigel E. Bush, Matthew
C. Mishkind, and Greg M. Reger
The National Center for Telehealth & Technology, Tacoma,
Washington
The rapid growth in the use of smartphones has opened a new
world of opportunities for use in behavioral
health care. Mobile phone software applications (apps) are
available for a variety of useful tasks to
include symptom assessment, psychoeducation, resource
location, and tracking of treatment progress.
The latest two-way communication functionality of smartphones
also brings new capabilities for
telemental health. There is very little information available,
however, regarding the integration of
smartphone and other mobile technology into care. In this
paper, we provide an overview of smartphone
use in behavioral health care and discuss options for integrating
mobile technology into clinical practice.
We also discuss limitations, practical issues, and
recommendations.
Keywords: smartphone, mobile device, mHealth, apps,
technology
Smartphones are mobile telephones with computer functionality
that allow users to run software applications and connect to the
Internet or other data networks. This technology provides users
with the ability to engage in some activities on their phone

much
in the same manner that they could with a traditional personal
computer except with the advantage and convenience of
compact
size and mobility. In 2008, smartphones only made up 10% of
cellular phones used in the United States. Before the end of
2011,
however, smartphones will likely become the most commonly
used cellular phone device (Entner, 2010), and by 2013, smart-
phones are expected to overtake PCs as the most common Web
access device worldwide (“Gartner Highlights Key Predictions,”
2010). At least 300,000 software applications or apps have been
developed for smartphones (“Introducing the App,” 2010), and
as
of November 2010, more than 8,000 health related apps were
available for users to download (Dolan, 2010).
Medical professionals have long been some of the earliest
adopters of personal mobile technology for assisting with the
daily
routine of their practice. Portable electronic devices and
special-
ized software have been utilized for health research, education,
communication, reference, and patient care from the very
earliest
commercially marketed examples in the 1990s, such as the
Apple
Newton (Schweitzer & Hardmeier, 1996; Stratton et al., 1998)
through the rise and decline of Palm Pilots and other personal
digital assistants (PDAs; Teall, 2009; Vishwanath, Brodsky, &
Shaha, 2009) to the current boom in multifunctional
smartphones.
This article was published Online First October 31, 2011.
Editor’s Note. This is one of 19 accepted articles received in

response to
an open call for submissions on Telehealth and Technology
Innovations in
Professional Psychology.—MCR
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 the National Center for
Telehealth &
Technology (T2) and an Affiliate Assistant Professor of
Psychiatry and
Behavioral Sciences at the University of the Washington School
of Med-
icine in Seattle. His research and writing is focused in the areas
of military
psychological health, telehealth, and technology-based
treatments.
RUSSELL A. MCCANN received his PhD in clinical
psychology from Seattle
Pacific University. He is a post-doctoral fellow at the National
Center for
Telehealth & Technology (T2). His research interests include
the integra-
tion of technology into applied psychology, religiosity, and
determinants of
forgiveness.
NIGEL E. BUSH was awarded his PhD in psychology by the
University of
Southampton in the United Kingdom He currently is a Research
Psychol-
ogist and Program Manager at the National Center for
Telehealth &
Technology and an Affiliate Associate Professor in the
Department of

Psychiatry and Behavioral Sciences at the University of
Washington in
Seattle. His research focuses on the use of technology for
prevention and
treatment of psychological health issues and traumatic brain
injury in US
military service members.
MATTHEW C. MISHKIND completed his PhD in experimental
psychology
from the University of Vermont with a focus on organizational
develop-
ment and behavior. He is the Acting Chief of the Clinical
Telehealth
Division at the National Center for Telehealth & Technology
(T2). His
research and professional interests are focused on expanding the
range of
telebehavioral health care delivery options.
GREG M. REGER is a licensed clinical psychologist who
completed his PhD
in clinical psychology at Fuller Theological Seminary. He is a
former
Army psychologist and is Acting Chief of Innovative
Technology Appli-
cations Division at the National Center for Telehealth &
Technology (T2).
Dr. Reger has extensive clinical and research experience with
innovative
technologies and has published widely on the use of virtual
reality to assess
and treat psychological health concerns.
DISCLAIMER: The opinions or assertions contained herein are
the private
views of the authors and are not to be construed as official or
reflecting the

views of the Department of the Army or the Department of
Defense.
CORRESPONDENCE CONCERNING THIS ARTICLE should
be addressed to David
D. Luxton, PhD, National Center for Telehealth & Technology
(T2),
Defense Center of Excellence (DCoE) for Psychological Health
& Trau-
matic Brain Injury, Old Madigan Army Medical Center Bldg.
9933C,
Tacoma, WA 98431. E-mail: [email protected]
Professional Psychology: Research and Practice In the public
domain
2011, Vol. 42, No. 6, 505–512 DOI: 10.1037/a0024485
505
Smartphone tools are now found in almost every facet of
conven-
tional medicine (Johnson, 2010; Oliveira, 2010; Solomon, 2009)
with some apps such as Epocrates (Epocrates, 2011) and
MedCalc
3000 Complete (Foundation Internet, 2010) medical calculator
almost ubiquitous. Examples of medical uses cited in the
literature
range from diabetes management (Ciemins, Coon, & Sorli,
2010;
Rao, Hou, Golnik, Flaherty, & Vu, 2010), perioperative practice
(Brusco, 2010), infectious disease management (Focosi, 2008;
Oehler, Smith, & Toney, 2010), immunization management
(Kaewkungwal et al., 2010), and CPR instruction (You, Park,
Chung, & Park, 2010), to highly specialized uses in radiology
(Baerlocher, Talanow, & Baerlocher, 2010) as well as digital
imaging and bio-optical sensing (Barsam, Bhogal, Morris, &

Lit-
tle, 2010; Choudhri & Radvany, 2010; Jonathan & Leahy,
2010).
Although handheld mobile platforms and smartphones have
been in use within the medical community for some time, the
adoption of the technology for specific use in behavioral health
care has been slower, but is on the rise. Some recent examples
of
mobile technology use in behavioral health include assessment
of
alcohol and substance use (Bernhardt et al., 2009; Freedman,
Lester, McNamara, Milby, & Schumacher, 2006), support of in-
dividuals with a traumatic brain injury and intellectual
disability
(DePompei et al., 2008), treatment of tobacco use (Obermayer,
Riley, Asif, & Jean-Mary, 2004; Brendryn & Kraft, 2008), and
for
severe mental illness (Depp et al., 2010). Recent advancements
in
mobile device technology and the development boom of mobile
device apps, however, have opened a new world of
opportunities.
We conducted a search on the BlackBerry App World site
(http://
appworld.blackberry.com/webstore/) in April 2011 and found
more than 200 unique mobile phone apps specifically associated
with behavioral health. The apps cover a wide array of common
topic areas such as anxiety, depression, smoking, alcohol use,
psychosis, diet, exercise, weight loss, nutrition, parenting,
cogni-
tive performance, relationships, relaxation, sleep, spirituality,
and
general wellbeing. As can be seen in Table 1, apps for
Blackberry
and other popular smartphone platforms, such as the iPhone and

Android, exist for clinical assessment, symptom monitoring,
psy-
choeducation, resource location, tracking treatment progress,
skills
training, and two-way communication with providers and other
clinical resources. With this paper, we provide an overview of
smartphone technology relevant for behavioral health care and
discuss examples of its application. We also discuss primary
issues
involved when integrating this technology into clinical practice.
Smartphone Use in Clinical Practice
Smartphone apps provide useful functions that can be integrated
into conventional manualized treatments. For instance, apps de-
signed for self-assessments can help patients assess and monitor
symptoms. In the context of therapy, these assessments can be
shared with the treating clinician, tracked over time, and
presented
in a useful visual display to characterize treatment outcome.
Smartphone apps can also be programmed to respond to critical
items in self-assessments to auto-detect significant distress and,
when appropriate, offer one-touch contact to a support hotline.
The
eMoods Bipolar Mood Tracker app (Gigaram Technologies,
2011), for example, consists of a daily tracking system that
enables
users to input and keep track of subjective mood ratings in an
electronic mood journal. The app also keeps track of hours of
sleep, anxiety levels, and medication use and can generate
reports
that can be sent to a family member, caregiver, or clinician.
Some evidence-based treatments include therapist audio record-
ing of therapy sessions for patients to review later. The conve -

nience, portability, and excellent quality of digital audio and
video
recording on today’s smartphones make them an ideal choice for
recording sessions. The capability of apps to record and date -
stamp
homework review can help ensure treatment compliance. More-
over, the integration of calendar and phone contacts by
smartphone
apps can improve tracking of therapy appointments and can hold
therapist contact information for convenient and immediate
refer-
ence.
Apps can also include virtual coaches that provide real -time
audio and visual instruction while a patient practices a skill. For
example, clinicians often provide therapeutic skills training,
such
as relaxation breathing techniques, and sometimes audio record
in-session training for their clients so that they can practice
later at
home. Interactive or adaptive virtual training tools could coach
the
skill rehearsal to ensure successful skill acquisition. Also,
physi-
ological variables could be monitored by an app that
incorporates
gaming motivations and reinforcement for increased relaxation.
Behavioral health apps can also take advantage of the global
positioning system (GPS) functionality of many smartphones
that
locates the device, and hence the user (patient), in geographic
space. This feature can be useful for locating patients with
demen-
tia if they wander away and can help caregivers find them (Mis-
kelly, 2005). Similarly, the GPS capabilities of many

smartphones
could be used to increase behavioral activation. That is, the
smart-
phone can track the location of the client, such as to a busy mal l
during exposure therapy.
Real-Time Two-Way Communication Capabilities
The latest generation of smartphones, such as the iPhone4 and
those running the Android operating system, have incorporated
a
video camera feature that allows synchronous and real-time
audio
and video capabilities from the palm of one’s hand. This
capability
provides real-time remote communication between patients and
providers similar to what is currently delivered by traditional
videoteleconferencing (VTC). Because smartphones are not
teth-
ered to networks at fixed geographic locations, the two-way
audio
and video capability provides new opportunities for tele-
behavioral health that is low cost, flexible, and mobile,
especially
in rural and underserved areas where clinical services are not
readily available. Although it is expected that these applications
will expand concepts of care delivery, research into the
usability
for health care delivery is scant. The National Center for Tele -
health and Technology (T2) is one organization that is leading
usability research on these smartphone functions for use among
military Service Members and health care providers. This
research
is important to demonstrate not only the capabilities of these
devices, but also whether Service Members and providers will
use

them, especially in more austere environments such as on
deploy-
ments overseas.
Information Resources and Psychoeducation
The smartphone platform is also an excellent and efficient
method for accessing databases or other clinical information ex-
506 LUXTON, MCCANN, BUSH, MISHKIND, AND REGER
Table 1
Examples of Behavioral Health Apps Based on Clinical Area,
Platform, and Purpose
Clinical area
App name Platform Purpose(s)
Developmental disorders
Autism Network Android Provides information, resources, and a
forum for autism
ADHD Psychopharmacology iPhone/BlackBerry/Android
Provides information on diagnosis and treatment of
ADHD
Behavior Tracker Pro iPhone/Android Tracks and graphs
behaviors
Life Skills Winner Pro Android Teaches life and social skills
Dyslexia Helper iPhone Provides treatment for dyslexia
Cognitive disorders
Dementia News Android Provides information about dementia
Alzheimer’s Info Android Provides information about

Alzheimer’s
Parkinson’s i-pocketcards iPhone Provides information on the
diagnosis, course, and
treatment of Parkinson’s
Geriatrics at Your Fingertips iPhone/BlackBerry Provides
information on the assessment and management
of geriatric disorders
Caregiver’s Touch iPhone Allows caregivers to store personal ,
appointment, and
health information
Substance-related disorders
Blood Alcohol Tracker Android Tracks BAC
AlcoDroid Android Tracks alcohol use
Substance Abuse & Addiction Assessments iPhone Assesses
substance abuse and addiction
Cravings Manager iPhone/Blackberry Helps control cravings
12 Steps AA Companion iPhone/Android Provides the “Big
Book” and other materials for
members of AA
Psychotic disorders
Schizophrenia Psychopharmacology iPhone/BlackBerry
Provides information on diagnosis and treatment of
schizophrenia
SchizoTracker Android Tracks symptoms and triggers for
individuals with
schizophrenia
Mood disorders
eMoods Bipolar Tracker Android Tracks mood and other

symptoms
Mood Journal Plus iPhone/BlackBerry Tracks mood and other
symptoms
T2 Mood Tracker iPhone/Android Tracks mood and other
symptoms
Depression iPhone Provides assessments for depression
eCBT Mood iPhone Treats mood using CBT
Anxiety disorders
PTSD Coach iPhone Provides information, assessment, and
tools for
individuals with PTSD
Breath 2 Relax iPhone Teaches breathing exercises
Stop Panic & Worry Self-Help Android Uses CBT to treat
anxiety and panic
Anxiety Release Hypnosis Program BlackBerry Provides
hypnosis for anxiety
iCounselor: OCD iPhone Treats OCD using CBT
Eating disorders
Anorexia News Android Provides information on anorexia
BMI Calculator iPhone/BlackBerry Calculates BMI
Eating Disorder Assessments iPhone/Android Assesses for
eating disorders
iCounselor: Eating Disorder iPhone Treats eating disorders
using CBT
Stop Bulimia iPhone Treats bulimia using hypnosis
Sleep disorders
Sleep Bot Tracker Log Android Tracks sleep patterns
Relax and Sleep Plus Android Provides ambient sounds
designed to help individuals
sleep
SleepCyclesApp Alarm BlackBerry Helps individuals wake up

more refreshed by using
alarms
Sleep � iPhone Provides relaxing music to help individuals
sleep
Better Sleep iPhone Provides natural and white noise to help
individuals
sleep
Other
Lookout Mobile Security Android Provides smartphone security
Healthful Apps iPhone Provides a database of useful health apps
DSM-IV-TR iPhone Provides DSM-IV coding information
ICD-10 Search Android Search for ICD-10 codes
Psych Central iPhone/Android Provides information on
psychology
(table continues)
507SPECIAL ISSUE: INTEGRATING SMARTPHONE
TECHNOLOGY
temporaneously. Apps, such as DSM–IV–TR (Application 6,
2011)
and ICD-10 Search (Queo Sistemas, 2010), provide users with
an
efficient reference for psychiatric diagnoses. Furthermore, there
are apps available, such as Psych Central, that summarize
current
behavioral health research findings and therefore can help clini -
cians to stay up-to-date in a focused area. Apps that are already
in
use in the medical field can also be useful for behavioral health

providers. The Epocrates app (Epocrates, 2011), for example, is
in
use by more than one million health care providers in the United
States (“Overview,” 2011) and provides reference information
on
pharmaceuticals, dosing, contraindications, interactions and
pric-
ing information. Also, the basic Web browsing function on most
smartphones allows users to access the world of information
available on the Internet, no matter where they are located.
The audio and video functionality on smartphones also allows
for both real-time and recorded media streaming and podcasts.
Smartphones therefore offer an engaging audiovisual alternative
to
text-based psychoeducation materials. Podcasts are becoming a
very popular way for individuals to obtain behavioral health in-
formation (Dingfelder, 2010). One behavioral health podcast
web-
site, thepsychfiles.com, produces podcasts that cover a wide
vari-
ety of topics. It is estimated that 3.8 million podcasts from this
website have been downloaded worldwide (Britt, 2011).
Podcasts
are also starting to be used by some peer-reviewed journals to
disseminate information to subscribers. For example, The
Ameri-
can Journal of Psychiatry offers audio podcasts that highlight
each
issue and provide clinicians with an alternative way to learn
about
current research being done in the field. It is likely that the use
of
smartphones and other smart mobile devices for disseminating
behavioral health information will increase as the adoption of
this

technology grows and developers find more creative ways to use
mobile technology for this purpose.
Smartphones can also be used to provide patients with psychoe-
ducation via text messaging. Although less technologically ad-
vanced than most apps, there is evidence that text messaging
can
be an effective way to disseminate behavioral health
information
(Kim & Jeong, 2007; Kubota, Fujita, & Hatano, 2004). Texting
is
especially popular among adolescents with over 50% of adoles -
cents with cell phones sending at least 50 text messages per day
(Lenhart, Ling, Campbell, & Purcell, 2010). Because text
messag-
ing offers a relatively simple and inexpensive way to send
infor-
mation to patients, text messaging will likely continue to be
popular despite the advent of more advanced ways to
communicate
using specialized apps.
Other Smartphone Capabilities
Many smartphones have the capability to connect to external
hardware devices, such as biofeedback sensors, for monitoring
physiological signals. Biofeedback apps are a relatively new in-
troduction to mobile devices that can be used for a range of
behavioral health purposes, to include management of stress and
related health and health problems, such as headaches
(Nestoriuc,
Martin, Rief, & Andrasik, 2008), insomnia (Taylor & Roane,
2010), chronic pain (Palermo, Eccleston, Lewandowski, de C.
Williams, & Morley, 2010), and hypertension (Linden, & Mose-
ley, 2006). The PLX xWave, for example, is a portable sensor
that

attaches to an iPhone, iPad, or iPod Touch that can track
gamma,
delta, theta, alpha, and beta brain waves to provide
neurofeedback.
Also, at the time of writing, Apple Inc. has plans for a
“Seamlessly
Embedded Heart Rate Monitor” for the iPhone platform. The
device has an integrated sensor for detecting a user’s cardiac
activity and cardiac electrical signals. Apps provi ding this kind
of
physiological monitoring may provide increased fidelity,
portabil-
ity, and functionality over some traditional home-based biofeed-
back monitors.
Games are among the most frequently downloaded and used
apps on the various smartphone app markets. Increased attention
is
being given to the potential to leverage video game technologies
to
promote health-related behaviors (Papastergiou, 2009) and this
capability could also be extended to smartphone behavioral
health
apps. Furthermore, the unique capabilities of smartphones com-
pared to traditional game consoles have the potential to improve
the game experience by mixing real world behaviors with
software
performance. For example, a number of apps combine GPS,
com-
pass, and real world viewing capabilities that overlay computer
generated information and stimuli to create augmented reality
experiences. Given the number of evidence-based interventions
that include difficult real world excursions for clients, there is
high
potential for engaging behavioral health apps that provide game
motivations for desired behaviors. Apps for behavioral

activation,
exposure-response prevention, exercise, and in vivo exposure
could prove quite useful, however, more research is needed in
this
area.
Social support is a frequently targeted area in clinical practice
and social networking via the Internet is recognized for its
poten-
tial to provide new opportunities for social engagement and
con-
nection (Amichai-Hamburger & Furnham, 2007; Campbell,
Cum-
mings, & Hughes, 2006). Several empirical studies have
Table1 (continued)
Clinical area
App name Platform Purpose(s)
Concussion iPhone Provides information on recognizing and
diagnosing
concussions
Epocrates iPhone/Android Provides information on medications
Parenting Toolbox Android Provides parenting skills training
Socialize! iPhone Encourages social interaction
Marriage Counselor by FeelSocial iPhone Provides marital
counseling
Brain Booster BlackBerry Improves cognitive functioning
iEnforce Fitness iPhone Encourages exercise
iCBT iPhone Provides treatment using CBT

demonstrated the benefits of social networking sites for mental
health and well being (Ellison, Steinfield, & Lampe, 2007; Liu
&
Larose, 2008) and smartphones increase opportunities for social
networking by making social media sites more accessible. Some
of
the most popular social networking websites (e.g., Facebook,
Twitter, MySpace) have developed apps in order for users to
more
easily connect with others from their smartphone (Facebook,
2011;
Twitter, 2011; MySpace.com, 2011). These apps provide
patients
with the opportunity to connect with others without having to
sit in
front of a computer, thus increasing the potential for them to
give
and receive support regardless of time or location. Several web-
sites that provide health resources are also available on social
networking sites, such as Facebook
(http://www.facebook.com/).
For example, Afterdeployment.org is a website that provides
mil-
itary service members, Veterans, and their family members with
health resources and interventions. The site also can be found
on
Facebook where users can interact with others interested in the
information on the website and ask one another questions that
may
aid them in seeking care.
Considerations
Although there are multitudes of possibilities that smartphone

technology brings to behavioral health care, there are also
several
key considerations and limitations that both providers and con-
sumers of care should be aware of. In the following section, we
provide a brief overview of these considerations in order to
famil-
iarize the reader with the basic limitations and best practices
when
considering use of smartphone technology in patient care.
Usability and Acceptance Issues
Available technologies and popular preferences for using those
technologies are constantly changing. It is therefore important
for
those planning the use of smartphone technology in behavioral
health care to consider usability and acceptance by end-users.
Feedback from users, when available, can be used to assess us -
ability and preferences of particular apps. Review of published
findings from usability and feasibility testing can be useful for
determining what products may be acceptable. It is also
important
to consider that some patients will embrace use of smartphones
while others might not prefer them or be able to afford them. It
is
therefore important to have alternative options available in the
clinical tool set.
Some smartphone apps allow for end-user customization that
could help to increase ease of use and preference for using a
particular app. For example, visual appearance or choice of
male
or female voice narration can be adjusted on some apps. Content
can also be “versioned” by developers to appeal to and best fit
the
needs of various audiences. Software built into smartphones as

well as specialized apps can also be used to improve
accessibility
for persons with disabilities. For example, the app TalkBack
(Eyes-
Free Project, 2011) on the Android platform provides spoken
feedback that can assist persons with visual impairments.
Overall,
it is important for providers to discuss usability issues with
their
clients and consider options for customizing the tools available.
Quality Standards and Safety
The sheer number of apps available makes quality control a
significant concern. Currently, no oversight or standards for be-
havioral health via smartphone and associated apps exist. It is
possible that behavioral health apps contain inaccurate
information
or purport to provide an assessment or intervention that is not
evidence based. Therefore, it is important for those planning the
use of smartphones and behavioral health apps to be aware of
the
evidence base for their use. We also recommend that users seek
information about the developer of an app as this might provide
some insight into the quality of the app. For example, PTSD
Coach
(Department of Veterans Affairs, 2011) is an app that was
devel-
oped by the VA’s National Center for PTSD and the Department
of Defense’s National Center for Telehealth and Technology.
Users can therefore use the app with confidence regarding its
purpose, accuracy, and adherence to established treatment
guide-
lines. Overall, there is a lack of published research in this area
and

more data is needed to address the quality and efficacy of
behav-
ioral health associated apps that are being produced.
Patient safety should also be considered when using smart-
phones in behavioral health practice. Dropped calls and battery
failures are some of the technological problems that could
occur.
Reliance on this technology with remote high-risk patients, such
as
those who are in crisis, might place them at greater risk if the
technology fails. It is therefore important for providers to
address
these potential issues with clients and to have backup plans
estab-
lished as part of a safety plan. One the other hand, the use of
smartphones or other mobile device technology can help
providers
to stay in closer contact with high-risk patients and to gather
data
rapidly, such as from symptom or behavioral checklists. Ulti -
mately, we recommend that providers use clinical judgment to
assess risk and to consider when and for which of their clients
is
the use of this technology appropriate.
Data Security and Privacy
Data security and patient privacy must be carefully considered
when integrating smartphone technology into behavioral health
care. Some of the most common threats to data security and
patient
privacy come from unauthorized access or physical loss of the
mobile device. One of the most basic steps that should be taken
to
reduce unauthorized access to smartphones is to use the built-in

password protection feature on the device. The use of third
party
encryption apps can also help to secure patient information that
is
stored and transmitted on smartphones. There are also apps
avail-
able, such as Lookout Mobile Security (Lookout, 2011), which
can
be used to remotely delete data or “wipe” the smartphone in
case
the phone becomes lost.
The app software used on smartphones also poses a unique risk
to patient confidentiality. Many apps gather and send user infor -
mation back to the software developers, which can include the
individual’s username and password, contact information, age,
gender, location, phone ID, and phone number. Furthermore,
55%
of apps tested in one study were found to send some of this
information to other companies (Thurm & Kane, 2010). This
can
pose a significant risk to user confidentiality if information
were
automatically released without the user’s consent. In order to
reduce risk to patient privacy, clinicians should be aware of
what
information apps collect and how this information is used once
it
is obtained. This information should then be presented to clients
in
an informed consent procedure that clearly states the benefits
and
risks associated with use of the smartphone.
TECHNOLOGY

In general, the Health Insurance Portability and Accountability
Act (HIPAA) does not apply to end-users who store or share
data
between other end users on a personal mobile device. If the user
transmits or shares protected health information with a health
care
provider (if a covered entity), however, the provider must
ensure
HIPAA compliance. Thus, it is important for behavioral health
practitioners to be cognizant of how data is stored and
transmitted
when integrating smartphones or other mobile technology into
their practice. The American Psychological Association (APA)
Practice Central site (http://www.apapracticecentral.org/)
provides
specific information regarding HIPAA requirements for
psychol-
ogists as well as information on the new The Health Information
Technology for Economic and Clinical Health Act (HITECH
Act).
Also, The Ethical Principles of Psychologists and Code of
Conduct
provides some useful guidance on the issue of client privacy
and
confidentiality. The Code states that Psychologists take
reasonable
precautions to protect confidential information obtained through
or
stored in any medium and recognize that the extent and limits of
confidentiality may be regulated by law or established by
institu-
tional rules or professional or scientific relationship. This
would

therefore apply to confidential information that can be
transmitted
and stored on smartphones or other mobile electronic devices.
Additional Ethical and Policy Related Issues
In addition to confidentiality concerns, communication with
clients via smartphones or other mobile devices involves several
other ethical and policy issues. For example, although texting
and
email provide almost immediate delivery of messages, users
may
falsely expect immediate responses (Luxton, June, & Kinn,
2011).
It is therefore important to clearly specify expected response
time
with clients. It is also relevant for the practitioner to consider
potential issues with multiple relationships and boundaries
setting.
The use of texting and email between clients and practitioners
could create situations where therapeutic boundaries blur, such
as
messages during off hours or for social reasons outside of the
scope of the therapeutic relationship. The Ethical Principles of
Psychologists and Code of Conduct (APA, 2010) provides
general
guidance regarding these types of issues that should be
considered
when communicating with clients via smartphones.
It should also be acknowledged that the technological and
functional advances of smartphones do not alleviate the need for
providers to follow existing policy and local jurisdictional
require-
ments. A prime example is the need to abide by state licensure
requirements set by state psychology licensing boards (APA

Prac-
tice Organization, 2010). Licensure is dictated by the state in
which the patient is located and in the most simplistic form this
requires a provider to be licensed in that state or risk liability of
practicing without a valid license. There are varied nuances in
these rules and the states are not consistent in how they
interpret
guidance pertaining to cross-state health care delivery or how
they
define telehealth services. Given the complexities of telehealth
and
the potential mobility of both providers and clients, state boards
are actively pursuing updates to these regulations to both clarify
and expand the level of cross-state care allowed. It is recom-
mended that practitioners understand local jurisdictional
require-
ments as well as their own malpractice insurance before
engaging
in cross-state care.
Conclusion
Current and emerging smartphone technology offers numerous
capabilities and benefits for consumers and providers of
behavioral
health care. Advances in smartphone capabilities are
increasingly
viewed as solutions to expanding the range of health care
delivery
options. These technological advances, however, are outpacing
many policies regarding the delivery of telemental health care.
This is most evident in standard of care discussions about the
delivery of clinical telemental health care to nontraditional
loca-
tions such as mobile clinics or directly into a patient’s home.
Although these policies are designed to protect consumers and

providers, the real consequence is often the creation of artificial
barriers that limit the full potential of telemental health care
delivery. Luxton, Sirotin, and Mishkind (2010) conducted a
review
of telemental health studies reported in peer-reviewed journals
to
provide an overview of safety issues associated with general
telemental health care and to evaluate the safety of telemental
health care delivered to unsupervised settings. Their review pro-
vides evidence that telemental health delivered to nontraditional
locations can be safely managed. Demonstrating safety and
usabil-
ity are first steps to determining standard of care as they show
both
practicality and feasibility of delivery solutions. Once these
first
steps are met, policies to expand the widespread use of smart-
phones to deliver synchronous telemental health care can be ad-
dressed.
Although there are a number of apps available today that could
address individual components used in evidence-based
treatments,
another approach is to develop specialized apps that deliver the
full
range of capabilities required for a patient and provider to
engage
in a specific manualized treatment. Despite the establishment of
clinical practice guidelines, dissemination and implementation
of
evidence-based treatments has progressed very slowly (McHugh
&
Barlow, 2010) and it is possible that apps designed to support
specific treatments could reduce provider implementation
barriers
and barriers to patient participation. If accurate, smartphone

apps
that support behavioral health clinical practice may go well
beyond
increasing personal convenience by further improving the
quality
and outcomes of behavioral health care.
Future widespread use of smartphone technology in the be-
havioral health field can be expected. Our increasingly mobile,
tech-savvy, and health conscious society will demand care
delivery solutions that expand beyond traditional office-based
requirements to better fit diverse needs and lifestyles. Smart-
phone technology has the potential to make behavioral health
care more accessible, efficient, and interactive for patients and
can improve the delivery of evidence-based treatments. As we
outlined in this paper, there are many advantages of the tech-
nology as well as key issues involved when planning its inte-
gration into clinical practice. More research is needed to pro-
vide data on the usability and clinical effectiveness of
smartphone technology in the behavioral health field. Over all,
the use of smartphones and other mobile technology has many
benefits for both clients and practitioners. We recommend that
behavioral health researchers and clinicians consider the eval -
uation and use of them as part of their practice, but also keep
the
evolving privacy, ethical, and policy issues in mind.
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Telehealth Issues in Consulting Psychology Practice
Thomas W. Miller University of Kentucky
Consulting psychologists have recognized the
importance of providing comprehensive consul-
tation and clinical services for consumers with
special needs. Often because of distance and
access to consultation services, remote and under-
served populations may not have the necessary
access to consultant specialists in psychology and
other disciplines. Such services are now available
through an innovative model of telehealth. Tele-
health technology and services have gained the
attention of scientists, clinicians, consultants, and
health educators in a variety of settings. Examined
are consultation case scenarios using telehealth
qualitative observations of consultants who have
used telehealth and liability issues consultants
may face using this technology. A model release of
liability is provided for consulting psychologists
who may consider its use in their consultation
practice. Case examples using telehealth appli-
cations are discussed, as are special applica-
tions for health care delivery to undeserved ru-
ral populations using telehealth technology.
Keywords: telehealth, liability, consulting,
algorithm
Telehealth is “the use of telecommunica-
tions and information technology to provide
access to health assessment, diagnosis, inter-
vention, consultation, supervision, education
and information across distance” (Nickelson,
1998). Several studies using telehealth tech-

nology provide case study reports of clinical
applications. Such reports are appropriate
given how recently the technologies involved
have been developed and implemented. Case
reports describe use of telehealth for conduct-
ing interviews in community mental health
clinics (Hogue, 2003; Miller, Veltkamp,
Kraus, Lane & Heister, 2003); multiple-ses-
sion evaluations for a range of disorders
(Ghosh, McLaren & Watson, 1997; Berek &
Canna, 1994); multiple session psychother-
apy including cognitive– behavioral treatment
of a child with a disruptive behavior problem;
use of telehealth in supervision, (Wood,
Miller & Hargrove, 2005); clinical supervi-
sion for allied health professions (Miller,
Burton, Sprang & Adams, 2003); psychiatric
consultations using videophones (Miller,
Veltkamp, Kraus, Lane & Heister, 1999); and
a session for children with special needs in
rural Kentucky (Miller & Miller, 1999). Such
reports as these provide early evidence of a
spectrum of potential applications for tele-
health consultation. There have been a num-
ber of services involving consulting psychol-
ogists offered in public service settings.
These services have provided a wide range of
services, including general adult and child
consultations and treatment of incarcerated
inmates. Finally, review articles of active
telehealth programs have been published
(Bashshur & Armstrong, 1996).
Thomas W. Miller, PhD, ABPP, is a professor in
the Department of Psychiatry, College of Medicine,

University of Kentucky in Lexington, Kentucky.
The author wishes to acknowledge the assis-
tance of Tag Heister, MLS, Deborah Kessler,
MLS, Deborah Burton, PhD Candidate, Jennifer
Trzaski, Kaysie Campbell, Michelle Chicoski,
Brenda Frommer, Richard Clayton, PhD,
Thomas Holcomb, EdD, PC. Amy Farmer, Rob
Sprang, MBA, Jennifer Gourley, Miranda Rog-
ers, Lon Hays, MD, and Otto Kaak, MD, for
their contributions to the completion of this ar-
ticle. Funding from the Center for Prevention
Research and National Institute on Drug Abuse
contract #05312 supported in part the comple-
tion of this article and publication.
Correspondence concerning this article
should be addressed to Thomas W. Miller, PhD,
ABPP, Department of Psychiatry, College of
Medicine, University of Kentucky, 3470 Blazer
Parkway, Lexington, Kentucky 40509-1810.
E-mail: [email protected]
Copyright 2006 by the American Psychological Association and
the Society of Consulting Psychology, 1065-9293/06/$12.00
DOI: 10.1037/1065-9293.58.2.82
Consulting Psychology Journal: Practice and Research, Vol. 58,
No. 2, 82–90
82
Consumers and practitioners in rural set-
tings have traditionally contracted indepen-
dently for specialized consultant services.

Some of the paradigmatic changes that are
being experienced in both urban and rural
settings include administrative applica-
tions, consultation models, information
systems, and evidence-based decision-
making in consultations. Summarized in
Table 1 are some of the emerging trends in
each of these categories. Most notable
among these changes are the multiple uses
of telehealth in consultation services for
psychologically related services.
Consultation Case Scenarios in
Telehealth
Case #1
A Veterans Administration psychologist
was referred a patient who had been re-
ported for incidences of child sexual abuse
by the State Department of Children and
Families. Because of the complexity of
problems and the lack of any staff special-
ized in working with perpetrators in this
rural area, the use of an innovative telecom-
munications approach was implemented to
provide multidisciplinary consultation to
the VA hospital and staff psychologist. On-
site team members included a child clinical
psychologist, an advanced practice nurse, a
clinical social worker, and a psychiatrist.
The team communicated with a consulting
psychologist, a specialist in treating perpe-
trators of child sexual abuse by video link
to a university-based Department of Psy-

chiatry through an inexpensive and cost-
effective model of telehealth. Through the
use of an 8x8 telemetric link, the provision
of needed interdisciplinary clinical consul-
tation and service was provided to this re-
mote site in a cost-effective and timely
manner. The telehealth services ranged
Table 1
Changing Trends in Consultation
Patterns Past trends Contemporary trends
Administrative applications Referral from medical centers,
independent practices, and
independent provider services
through consultant contracting.
Consultants establish networks and
alliances; psychologists contracting
through integrated delivery system
of service providers by telehealth
models and technology.
Consultation models Provider-focused, psychologists are
individual providers/specialists.
They provide services on an
independent basis without
integrating multidisciplinary
input.
Client-focused, consumer-focused
clinical models, psychologists, and
team of providers and specialists
provide service systems integrating
treatment planning, implementation

and evaluation.
Information systems Paper, fax, and clinical records,
provider developed record
systems, local accessibility
record.
Interactive television consultation,
electronic health records, on-line
support systems, E-mail, electronic
files, and information exchange for
comprehensive and integrated
clinical care.
Evidence-based decision
making in consultation
Few incentives for prevention-based
initiatives or for health promotion
and prevention in programs in
health, nutrition, exercise,
addictive disorders. Interactive
Video emotional and behavior
telehealth models in disorders,
attention deficit, intervention
services to hyperactivity disorders
and community centers.
Prevention-oriented healthy lifestyles/
wellness and healthcare promotion,
clients receive accurate information
through telehealth, screening based
on evidence-based decision-making.
83Consulting Psychology Journal: Practice and Research
Spring 2006

from continuing education on perpetrator
treatment, consultation about each of the
referred perpetrators to a clinical diagnostic
evaluation, a multidisciplinary team treat-
ment plan, and subsequent implementation
of the treatment plan involving weekly tele-
health supervision for treatment staff at the
remote VA site, family relations and sub-
sequent contact and follow-up involving
the ongoing communication and monitor-
ing of the home and family situation.
Case #2
A state hospital-based psychologist was
referred an inpatient case involving a court-
ordered evaluation for a cult member and
criminal activity. In the course of the
emerging presence of this cult, the super-
intendent of the school system in which the
cult activity was occurring recognized the
need for professional assistance in manag-
ing the situation and sought clinical consul-
tation services. The case involved several
high school teenagers described as mem-
bers of a “vampire cult.” They were
charged with first-degree murder in the
bludgeoning deaths of the parents of a cult
member. Through telehealth technology,
clinical specialists in the treatment of cults,
the sociology of cults, and multidisci-
plinary telehealth held a series of consulta-
tions to the hospital and school system.

Telehealth consultations provided the
school personnel in this rural community
with the education expertise and assistance
necessary to manage and provide an under-
standing as to how school personnel should
consider dealing in with cult members in
the school system.
Many of the necessary consultations were
accomplished by using portable video tele-
phone equipment that utilized long distance
telephone lines. The set-top videophone is
designed for clinical use. This set-top
videophone integrates a digital video cam-
era, a high-performance modem, and a
powerful video processing system using a
portable video communications processor.
Case #3
A psychologist in an outpatient commu-
nity mental health center and clinic in a
rural Midwestern setting was presented
with a clinical case of a differential diag-
nosis and treatment planning involving a
12-year-old child with Attention Deficit
Hyperactivity Disorder (ADHD). A multi-
disciplinary clinical consultation using tele-
health technology was conducted. Partici-
pating professionals were a clinical psychi-
atrist, special educator, speech language
pathologist, and school psychologist. The
multidisciplinary consultation using tele-
health technology was accomplished by
using the set-top videophone. This consul-
tation provided interaction opportunities

among school personnel, medical and
health-related professionals that assisted
in the differential diagnosis and treatment
planning for the psychologist in the rural
outpatient clinic setting. A model algo-
rithm practice guideline is offered in Fig-
ure 1. This summarizes the steps a con-
sultant should consider in the delivery of
consultation services.
Qualitative Observations With
Telehealth Technology
Current technology used in providing
telehealth clinical services involves the
Polycom system. This is an improvement in
technology over the earlier systems, both of
which transmit through normal phone lines.
The limitations of the earlier system are
such that the video image is married by
frequent disruption whenever any move-
ment occurs in the camera. This makes it
such that as long as the person is sitting
completely still, their image is relatively
intact, but as soon as they move, or make
any facial gestures, the image becomes a
blur. The Polycom system is an improve-
ment in that it compresses much more in-
formation in a shorter amount of time, thus
allowing for a much greater resolution in
84 Consulting Psychology Journal: Practice and Research
Spring 2006

video quality. This allows for every move-
ment of the face and body to be seen.
Much of the diagnostic qualities of a clin-
ical evaluation involves observing behavior.
Any system must allow one to observe not
only gross motor behaviors, but also subtle
nonverbal communication that one normally
uses in facial expression and body language.
It is the information that we receive from this
nonverbal body language that comprises an
important element in a clinical evaluation. As
technology improves to increase the visual
resolution through telephone lines with im-
proved information compression software
and hardware, the technical limitations of
telehealth will be virtually eliminated. There
is still the limitation of not being physically
present with the client, and this perhaps will
never be bridged by telehealth technology.
This was not always a hindrance to the eval-
Figure 1. Model algorithm for use of telehealth.
Spring 2006
uation. It was mainly noticeable at times
when poignant subjects were broached and
the consultants’ ability to confer empathy
through body language was limited.
One interesting phenomenon that occurs

with telehealth equipment is that there usu-
ally is approximately a 1 to 2 second delay
in the video and audio information. This
creates an interesting situation, such that if
someone pauses while answering a ques-
tion and then when another question or
comment is made, if that person also starts
to talk at that the same time, there will
actually be a break in the audio information
as your information confronts the audio
information coming from the other site.
This information coming in from the other
site will often interrupt what the other per-
son had just started to say, and therefore
both parties will pause in a somewhat em-
barrassed moment waiting to see who re-
ally wants to talk first. Over time, this has
led some consultants using telehealth tech-
nology to allow for much longer pauses
after a person finishes a statement to see if
they are going to continue with their conver-
sation, or whether they are ready for another
question or comment from the clinician.
Style and pattern of conversation be-
comes another qualitative issue. Two
groups of communicators along these lines
are realized. The first population tends to
go from sentence to sentence rather rapidly,
therefore making it somewhat easier for the
clinician to know when they have stopped.
There is a second group of people who
seem to pause 2 seconds between major
statements or major subjects naturally. It is
this 2 second pause that is the most difficult
to judge, because the interviewer is left

with the immediate decision of whether
they are ready for the interviewer to ask
another question. Another interesting con-
sequence of the audio format of telehealth
exchanges is that it can sometimes be dif-
ficult to hear the parents over a very bois-
terous child or in couples therapy when one
person speaks over another. Since the in-
formation is only conferred by a single
microphone, which gathers sound from the
whole room, the competition involved can
be quite difficult to clarify.
In a normal evaluation setting, often the
consultant will have the client sitting close
to them and the child playing off in the
distance, so that although they may be loud,
it is easier to pay attention to what the
parent is saying. In my own telehealth prac-
tice, after approximately 30 – 45 minutes, it
may be necessary to take their child out of
the room while finishing the session with the
parent. At the same time, this system allows
for excellent diagnostic information, since
when the child is loud, the mother also is
having trouble hearing what the consultant is
saying, and what they choose to do with this
situation can be quite diagnostically helpful.
Finally, consultants who work with chil-
dren have a natural playfulness they em-
ploy with children. There are some intrigu-
ing aspects to the telehealth. One of these is
the zoom function of the camera, which can
easily be found on most remote controls for

the camera which the clinician can then
change, impacting facial expression on the
face on the camera screen.
With children, this has the tendency to
see how they can focus and how they in-
teract with people. They often will be most
intrigued and ask for repetitions of a phe-
nomenon. Growling and keeping an angry
face permits the clinician to zoom in on the
face and increase the loudness of my growl
watching how children then want me to
repeat this, as well as watching how they
regulate the emotion of fear has been quite
diagnostic. Some children will cower and
cling to their parent, yet at the same time
knowing that it is pretend, ask for more,
enjoying the excitement of the scary situa-
tion. Other children will respond aggres-
sively taking on their own monster roar and
even sometimes swinging at the screen or
hitting the microphone in retaliation.
Some consultants use the telehealth
equipment to show close-ups of various
Spring 2006
stimuli or thematic apperception cards.
This is used early on in the interview, usu-
ally to develop some rapport with the pa-
tient since often they start the session in a
very restricted affect, being either over-

whelmed by the technology or scared about
the fact that they are in some hospital and
know that they are going to be evaluated
for their behavior. Showing these cards
over the telehealth network places the card
in full large view of the child, and often
they will be fascinated by the cards and
provide clinical relevant responses helpful
in diagnosis.
Reflections on the Utility of Telehealth
Technology
The telehealth applications have been
specifically directed at consultations that
are requested by clinicians working in a
rural community. Some of the clients seen
are at least 2 to 5 hours away from the
nearest specialist. They are referred usually
by family practitioners. The great utility of
telehealth then occurs in the fact that these
people are receiving consultation that is
usually not available to them and therefore
allows their clients to have a full evaluation
and consultation with a consulting psychol-
ogist who has the specific expertise that is
beneficial to the rural client and practitioner.
Noticeable in some clients are some
amount of apprehension at first in using the
telehealth equipment. In rural settings,
there are some families that may not even
have a telephone or a TV in their house-
hold, although this is a small minority. Tak-
ing these families and placing them in front
of telehealth technologies from the latest

part of the 20th century can be quite over-
whelming. Often clinicians notice that the
children warm up rather quickly, whereas
the mother or father tend to hesitate in
answering and will often ask a question
several times if they are being heard. Uni-
formly, at the end of an hour of a telehealth
session, the parents will express great grat-
itude, usually along the lines that this was
the first time that they have actually under-
stood, or someone explained what their
child’s diagnosis was, or that they were
relieved to find out that there were actually
medications or counseling services that
would help their child improve.
Another aspect of serving as a consul-
tant to clinicians in a rural community is
that the clinician tends to restrict the clini-
cal note to only the essential information
required. Given that these clinicians prob-
ably have to see 50 – 60 patients in a day, a
lengthy four-page note would be useless for
them, and they would probably gravitate
only to the plan. Notes are kept to less than
one page, and use a bulleted presentation
with specific behaviors emphasized, the di-
agnosis, and a very simple concise plan.
The feedback received from clinicians that
have ordered the consults is that they are
greatly appreciative of the telehealth option,
especially given the isolation and large re-
sponsibility they often undertake in being the
only provider in these communities.

Liability in Telehealth
A critical factor involves liability for
telehealth clinical services. Telehealth lia-
bility for consultation services involves two
potential types of telehealth liability that
consultants must recognize and address.
These include liability for negligence or
abandonment. Consultants may run the risk
of liability for negligence whenever they
provide telehealth services. Consultants
must address the following areas and real-
ize that proof must exist before one is lia-
ble. To prove liability for negligence, con-
sumers must show that the consultant owes
the consumer a duty of reasonable care.
Has reasonable care been provided? Con-
sultants breached their duty of reasonable
care to patients when the consultant failed
to do something or provide some service
that they should have provided and did not
in fact provide in the course of using tele-
health medicine. Agencies can breach their
duty to patients in either of the following
Spring 2006
ways: Agency staff members do something
that they should not do. As a result of
failure to provide reasonable care, consult-
ants’ breach of duty may cause injury or
damage to the consumer. The best way to
define “caused” is in terms of “but for.” But

for the consultants’ breach of duty, the con-
sumer would not have been injured or dam-
aged. To prove injury or damage, the con-
sumer must show damage or extreme and
outrageous conduct on the part of the con-
sultant. Extreme and outrageous conduct is
behavior that would be disturbing, inappro-
priate or cannot be tolerated. Liability may
also result when consultants, primary care-
givers, and/or patients do not thoroughly
Figure 2. Release of liability model.
Spring 2006
understand how to operate the equipment
used in providing telehealth services. It is
essential that successful training in the use
of the equipment to the consultant and con-
sumer is assured.
Risk management strategies should ed-
ucate consultants and consumers about
telehealth equipment. Who will provide
training, what mechanisms are used to eval-
uate the effectiveness of training, and how
to document deficits in knowledge follow-
ing completion of initial training.
Another concern with respect to liability
involves liability for abandonment. Aban-
donment may occur when the consultant

would unilaterally terminate the relation-
ship with a client or the relationship was
terminated without reasonable notice, and
termination occurred when further attention
was needed. Consultants using telehealth
technology continuously monitor the cli-
ents’ ability to participate in telehealth ac-
tivities and confirm their understanding of
their responsibilities in the use of telehealth
equipment. A model disclaimer is offered
in Figure 2.
In summary, a consulting psychologist
using telehealth in the course of their prac-
tice, should employ a practice guideline for
its use, effectively asses risk management,
understand liability in the use of telehealth
and consider a disclaimer. These are critical
steps that must be addressed in each con-
sultation. There remain several concerns
about the use of telehealth technology in
the delivery of direct patient care services
and in consultation services. What remains
clear is that the value of utilizing telehealth
Figure 2 (continued)
Spring 2006
technology where services to patients re-
quires specialized services not available in
such underserved, rural, or distant sites, this

medium of care provides access for patients
and clients. There are persistent questions,
which continue to emerge and serve as a
sounding board for consulting psycholo-
gists who are using telehealth in their prac-
tice. This is a period of opportunities to
consider different levels and models of
consultation services through the use of
such telehealth technology. The current
models provide systems based on improved
knowledge and technology which will ulti-
mately provide an improved quality of life
to many underserved consumers.
References
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Berek, B., & Canna, M. (1994). Telemedicine
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Ghosh, G. J., McLaren, P. M., & Watson, J. P.
(1997). Evaluating the alliance in video-link
teletherapy. Journal of Telehealth, 3, 33–35.
Hogue, E. (2003). Telehealth and risk manage-
ment in home health. Home Healthcare
Nurse, 21, 699 –703.
Miller, T. W., Burton, D., Sprang, R., & Adams,
J. (2003). A model for clinical supervision in
allied health. The Internet Journal of Allied

Health Sciences Practice, 1, 1–10.
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cine: New directions for health care delivery
in Kentucky schools. Journal of the Ken-
tucky Medical Association, 94, 163–167.
Miller, T. W., Veltkamp, L. J., Kraus, R. F.,
Lane, T., & Heister, T. (1999). An adoles-
cent vampire cult in rural america. Child
Psychiatry and Human Development, 29,
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Nickelson, D. (1998). Behavioral telehealth:
Emerging practice, research, and policy op-
portunities. Behavioral Sciences and the
Law, 14, 443– 457.
U.S. Department of Health and Human Services
(1997). Exploratory evaluation of rural ap-
plications of telemedicine. Retrieved (date),
from http://www.ntia.doc.gov.
Wood, J., Miller, T. W., & Hargrove, S. (2005).
Clinical supervision in rural settings: A tele-
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search and Practice, 36, 173–179.
Spring 2006
Treatment Preference among Suicidal and Self-Injuring Women

with Borderline Personality Disorder and PTSD
Melanie S. Harned, Mathew A. Tkachuck, and Kelly A.
Youngberg
Behavioral Research and Therapy Clinics
Objectives: This study examined treatment preferences among
suicidal and self-injuring women
with borderline personality disorder (BPD) and PTSD. Method:
Women (N = 42, Mage = 34) with
BPD, PTSD and recent intentional self-injury were evaluated
upon entry into a psychotherapy outcome
study. Results: The majority preferred a combined dialectical
behavior therapy (DBT) and prolonged
exposure (PE) treatment (73.8%), followed by DBT alone
(26.2%), and PE alone (0%). Women who
preferred the combined treatment were more likely to report a
desire to obtain relief from PTSD and to
receive specific DBT and PE treatment components as reasons
underlying this preference. Few women
(21.4%) reported concerns about PE, but those who did were
more likely to prefer DBT alone. More
severe PTSD re-experiencing symptoms, a childhood index
trauma, and less reduction in positive affect
after a trauma interview predicted a preference for the combined
treatment. Conclusions: These
results may help to inform treatment for these complex patients.
C© 2013 Wiley Periodicals, Inc. J.
Clin. Psychol. 69:749–761, 2013.
Keywords: PTSD; borderline personality disorder; dialectical
behavior therapy; prolonged exposure;
treatment preference; suicidal behavior
Borderline personality disorder (BPD) and posttraumatic stress

disorder (PTSD) are com-
monly co-occurring disorders with comorbidity rates up to 58%
(Harned, Rizvi, & Linehan,
2010; Zanarini, Frankenberg, Hennen, Reich, & Silk, 2004; Yen
et al., 2002). Individuals with
BPD and PTSD are more impaired in a variety of areas than
those with either disorder alone
(Bolton, Mueser, & Rosenberg, 2006; Harned et al., 2010;
Pagura et al., 2010), and PTSD often
maintains or exacerbates BPD criterion behaviors such as
suicidal and nonsuicidal self-injury
(NSSI), other impulsive, self-destructive behaviors (e.g.,
substance use), emotion dysregulation,
and dissociation (for a review see Harned, in press).
Accordingly, PTSD has been found to
decrease the likelihood of remitting from BPD over 10 years of
naturalistic follow-up (Zanarini,
Frankenburg, Hennen, Reich, & Silk, 2006). Despite the
severity and chronicity of impairment
in this population, little research has evaluated effective
approaches for treating PTSD among
BPD patients, particularly those with a severe level of disorder
(e.g., suicidal and self-injuring
patients).
One approach is to provide treatment focused primarily on
PTSD. Although several empiri-
cally supported treatments for PTSD exist that have been found
effective with less severe BPD
patients (Feeny, Zoellner, & Foa, 2002; Clarke, Rizvi, &
Resick, 2008), these treatments remain
∗ This work was supported by Grant No. R34MH082143 from
the National Institute of Mental Health to the
first author. Portions of these data were presented at the 2011
convention of the Association of Behavioral

and Cognitive Therapies, Toronto, CA.
We would like to thank the patients, therapists, assessors, and
staff at the Behavioral Research and Therapy
Clinics for their contributions to this research.
Dr. Harned is a trainer and consultant for Behavioral Tech,
LLC.
aBehavioral Research and Therapy Clinics, 3935 University
Way NE, Box 355915, University of
Washington, Seattle, WA, 98195-5915.
Please address correspondence to: Melanie S. Harned at the
Behavioral Research and Therapy Clin-
ics, 3935 University Way NE, Box 355915, University of
Washington, Seattle, WA, 98195-5915. E-mail:
[email protected]
JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 69(7), 749–761
(2013) C© 2013 Wiley Periodicals, Inc.
Published online in Wiley Online Library
(wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.21943
750 Journal of Clinical Psychology, July 2013
largely inaccessible to patients with severe BPD. Exposure-
based treatments such as prolonged
exposure (PE; Foa, Hembree, & Rothbaum, 2007) have the most
empirical support for PTSD
(Institute of Medicine, 2007; Powers, Halpern, Ferenschak,
Gillihan, & Foa, 2010), but severe
BPD patients are likely to be excluded due to safety concerns
(e.g., acute suicidality, recent seri-
ous self-injury) or other severe comorbidities (e.g., substance
dependence, dissociative disorders;

Foa et al., 2007). Clinicians in routine practice often use even
broader exclusionary criteria for
PE that would rule out most if not all BPD patients, including
suicidality, dissociation, depres-
sion, a history of multiple childhood traumas, and any comorbid
diagnosis (Becker, Zayfert, &
Anderson, 2004; van Minnen, Hendriks, & Olff, 2010).
Similarly, the consensus among PTSD
experts is that a treatment approach based primarily on memory
processing (such as PE) is
inappropriate for cases of “complex PTSD” (i.e., PTSD with
associated features that are com-
mon in severe BPD such as emotion dysregulation, behavioral
dysregulation, and dissociative
symptoms; Cloitre et al., 2011). Given the common practice of
excluding severe BPD patients
from PTSD treatment, little is known about the efficacy of these
treatments for this population.
A second approach is to provide treatment focused primarily on
BPD. Dialectical behavior
therapy (DBT; Linehan, 1993) is the most empirically supported
treatment available for BPD
and has been found effective in reducing suicide attempts,
nonsuicidal self-injury (NSSI), general
psychological distress, crisis service use, and treatment dropout
(Kliem, Kroger, & Kosfelder,
2010; Leichsenring, Leibing, Kruse, New, & Leweke, 2011).
DBT focuses primarily on helping
BPD patients achieve behavioral control by increasing
behavioral skills, and does not typically
directly target PTSD. When PTSD is not directly targeted, the
rate of PTSD remission during
DBT is relatively low (35%; Harned et al., 2008). Nonetheless,
treatments such as DBT that
focus on teaching coping skills (e.g., emotion regulation,

interpersonal effectiveness) are viewed
by PTSD experts as safer and more appropriate than treatments
focused on memory processing
for patients with “complex PTSD” (Cloitre et al., 2011). Thus,
DBT may be a reasonable and
effective alternative to PTSD-focused treatment for severe BPD
patients with PTSD.
A third approach is to provide an integrated treatment that
targets BPD and PTSD simul-
taneously. In this case, integrating DBT and PE would represent
the best evidence synthesis of
the available treatments for BPD and PTSD, respectively. In
addition, DBT has been shown
to be effective in reducing behaviors commonly used as
exclusion criteria for PE among se-
vere BPD patients with PTSD, including imminent suicide risk,
suicide attempts, NSSI, severe
dissociation, and substance dependence (Harned, Jackson,
Comtois, & Linehan, 2010). Thus,
an integrated treatment approach that utilizes DBT to increase
behavioral skills and achieve
stabilization prior to and during PE may be optimal for severe
BPD patients with PTSD, and
a recent open trial of an integrated DBT and PE treatment
showed promising results (Harned,
Korslund, Foa, & Linehan, 2012). This type of phase-based
treatment (coping skills followed
by memory processing) is also endorsed by a majority of PTSD
experts as a frontline treatment
for “complex PTSD” (Cloitre et al., 2011).
Although clinicians and PTSD experts generally believe that PE
alone is inappropriate
for severe BPD patients and that a skills-focused treatment such
as DBT, possibly combined

with PE, is preferable, it is unknown whether severe BPD
patients share these beliefs. Current
best practice standards emphasize the importance of consideri ng
patient preferences in the
treatment decision-making process (American Psychological
Association, 2006), and research
indicates that providing patients with their preferred treatment
improves outcomes and reduces
dropout (Swift & Callahan, 2009). Studies of treatment
preferences for PTSD have found that
exposure therapy, including PE, is a preferred treatment in
undergraduate, trauma-exposed,
and treatment-seeking PTSD samples (Angelo, Miller, Zoellner,
& Feeny, 2008; Becker, Darius,
& Schaumberg, 2007; Cochran, Pruitt, Fukuda, Zoellner, &
Feeney, 2008; Feeny, Zoellner,
Mavissakalian, & Roy-Byrne, 2009; Tarrier, Liversidge, &
Gregg, 2006; Zoellner, Feeny, &
Bittinger, 2009; Zoellner, Feeny, Cochran, & Pruitt, 2003), and
preliminary evidence suggests
that providing PTSD patients with their preferred treatment
enhances outcomes (Feeny et al.,
2009). These findings suggest that the underutilization of
exposure treatments for PTSD,
including PE, appears to be primarily due to therapist factors
(e.g., lack of training, concerns
about PE) rather than client factors (e.g., unwillingness to
participate in PE). Several of these
studies have also begun to examine predictors of treatment
preference, finding that demographic
BPD and PTSD Treatment Preference 751
factors (higher education, nonminority status) predict a

preference for PE over sertraline,
whereas psychopathology factors (more severe PTSD,
depression, and anxiety) predict a
preference for sertraline over PE (Angelo et al., 2009; Feeny et
al., 2009; Zoellner et al., 2009).
To date, no research has examined treatment preferences among
BPD patients with PTSD
specifically, and understanding the treatment preferences of
these patients may help to inform
and enhance treatment for this difficult-to-treat population. The
present study examines this
issue in a treatment-seeking sample of suicidal and self-injuring
women with BPD and PTSD.
Our three primary aims were to (a) determine whether suicidal
and self-injuring BPD women
with PTSD prefer DBT, PE, or a combined DBT and PE
treatment, (b) evaluate the reasons
underlying treatment preference, and (c) examine potential
predictors of treatment preference
that have been evaluated in prior studies (i.e., demographics,
PTSD severity, psychological
distress/comorbidity) as well as ones new to this study and
client population (i.e., intentional
self-injury history, emotional experiencing).
Methods
Participants
Participants were 42 women with BPD and PTSD who were
accepted into one of two psy-
chotherapy outcome studies. Inclusion criteria were as follows:
BPD, PTSD, 18–60 years of age,
female, and recent (past 2–3 months) suicidal behavior or
NSSI.1 Participants were excluded if

they met criteria for a psychotic disorder, mental retardation,
bipolar disorder, or were mandated
to treatment.
The sample ranged in age from 19 to 57 years (mean [M] =
34.0, standard deviation [SD]
= 12.1). Participants were White (76.2%), biracial (19.0%), and
Asian American (4.8%). In
addition, 9.5% of participants were of Hispanic ethnici ty.
Nearly all participants had graduated
from high school (95.2%) and 33.3% had graduated from
college. The majority were single,
divorced, or separated (78.6%) and earned less than $20,000 in
the past year (81.5%). Index
traumas included childhood sexual abuse (52.4%), adult rape
(14.3%), childhood physical abuse
(9.5%), physical assault by an intimate partner (9.5%), and
other (14.3%).
Procedures
Written informed consent was obtained from all participants and
all studies were approved by
an institutional review board. Participants were recruited via
advertisements and outreach to
area treatment providers. The studies were advertised as a
“Dialectical Behavior Therapy Pro-
gram for Suicidal and Self-Injuring Women with Borderline
Personality Disorder and PTSD.”
After an initial phone screen, participants completed an in-
person assessment to evaluate study
inclusion/exclusion criteria and gather more detailed diagnostic
and pre-treatment information.
A total of 174 individuals completed the initial phone screen, 80
of whom were rejected. Reasons
for rejection at the phone screen included no recent suicidal

behavior or NSSI (n = 56), does
not meet cutoff for PTSD (n = 8), does not meet cutoff for BPD
(n = 8), older than 60 years of
age (n = 3), not interested (n = 3), mandated to treatment (n =
1), and lives out of area (n = 1).
Of the 94 individuals that passed the initial phone screen, 78
completed the in-person screening
assessment; 34 of whom were rejected for the following
reasons: did not meet criteria for BPD
(n = 11), did not meet criteria for PTSD (n = 8), bipolar
disorder (n = 6), not interested (n = 2),
lives out of area (n = 2), no recent suicide attempt or NSSI (n =
1), never called back (n = 1), not
willing to discontinue current treatment (n = 1), psychotic
disorder (n = 1), and unable to make
weekday appointments (n = 1). The remaining 44 individuals
were accepted into the studies and
the current analyses examine data collected from the 42
participants who completed the baseline
assessment. Individuals who were excluded at any point during
the screening process did not
1One participant was accepted into the study who was
determined to be at imminent risk of suicide (i.e.,
current severe suicidal ideation with a suicide plan and intent to
commit suicide in the next 4 weeks), but
who had not engaged in recent suicidal or nonsuicidal self-
injury.
significantly differ from those who were accepted in terms of
age, racial background, education,

or income (ps > .09).
Measures
Demographics. A demographic questionnaire assessed
participants’ self-reported age,
racial/ethnic background, education, and income.
Diagnostic interviews. The International Personality Disorder
Examination (Loranger,
1995) was used to diagnose BPD using Diagnostic and
Statistical Manual of Mental Disorders,
4th Edition, Text Revision (DSM-IV) criteria. The PTSD
Symptom Scale – Interview (PSS-I;
Foa, Riggs, Dancu, & Rothbaum, 1993) was used to assess the
presence and severity of PTSD in
relation to a specific index trauma. The PSS-I comprises 17
items corresponding to the DSM-IV
PTSD diagnostic criteria and items are rated on 0–3 scales for
combined frequency and intensity
in the past 2 weeks. The PSS-I has been found to have excellent
inter-rater reliability for the
PTSD diagnosis (κ = .91) and overall severity ratings (r = .97;
Foa et al., 1993).
Treatment preference. Treatment preference was assessed using
an adapted version of
Zoellner and colleagues’ (2003) treatment choice measure.
Participants were provided with
written descriptions of DBT and PE. Each description reviewed
the empirical support for the
treatment, treatment targets, primary treatment components, and
the length of the treatment.
Participants responded to a forced choice item asking, “If you
had a choice between receiving
Dialectical Behavior Therapy (DBT), Prolonged Exposure (PE),

or a combined DBT and PE
treatment for your psychological problems, which would you
choose?” Participants were then
asked to list and rank the top five factors that influenced their
treatment choice using an open
response format.
Demographics. Five demographic variables were examined: age,
marital status (0 = non-
married, 1 = married), education (0 = high school graduate or
less, 1 = college graduate or
beyond), ethnicity (0 = non-White, 1 = White), and annual
income (0 = up to $9,999, 1 =
$10,000+).
PTSD. The PSS-I (Foa et al., 1993) was used to calculate the
number of criteria met in
each PTSD symptom cluster (re-experiencing, avoidance, and
hyperarousal). Participants’ index
traumas were categorized as either 0 = adult trauma (aged 17+
years) or 1 = childhood trauma
(< aged 17 years).
Intentional self-injury history. The Suicide Attempt Self-Injury
Interview (Linehan et al.,
2006) is a psychometrically sound interview that was used to
determine (a) the number of past
year suicide attempts, (b) the number of past year NSSI acts,
and (c) the average medical risk
of all past year intentional self-injury acts. The Suicidal
Behaviors Questionnaire (Linehan,
unpublished) assessed the frequency of self-reported suicidal
ideation in the past year.
Psychological distress and comorbidity. Interviewer-rated
depression and general anx-

iety were assessed via the Hamilton Rating Scale for Depression
(Hamilton, 1960) and the
Hamilton Rating Scale for Anxiety (Hamilton, 1959). The
Structured Clinical Interview for
DSM-IV, Axis I (SCID-I; First, Spitzer, Gibbon, & Williams,
1995) was used to determine the
total number of Axis I diagnoses (including mood, anxiety,
eating, substance use, somatization,
and psychotic disorders) and to determine a Global Assessment
of Functioning (GAF) score.
The International Personality Disorder Examination (Loranger,
1995) was used to determine the
total number of current Axis II diagnoses. Two self-report
measures–Dissociative Experiences
Scale-Taxon (Waller & Ross, 1997) and Anxiety Sensitivity
Index (Reiss, Peterson, Gursky, &
McNally, 1986)–were also used.
Emotional experiencing. An adapted version of the Positive and
Negative Affect Schedule
(Watson, Clark, & Tellegen, 1988) was used to measure current
emotional states before and
after the PSS-I interview in which participants described their
trauma history and current
PTSD symptoms. Change scores (pre-post PSS-I) were
calculated to determine the degree to
which discussing trauma and PTSD led to changes in positive
and negative affect states. Other
self-report measures of emotional experiencing are as follows:
the Experience of Shame Scale
(Andrews, Qian, & Valentine, 2002); the Trauma Related Guilt
Inventory (Kubany et al., 1996);

the State-Trait Anger Expression Inventory (Spielberger,
Krasner, & Solomon, 1988); and the
Difficulties in Emotion Regulation Scale (Gratz & Roemer,
2004).
Data Analysis
Qualitative data analysis. Participants’ open-ended responses
about the reasons un-
derlying their treatment preference were analyzed using the
constant comparative method of
qualitative data analysis (Maykut & Morehouse, 1994). During
an initial discovery phase, three
coders individually reviewed the responses and made a list of
common themes, concepts and
ideas. The three individual lists were compared and refined to
create a common list of induc-
tively derived preliminary categories. Next, two coders who
were not experts in either DBT or
PE individually coded the data into the preliminary categories,
discussed the results, reached
a consensus, and then finalized the categories. An expert coder
then categorized the data into
the final categories, and inter-rater agreement was calculated
using Randolph’s free-marginal
kappa (Randolph, 2005). Any conflicting categorizations were
discussed until a consensus was
reached. These final (sub)categories were then grouped into
higher order categories reflecting a
similar theme.
Quantitative data analysis. Following qualitative coding of all
reasons for treatment
preference, 2×2 chi-squares and Fisher’s exact tests were
conducted to compare rates of each
subcategory and higher order category by treatment preference.

These analyses were conducted
for the primary reason (i.e., the first/most influential reason) as
well as for all five reasons
combined. A series of five logistic regressions were conducted
to examine demographics, PTSD,
intentional self-injury history, psychological distress and
comorbidity, and emotional experienc-
ing as predictors of treatment preference. Significant predictors
from each of these models were
then examined together in a final logistic regression model.
Results
Treatment Preference
The majority of participants preferred to receive a combined
DBT and PE treatment (n = 31,
73.8%) and the remainder preferred to receive DBT alone (n =
11, 26.2%). No participants
indicated a preference for PE alone.
Qualitative Analysis of Reasons for Treatment Preference
Of the 42 participants, 40 provided at least one reason for their
treatment preference. These
participants provided a total of 140 reasons (M = 3.50, SD =
1.62) and the number of reasons
given did not differ between women who preferred DBT with
PE (M = 3.48, SD = 1.66) and
those who preferred DBT alone (M = 3.54, SD = 1.57), t (38) =
0.11, p = .91. Table 1 shows the
11 subcategories and five higher order categories that emerged
from the qualitative data analysis,
including example responses from each subcategory. Inter-rater
reliability for classifying reasons
into subcategories was good (Randolph’s free-marginal kappa =

77.7%).
Table 1
Summary of Categories of Reasons for Treatment Preferences
Categories Example responses
Wants relief from distress
PTSD causes distress • “Suffering from PTSD so much.”
• “Constantly haunted by memories, flashbacks, nightmares of
my
childhood in particular.”
BPD causes distress • “I am most concerned about my
Borderline issues. They have
gotten me into a lot of trouble – stealing/self-injury.”
• “Suicidal a lot and always wanting to cut.”
Both PTSD and BPD cause
distress, or distress is more
general
• “PTSD is what slips me back into BPD episodes where I will
spiral down for months at a time.”
• “Not feel hopeless.”
Wants specific treatment components
Wants DBT components • “Group skills training.”
• “Availability of phone contact. DBT.”

Wants PE components • “Education about trauma.”
• “Confronting the memories.”
Wants common components • “I want to learn new/more coping
skills.”
• “Individual therapy.”
Concerns about treatment
Concerns about DBT • “Scared of groups.”
• “I [don’t] care to be in a group . . . because I feel that others
may
inhibit the learning process.”
Concerns about PE • “Prolonged Exposure treatment sounds
really scary.”
• “I am scared that I will dissociate and hurt myself or others.
No
PE.”
Treatment efficacy
Efficacy of DBT • “I have read that DBT is extremely effective
for my disorders.”
• “Have been in DBT prior and found it very helpful.”
Efficacy of PE • “PE. Although most challenging it will finally
get to my
emotions and memory of trauma.”
• “PE supports a fuller life by decreasing trauma-related fears of
situations.”
General efficacy • “The understanding that the treatments work
for others with

these problems.”
• “Trust in the treatment.”
Will do anything to get better • “I want any and all therapies
that may be able to help me.”
• “I would do almost anything at this point in my life if you told
me it would make my future normal and better.”
Note. PTSD = posttraumatic stress disorder; BPD = borderline
personality disorder; DBT = dialectical
behavior therapy; PE = prolonged exposure.
Quantitative Analysis of Reasons for Treatment Preference
The most common primary reasons underlying treatment
preference were a desire to obtain relief
from distress (n = 13, 32.5%) and to receive specific treatment
components (n = 13, 32.5%).
These were followed by concerns about treatment (n = 6,
15.0%), beliefs about treatment efficacy
(n = 5, 12.5%), and a willingness to do anything to get better (n
= 1, 2.5%). When all five reasons
were combined, 62.5% (n = 25) expressed a desire to receive
specific treatment components,
52.5% (n = 21) described wanting relief from distress, 25.0% (n
= 10) cited treatment efficacy,
22.5% (n = 9) reported concerns about treatment, and 10.0% (n
= 4) indicated they would do
anything to get better.
As shown in Table 2, women who preferred DBT alone were
more likely to cite concerns about
treatment, and PE in particular, as a reason for their treatment
preference (Fisher’s exact tests
p < .001 for both primary and combined reasons). In contrast,

women who preferred a combined
Table 2
Frequency of Primary and Combined Reasons for Treatment
Preference
Primary reason Combined reasons
Category DBT + PE DBT only DBT + PE DBT only
(n = 29) (n = 11) (n = 29) (n = 11)
Wants relief from distress 12 (41.4%) 1 (9.1%) 19 (65.5%) 2
(18.2%)*
PTSD causes distress 3 (10.3%) 0 (0%) 10 (34.5%) 0 (0%)*
BPD causes distress 1 (3.4%) 1 (9.1%) 1 (3.4%) 1 (9.1%)
Both PTSD and BPD cause
distress, or distress is more
general
8 (27.6%) 0 (0%) 10 (34.5%) 1 (9.1%)
Wants specific treatment components 11 (37.9%) 2 (18.2%) 22
(75.9%) 3 (27.3%)**
Wants DBT components 6 (20.7%) 2 (18.2%) 13 (44.8%) 2
(18.2%)
Wants PE components 1 (3.4%) 0 (0%) 8 (27.6%) 0 (0%)
Wants common components 4 (13.8%) 0 (0%) 10 (34.5%) 1
(9.1%)
Concerns about treatment 0 (0%) 6 (54.5%)*** 1 (3.4%) 8
(72.7%)***

Concerns about DBT 0 (0%) 0 (0%) 1 (3.4%) 1 (9.1%)
Concerns about PE 0 (0%) 6 (54.5%)*** 1 (3.4%) 8 (72.7%)***
Treatment efficacy 3 (10.3%) 2 (18.2%) 7 (24.1%) 3 (27.3%)
Efficacy of DBT 1 (3.4%) 2 (18.2%) 4 (13.8%) 3 (27.3%)
Efficacy of PE 1 (3.4%) 0 (0%) 2 (6.9%) 0 (0%)
General efficacy 1 (3.4%) 0 (0%) 2 (6.9%) 1 (9.1%)
Will do anything to get better 1 (3.4%) 0 (0%) 3 (10.3%) 1
(9.1%)
Other 2 (6.9%) 0 (0%) 7 (24.1%) 2 (18.2%)
Note. PTSD = posttraumatic stress disorder; BPD = borderline
personality disorder; DBT = dialectical
behavior therapy; PE = prolonged exposure.
For the Combined Reasons, subcategory totals may not equal
the larger category total because participants
may have provided responses in more than one subcategory.
Chi-square and Fisher’s exact tests were used
to compare groups.
*p < .05. **p < .01. ***p < .001.
DBT and PE treatment were more likely to describe wanting
relief from distress (Fisher’s exact
test p = .01), particularly PTSD and trauma-related distress
(Fisher’s exact test p = .04), as a
reason underlying their treatment preference. In addition,
women who preferred a combined
DBT and PE treatment were more likely to report wanting
specific treatment components as a
reason for their treatment preference (Fisher’s exact test p <
.01).
Prediction of Treatment Preference
As shown in Table 3, the logistic regression model examining

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