Dr. Anthony Ragusea is a currently a practicing clinical psychologist in Key West, Florida and on Breakthrough.com.

Clinical psychologists like myself see great potential in telehealth, but
we see major obstacles as well. Psychological assessment is a core skill
for psychologists and a major part of their practices (at least for most).
My view is not that computers are an inappropriate modality for
psychological testing, my view, (as I will explain) is that many of our
most important and rigorously designed tests simply cannot be administered
remotely using computers.


The Myers-Briggs, for example, is a personality
test that indeed is available online and has been for years, but it is not
considered a serious test of personality by experts on test design. It is
not admissible in court and the research clearly shows that it’s not much
better than a horoscope. So let me draw a distinction between serious,
rigorously designed tests, and those that are not rigorously designed and
thus the designers/publishers are less concerned about the issues I’m about
to summarize. That said, there ARE tests available via computer that are
good, solid tests (e.g., the Strong Interest Inventory (career-aptitude
test), behavioral rating tests like the CBCL and BASC-2, etc.) but these
tests don’t NEED to be administered in person, and also in my experience
tests are more EXPENSIVE by computer than paper. The MMPI-2 (the most
widely used, respected, and researched personality assessment test in the
world) is also available for computer administration, but not on the
Internet, the client needs to be in the office with the computer. And it’s
more expensive than paper administration, again. Companies tend to charge
high fees for software, plus high fees for each test administration, and
sometimes subscription fees to maintain the service. I suspect this cost
issue is a major barrier for most private practitioners.

In articles I’ve written, I’ve argued that as of now it is not ethical for
psychologists to try to conduct certain kinds of psychological evaluations
(like forensic evals) solely via telehealth.

Here are some of the issues. One is that some tests MUST be administered
in person as they are currently designed because they involve interaction
between the examiner and client. IQ and memory tests, for example, have
puzzle pieces, test booklets that require pencil writing and drawing by the
client, etc. In addition, the examiner needs to have control over the
testing environment and how the test is administered–the examiner may pick
and choose which subtests are administered, for example, or alter the test
protocol for a specific purpose. The examiner also needs to be able to
observe HOW the client is behaving and dealing with test items, the test
items are only part of the evaluation. Behavioral observation during test
administration is crucial to evaluating people. For example, the Rorschach
Inkblot test could be adapted to computer administration, but then I can’t
SEE a potentially schizophrenic client becoming afraid and anxious in
response to an inkblot that looks like Satan to the client. That’s
important information. It might be possible to adapt IQ and memory tests
to a computer-based format, but the therapist would still need control over
the administration in real-time, and would need to be able to observe the
client.

Another issue relates to STANDARDIZED ADMINISTRATION. Rigorous tests like
IQ, memory, neuropsychological, and others are often designed to be
administered under highly specific conditions. Manuals specify the kind of
environment the test should be taken in, where the client should be
sitting, exactly what the examiner should say, etc. Now, some aspects of
standardization are better enforced via computer than by a live person, but
what can’t happen is that the client be permitted to, for example, take
these tests on their laptop in their bedroom with music blasting in the
background. The reason is that it is crucial that all clients take the
tests under the same conditions, so that the test validly assesses whatm
it’s designed to assess and to permit legitimate comparisons between
different subjects who take it. Changing the protocol potentially ruins
the test’s validity.

The next issue is whether a computer is equivalent to a piece of paper. I
don’t think we have a good body of research on this topic yet. Intuitively
I would think that a test that is administered just on paper without any
interaction with the examiner should likely be equivalent on a computer
(assuming the test-taking conditions are otherwise the same). But we don’t
KNOW that. For example, does eye fatigue affect performance when taking a
test on a computer monitor? It may depend on the test. Some tests may
need to be entirely re-normed on a population that takes it on the
computer, and that’s expensive.

The next issue is very important, and relates to TEST INTEGRITY. There
are hundreds of tests out there, many of them not very well designed, and
many that don’t worry about test integrity. By that I mean are the test
items and information about how they are scored and interpreted available
to the public. The Myers-Briggs items, for example, are easily accessible
by anyone, as is the scoring and interpretive method. Many serious,
rigorously designed tests require complete test integrity. It is
potentially illegal, and certainly a violation of ethical standards, for a
psychologist to make MMPI-2 items, for example, available for anyone to
see. The MMPI-2 must NEVER leave the control of the examiner. The MMPI-2
is the world’s most well-respected and researched personality test, and
part of its validity comes from the fact that whoever takes the test has no
prior familiarity with it. There are examples of people who illegally post
MMPI-2 items online so that, for example, people in child custody cases can
see them and be coached on how to answer them in a custody evaluation.
Obviously, that can’t be permitted. Results of personality, IQ, and
achievement tests can have extremely serious consequences in real life, so
it is CRITICAL that the public does not have access to them and is naive to
how the tests are scored and interpreted. This is why these tests can’t be
administered openly on the Internet, because somebody could copy the items
down, take screenshots of items, etc.

I once consulted with a psychologist who was doing online work and wanted
to administer the MMPI-2 to clients located at distant locations. The only
way I could tell her to do it ethically was to have the client take the
test at a health clinic in their hometown and arrange with staff there
about how to handle the test materials to maintain test integrity. But
that’s difficult and time consuming, and I don’t know if she ever followed
through.

The last issue is one that I touched on earlier–the importance of live
observation. If I’m evaluating a person and the outcome of my eval will
have serious consequences, it is absolutely necessary that I see the client
in person, at least for part of the eval. Otherwise, I can’t smell
alcohol, I may miss subtle behaviors that are clinically important, I may
not be able to see subtle signs of neurological damage like difficulty
walking, writing, grasping things, I may miss family interactions that are
clinically important, etc. Even video can’t replace it. It’s similar to
the reasons why the AMA doesn’t want physicians prescribing online to
people they’ve never evaluated in person. If a person takes a test from
their home computer and I can’t see them, how can I even be sure that the
person who took the test was the client?

So, to summarize, there are certainly tests that can be administered
online appropriately, but others that, as of right now cannot, either
because the design of the test makes it impossible to adapt to a computer
or because of concerns about security and test integrity. Sometimes there
are concerns that a computer-based test is NOT equivalent to taking it on
paper. Bottom line is that as of right now I can’t administer the core
battery of tests that I administer in a psychological evaluation, which
really limits what I can do with telehealth. Other mental health
professions aren’t qualified to administer the tests that psychologists
are, so they don’t feel the constraint. But I do think this limitation
puts a damper on psychologists’ enthusiasm about moving their practice into
the Internet age. All this could change in the future if there is a major
push by test developers to design all tests for computer administration and
price them reasonably, but that’s where things stand now.