Vocational Rehabilitation Counseling at a Distance: Challenges, Strategies and Ethics to Consider.

Today's vocational rehabilitation counselors are faced with many challenges that have an impact on the services they provide (Leahy & Szymanski, 1995). One challenge involves providing vocational rehabilitation services to consumers residing in rural areas. This task is significant, as 15 million Americans with disabilities live in rural areas (Seekins, Jackson, & Offner, 1993). Counselors must undergo extensive, time-consuming travel to provide services for these consumers. However, for these consumers to travel to frequent appointments at centrally-located vocational rehabilitation agencies is also inconvenient and expensive. Furthermore, people with disabilities living in rural areas commonly receive disproportionately fewer resources than do people in metropolitan areas (Allen & Seekins, 1994). The government's tendency toward decreasing human service allocations will mean even fewer dollars available for rural rehabilitation programs.

One remedy for these problems is to supplement traditional services with distance vocational rehabilitation counseling (telecounseling) for individuals unable to access vocational rehabilitation agencies. Telecounseling, a concept derived from telemedicine and distance education, involves counseling and support when distance or time separates the consumer from the counselor. Although distance technology has been discussed at length in the medical and educational fields, no other reports found in the literature relate distance technology to the profession of vocational rehabilitation counseling. This article is designed to provide a brief background on distance technology services. Furthermore, it will focus on the special challenges, advantages, and ethics associated with providing vocational rehabilitation counseling to individuals via telecounseling. Strategies recommended for effective telecounseling in the vocational rehabilitation profession are also addressed.

Background

The ability to provide services at a distance relies on a variety of technologies from simple systems (e.g., telephone, audio and videotapes) to more complex systems, (e.g., Internet, audio conferencing, facsimile machines and real time video). The use of the telephone as a component of health care has been discussed at length in the literature. Telephone communication systems have been key to suicide hot lines, 24-hour counseling services, and mental health consultation in inaccessible regions. Furthermore, counselors used telephones to assess obsessive-compulsive disorders (Baer, Brown-Beasley, Sorce & Henriques, 1993) and to test for the human immunodeficiency virus (HIV) (Frank et al., 1997). Telephones also effectively provided support to Alzheimer's care-providers who were isolated from other natural supports (Gallienne, Moore, & Brennan, 1993; Mahoney, Tarlow, & Sandaire, 1998; Smyth & Harris, 1993). Self-administered psychotherapy for depression (Osgood-Hynes et al., 1998) and hypertension monitoring (Friedman et al., 1996) were also successfully implemented via telephone. Similarly, many elders lived in their homes safely due to telephone reassurance programs (Guy, 1995). Finally, the telephone has proven extremely useful for people who can not receive traditional services because of physical impairments or psychiatric disabilities that make travel inconvenient or impossible (Mermelstein & Holland, 1991).

Telephone communications are the most used, low-tech resource in distance education. The telephone was used for admission interviews, individual feedback sessions (McNamara, Nemec, & Farkas, 1995), and audio teleconferencing (Bitter, 1995). In particular, the telephone made distance learning possible for many students living in rural areas. The pervasiveness and low cost of telephone use in the United States makes telephone-based distance learning a sensible option for distance education programs (Threlkeld & Brzoska, 1994). Furthermore, outcome assessments verified that use of the telephone facilitated distance education effectively (Threlkeld & Brzoska, 1994). The efficacy of the telephone in medical and educational settings provides hope that it may be a practical mode of service delivery in vocational rehabilitation counseling environments.

Electronic mail (e-mail) is a new type of communication that uses computers to send messages almost instantaneously from sender to receiver. Despite its newness, it has been used in the medical and educational fields to perform distance services. The asynchronous nature of e-mail communication eliminates the frustration of frequent calls. Professionals and consumers have the benefit of being able to respond at convenient times (Bader & Braude, 1998). Furthermore, patients are able to increase their involvement in overseeing and documenting the health care process (Mandl, Kohane, & Brandt, 1998). In regard to distance education, e-mail simplifies student-teacher communication, promotes discussion among students, and provides opportunities for contact and collaboration with peers from around the world (Ancis, 1998; Burgstahler, 1995; Markwood, 1994).

Telephone and E-mail Systems in Vocational Rehabilitation

The use of telephone and e-mail systems provides effective techniques for consumer-counselor communication because they are fast, convenient, and efficient. These characteristics are particularly important in vocational rehabilitation, for several reasons. For instance, vocational rehabilitation counselors have large caseloads and extensive case management responsibilities (Rubin & Rossler, 1995). Access to a convenient method of communication becomes crucial for these counselors. Additionally, consumers residing in rural locations may find traveling to vocational rehabilitation agencies difficult. Furthermore, it is a costly and inefficient use of time for counselors to travel to rural locations to provide individualized services. Therefore, telephone and e-mail systems may be effective in augmenting vocational rehabilitation services. Specifically, these modes of communication may be used to conduct preliminary screenings for vocational potential. They may also be adopted to improve adherence to individualized plans of employment. Furthermore, telephone and e-mail systems could resolve simple problems that develop during the course of service delivery. Therefore, telecommunications technology may eliminate unnecessary routine appointments, saving consumers and counselors time, effort and money.

E-mail has an advantage over the telephone due to its asynchronous nature. This characteristic prevents "telephone tag" and avoids the interruptions associated with telephone calls (Neill, Mainous, Clark, & Hagen, 1994). E-mail provides an easy, inexpensive mode for consumers to communicate with their counselors. Although all individuals do not have access to e-mail, the number of individuals who use e-mail continues to increase (Kane & Sands, 1998). The United States Postal Service installed 100 kiosks that provide e-mail availability to individuals who do not own computers (Forrester Research, 1996). Additional efforts of this nature will be necessary to aid the trend of increased e-mail access. Overall, increasing numbers of rehabilitation consumers will have e-mail use in the future. This tool will provide them with the potential of improving rehabilitation services and decreasing costly travel time. Telephone and e-mail systems are effective modes of distance communication. They do, however, lack visual cues utilized in establishing effective counseling relationships.

Real Time Video as Distance Technology

The use of (two-way) real time video allows consumers and counselors to view each other as they communicate. Televisions or computers serve as the delivery system for real time video. This modality is interactive; information can be provided and feedback given at the same time. Thus, communication is enhanced as the participants can see each other as they interact.

Real time video was recently introduced in the medical and educational fields. The medical field uses this technology for performing surgical operations (Lugo-Vicente, 1997), monitoring patients' vital signs (Jones, 1997), and listening to the heart sounds of patients in distant locations (Falstone et al., 1998). Educational programs use real time video for "classroom" teaching, discussion, and assistance (Burgstahler, 1995).

Real time video is another technology to be considered in the future of vocational rehabilitation counseling. This mode of service delivery allows the participants to view and interact with each other from distant points. Counselors and consumers have the advantage of reading the body language and facial expressions of one another with real time video. This visual component helps counselors establish rapport with their consumers. Specifically, real time video may be beneficial for vocational rehabilitation activities such as job club, job seeking skills, role-play activities, and interview practice.

Challenges of Distance Vocational Rehabilitation Counseling

Although the previous section provided some exciting applications of technology, these same applications present some challenges for vocational rehabilitation counseling. One challenge involves the inevitable technical difficulties that arise occasionally. Vocational counselors must be prepared with alternate plans of service delivery in the event of technical failures. For example, using the telephone as a back up when a video conferencing system fails.

Consumers may also be apprehensive about distance counseling due to the nontraditional nature of distance counseling sessions and the telecommunications technology. Strategies counselors may use to decrease consumers' anxiety include training consumers, "humanizing" the environment, and portraying a favorable outlook on the distance counseling process.

According to Alimandi, Andrich, and Porqueddu (1995), individuals with disabilities were capable of interacting with distance counselors in a relaxed and natural manner after participating in computer training. Additionally, consumers' attitudes regarding technology improved after the training. These researchers demonstrated that the key issue for the success of the telecounseling was the ability of the participants to relate to each other.

Professionals who "humanize" the counseling environment help consumers accept distance counseling. The term humanize was introduced in the distance education literature and refers to the establishment of a safe, accepting environment (Ancis, 1998). A humanized environment is one in which the barrier of distance is broken down through the establishment of rapport between the participants. The creation of rapport increases consumers' interest, motivation, and comfort (Ancis, 1998). "There is no substitute for a positive, caring, non-threatening environment" (Spitzer, 1998, p. 55). Overall, this human dimension is as significant to the success of distance activities as the technical dimension (Spitzer, 1998). Therefore, rehabilitation counselors must develop the human dimension of distance services as well as the technical dimension.

In addition to providing training and humanizing the environment, the professional must have a positive attitude toward technology and distance activities (Alimandi et al., 1995; Anis, 1998). The counselor who views distance counseling with an open mind creates an atmosphere responsive to effective counseling. Likewise, a facilitative environment is produced when the counselor views distance counseling as an effective tool for providing services to consumers who have limited opportunities.

Conversely, counselors who communicate discomfort and frustration with technology create a barrier to distance counseling. Approximately 50%-60% of the mental health professionals surveyed expressed reluctance toward learning about technology (Rosen & Weil, 1995). This reluctance is not an excuse to disregard a tool which will help individuals with disabilities reach their highest level of functioning. According to McCollum and Chan (1985), rehabilitation counselors who reject the use of advanced technology are not assisting their clients effectively. Professionals must recognize that technology is a necessary component of rehabilitation counseling. "The profession of rehabilitation counseling can not remain passive as the information age begins to transform our society" (McCollum &Chan, 1985, p. 216). Therefore, although some rehabilitation counselors may express discomfort toward technology, they must go beyond their comfort zones to ideally serve their consumers.

The literature documents several activities that may help counselors reduce their anxieties toward technology. First, distance counseling should be introduced to counselors slowly. Individuals accept change when they experience success with moderate, focused and specific changes (Gay, 1996). Next, counselors require adequate training to decrease their anxieties and to increase their comfort levels (O'Toole & Wagner, 1985). Similarly, professionals who read about distance technology, participate in workshops, talk with and shadow experienced colleagues (Anis, 1998), and have access to adequate technological support (Spitzer, 1998) become comfortable with distance technology. All of these activities could be instrumental in improving rehabilitation counselors' attitudes toward technology.

The development of a counseling relationship via technological systems is also a significant task (Mermelstein & Holland, 1991; Neill et al., 1994). Opponents of distance counseling indicated that the distance between the counselor and consumer might compromise the counseling relationship (Ostbye & Hurlen, 1997). Although compromising the relationship is a concern, relevant literature provided evidence that distance learning (Eldredge, Gerard, & Smart, 1994; Spitzer, 1998) and distance counseling (Frank et al., 1997; Osgood-Hynes et al., 1998; Selmi, Klein, Greist, Sorrell, & Erdman, 1990) can be as effective as the traditional approaches.

For instance, Frank et al. (1997) studied participants who were given home human immunodeficiency virus (HIV) tests, accompanied by pretest and posttest telemedicine counseling. The results determined that home collection kits, coupled with telecounseling, provided consumers with anonymous and accurate results in an accessible manner. Selmi, et al. (1990) also analyzed the efficacy of distance counseling. These researchers evaluated a computer cognitive-behavioral treatment program given to individuals who were mildly to moderately depressed. Consumers were randomly assigned to a computer administered cognitive-behavioral treatment, to a therapist administered cognitive-behavioral treatment, or to a waiting list control condition. Results verified that the computer treatment program was as effective as the therapist in treating individuals who were mildly to moderately depressed. Finally, Osgood-Hynes et al. (1998) found that self-help computer-aided telephone systems were competent in treating individuals who were mildly to moderately depressed. Overall, these studies confirmed that distance counseling is as effective as traditional counseling.

A socioeconomic challenge to telecounseling involves inequitable access to technology. Internet use is skewed toward affluent, educated users. This inequity may widen social disparities in access and outcomes in vocational rehabilitation counseling. The Internet is, however, poised to become less expensive and more user friendly. Businesses, such as telephone companies, cable television companies, and technology companies, identified,, this market for knowledge as a primary field for investment and expansion (Mandl et al., 1998).

Although e-mail is not available to as many individuals as the telephone, the use of e-mail has increased. Researchers documented that in 1992 roughly 2% of the United States population had e-mail access. Four years later, e-mail access increased to 15% of the population. These researchers predicted that by the year 2001, the majority of U.S. consumers will have access to email (Forrester Research, 1996). This trend correlates with low cost Internet use, mass marketed on line services, and employer-provided e-mail accounts.

Ethics

Ethical issues pose legitimate concerns regarding telecounseling. The novelty of telecounseling does not excuse it from traditional standards of the counseling practice. One such standard is protection of consumer confidentiality. The greatest concern expressed in the literature involved potential lack of client confidentiality while using e-mail for consultation (Neill et al., 1994). Consumers who use e-mail in the workplace for consultation are not assured of confidentiality and may inadvertently expose personal details to their employers. Furthermore, consumers who use accounts at home may lack privacy from their families. In order to achieve consumer confidentiality, encryption techniques should be developed and adopted by all vocational rehabilitation agencies. For instance, every e-mail user should have a distinct identifier for logging onto the system. Additionally, procedures should be in place that restrict users' access to only information for which they have a legitimate need. Furthermore, agencies should take steps to limit unauthorized access to computer systems (National Research Council, 1997). Some basic encryption already exists in many e-mail programs, but it is underused. Adoption of digital certificates will quicken over the next year and personal e-mail will be sufficiently protected (Forrester Research, 1996). Until e-mail users' confidentiality is secured, sensitive topics should not be discussed through e-mail systems due to the possibility for interception of the messages.

Advantages of Telecounseling

Although the previous section outlined some valid challenges related to counseling at a distance, the benefits of this modality far outweigh these difficulties. One of the primary advantages is that telecounseling could increase access to resources related to vocational training beyond those traditionally available (Kreutzer, West, Sherron, Wehman, & Fry, 1992). Technologies capable of delivering information over distances are particularly applicable for people with disabilities whose mobility is restricted, for people who live in areas where public transport is not available, and for care-providers who are unable to leave their homes. For instance, research related to patients who were too ill to travel to their therapists' offices, concluded that telecounseling is an important therapeutic tool (Mermelstein & Holland, 1991).

Distance technology is also an important device for individuals who have disabilities that make it difficult to communicate in other ways (Burgstahler, 1995). The exciting aspect of distance technology is that it lessens individuals' disabilities and serves as an equalizer (Oestreich, 1995). "The advent of adapted computer systems, means that the user with a disability becomes an enabled user, not a disabled user" (Coombs, 1991, p. 15).

An additional advantage is that distance communication technologies can be seen as cost-effective. Jones (1997) indicated that telemedicine is more cost-effective than traditional office visits. Additionally, Osgood-Hynes et al. (1998) explained that distance technology improves access to effective psychological treatment at a reasonable cost. Cost-effectiveness of distance technology was also demonstrated in relation to distance education (Ancis, 1998). No studies exist that specifically evaluate the cost of telecounseling in the vocational rehabilitation setting. The related research, however, provides optimism that distance rehabilitation counseling may eventually prove to be a cost-effective mode of service delivery.

Distance counseling is also more efficient than the traditional method (Alimandi et al., 1995; Guy, 1995; Kreutzer et al., 1992). The actual counseling process occurs faster at a distance than in person (Alimandi et al., 1995) and eliminates the travel time. These characteristics allow ideal use of clients' time and energy. Furthermore, idle time is minimized due to the real time interaction that telecounseling offers (Alimandi et al., 1995).

Another potential advantage of distance vocational rehabilitation counseling is that it increases consumers' self-confidence, as it opens up new opportunities for them (Kreutzer et al., 1992). Individuals with disabilities in distance education courses found that participation helped them adjust to their disabilities through the discipline it required and the feelings of achievement it furnished (Kenny & Murray, 1993). Additionally, computer use increased the motivation of individuals of various ages, backgrounds, interests, and abilities (Kreutzer et al., 1992). The same may be true for distance vocational rehabilitation counseling. It has the potential to provide individuals with disabilities greater access to employment opportunities, resources, and technology necessary to obtain suitable and gainful employment.

Accessibility Issues

The increase of technological communications provides an opportunity for individuals with disabilities to have information and services delivered to them. Thus, these individuals are able to avoid the necessity of travel to service providers (Coombs, 1991). The capacity to link a personal computer with adaptive software and hardware to a modem and telephone can bring the world to the individual with the disability.

Interface conflicts, however, may prevent the use of an application (Kreutzer et al., 1992). For example, online services that have specific requirements for communication software may require communication packages that are inaccessible with adaptive systems. A more accommodating approach is an online system with menus that allow both moving highlight bars and entering standard keystrokes to make selections. Similarly, graphic displays create access problems for users who are blind and who depend on output from a speech synthesizer. A keyword beside the graphic icon should give the text output needed by the synthesizer while continuing to take advantage of the graphics capability. Therefore, the more an online service strives to be accessible by a wide variety of terminal programs, the more likely the service will also be available to help individuals with disabilities (Coombs, 1991). A system that includes both redundant displays and alternative inputs would expand its accessibility. Flexible, user-definable systems adapt to the human user rather than the other way around. Adaptive hardware and software are improving and they are compatible with a growing number of computer systems (Coombs, 1991).

Telecounseling in Vocational Rehabilitation Counseling

The union of vocational rehabilitation counseling and telecounseling may offer an extraordinary opportunity to expand the availability and affordability of modern vocational rehabilitation counseling practices. The potential use of telecounseling in vocational rehabilitation is vast. The subsequent section will offer an example of a potential application of distance counseling in relation to the vocational rehabilitation process.

Initially, distance technology serves as a tool in consumer assessment and evaluation. The selection of the technology to be used throughout the vocational rehabilitation process is based on the consumer's preference and the availability of the technology. Distance technology must be adaptable to a number of technologies and should utilize existing technologies and hardware to accomplish its goals with minimum cost of delivery (Eldredge et al., 1994). An initial interview begins the assessment process and is completed via telephone, e-mail, or real time video. This interview is the consumer's introduction to the rehabilitation agency's purpose, services, and objectives (Brabham, Mandeville, & Koch, 1998). It is the major appraisal activity in the assessment process. During the interview, the counselor builds a relationship with the consumer and obtains vocationally relevant information (Bolton, 1998). For instance, information related to the consumer's medical, social, economic, vocational, and educational history is collected and analyzed during this stage. This benefits the consumer as the task of information and data collection is accelerated (Schmitt & Growick, 1985). The ultimate objective of the assessment is to determine the nature and scope of services that will enable the client to function as independently as possible (Bolton, 1998).

Following the initial interview, a computer software program, designed to evaluate consumer data, assesses the information from the interview. Next, the counselor uses the results of the assessment to help identify the consumer's strengths and limitations related to his or her vocational development. Shortly after, the counselor meets, either in person or at a distance, with the consumer, explains the results of the assessment, and explores the consumer's vocational options (Schmitt & Growick, 1985). Overall, the stage of vocational development may be appropriately accomplished via telecounseling.

The next stage of rehabilitation counseling involves the development of the individualized plan of employment (IPE). The IPE is the primary document of the rehabilitation process and is based on the conclusions of the assessment and the consumer's input (Brabham et al., 1998). The IPE is completed within a counseling context and is facilitated through the use of distance technology. The technology of choice is used to connect the consumer and the counselor as they complete the plan together.

The counselor and consumer work on job development and placement next. This process involves matching the consumer to an appropriate job on the basis of his or her interests, education, aptitudes, skills, experience, and physical ability. This step may also be accomplished at a distance. The vocational counselor communicates job leads, conducts job-seeking skills training, and holds job club with the consumer via the preferred technology.

Job club is an approach that uses multiple techniques to increase clients' job seeking competence. These techniques include peer support, family support, role models, role-play, practice in completing job applications, and job interview simulation. This favorable approach of job-seeking skills training (Rubin & Roessler, 1995) is also accessed at a distance. E-mail and listservs (mailing lists offering a discussion format for individuals with common interests) are well-suited to promoting a distance job club. Through the Internet, participants can correspond, engage in e-mail discussion groups, and access information in numerous databases and libraries (Bitter, 1995). These activities are advantageous as they encourage consumers to receive support from other rehabilitation consumers at a distance. Furthermore, interview role-playing scenarios may be effectively conducted on the Internet (Bitter, 1995). Individuals can (through e-mail and the Internet) transmit interactions related to demonstrating various job-seeking roles. The counselor is able to then evaluate the success of the role-play.

Critics of conducting job club through distance technology may indicate that it is an impersonal approach to this vital activity. However, current literature documented that many individuals found group activities conducted at a distance were more conductive to open and honest expression than the traditional approach (Anis, 1998).

The final stage of vocational rehabilitation, follow-up, occurs once the consumer gains employment. This stage is designed to help the consumer maintain employment over time (Brabham et al., 1998). The counselor and consumer use the telephone or email to contact each other periodically to assure success in employment.

Conclusion

In summary, telecounseling is a viable mode of service delivery that should be considered to supplement vocational rehabilitation counseling services. It is an effective method to reach individuals with disabilities who are isolated from vocational rehabilitation agencies. Challenges such as consumer comfort, technical difficulties, ethics, and cost-effectiveness, must be addressed prior to integrating this technology into the vocational rehabilitation field. Telecounseling will not totally replace the conventional mode of service delivery. Rather, it will complement the conventional mode to improve access to and the caliber of vocational rehabilitation counseling. Furthermore, it is important to keep in mind that distance communication has two dimensions, the technical and the human (Spitzer, 1998). The human dimension is at least as significant to the success of distance vocational rehabilitation counseling as the technical dimension. Therefore, rehabilitation counselors must develop the human component of distance services in addition to the technical dimension.

Research Implications

Technology is becoming an integral part of all professions and can potentially be used as an important adjunct to vocational rehabilitation counseling. Many persons in the field of rehabilitation counseling agree that computers have a particularly valuable role in vocational rehabilitation activities (Kreutzer et al., 1992). The use of telecounseling to assist individuals with disabilities, however, is a relatively new approach. No other reports were found in the literature relating distance counseling to vocational rehabilitation counseling. Increasing evidence, however, suggests that distance vocational rehabilitation counseling will result in substantial cost savings, consumer satisfaction, and increased employment rates. Future research is necessary to determine if telecounseling does, in fact, lead to improved vocational rehabilitation services. The following questions may prove to be valuable in future research endeavors:

   1. Is confidentiality adequately protected in distance counseling?

   2. How will efficacy and usefulness of distance vocational rehabilitation
   counseling be evaluated?

   3. Will it be possible to determine the utility of distance vocational
   rehabilitation based on a monetary cost-benefit analysis, consumer
   satisfaction, counselor perception, job placement rates, or a combination
   of these factors?

References

Alimandi, L., Andrich, R., & Porqueddu, B. (1995). Teleworking in connection with technical aids for disabled persons. Journal of Telemedicine and Telecare, 1 (3), 165-172.

Allen, J., & Seekins, T. (1994). A resource management framework for designing rural service delivery programs (Report No. BBB 30061). Missoula, MT: University of Montana. (ERIC Document Reproduction Service No. ED 399121)

Ancis, J. R. (1998). Cultural competency training at a distance: challenges and strategies. Journal of Counseling and Development, 76, 134-142.

Bader, S. A., & Braude, R. M. (1998). "Patient informatics": Creating new partnerships in medical decision making. Academic Medicine, 73(4), 408-411.

Baer, L., Brown-Beasley, M. W., Source, J., & Henriques, A. I. (1993). Computer-assisted telephone administration of a structured interview for obsessive-compulsive disorder. American Journal of Psychiatry, 150, 1737-1738.

Bitter, J. A. (1995). Technological resources for rehabilitation distance learning. Journal of Rehabilitation Administration, 19, 279-285.

Bolton, B. (1998). Rehabilitation counseling assessment. In R. Parker & E. M. Szymanski (Eds.), Rehabilitation Counseling Basics and Beyond (pp. 411-435). Austin, TX: Pro-ed.

Brabham, R., Mandeville, K. A. & Koch, L. (1998). The state federal vocational rehabilitation program. In R. Parker & E. M. Szymanski (Eds.), Rehabilitation Counseling Basics and Beyond (pp. 41-70). Austin, TX: Pro-ed.

Burgstahler, S. E. (1995). Distance learning and the information highway. Journal of Rehabilitation Administration, 19, 271-276.

Coombs, N. (1991). Window of equal opportunity-Online services and the disabled computer user. Research and Education Networking, 2(9), 15-19.

Eldredge, G. M., Gerard, G., & Smart, J. (1994). A distance education model for rehabilitation counseling. Journal of Rehabilitation Administration, 18(2), 75-79.

Falstone, J. J., Moidu, K., Sheehan, C. A., Gottlieb, K., Galusha, L., & Nair, S. (1998). Is telemedicine justifiable? Connecticut Medicine, 62(7), 423-427.

Forrester Research Incorporated. (1996). The e-mail explosion. (Available from Forrester Research Incorporated, 1033 Massachusetts Avenue, Cambridge, MA 02138)

Frank, A. P., Wandell, M. G., Headings, M. D., Conant, M. A., Woody, G. E., & Michel, C. (1997). Anonymous HIV testing using home collection and telemedicine counseling. Archives of Internal Medicine 157, 309-314.

Friedman, R. H., Kazis, L. E., Jette, A., Smith, M., Stollerman, J., Torgerson, J., & Carey, K. (1996). A telecommunications system for monitoring and counseling patients with hypertension impact on medication adherence and blood pressure control. American Journal of Hypertension, 9, 285-292.

Gallienne, R. L., Moore, S. M., & Brennan, P. F. (1993). Alzheimer's caregivers psychosocial support via computer networks. Journal of Gerontological Nursing, 19(2), 15-22.

Gay, A. F. (1996). Facilitating alternative learning techniques for adults with learning disabilities through the use of technology. In N. Gregg, C. Hoy, & A. F. Gay (Eds.), Adults with learning disabilities: theoretical and practical perspectives (pp. 368-392). New York: Guilford Press.

Guy, D. H. (1995). Telephone care for elders physical, psychosocial, and legal aspects. Journal of Gerontological Nursing, 21(12), 27-34.

Jones, M. G. (1997). Telemedicine and the national information infrastructure: Are the realities of health care being ignored? Journal of the American Medical Informatics Association, 4(6), 399-412.

Kane, B., & Sands, D. Z. (1997). Guidelines for the clinical use of electronic mail with patients. Journal of the American Medical Informatics Association, 5 (1), 104-111.

Kenny, S., & Murray, B. (1993). New home-delivered training prospects for people with disabilities. International Journal of Rehabilitation Research, 16, 195-208.

Kreutzer, J. S., West, M., Sherron, P., Wehman, P. H., & Fry, R. (1992). Computer technology in vocational rehabilitation. Journal of Head Trauma Rehabilitation, 7(3), 70-80.

Leahy, M. J., & Szymanski, E. M. (1995). Rehabilitation counseling: Evolution and current status. Journal of Counseling & Development, 74, 163-166

Lugo-Vicente, H. L. (1997). Role of Internet in medicine. Boletin Asociacion Medica De Puerto Rico, 89(4-6), 82-87.

Mahoney, D. F., Tarlow, B., & Sandaire, J. (1998). A computer-mediated intervention for Alzheimer's caregivers. Computers in Nursing, 16(4), 208-216.

Mandl, K. D., Kohane, I. S., & Brandt, A. M. (1998). Electronic patient-physician communication: problems and promise. Annals of Internal Medicine, 129, 495-500.

Markwood, R. A. (1994). Computer tools for distance education. In B. Wilson (Ed.), Distance education strategies and tools (pp. 199-211). Englewood Cliffs, NJ: Educational Technology Publications.

McCollum, P. S., & Chan, F. (1985). Rehabilitation in the information age: Prologue to the future. Rehabilitation Counseling Bulletin, 28(3), 211-218.

McNamara, S., Nemec, P. B., & Farkas, M. D. (1995). Distance learning at Boston University. Journal of Rehabilitation Administration, 19(4), 291-297.

Mermelstein, H. T., & Holland, J. C. (1991). Psychotherapy by telephone a therapeutic tool for cancer patients. Psychosomatics, 32(4), 407-412.

Marti Riemer-Reiss, Ph.D., CRC, Montana State University-Billings, Department of Counseling and Human Services, 1500 North 30th Street, Billings, MT 59101-0298.

National Research Council. (1997). For the record: Protecting electronic health information. Washington, DC: National Academy Press: Committee on Maintaining Privacy and Security in Health Care Applications of the National Information Infrastructure.

Neill, R. A., Mainous, A. G., Clark, J. R., & Hagen, M. D. (1994). The utility of electronic mail as a medium for patient-physician communication. Archives of Family Medicine, 3(3), 268-271.

Oestreich, R. P. (1995). Comments on Burgstahler. Journal of Rehabilitation Administration, 19, 277-278.

Osgood-Hynes, D. J., Greist, J. H., Marks, I. M., Baer, L., Weneman, S. W., Wenzel, K. W., Manzo, P. A., Parkin, J. R., Spierings, C. J., Dottl, S. L., & Vitse, H. M. (1998). Self-administered psychotherapy for depression using telephone-accessed computer system plus booklets: An open U.S.-U.K. study. Journal of Clinical Psychiatry, 59, 358-365.

Ostbye, T., & Hurlen, P. (1997). The electronic house call. Consequences of telemedicine consultations for physicians, patients, and society. Archives of Family Medicine, 6(3), 266-271.

O'Toole, W. M., & Wagner, W. G. (1985). Effects of microcomputer training on performance and attitudes of rehabilitation counseling students. Rehabilitation Counseling Bulletin, 28(3), 175-178.

Rosen, L. D., & Weil, M. M. (1995). Tips for mental health professionals to merge on-line. Treatment Today, 7, 48-49.

Rubin, S. E., & Roessler, R. T. (1995). The role and function of the rehabilitation counselor. In Foundations of the vocational rehabilitation process (4th ed.). Austin, TX: Pro-Ed.

Seekins, T., Jackson, K. O., & Offner, R. (1993). The demography of rural disability. Missoula, MT: Rural Institute on Disabilities, University of Montana.

Selmi, P. M., Klein, M. H., Greist, J. H., Sorrell, S. P., & Erdman, H. P. (1990). Computer-administered cognitive-behavioral therapy for depression. American Journal of Psychiatry, 147(1), 51-56.

Schmitt, P., & Growick, P. (1985). Computer Technology in Rehabilitation Counseling. Rehabilitation Counseling Bulletin, 28(4), 233-241.

Smyth, K. A., & Harris, P. B. (1993). Using telecomputing to provide information and support to caregivers of persons with dementia. Gerontologist, 33(1), 123-127.

Spitzer, D. R. (1998). Rediscovering the social context of distance learning. Educational Technology, 38(2), 52-56.

Threlkeld, R., & Brzoska, K. (1994). Research in Distance Education. In B. Wilson (Ed.), Distance education strategies and tools (pp. 41-66). Englewood Cliffs, NJ: Educational Technology Publications.