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R.20-10-002 (Prison Phone Rates) Center for Accessible Technology Testimony of Paul Wright Exhibits 1-10

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Exhibit 1
HRDC, June 19, 2017 Comment on Report and Order and Further Notice of Proposed
Rulemaking, Fed. Comm. Comm’n, In the Matter of Promoting Technological Solutions to
Combat Contraband Wireless Device Use in Correctional Facilities, GN Docket 13-111

Human Rights Defense Center
DEDICATED TO PROTECTING HUMAN RIGHTS

July 17, 2017

The Honorable Ajit V. Pai, Chairman
Federal Communications Commission
445 12th St. S.W.
Washington, D.C. 20554
Re:

Reply Comment on Report and Order and Further Notice
of Proposed Rulemaking, GN Docket 13-111

Dear Chairman Pai:
The Human Rights Defense Center (HRDC), which publishes Prison Legal News, respectfully
submits this Reply Comment for GN Docket No. 13-111 in response to comments filed in
response to the Further Notice of Proposed Rulemaking: Promoting Technological Solutions
to Combat Contraband Wireless Device Use in Correctional Facilities, issued by the Federal
Communications Commission (FCC or the Commission). 1
As noted in our initial comment, 2 HRDC supports the legitimate efforts of correctional agencies
to promote public safety. We do not, however, support initiatives that are implemented due to the
corruption and wrongful acts of correctional employees who are allowed to willfully create those
potentially dangerous situations and, as such, we disagree with Cell Command, Inc.’s assessment
that “only the FCC can ensure the safety of the public again” with respect to contraband cell
phones in detention facilities. 3 Prisons and jails in this country are charged with and funded to
ensure public safety, and to the extent that correctional employees create safety issues that may
arise through the use of cell phones by prisoners, those facilities are responsible for any costs
associated with the identification and disabling of illicit wireless devices.

FCC Report and Order and Further Notice of Proposed Rulemaking, GN Docket No. 13-111, adopted March 23,
2017.
2
Human Rights Defense Center Comment on Report and Order and Further Notice of Proposed Rulemaking, GN
Docket 13-111, filed June 19, 2017.
3
Cell Command, Inc.’s Comments in Response to the Commission’s Further Notice of Proposed Rulemaking, GN
Docket 13-111, filed June 19, 2017.
1

P.O. Box 1151
Lake Worth, FL 33460
Phone: 561-360-2523 Fax: 866-735-7136
pwright@prisonlegalnews.org

Page |2

Multiple examples of guards smuggling cell phones into correctional facilities, as well as the FBI
supplying a prisoner with a cell phone as part of an investigation into the Los Angeles County
jail system, were submitted with our initial comment. 4 On July 6, 2017, yet another corrections
officer pleaded guilty to smuggling cell phones and drugs into the California Department of
Corrections and Rehabilitation’s Richard J. Donovan Correctional Facility over a two-year
period, in exchange for approximately $45,000. See Attachment 1.
In its comment, the American Correctional Association (ACA) purports to be “vitally concerned,
as a matter of life and death for our members and as a matter of public safety,” and stresses that
a technological solution is possible “if the FCC is able to view this as a public safety matter that
trumps the FCC’s traditional modes of operation.” 5 The ACA goes on to “insist” that the FCC
use “utmost efforts” to implement a system that “employs existing technology to protect the
public and our members from contraband cell phones.” Id. While the ACA contends that the
number of phones being smuggled into correctional facilities is on the rise, it fails to mention
that the smugglers are usually correctional employees – and then complains the efforts required
to combat this issue are becoming “burdensome for corrections.” Ensuring public safety that is
threatened by the acts of correctional employees should not be “burdensome” to prison and jail
officials; it should be dealt with at the source of the problem – guards who smuggle cell phones
to prisoners. The refusal to address systemic corruption by public employees is a matter of lack
of political will on the part of detention facilities, not a technological issue.
As leaders of the national Campaign for Prison Phone Justice fighting for FCC regulations that
will result in comprehensive reform of the prison telecom industry, HRDC finds it interesting
that the ACA believes that leaving the selection of specified technologies to the marketplace is
an “inappropriate” concept and speaks to “the failure of the market to arrive at a meaningful
solution” over decades – much like the complete market failure that has resulted in the price
gouging of prisoners and their families for prison phone calls.
HRDC believes that it is totally inappropriate at every level to have prisoners and their families
shovel yet more of their limited money into the coffers of the largely hedge fund-owned ICS
industry due to widespread corruption by corrections employees and the complete inability and
unwillingness of correctional administrators to control and discipline their corrupt staff. To be
clear, if these were government procurement contracts where the government agencies were
using their own funds to experiment in the boondoggle of MAS technology, we would not be
submitting this comment. Rather, our concerns center exclusively around who is going to pay for
it and to date it is clear that the corrections agencies and their collaborators in the ICS industry
expect prisoners and their families to foot the bill for a problem that is largely caused by corrupt
government employees, through elevated ICS phone rates and fees.
This is not surprising, as some of the same companies that provide Inmate Calling Services also
have a stake in the technologies that have been developed to combat contraband wireless devices
in correctional facilities. Some ICS providers like Global Tel*Link (GTL) stated that fact openly
in a comment filed on this docket, in addition to publicly stating that prisoners and their families
will incur the cost to combat the greed of correctional facilities and employees:
Human Rights Defense Center Comment on Report and Order and Further Notice of Proposed Rulemaking, GN
Docket 13-111, filed June 19, 2017 (Attachments 1, 2, 3 & 8).
5
American Correctional Association Comments on Combating Contraband Wireless Device Use in Correctional
Facilities, GN Docket No. 13-111; FCC 17-25, filed June 23, 2017.
4

Page |3

Finally, the Commission should address how solutions to combat contraband
devices will be funded. There is a growing trend to require inmate calling
service providers to include MAS-like services in the bundle of services
provided to correctional facilities. In light of the high cost to implement the
technologies needed to fight against contraband devices, without a
Commission-sanctioned cost recovery mechanism, the rates for inmate
calling services are likely to increase when such solutions are required by
correctional facilities. It is therefore essential for the Commission to address
directly the funding of MAS and other solutions for combatting contraband
wireless devices in correctional facilities. 6
Other companies aren’t as transparent. CellBlox Acquisitions, LLC makes no mention in its
comment that it is owned by Securus Technologies, Inc. (Attachment 2), and does not address
cost at all. 7 In fact, one of the CellBlox comment authors, Dan Wigger (Vice President and
Managing Director, Wireless Containment Solutions), was a panelist selected to discuss
Managed Access Systems at the FCC’s Field Hearing on Contraband Cellphones conducted in
Columbia, South Carolina on April 6, 2016, where he also failed to mention that Securus had
hired him to “be responsible for the day-to-day management of our Managed Access Systems
(MAS) business that installs proprietary high tech software preventing contraband wireless
device use in prisons and jails in the United States” (emphasis added). 8
The government, correctional agencies and employees, and guard unions are mainly responsible
for the corruption that has been allowed to exist with respect to contraband cell phones; they are
the ones who have profited from smuggling phones into facilities. Prisoners and their families
should not be required to pay for the greed of correctional employees. Should the FCC move
forward with this issue, it should require correctional facilities to bear the cost of any systems
implemented to detect cell phones, and ensure that new regulations only benefit those facilities
that are doing all they can to deal with this issue as detailed in our initial comment. 9
Thank you for your time and attention to this important matter.
Sincerely,
Paul Wright
Executive Director, HRDC
Attachments

Comments of Global Tel*Link Corporation, GN Docket 13-111, filed June 19, 2017.
Initial Comments of CellBlox Acquisitions, LLC, GN Docket No. 13-111, Filed June 19, 2017.
8
Human Rights Defense Center Ex Parte Submission, Failure to Disclose Identify of a Securus Technologies
Employee, Docket No. 13-111, filed April 7, 2016.
9
Human Rights Defense Center Comment on Report and Order and Further Notice of Proposed Rulemaking, GN
Docket 13-111, filed June 19, 2017 (e.g., Attachment 9).
6
7

Exhibit 2
Ex Parte Letter from HRDC to Former FCC President Ajit Pai, In the Matter of Rates for
Interstate Inmate Calling Services, WC Docket No. 12-375

Human Rights Defense Center
DEDICATED TO PROTECTING HUMAN RIGHTS
www.humanrightsdefensecenter.org

www.prisonlegalnews.org

September 6, 2019
Federal Communications Commission
443 12th St., SW
Room TW-A325
Washington, DC 20554
Re: WC Docket No. 19-232
To the Federal Communications Commission:
The Human Rights Defense Center (HRDC) is the co-founder of the national Campaign for Prison Phone
Justice i, which is committed to reducing barriers to communication between prisoners and their support
networks. HRDC submits this comment for the administrative record and states our support for National
Communications International Corporation’s (NCIC) petition for Inmate Calling Services (ICS)
forbearance from the application of Universal Service Fund (USF) contribution requirements.
The Federal Communications Commission (FCC) maintains responsibility for ensuring fair and equitable
access to communication services across this country. There are currently 2.3 million people incarcerated
in the United States ii who are generating a combined estimated $1.2 billion annual revenue for private
ICS companies iii. As NCIC has outlined in its petition, the costs associated with ICS are excessively
onerous for the people who use ICS and must therefore be regulated.
Although FCC capped the costs of interstate telephone calls in 2015 iv, lax USF guidelines have enabled
ICS companies to circumvent the intended caps and increase the costs for every jail and prison telephone
call. In order to preserve their core revenue in the face of the FCC cap on interstate telephone rates, ICS
companies now include a universal service line item to cover the costs of USF contributions; NCIC
estimates that this line item adds $58 million to the annual cost burden on prisoners and their loved ones.
Individuals who are forced to use ICS already pay the highest costs for telephone calls in the country. In
15 states, a single 15 minute telephone call can exceed $15.00 v. In the state of Washington, jail telephone
rates have been increasing steadilyvi despite public attention to the injustices of expensive ICS. These
costs disproportionately impact low-income families—the very people intended to benefit from the USF
into which the extra fees are being deposited. As yet another fee that has been allowed to inflate these
costs, the implementation of the USF contribution requirements has demonstrably injured its intended
beneficiaries.
It is clear that excessive fees collected under the pretense of USF contribution requirements must be
overturned to facilitate fair and equitable jail and prison telephone access. In this petition, NCIC has
effectively argued that abolishing USF contribution requirements will minimally impact the FCC budget,
successfully reduce financial encumbrances on prisoners and their families, and present an opportunity to
remedy the intended purpose of USF contributions. HRDC fully supports this petition and asks FCC to

P.O. Box 1151, Lake Worth, FL 33460
Phone: 561-360-2523
Email: pwright@prisonlegalnews.org

keep actively improving the terms of ICS moving forward as well. Prison phone justice demands nothing
less than clear and immediate action from the highest authorities in this country.
Sincerely,

Paul Wright
Executive Director, HRDC

i
https://www.prisonphonejustice.org/
ii
https://www.prisonpolicy.org/reports/pie2019.html
iii
https://www.bloomberg.com/news/articles/2012-10-04/prison-phones-prove-captive-market-for-private-equity
iv
https://apps.fcc.gov/edocs_public/attachmatch/DOC-335984A1.pdf
v
https://www.prisonpolicy.org/phones/
vi
https://www.prisonlegalnews.org/news/2018/oct/12/washington-state-jail-phone-rates-increase-video-replacesperson-visits/

Exhibit 3
Lindsey Cramer, Margaret Goff, Bryce Peterson, and Heather Sandstrom, Parent-Child Visiting
Practices in Prisons and Jails: A Synthesis of Research and Practice (April 2017)

LOW-INCOME WORKING FAMIL IES INITIATIVE

RE S E AR CH RE P O R T

Parent-Child Visiting Practices
in Prisons and Jails
A Synthesis of Research and Practice
Lindsey Cramer
April 2017

Margaret Goff

URBAN

Bryce Peterson

N S T I T UT E • E L E V A T E • T H E • D E BA T E

Heather Sandstrom

: : :URBAN
••••

INSTITUTE

AB O U T T HE U R BA N I NS T I T U TE
The nonprofit Urban Institute is dedicated to elevating the debate on social and economic policy. For nearly five
decades, Urban scholars have conducted research and offered evidence-based solutions that improve lives and
strengthen communities across a rapidly urbanizing world. Their objective research helps expand opportunities for
all, reduce hardship among the most vulnerable, and strengthen the effectiveness of the public sector.

Copyright © April 2017. Urban Institute. Permission is granted for reproduction of this file, with attribution to the
Urban Institute. Cover photo by Joe Amon/The Denver Post via Getty Images.

Contents
Acknowledgments

iv

Introduction

1

Background

6

Importance of Parent-Child Relationships

6

Role of Parent-Child Visits

7

Key Components of Visiting

10

Visit Type

10

Visit Structure

13

Frequency and Length of Visits

15

Collaboration with Correctional Administrators and Staff

16

Role of Primary Caregivers

17

Respecting Family Dynamics

20

Gender-Specific Programming

21

Recommendations for Practice

24

Recommendations for Research

26

Notes

28

References

29

About the Authors

32

Statement of Independence

33

Acknowledgments
This report was funded by the Annie E. Casey Foundation through the Urban Institute’s Low-Income
Working Families initiative. We are grateful to them and to all our funders, who make it possible for
Urban to advance its mission.
The views expressed are those of the authors and should not be attributed to the Urban Institute,
its trustees, or its funders. Funders do not determine research findings or the insights and
recommendations of Urban experts. Further information on the Urban Institute’s funding principles is
available at www.urban.org/support.
The authors also thank Margaret Simms, institute fellow, and Jocelyn Fontaine, senior research
associate, at the Urban Institute for their review of this paper and their thoughtful insights and
feedback. Finally, the authors thank the researchers and practitioners who were gracious with their
time and participated in informant interviews.

IV

ACKNOWLEDGMENTS

Introduction
Recent estimates indicate that 2.7 million children in the United States have a parent incarcerated, and
more than 5 million—7 percent of all children in the United States—have had a parent incarcerated at
1

some point in their life (Murphey and Cooper 2015; The Pew Charitable Trusts 2010). Black children
and children from economically disadvantaged families are more likely to experience parental
incarceration (figures 1.A and 1.B). In fact, nearly twice as many black children (11.5 percent) have had a
parent who lived with them go to jail or prison compared to white children (6 percent). And a child living
in poverty is three times more likely (12.5 percent) to have experienced parental incarceration than a
child whose household income is at least twice the federal poverty level (3.9 percent) (Murphey and
Cooper 2015).
FIGURE 1.A

Minor Children with an Incarcerated Parent, by Race
0

rirl
0

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rirl rirl rirl rirl rirl rirl rirl rirl

WH ITE

BLACK

HISPAN IC

1 in 17 {6%)

1 in 9 (11.5%)

1 in 16 {6.4%)

rirl rirl rirl rirl rirl rirl rirl rirl

FIGURE 1.B

Minor Children with an Incarcerated Parent, by Income
0

0

0

0

0

0

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0

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rirl rirl li""il
0

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rirl li""il rirl rirl rirl rirl rirl li""il

rirl rirl li""il rirl rirl rirl rirl rirl

rirl rirl rirl rirl rirl rirl rirl rirl

BELOW POVERTY

1-2X POVERTY LEVEL

2X POVERTY LEVEL OR MORE

1 in 8 (12.5%)

1 in 11 (9.1%)

1 in 26 (3.9%)

Source: 2011–12 National Survey of Children’s Health, as analyzed in David Murphey and P. Mae Cooper, Parents Behind Bars:
What Happens to their Children? (Bethesda, MD, Child Trends, 2015).

Despite these statistics, research on the true scope and nature of parental incarceration remains
lacking for several reasons:

Most studies have focused on measuring the number of parents in prison, but less is known



about how many parents have spent time in jail. Therefore, it is likely that many more children
are affected by parental incarceration than what researchers have estimated.
Prior research has been unable to accurately quantify how many children have incarcerated



mothers compared to incarcerated fathers, resulting in a limited understanding of the
differential effects of paternal versus maternal incarceration.
Finally, there has been little research on how parental incarceration affects children over their



life course or how length of incarceration affects a parent’s ability to communicate with their
children and maintain contact after release.
Still, it is clear that the millions of children affected by parental incarceration are a vulnerable
population. Losing a parent to incarceration is traumatic, and the disruption of the parent-child
relationship and attachment is considered an adverse childhood experience. Adverse childhood
experiences are associated with an increased risk of trauma and the potential for lasting effects such as
2

risky health behaviors, chronic health conditions, and early death. Parental incarceration has also been
associated with children who exhibit antisocial behavior and poor school performance (Murray,
Farrington, and Sekol 2012). The negative effects of parental incarceration are often compounded by
other adverse experiences these children are more likely to experience, including poverty, parental
divorce or separation, and exposure to violence (Murphey and Cooper 2015).
To mitigate these risks, some correctional agencies offer parent-child visits in prisons or jails, often
with the help of community-based organizations. Parent-child visits are consistent with one of the
central tenets of the Children of Incarcerated Parents Bill of Rights, specifically that children have the
right to speak with, see, and touch their parents (see box 1). Developed by the San Francisco Children of
Incarcerated Parents Partnership in 2003 and based on young people’s experiences with parental
incarceration, the bill of rights identifies a child’s need for and right to a relationship with their parent
involved in the justice system. The bill of rights has been widely accepted and used by several
organizations working with children of incarcerated parents and their families.

2

PARENT-CHILD VISITING PRACTICES IN PRISONS AND JAILS

BOX 1

Children of Incarcerated Parents Bill of Rights
1.

I have the right to be kept safe and informed at the time of my parent’s arrest.

2.

I have the right to be heard when decisions are made about me.

3.

I have the right to be considered when decisions are made about my parent.

4.

I have the right to be well cared for in my parent’s absence.

5.

I have the right to speak with, see, and touch my parent.

6.

I have the right to support as I face my parent’s incarceration.

7.

I have the right not to be judged, blamed or labeled because my parent is incarcerated.

8.

I have the right to a lifelong relationship with my parent.

Source: San Francisco Children of Incarcerated Parents Partnership (2003).

Correctional agencies typically offer different types of parent-child visits, including video visits, inperson visits with or without contact, and extended family visits. Video visits allow visitors to
communicate with loved ones through video conferencing. Some jurisdictions require visitors to drive
to the facility, but others offer video visits in central, off-site locations or even in the family’s own home
through a web-based application similar to Skype. In-person, noncontact visits place a barrier, such as
Plexiglass, between incarcerated parents and their children. Contact visits allow children and parents to
physically interact with each other, often in a designated visiting room. Some facilities offer contact
visits as the standard form of visiting for all incarcerated people, but it is more commonly offered
specifically to parents as part of a larger family strengthening program. Extended family visits allow
children and immediate family members longer visits, which may last overnight in facilities designated
for this purpose.
Research on the effectiveness of different types of visits is limited, but many experts believe that
contact visits conducted in supportive, safe, and child-friendly environments are likely the best option
to help most families mitigate the harmful effects of parental incarceration. Further, a growing body of
research supports the use of contact visits, which allow children to see that parents are safe and healthy
while in prison or jail (Tasca et al. 2016). Spending time together as a family through play, conversation,
or sharing a meal can also help mitigate children’s feelings of abandonment and anxiety (Hairston 2007).
Parents and children can use these activities to work on existing relationships, establish new bonds, or
repair strained relationships (Hairston 2007; Tasca et al. 2016). This type of relationship building can
help children feel more attached to their parents and benefit their well-being, emotional adjustment, selfesteem, and school behavior (Arditti 2008; Fraser 2011; Poehlmann et al. 2010; Sack and Seidler 1978).

PARENT-CHILD VISITING PRACTICES IN PRISONS AND JAILS

3

expertise. These interviews gathered perspectives on why visiting is important and what makes it
beneficial. Interviewees also highlighted additional areas of research or practice that would benefit
from further study. We then synthesized our notes and identified key takeaways from each
conversation. We incorporate insights from the interviews throughout the paper to help supplement
findings from the literature and fill gaps that remained after our review.
This paper presents key findings on what is known about the design, implementation, and
effectiveness of parent-child visits. Though we use terms such as “effective” and “effectiveness” to
describe aspects of parent-child visits, these terms only reflect the perspectives we heard from the
subject matter experts and the information we gathered from our literature review. We did not collect
any new data or conduct any new research to measure the effects of any visiting practices. It is also
worth noting that we use the terms “visits” or “visiting” in this paper rather than “visitation.” The experts
informed us that “visitation” has negative connotations among families affected by incarceration
because of its association with government systems and agencies. By using “visits” and “visiting,” we
hope to foster a more natural dialogue around parent-child visiting.
We begin with an overview of the importance of parent-child visiting and the known effects of visits
on children and parents. We then discuss six key components of designing and implementing parentchild visiting programs in correctional settings and propose a set of recommendations for practitioners.
We conclude with a proposed agenda that identifies areas warranting further research.

PARENT-CHILD VISITING PRACTICES IN PRISONS AND JAILS

5

Background
Importance of Parent-Child Relationships
To fully understand the harmful effects of incarceration on the parent-child relationship, we must first
recognize the importance of that relationship to a child’s healthy development, which is underscored by
attachment theory. Attachment theory is rooted in the idea that children should experience warm,
intimate, and continuous connections with their parents or parental figures in a way that elicits
satisfaction and enjoyment (Bowlby 1951). These relationships are crucial to a child’s lifelong physical
and psychological well-being. Attachment theory positions the parent-child relationship as the
foundation on which children learn how to form and sustain healthy relationships with others: when a
child’s caregiver is warm and responsive to their needs, they learn to trust and depend on others.
Supportive relationships with adult caregivers help buffer children from environmental stressors,
such as poverty, neighborhood violence, and unstable housing. When those relationships are disrupted,
children are less likely to trust and feel strongly connected to their parents and caregivers (Bowlby
1960). This lack of attachment can have long-term, potentially devastating effects. When children are
too young to fully understand why they are separated from an incarcerated parent, feelings of
abandonment and rejection are often magnified (Flynn 2014). Without an opportunity to maintain a
relationship with their parents, children will continue to experience harsh consequences (Gjelsvik,
Dumont, and Nunn 2013). Some research suggests that, as a result, children of incarcerated parents are
more likely to have insecure attachments to their incarcerated parents and primary caregivers
(Poehlmann 2005; Poehlmann-Tynan 2015).
Parental incarceration is more than a temporary separation of child and parent, and incarceration
affects children differently than other forms of parental loss (e.g., death, divorce, military deployment)
because of the associated social stigma and the uncertainty surrounding the length of the separation
(Arditti 2012; Murray, Farrington, and Sekol 2012; Phillips and Gates 2011). Caregivers and children
affected by parental incarceration experience more trauma than other families (Arditti and Salva 2015),
which can manifest as depression, anxiety, irritability, aggression, social isolation, difficulty sleeping,
behavioral regression (especially in younger children), and an inability to regulate emotions and
behaviors (Arditti, Lambert-Shute, and Joest 2013; Poehlmann 2005; Sack and Seidler 1978).

6

PARENT-CHILD VISITING PRACTICES IN PRISONS AND JAILS

Role of Parent-Child Visits
Parent-child visits can help mitigate the effects of parental incarceration (Arditti 2012; Fraser 2011;
Johnston 1995; Poehlmann et al. 2010; Sack and Seidler 1978). Experts we interviewed indicated that
many parents with substance abuse or mental health issues can receive treatment while in prison that
allows them to better connect with their family members. This offers a clean slate for incarcerated
parents and their families to work through the past and begin to move forward. Family members can
also help the incarcerated parent plan for their future after release.
In-person, noncontact visits allow parents to speak to their children or other visitors behind a
barrier that prevents physical contact. Experts maintain that noncontact visits make it difficult for
family members to see or hear their loved ones, which combine with the general lack of privacy to
create a poor experience. Further, a child might not understand why they cannot touch their parent,
leading them to cry or otherwise misbehave in a way that prevents them from engaging with their
parent. Children may also be exposed to negative interactions through visits occurring beside them.
Noncontact visits are stressful and potentially traumatic for children. Beckmeyer and Arditti (2014)
conducted structured interviews with 69 incarcerated parents enrolled in a family strengthening
program who received visits from a child between the ages of 5 and 18. They found that child
misbehavior during visits led to parents reporting lower ratings of parent-child closeness, negating the
potential benefits of the visits. This can be doubly harmful to children because many state correctional
policies stipulate that children whose behavior cannot be controlled during visits may lose visiting
privileges (Boudin, Stutz, and Littman 2013).
Contact visits allow parents to physically interact with their children (and possibly other family
members). Research indicates that parent-child visits are most beneficial when they allow for physical
contact, are offered in a child-friendly setting, are part of a family strengthening program, and provide
proper emotional preparation and debriefing before and after (Arditti 2012; Fraser 2011; Johnston
1995; Peterson et al. 2015; Poehlmann et al. 2010; Sack and Seidler 1978). Experts also find that
physical contact and privacy during visits benefit both children and parents and help them cope
emotionally and reconnect with each other. For children specifically, contact visits can reduce feelings
of abandonment and anxiety and promote emotional security by letting children know their parents are
okay (Hairston 2007). This can benefit children’s overall well-being and social adjustment by letting
them express their feelings about being separated from their parent while receiving reassurance they
are still wanted and loved (Arditti 2008; Poehlmann et al. 2010; Sack and Seidler 1978). Experts also
report that children who participate in contact visits behave better in school.

PARENT-CHILD VISITING PRACTICES IN PRISONS AND JAILS

7

We forget about the opportunity costs to children and their families and going to these
places to go to a visit. I think the more we can build in opportunity, it’s not just reducing risk.
In what way, for example, is enhanced visitation an opportunity for youth?
—Joyce Arditti, professor, Virginia Polytechnic Institute and State University

But if implemented improperly, parent-child visits can harm or retraumatize children (Arditti 2008;
Fraser 2011; Hairston 2007). For example, visits to high-security facilities, where children are often
subjected to invasive search procedures, can be a traumatic experience (Arditti 2008; Fraser 2011;
Hairston 2007). Experts noted that some visits may not provide a setting or amount of time conducive
to addressing underlying issues between parents and children, negating any potential benefits.
Frequent visits may also set unrealistic expectations for a parent’s level of involvement after release.
Experts also said that the more children visit a prison or jail, the more normalized the experience of
incarceration becomes, which can be potentially harmful.
Parent-child visits can also have differential effects on parents. Experts noted that opportunities for
parents to see their children while incarcerated can support parental attachment and promote a
continued bond after release. They also explained that visits can motivate parents to comply with
facility rules, leading to fewer disciplinary reports, and participate in correctional programming. Extant
research shows that parents who receive more visits from their children have lower rates of recidivism
after release (Cochran 2012, 2013; Duwe and Clark 2013; Hairston 1991; Pierce 2015; PoehlmannTynan 2015). Cochran (2013) examined the visiting patterns of over 2,000 people convicted of felonies
serving at least 12 months in Florida state prisons between November 2000 and April 2002. He
identified four patterns of visiting that had disparate effects on recidivism: (1) no visits (the person did
not receive any visits while incarcerated), (2) near-entry visiting (visits were most frequent when
someone was first incarcerated then tapered off), (3) near-release visiting (visits increased in the
months before release), and (4) sustained visiting (visits occurred regularly throughout incarceration).
Though most incarcerated people received no visits at all, people who received sustained visits were
least likely to recidivate. Given the promising correlations between regular parent-child visits and
reduced institutional misconduct and recidivism, visits could be an important motivator for improving
parent outcomes during and after incarceration.

8

PARENT-CHILD VISITING PRACTICES IN PRISONS AND JAILS

Conversely, experts indicated that some parents do not welcome visits and view them as
potentially harmful to their relationship with their children. Parents may not want their children to see
them in a correctional setting and might prefer to avoid in-person visits or to sever communication with
their children entirely while incarcerated. Visits may cause them to feel shame for being incarcerated,
and they may also have concerns about exposing their children to the stressful prison environment and
the trauma of repeated separation. Programs can address these concerns by incorporating parent-child
visits into a comprehensive family strengthening program, discussed in more detail below, that instructs
parents, their children, and primary caregivers on the importance of visits and offers a therapeutic
visiting environment for contact visits.
In sum, previous research and our interviews with experts suggest that parent-child visiting is
neither innately harmful nor therapeutic. A confluence of family dynamics and systematic issues
determines whether visits mitigate or exacerbate the separation and trauma a child experiences when
their parent is incarcerated.

PARENT-CHILD VISITING PRACTICES IN PRISONS AND JAILS

9

Recommendations for Practice
Based on our literature review and conversations with experts in the field, we identified several
recommendations for implementing parent-child visiting. Experts largely agreed that although more
visiting opportunities are needed in correctional facilities, we must also improve how visiting is
implemented.
Facilities should offer more opportunities for parent-child visits, especially contact visits.
Because of the potential of parent-child visiting to affect positive outcomes, experts cited a need to
offer contact visits more frequently in jails and prisons and to make these visits available to more
parents. Practitioners and correctional staff should work together to create more welcoming
environments for parents and children through child-friendly visiting rooms and search procedures,
clearly communicated visiting policies, and family-focused and developmentally appropriate activities.
Programs should offer more support to children and caregivers. A significant gap still exists in the
support offered to children and caregivers before, during, and after visits. Experts urged programs to
offer more therapeutic support for family members alongside material support such as transportation
assistance and child care. This would help reduce the stress children and caregivers experience when
visiting incarcerated family members and would help maximize the benefits of visits. Experts also
encouraged programs to provide more services to families in the community rather than in program
offices to make services more accessible to families.
To improve visiting practices, listen to incarcerated parents and their families about their needs
and what types of services they find helpful. Programs may want to consider interviewing family
members and tailoring their services accordingly. However, experts noted that visits can be improved
simply by making them more therapeutic and natural. This can be done by providing professional health
or psychological resources during visits to coach families through the experience and help them address
trauma or stress, improve communication, and set realistic expectations for reunification.
Practitioners and correctional agencies should provide ongoing staff training. Correctional staff
members should be trained to appropriately communicate and engage with incarcerated parents, their
children, and the children’s caregivers. For example, staff members should be cognizant of the confusion
many families face when trying to navigate visiting policies and work with them to help them
understand the rules and procedures. Program staff members should also be trained to interact with
children in an age-appropriate manner.

24

PARENT-CHILD VISITING PRACTICES IN PRISONS AND JAILS

Practitioners and correctional agencies should understand how families function and be
prepared to work with families experiencing trauma and stress. All families are different and
experience different levels of dysfunction, and programs should understand that visits may not always be
the best intervention. Therefore, staff members should be trained in alternative interventions. If visits are
deemed helpful, staff members should know how to intervene and provide appropriate support.
Practitioners should engage with research and evidence to help inform and guide implementation
and continuous quality improvement of parent-child visiting. This can be done by reading the extant
literature on parent-child visits and through program evaluations or assessments. Programs should
always be improving their data collection and evaluation efforts to better document outcomes. This will
help practitioners continuously adapt and modify their services to help strengthen family relationships,
improve parent-child communication, and provide opportunities for appropriate interaction.

PARENT-CHILD VISITING PRACTICES IN PRISONS AND JAILS

25

Exhibit 4
Rafael Ballagas, Joseph ‘Jofish’ Kaye, Morgan Ames, Janet Go, and Hayes Raffle,
Family Communication: Phone Conversations with Children (June 2009)

IDC 2009 – Workshops

3-5 June, 2009 – Como, Italy

Family Communication:
Phone Conversations with Children
Rafael Ballagas, Joseph ‘Jofish’ Kaye, Morgan Ames, Janet Go, Hayes Raffle
Nokia Research Center
Palo Alto, CA

{tico.ballagas, jofish.kaye, hayes.raffle}@nokia.com
we looked at videoconferencing using Skype or iChat. [6]

ABSTRACT

In the first study, we began by asking families to fill out some
background information with their children, about typical days
and the structure of the family. Then we spent a “typical evening”
with our participants: we would bring dinner as part of the study
which we’d eat with the family, discuss the background
information and have the children give us a tour of their room.
Later we’d talk with the parents about their interactions with their
children, and their thoughts on children, toys, technology, and any
rituals, rules, regulations or other limitations on technology use.
These visits typically took around three hours.

We interviewed and observed families in their homes to
understand how they communicate across generations and across
distances. The phone is still the most common way for keeping
children in touch with distant relatives. However, many children
can’t talk on the phone by themselves until 7 or 8 years old. This
paper examines the challenges children have with phone
conversations, and looks at how families are currently working
around these issues. These findings can help inform the design of
future family communications technologies.

Categories and Subject Descriptors

In the second study, we conducted field studies and interviews
with 7 families who used videoconferencing to communicate
between grandparents and grandchildren. We visited these
families in teams of two. Researchers sat with the family and
observed a “typical” video call with remote grandparents, which
had been previously arranged for our visit. In five of the seven
interviews, the two researchers then split up separately to
interview the local parents and the remote grandparents. We asked
how the family started using video chat, what they think of it
now, and how it fit into their broader communication patterns and
the work they do to create a sense of “family.” In two of the
family interviews, we were not able to interview the remote
grandparents. We video- and audio-taped all calls for later
analysis. These visits typically took around an hour and a half.

H.5.2. User Interfaces: User-centered design

General Terms

Design, Human Factors

Keywords

Intergenerational, mobile, phone, children, grandparents, design,
user interfaces, family communication

INTRODUCTION

Children and grandparents typically have the most time and
motivation for communication, but currently lack the tools to
communicate together satisfactorily. Technologies have the
potential to improve communication across generations and
distances to foster a greater sense of family togetherness. To
inform the design of such technologies, we studied existing family
communications patterns in a total of 23 families in the San
Francisco Bay area.

In each case, we would take notes, transcribe video and audio
recordings, identify salient points, and work as a team to identify
points of interest for further observation.

FINDINGS

Unsurprisingly, the most common way for keeping children in
touch with distant relatives was through the phone. Through our
observations, we uncovered several sets of challenges that
children have with communicating over the phone.

STUDY DESIGN

In this paper, we briefly discuss two consecutive studies of
families in the Bay Area: a study of 18 families across a broad
socio-economic spectrum in which we focused on their
communication technology use, and a follow-up study of 7
families (including two families from the original study) in which

Cognitive Challenges

Children under 5 years old have a hard time understanding how to
communicate with a remote person using a telephone [3]. During
conversation, young children tend to forget about the special
circumstances of the phone conversation and communicate as if
the person were in the room with them. Typical behaviors include
incidents of gesturing to objects in the room where both the
gestures and the objects are unseen by the remote conversation
participant (see Fig. 1). Children sometimes forget that they need
to hold the phone in a certain posture to hear the remote
participant or be heard by the distant family members. Young

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Gardner’s theory of multiple intelligences [2] allows us to look at
this challenge from another perspective. While children with a
high “verbal intelligence” were most successful with the phone,
other children preferred to communicate with co-located parties
who were not limited to words alone. One four year old boy
illustrated the active, mobile and physical character of so much of
children’s communication and play:

children also have difficulties articulating clearly with words
alone: they rely on body language and facial expressions as a
critical part of the communication process.
Many of these findings are consistent with the literature on child
development. The difficulty to imagine the point of view of
another party seems to require both a theory of mind [4] and an
ability to take another’s perspective [7]. When talking on the
phone, a child must hold an inert piece of plastic and imagine that
the other person is present. This is inherently an abstract and
rather strange idea. Compounding this is the fact that the speakers
do not share context and cannot read typical cues like tone of
voice, posture and subtle gestures that are usually such valuable
communication skills for children.

Mother: “Son, do you want to call somebody?”
Son: “Nope, I just want to hit somebody”
(son breaks into a sprint chasing his older sister around the
house)
There is a clear mismatch between children’s needs and the
opportunities afforded by telephony.

Social Challenges

The art of conversation is a skill that slowly develops. Important
aspects of conversation like turn-taking, asking questions,
listening skills, and storytelling are often lacking in children
leading to significant breakdowns in the phone conversation. By 5
years old, children already seem to be able to carry on
conversations in person, and may understand how to use the
phone, but need help with conversation. We observed that even
children that are normally talkative face-to-face can regress to yes
and no responses in phone conversations.
This is not surprising. Phone conversations introduce an artificial
constraint of one-to-one communication; normal conversation is
not usually structured in this way. While speakerphones help to
alleviate this problem, few participants in our study used this
feature. Without speakerphone, children’s ability to learn
telephony skills is limited: children often learn by observing and
copying people older and more experienced than they are. [8] But
children can not easily learn from more experienced users if they
hear only one half of a phone conversation. The co-present
mentor’s dialogue lacks any meaningful context for the learner.

Attentional / Motivational challenges

The cognitive and social challenges with telephony lead children
to be unmotivated to talk on the phone. In our studies, children up
to 9 years old had difficulties staying engaged in the phone
conversation. Although most phones are portable today, children
are often expected to sit still and “be on good behavior” while
talking to a remote grandparent or other family member. This was
difficult for many children. Children’s words and actions
suggested that they didn’t feel connected with the remote party,
and typically perceived talking on the phone to be a chore.

Figure 1. Illustration of cognitive challenges in phone
conversation: this study participant (age 4) is gesturing to
items in the room that are unseen by the remote participants
(left and center) as well as sometimes forgetting to hold the
phone up to her face while talking (right).

MAKING PHONE CALLS SUCCESSFUL

Furthermore, language is not always the easiest way for children
to communicate. Children generally have an easier time
expressing their knowledge and ideas through action rather than
through words. Bruner [1] theorized that all knowledge begins
with action, progresses towards iconic representations, and then
can be expressed with language. His theory suggests that a
language-based medium like telephone would be more complex
for children than a medium that leveraged action, bodily
movement, or imagery.

There were a variety of strategies that we observed to overcome
these challenges. The most common strategy was parental
scaffolding where parents directly helped the children to
overcome the various challenges they experienced. For example,
parents for children under 7 reported that they need to help
children initiate the phone call by dialing the number and even
prepping the remote family members before handing off to the
children. Parents would monitor the child’s conversation progress
closely and would step in when breakdowns were occurring. For
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(Mother reaches for the phone to make sure the son doesn’t
hang up)
Son: “love you”
(Son abruptly closes the clam-shell phone, hanging up the
call)

example, it was very common for parents or family members of
younger children to hold the phone in the correct posture (see Fig.
2). Similarly, when children started to gesture, parents would
remind them that the other party couldn’t see them.

To overcome the attentional challenges, we saw an interesting
trend of remote relatives using silliness to engage the children in
the conversation. For example, one set of grandparents would ask
deliberately wrong questions to provoke their grandchild into
conversation.
It’s the typical thing, you say something totally inaccurate
and Kate says “No!...I’m 5!” So you can tell they’re saying
“I hear you’re turning 26.” or “I hear you lost a finger.”
“No, a tooth!” And then you can get them starting talking.
Silliness seemed to improve enjoyment from both sides of the
conversation as well as leading to generally longer phone
encounters between children and grandparents. In general, adults
engage with children through play (not “conversation”). While
phones are accessible and ubiquitous, it is not obvious how to
“play” with someone over a phone.

THE EMERGENCE OF VIDEO CONFERENCING

Some families in the first study used Skype or iChat for children
and remotely located grandparents to communicate. We took the
opportunity to interview a total of seven families who used home
videoconferencing and observe a videocall [6].
Home videoconferencing allowed the families we studied to
overcome many of the challenges of phone conversation. The
primary advantages to grandparents are that children are willing
to videoconference for much longer than they are willing to talk
on the telephone, and that videochat is more enjoyable. This
enables grandparents to keep up their relationship with their child
in a way that can be hard over the phone. To form relationships
with young children, conversation is not successful in itself:
families must be able to play together.
Play is supported by the physicality video allows, including richer
physical expression through facial expressions and body
language. Physicality manifests itself in several ways: children
use the video camera to show-and-tell their new lunchbox - or
lizard, or rocks, or nightlight. Others take advantage of the
opportunities for performance: we saw grandchildren singing
songs or playing the trumpet to perform for appreciative
grandparents. We witnessed many “skype kisses”, where family
members leaned towards the camera and made kissing sounds and
gestures (sometimes including family pets). Less formal
performance also occurred: we saw children being told off by
their parents for ‘acting out’ for the camera. Video heightens
shared context and provides opportunities for social interaction
around the situation; the visual awareness also affords different
conversation topics where users can show rather than tell.

Figure 2. Parental scaffolding is a common way to
overcome various issues. Here are two examples of family
members holding the phone for the child to help them
speak clearly into the microphone.
To overcome the social challenges we saw a variety of strategies.
Some families would prepare for an upcoming conversation by
posing questions like: “What do you want to tell grandma today?”
This would allow them to discuss potential topics and prime the
children for a successful call. Additionally, we saw a lot of
instances where parents would prompt children with things to say
during the conversation. Here is an example from a 3 year old
boy.
Son (talking on the phone): “Christmas!”
Mother: “Say cars”
Son: “Cars”
(Son begins kissing the phone speaker)
Mother: “Say bye-bye Ti-Ti”
Son: “bye-bye Ti-Ti”
Mother: “Say we love you... we love you”

Grandfather: “What’s that on your cheek?”
Granddaughter: “It’s an ice cream, we went to the carnival”
(referring to her fake tattoo)
The third aspect of interest is the role of groups. The videocalls
we observed frequently at least began as group activities, with the
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Make interactions more engaging: Technologies need to provide
opportunities for silliness to help keep children engaged. Some
family members are naturally silly, while others may need some
support through prompting or assistance of fictional characters
that are familiar to the children.
Although video conferencing is a promising development in
improving family communications, it is clearly only one point in
the design space. It is probably part of the answer, but not the
only answer. We should learn from its successes to explore new
interfaces with different properties. For example, what might an
asynchronous media sharing interface look like? How can
tangible interfaces [5] help support children’s needs? We plan to
explore these new interfaces for family communication as a part
of future work.

whole family assembling in a group in front of the screen, as if for
a family portrait. This provided opportunities for parental
scaffolding in a variety of ways: making sure children stayed
within the field of view of the camera, prompting questions, or
even fixing the children’s hair in the “mirror” provided by the
local video feed.
While videoconferencing provided these (and other) advantages,
it also has significant problems. The first and most apparent is the
technical work that needs to go into using a video call. We saw
families rebooting computers and routers at both end of the
conversation, coordinating by (reliable) cellphone to connect by
(unreliable) video conferencing. Bandwidth is scarce: one
thirteen-year-old was scolded by her parents for trying to
download a large file (a demo version of a game) while the family
was trying to videoconference. In addition, it was often necessary
for the most technically savvy member of the family to set up the
videoconferencing system in the first place, typically while on a
visit such as Christmas or Thanksgiving. There was also a
significant amount of social work that went into
videoconferencing. For example, one grandparent would always
put on her jewelry before a call; another family hypothesized that
they would never be able to videochat with one of their
grandparents because she was ashamed of her cluttered and messy
house.

REFERENCES

Video provides more opportunities to play, including showing
(not telling) things or skills, the ease of sharing the
communication with multiple parties, and a greater sense of
shared perspective. However, the technical challenges of
videoconferencing could hinder this, as video chat tended to be a
more precious, and thus more formal, affair.

1.

Bruner, J., and President and Fellows of Harvard College.
Toward a theory of instruction. Belknap Press of Harvard
University Cambridge, Mass, 1966.

2.

Gardner, H. Frames of mind: The theory of multiple
intelligences. Basic Books, 1993.

3.

Gillen, J. Moves in the Territory of Literacy? The Telephone
Discourse of Three-and Four-Year-Olds. Journal of Early
Childhood Literacy 2, 1 (2002), 21.

4.

Gopnik, A., Meltzoff, A., and Kuhl, P. The Scientist in the
Crib: Minds, Brains, and How Children Learn. William
Morrow & Col., Inc., PO Box 1219, 39 Plymouth St.,
Farfield, NJ 07007 (US, $24; Canada, $35)., 1999.

5.

Ishii, H., and Ullmer, B. Tangible bits: towards seamless
interfaces between people, bits and atoms. CHI ’97:
Proceedings of the SIGCHI Conference on Human Factors
in Computing Systems. ACM Press (New York, NY, USA,
1997), 234–241.

6.

Kaye, J. ’J.’, Go, J., Ames, M., and Spasojevic, M. The joys
and frustrations of family videoconferencing. Under
consideration for Proc. Ubicomp 2009.

7.

Piaget, J. The grasp of consciousness: Action and concept in
the young child. Law Book Co of Australasia, 1977.

8.

Vygotsky, L. Mind in society. Harvard University Press
Cambridge, MA, 1980

CONCLUSION

Given these findings, we provide the following takeways for the
design of family communication interfaces for children.
Modify the rules of exchange: Make communication more simple
and easier to initiate. Interfaces should also elicit sharing or
storytelling and support building connections through interactive
play (not just conversation).
Replace the one-to-one communication model: Interfaces for
family communication are likely not going to be used by the child
in isolation, we should design these interfaces to be used
collaboratively with child and parent together enabling a shared
group communication exchange.

324

Exhibit 5
Joanne Catherine Tarasuik, Roslyn Galligan, and Jordy Kaufman, Almost Being There:
Video Communication with Young Children (2011)

OPEN

0 ACCESS Freely available online

Almost Being There: Video Communication with Young
Children
Joanne Catherine Tarasuik, Roslyn Galligan, Jordy Kaufman*
Brain and Psychological Sciences Research Centre, Swinburne University of Technology, Melbourne, Victoria, Australia

Abstract
Background: Video communication is increasingly used to connect people around the world. This includes connecting
young children with their parents and other relatives during times of separation. An important issue is the extent to which
video communication with children can approximate a physical presence such that familial relationships can be truly
maintained by this means.
Methodology/Principal Findings: The current study employed an adaptation of the Separation and Reunion Paradigm with
children (17 months to 5 years) to investigate the potential for video communication with a parent to afford a sense of
proximity and security to children. The protocol involved a free-play session with the parent, followed by two separationreunion episodes. During one of the separation episodes the parent was ‘virtually available’ to the child via a video link.
Our results revealed three important differences. First, children left alone played longer in a strange room when their
parent was virtually available to them compared to when the children were left alone with neither physical nor video
contact with their parent. Second, younger participants sought physical contact with their parent less at the end of the
video separation episode compared to when they were left entirely alone. Finally, the comparison between free play with
video and free play with parent, revealed that the children exhibit a similar level of interactivity with their parent by video
as they did in person.
Conclusions/Significance: For young children a video connection can have many of the same effects as a physical presence.
This is a significant finding as it is the first such empirical demonstration and indicates considerable promise in video
communication as a tool to maintain family relationships when physical presence is not possible.
Citation: Tarasuik JC, Galligan R, Kaufman J (2011) Almost Being There: Video Communication with Young Children. PLoS ONE 6(2): e17129. doi:10.1371/
journal.pone.0017129
Editor: Malcolm Semple, University of Liverpool, United Kingdom
Received September 30, 2010; Accepted January 20, 2011; Published February 24, 2011
Copyright: ß 2011 Tarasuik et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This research was supported by the Eric Ormond Baker Charitable Fund (http://www.eqt.com.au/not-for-profit-organisations/grants/trust-list/
trustdetail.aspx?ID = 24). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: Jkaufman@swin.edu.au

with 42% reporting that they had engaged in video communication with family or friends [3]. With more than 443 million active
members of just one internet communication service [4], the
popularity of this phenomenon for adults in society is undeniable.
Video communication is also increasingly prevalent in connecting young children and their relatives. Encouraging and supporting such interactions has been the development of purposebuilt internet software and the marketing of specially designed
devices [5]. A number of popular media reports attest to the
burgeoning popularity of video communication for this purpose
[6–8].
Advances in technology are often credited with dramatic social
changes with potentially widespread (and often unpredictable
and/or negative) effects on children’s psychological and physical
development [e.g. 9,10]. Presumably, this is partially due to a
shift away from patterns of behavior established over periods
measurable in evolutionary time. Arguably however, video communication permits a greater amount of intergenerational contact
more akin to what our forebears experienced than what is typical
in modern society. Indeed, Western societies experienced
pronounced changes in family and living arrangements during
the 20th century [11], and in today’s society family members are

Introduction
Since Bowlby [1] first introduced attachment theory, it has been
accepted that physical proximity is necessary for young children to
form and maintain a secure attachment with an adult. The notion
that physical proximity is necessary for attachment seemed
obvious (if not tautological) since a sufficient degree of interactivity
seemed necessary for a child to form a close relationship with
another person, and there was no modality for inter-activity other
than physical proximity. The apparent case that physical presence
is needed is strengthened by previous research indicating that
young children have difficulties with traditional telephone conversations [2]. Now, with video communication, it is feasible for
people to have real-time enriched communication without physical
proximity. This interaction opportunity raises important and interesting questions about the extent, if at all, to which virtual proximity is
enough for young children to maintain or possibly create relationships
and establish a feeling of security with others.
Communication via the internet is a particularly popular means
of maintaining contact with family members. In a recent survey of
online users, almost half of over 6000 respondents indicated that
the internet has improved relationships with their family overall,
PLoS ONE | www.plosone.org

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February 2011 | Volume 6 | Issue 2 | e17129

Video Communication with Young Children

often geographically separated [12,13]. Many grandparents, for
example, do not reside in close proximity to their grandchildren,
and have limited face-to-face contact due to time and monetary
restraints [14]. Research indicates that grandparent-grandchild
relationships are beneficial and important for both generations
[For a review see 15] and for those that are geographically
separated, video communication may make such relationships
possible.
Of potentially greater relevance to the focus of this paper,
children are also separated from their parents for a variety of
reasons. Almost half of divorces involve children, and more than
half of young children (,5 years) from separated families see their
non-custodial parent less than once a fortnight [12]. Extensive
business travel also separates many families [16] as do the ‘Fly-in
Fly-out’ work practices that are increasingly being implemented
within the mining industry [17]. Longer-term separations can also
arise when a parent is on a military tour of duty. With hundreds
of thousands of Military Personnel from the US alone on Active
Duty in foreign Countries [18] an increasing number of children
await their parent’s return, just to see them leave once again
[19]. Furthermore, through the incarceration of a parent, many
children are also separated from their mother [20] and/or father
[21], and often for considerable periods of time. With many
custodians unable or unwilling to take young children into the
prison environment, a considerable number of these children have
little or no contact with their incarcerated parent [22].
During such times of separation, video communication may
provide these young children with the connection to their parent(s)
and assist the children by psychologically lessening the distance
caused by geographical separation.
Video communication is a seemingly rich experience, however a
large body of research exists illustrating that young children treat
people on video differently than people that they see face-to-face
[E.G 23], and therefore it is important to establish the extent to
which children that engage in video communication with someone
that they have an emotional bond to, such as their parent, behave
as if they are proximal to that person during the interaction. The
answer to this question will provide insight into the potential of
video communication as a means of establishing and maintaining
relationships between young children and absent parents. Significant similarities in how children react emotionally to a virtual
and physical presence would be suggestive of such potential. In
contrast, if children respond to a virtual connection as if the
children were physically alone, then maintaining relationships with
children via video would be problematic at best.
Our experimentation strategy involved a modified version of the
Separation and Reunion Paradigm [24]. Such paradigms have
been used for decades to examine the behavior of children when
they are separated from their parent [25], and can therefore be
employed to investigate if a child feels separated from their parent
when they are physically alone, but virtually connected via a video
link. Establishing whether a virtual connection to their parent
attenuates typical separation behaviors in a child will be an initial
step in determining the extent to which the virtual connection can
serve as a proxy for physical presence. We expected that for
children as young as 17 months-of-age, the presence of their
parent by video link would have effects similar to having a parent
physically present. Therefore we hypothesized that children would
remain content to be alone in the room for longer if their parent
was virtually available to them and that children would use the
virtual presence of their parent as a secure base for exploration
[1,24]. Children were also expected to behave differently during
the reunion if they had virtual access to their parent during the
separation and would be less inclined to seek comfort from or close
PLoS ONE | www.plosone.org

proximity to their parent than when they did not have contact
during the separation.
Conversely, an alternative hypothesis was that the presence of
the parent via the video link would serve only as a reminder to the
child that their parent was not actually present, and that children
of some ages would find the virtual presence of their parent
distressing rather than reassuring. This later hypothesis reflects
previous research findings that demonstrate that toddlers treat
face-to-face and online interaction differently [23].

Materials and Methods
Apparatus and Materials
The experiment was conducted in two adjoining lab spaces; a
playroom and a computer room. A 175 cm6300 cm lab was set
up as the play room and contained a couch and age appropriate
toys including a drawing easel and pens, blocks, a train set and soft
toys. The computer monitor sat on a shelf 1 m high positioned
across the front wall with the computer box located out of reach of
the children. An Ethernet cable connected the computer in the
play room to a computer in the next room.
Three cameras were positioned within the play room: Camera
A was attached to the wall in the back left corner of the room,
behind the couch; Camera B was attached to the couch arm in the
back right corner of the room; and Camera C was attached to the
computer monitor. See Figure 1(a). The video communication
sessions were accomplished and recorded using the Apple Inc.
software application iChat. The picture-in-picture feature was
activated, resulting in the parent’s webcam footage occupying the
full screen of the playroom monitor with the playroom webcam
footage presented in a small box in the top right corner of the
monitor and the reverse on the parent’s computer monitor. See
Figure 1(b).
A sub-set of participants (n = 28) completed a questionnaire
based on the Attachment Q Set (Waters, 1995). The questionnaire
asked parents to rank on a 5 point Likert scale (21, 2.5, 0, +.5,
+1) ranging from 21 = ‘‘not at all like my child’’, to 1 = Very much
like my child, the degree to which statements (borrowed from the
Attachment Q Set cards), are generally characteristic of their child.
For the current study only the specific behavioral characteristic
that would be most descriptive of the prototypically secure child,
have been considered and a security score was obtained by averaging
those item scores. Comparable to the Q Set scoring, a score of +1
would reflect a perfect positive correlation to a prototypically
secure child whereas a score of 21 would reflect a perfect negative
correlation to a prototypically secure child. Positive scores would
therefore indicate a child is securely attached. Results for the
subset of participants whose parent completed this questionnaire
revealed that all security scores corresponded to that of a secure
child (M = .40, SD = .21). The findings of the current study are
likely reflective only of securely attached children.

Participants
Forty-five children participated in the experiment, however, as a
result of technical problems in our apparatus four participants
have been excluded from the analysis. Participants included in the
analysis were 41 children aged 16.9–64.8 months (M = 35.2,
SD = 14.3), including 21 females and 20 males. Ten children were
aged 17 months ,2 years, 7 were aged 2,2.5 years, 8 were aged
2.5,3 years, 8 were aged 3 years, 6 were aged 4 years and 3 were
aged 5 years. The majority of children (85%) participated with
their mother rather than their father. Participants were recruited
through various avenues including advertisements online and in
newsletters, and word-of-mouth referrals.
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Video Communication with Young Children

A

- 300cm Camera A

175
I

0

°Camera C

Camera Bo~- - ---'
Door

B

Camera C

Footage of play-room

Footage of parent

Figure 1. The physical arrangement of the playroom (A). Camera C was attached the computer monitor through which the video
communication occurred (B).
doi:10.1371/journal.pone.0017129.g001

Procedure

session followed by two separation-reunion episodes. During one
of the separation episodes the parent was ‘virtually present’ to the
child via a video link, allowing audio and visual real-time
interaction. This will be termed the Video separation episode, and

Each parent-child dyad participated in a separation and reunion
protocol, which was based on that used previously by Ainsworth,
Bell and Stayton [24]. The current protocol involved a free-play
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Video Communication with Young Children

was counter-balanced to occur during either Separation 1 or
Separation 2.
Free-play session. The parent and child were left alone in
the play room for 10 minutes with no instructions other than to
interact normally, and that the researcher would return after
10 minutes.
Video separation episode. The researcher entered the play
room and asked the parent for their assistance in another room.
The parent told their child that they would return soon and left the
room. The researcher then took the parent into the next room
from where they could communicate via the video link with their
child. The parent was not provided with any further instructions
and left to interact with their child via the video link for up to five
minutes, or until the child showed signs of distress. The parent
then returned to the playroom for the reunion episode.
Reunion episode 1. The parent returned to the play room
without any further instructions. The reunion episode lasted five
minutes before the researcher again entered the room and used
the same instructions as before to facilitate the second separation
episode.
Non-video separation episode. This episode was the same
as the Video separation episode except that the child could not see or
hear the parent. However the parent could see and hear the child.
Reunion episode 2. The parent returned to the play room
without any further instructions. This episode lasted five minutes
before the researcher then entered the room to conclude the session.

thirty 10-second intervals for which the child was in the room, the
play percentage was 50%.
Inter-rater Reliability. Cohen’s Kappa was computed to
determine inter-rater reliability for proximity (k = .77, p,.001), and
play (k = .72, p,.001) with 40% of cases. Additionally there was an
inter-coder correlation of 99% on contentment duration (p,.001).

Results
Preliminary statistical analyses indicated that the child’s gender
and previous video communication experience did not have any
effects on the dependant variables. Therefore these variables have
been eliminated from further analysis. Individual participant data
can be found as Data S1.
Table 1 shows the median values of behavioral indicators for
each episode, and results of statistical tests. All cases where
participants were distresses immediately on separation, and thus
the episode was terminated, are treated as having a duration of
zero. Analyses where these cases were counted as missing did not
alter the pattern of results.
The duration of contentment showed a marked difference
across the two separation conditions with participants content to
remain separated from their parent for significantly longer during
the video separation episode compared to the non-video
separation episode. In entirety, 85% of the participants were
content for the whole video separation interval; whereas only 37%
remained content when there was not a video link available.
We compared the amount of time that participants played
during the free-play session, the video separation episode, and the
non-video separation episode. A Friedman test indicated these
conditions differed, x2(2, n = 41) = 35.86, p,.001. Median values
showed that participants played most during the free-play session,
followed by the video separation episode and least during the nonvideo separation episode. Further planned comparisons using
Wilcoxon Signed Ranks tests indicated that participants played
significantly more during the free-play episode than during either
the video or non-video separation episodes, and participants
played significantly more during the video separation episode than
during the non-video separation episode.
To control for the differences in the amount of time that
participants remained in the room across the free-play and the two
separation episodes, the percentage of time periods during which
participants played while they were in the room was compared
across conditions. A Friedman test showed that the percentage of
time spent playing varied significantly, x2(2, n = 41) = 35.58,
p,.001. Median values showed that participants played for the
greatest percentage of time during the free-play session, whereas
they played for only about half the time in both separation
episodes. Further planned comparisons indicated that participants
played significantly more during the free-play episode than both
the video and non-video separation episodes, however the
separation episodes did not significantly differ.
Comparing the amount of time that participants spent
interacting with their parent during the free-play and video
separation episode showed that participants interacted to the same
degree with their parent during the video separation episode as the
free-play episode.
For the children under three years-of-age, we also tested for
proximity seeking behavior after each separation episode.
Significantly more children of these ages moved towards their
parent during the reunion that followed the non-video separation
than the reunion that followed the video separation.
To examine other possible age differences Kruskal-Wallis tests
were performed to compare results across different age groups

Coding
Separation Episodes. From the video recordings of the
episodes, the measure contentment duration was calculated to indicate
the period of time that the child was content to be physically alone
in the playroom, with and without virtual access to their parent via
the video link. This was defined as the period of time (in seconds)
that the child was physically alone in the room until they began to
cry and continued crying for 10 seconds, or tried to leave the
room. This variable had a maximum value of 300 seconds, as this
was the maximum duration of each separation episode.
Reunion Episodes. To compare the reunion episodes following the video and non-video separation episodes, a proximity
variable was created, noting whether or not the child moved
towards the parent when they entered the room after each
separation. This variable was only investigated in children under
3 years of age, as proximity seeking behavior is normal for such
children and less usual for older children in Phase 4 of the
development of attachment [1].
Comparison Across Episodes. To investigate the amount
of time that the child played with toys and/or interacted with their
parent, each 10 second period of the free-play, the video
separation and the non-video separation episodes were coded.
Only the first five minutes (I.e. 300 seconds) of the free-play
session was coded to allow comparisons to be drawn between the
free-play session and the separation episodes. Thus there were
thirty 10-second intervals in each of the three periods (or less in the
cases when the child remained in the room for less than the full
300 seconds of the separation episode).
Using the results of the 10-second interval coding the play
criterion and the interaction criterion were defined as the number of
10-second periods during which the participant touched/played
with the toys or otherwise interacted with their parent, respectively.
The maximum score for any episode was 30. Variables were also
computed to investigate the percentage of each episode that
participants played, and percentage of each episode that participants interacted with their parent, since separation episodes were
not all of equal duration. For example if a child played for 15 of the
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Table 1. Medians of the Behavioral Indicators for Each Episode and Results of Wilcoxon Signed Rank Tests used to compare
Behaviors across Episodes.

Measure

P- value

Condition

Mdn

Z

Duration of contentment

,.001

Video separation episode

300 sec

23.81

Non-video separation episode

79 sec

Amount of play

,.001

Free-play episode

28 periods

Amount of play

,.001

Amount of play

Percentage of play

Percentage of play

Percentage of play

Amount of interaction

Percentage of interaction

Proximity (Age ,3yrs old)

Continued for the entire 300 s
of the video separation episode

,.001

,.001

,.001

.46

.02

.162

.034

.033

Video separation episode

12 periods

Free-play episode

28 periods

Non-video separation episode

4 periods

Video chat separation episode

12 periods

Non-video separation episode

4 periods

Free-play episode

97%

Video separation episode

40%

Free-play episode

97%

Non-video separation episode

50%

Video chat separation episode

40%

Non-video separation episode

50%

Free-play episode

27 periods

Video separation episode

24 periods

Free-play episode

87%

Video separation episode

87%

Non-video separation reunion

41.2%

Video separation reunion

5.9%

Participants aged 2,2.5 yrs

42.9%

Participants not aged 2,2.5 yrs

82.4%

24.42

25.26

23.20

24.89

25.08

20.74

22.4

21.40

22.121

22.135

doi:10.1371/journal.pone.0017129.t001

in play, and response to reunion, all of which are common indices
of attachment security [24].
Firstly, we consider duration of contentment, as that is arguably
the most direct measure of how secure our participants felt when
they were in the room. Children of all ages were content to be
alone without a parent physically present significantly longer in the
video separation than the non-video separation episode. Further, a
greater percentage of children were content for the entire fiveminute video separation than non-video separation. Interestingly
almost all of the participants that did not remain content for the
entire five minutes of the separation, showed signs of distress
within two minutes of their parent leaving the room. Despite the
brevity of the separations, it is probable that provided the
opportunity, the content participants would have remained
content far beyond the given five minutes, however future studies
should address this question.
Secondly, our interaction measures revealed that children
interacted slightly (though not significantly) more with their parent
during the time that the parent was in the room than during the
video separation episode. Notably however, there was no
significant difference between the two episodes in the percentage
of time that children interacted with parents. Thus, when children
were content in the room they interacted with their parent as
much in the video separation as they did when the parent was
actually present. This is important because it suggests significant
similarities between the quality of the virtual presence compared
with real presence.
Thirdly, play was also an important measure in our study as it is
an indicator of the extent to which a virtual parental presence can

(Gp1, n = 10: 1.5,2 years, Gp2, n = 7: 2,2.5 years, Gp3, n = 7:
2.5,3 years, Gp4, n = 7: 3,4 years, Gp5, n = 9: 4,6 years). No
significant age differences were found for three of the variables: the
percentage of interaction during the video separation episode; the
difference in contentment duration between the video and nonvideo separation episodes; and the duration of contentment for the
non-video separation episode.
Age groups differed significantly on duration of contentment for the
video separation episode, x2(4, n = 41) = 10.531, p = .032. The
3,4 year-old and the 4,5 year-old participants were content
equally for the longest period of time (Md = 300 s) and the 2,2.5
year-old participants were content for the shortest period of time
(Md = 70 s). See Figure 2.
Moreover, there was a significant difference across age groups in
the number of participants who were content for the entire
300 seconds of the video separation, x2(4, n = 41) = 10.676,
p = .030. The 3,4 year-old and the 4,5 year-old participants
were most likely to continue for the entire 300 seconds and the
2,2.5 year-old participants were the least likely.

Discussion
The fundamental contribution of this research is the discovery that
a parental presence via video link is sufficient to allow young children
to feel secure in an unfamiliar environment. This empirical verification
is crucial in considering the potential of video communication to play a
role in the maintenance or formation of secure attachments.
Our conclusions are based on four measures of child behavior:
duration of contentment, interaction with the parent, engagement

.·ffiii.
-~-·

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Video Communication with Young Children

300 + - - - - - - - - - - - - - - - - - - - - - ---- - - - ---- ------1

250

--video separation
- - Non video separation
- - - Video separation mean
- - - Non video separation
mean

150

50

+------

+------~------~------~-----~------~
18m > 2yrs

2 > 2.5yrs

2.5 > 3yrs

3 > 4yrs

4 > 6yrs

Figure 2. Age differences of the duration of contentment (in seconds) during the separation episodes.
doi:10.1371/journal.pone.0017129.g002

their parent within the measure play. Collapsing across interaction
and play measures may be considered an option to overcome this
discrepancy, however this variable would not allow comparison
with the non video separation as there was no opportunity for
interaction during that episode.
Additionally, there may be subtleties of how one interacts, plays
and talks with a parent when they are actually present rather than
virtually present that accounts for differences in play between these
conditions. When playing and interacting within the presence of
the parent, a child can interact, talk and play simultaneously and
can readily assume that their parent is watching them. However,
during the video separation, children may have paused more often
in their play to turn and look at their parent on the monitor to
interact with them. This may be especially so when children are
not familiar with this medium, or when the video separation is
occurring in a strange situation.
Finally, observations of the reunions demonstrated that the
younger participants (under 3 years), were significantly more likely
to move to contact their parent following the non-video separation
than the video separation. This result is consistent with the
literature that suggests that a child tends to seek proximity when
attachment behavior is intensely activated [26], and that the nonvideo separation appears to have activated this behavior in the
younger participants.
In sum, our results form compelling evidence that a parent’s
virtual presence is sufficient to increase the level of security felt
by young children with pre-existing strong attachments in an
unfamiliar environment. This is an important finding as it suggests

substitute for a physical secure base for exploration. Results
indicated that children across all ages played for longer during the
video separation than the non-video separation. However this
result may arise, at least in part, because children could only play
for the duration that they were in the room. Children who are
content longer will have more time to play in the room and thus
did so. Conversely, children who feel secure enough to use the
video as a secure base for exploration will also be likely to stay in
the room longer (and consequently play for longer).
In an attempt to partially control for duration of contentment
we compared the percentage of time that they played for while
they were content to be in the room. However, results revealed
that children only played for about half of the time that they were
in the room during both separations compared to when they were
present with their parent. The failure to find differences in
percentage of play between the video separation episode and the
non-video separation episode may, however, be due to other
differences in the nature of interaction in these two separation
episodes.
Furthermore, the interaction measure should be considered in
any interpretation of how much children played. Since video
communication is still a relatively unusual activity in most
households, the novelty of talking to a parent over a video link
could be interpreted as ‘‘play’’ for many children. This might
explain why the play percentage was not higher in the video
separation condition than the non-video condition. That is, the
play measure may be underestimating play during the video
separation episode since we did not include video interaction with
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Video Communication with Young Children

that relationships between children and their parents could benefit from video communication when face-to-face contact is not
possible.
It is conceivably possible that some children were happier
during virtual communication because they were distracted from
their separation by the novelty of talking to a parent via video.
Although studies are underway to assess this possibility, it is
important to note that a video of a person could also remind the
child of the person’s absence, rather than distract them from it. To
some extent, the novelty issue was addressed through our analysis
of the children’s prior experiences with video communication.
Children with less video communication experience would
arguably be more likely to be subject to such a ‘‘novelty effect.’’
However, our results did not reveal effects of previous video
communication experience on any dependent variable.
However, as video communication becomes more commonplace in society the role of prior experience with this medium may
change, particularly if children are exposed to video communication at a very early age. These children may develop a level of
expertise that allows them to better understand the precise extent
to which a video can stand in for an actual person and where it
suffers limitations. This might affect results in studies such as ours
by attenuating the effect of age on duration contentment, or how
play and interaction with the parent is negotiated via video.
Investigation of which aspects of this communication medium are
the most beneficial or problematic for young children is also
required. As previous research has shown that young children
have difficulties with traditional telephone conversations [2], it
would be beneficial to extend the current protocol to investigate
differences in a child’s behavior with the availability of their parent
via a video link compared to an audio stream and compared to
actual presence. Future studies should also include children
younger than those included in the present study, and also involve
extended relatives rather than parents. Numerous anecdotal
accounts report babies being introduced to absent grandparents
and parents from an early age with regular interactions occurring
via video link [8]. Many other such questions remain to be
answered on how children negotiate and use this virtual medium

when it has always been part of their life, and how it enables them
to develop and maintain relationships with important others.
The study described here investigates the developmental effects
of a relatively new technology, but somewhat ironically its usage
has the potential to bring us closer to societal norms that existed in
the past. Whereas only a few decades ago multiple generations
often lived under one roof (or at least within the same
neighborhood), extended families are increasingly separated by
large distances so face-to-face contact is limited [11]. The evidence
presented in this paper indicates that these video episodes may be
sufficient for interaction that is meaningful to a young child.
Continuing forward, researchers must ecologically determine if
video communication provides a ‘‘real enough’’ experience to
maintain relationships during longer-term separations, and
ascertain the unrealized benefits to the children and parents,
and potentially other members of the extended family. Our
research paves the way for future studies that examine more
directly the impact of video communication with children who
may otherwise feel completely separated from relatives during
times of physical absence.

Supporting Information
Data S1

Supporting data.

(XLS)

Acknowledgments
The authors would like to thank: The parents and children who
volunteered to participate; Jenny Richmond for her advice on the methods
and results section; Denny Meyer for her statistical assistance; Allan
Kaufman, Andrew Bremner, Amy Needham and Teresa Farroni for
commenting on earlier drafts; and our interns Leon Cheung, Li Sher Tan
and Elif Yurtserver for their assistance with the study.

Author Contributions
Conceived and designed the experiments: JK JT. Performed the
experiments: JT. Analyzed the data: JT JK RG. Wrote the manuscript:
JT JK RG.

References
1. Bowlby J (1969) Attachment and loss (Vol 1). New York: Basis Books.
2. Ballagas R, Kaye JJ, Ames M, Go J, Raffle H (2009) Family communication:
phone conversations with children, Proceedings of the 8th International
Conference on Interaction Design and Children. Como, Italy: ACM;
DOI:10.1145/1551788.1551874.
3. Symantec Corporation (2009) Norton online living report. Available: http://
www.nortononlineliving.com/documents/NOLR_Report_09.pdf Accessed
2010 Jan 30.
4. Ebay (2009) Ebay, PayPal, Skype financial highlights Q1 09. Available: http://
www.slideshare.net/earningreport/presentation-on-q1-2009-earning-report-ofebay-inc. Accessed 2009 Dec 10.
5. Vetere F, Davis H, Gibbs M, Howard S (2009) The magic box and collage:
Responding to the challenge of distributed intergenerational play. Int J Hum
Comput Stud 67(2): 165–178. DOI: 10.1016/j.ijhcs.2008.09.004.
6. Taub EA (October 29, 2009) Helping grandpa get his tech on. The New York
Times - New York Edition.
7. Biederman M (December 12, 1999) Tomorrowland returns, with video
conferencing. The New York Times - New York Edition.
8. Harmon A (November 28, 2008) Grandma’s on the computer screen. The New
York Times.
9. Dennision BA, Erb TA, Jenkins PL (2002) Television viewing and television in
bedroom associated with overweight risk among low-income preschool children.
Pediatrics 109: 1028–1103. DOI: 10.1542/peds.109.6.1028.
10. Linebarger DL, Walker D (2005) Infants’ and toddlers’ television viewing and
language outcomes. Am Behav Sci 48(5): 624–645. DOI: 10.1177/
0002764204271505.
11. De Bruycker T (2008) Selection versus structure: Explaining family type
differences in contact with close kin. J Fam Issues 29(11): 1448–1470. DOI:
10.1177/0192513X08318154.

PLoS ONE | www.plosone.org

12. Australian Bureau of Statistics (2008) Family characteristics and transitions,
Australia, 2006–07. Available: http://www.abs.gov.au/ausstats/abs@.nsf/mf/
4442.0 Accessed 2009 Nov 30.
13. U.S. Census Bureau (2009) Custodial mothers and fathers and their child
support: 2007. Available: http://www.census.gov/prod/2009pubs/p60-237.pdf
Accessed 2010 Jan 30.
14. American Association of Retired People (2002) The grandparent study 2002
report. Available: http://assets.aarp.org/rgcenter/general/gp_2002.pdf Accessed
2008 Nov 12.
15. Smith PK, Drew LM (2002) Grandparenthood. In: Bornstein M, ed. Handbook
of parenting: Being and becoming a parent. New Jersey: Lawrence Erlbaum &
Associates. pp 141–172.
16. Westman M, Etzion D, Chen S (2009) The impact of international business trips
on the travellers and their spouses. In: Rossi AM, Quick JC, Parrewe PL, eds.
Stress and the quality of working life: The positive and the negative: Information
age. pp 19–39.
17. The Chamber of Minerals & Energy Western Australia (2005) Fly in/Fly out: A
sustainable perspective. Perth, Western Australia. Available: http://www.
peopleforthefuture.com.au/files/files/20_FIFO_Report.pdf. Accessed 2009
Oct 10.
18. US Census Bureau (2008) National security and Veterans Affairs. Available:
http://www.census.gov/prod/2007pubs/08abstract/defense.pdf. Accessed
2009 Sep 10.
19. Lester P, Peterson K, Reeves J, Knauss L, Glover D, et al. (2010) The long war
and parental combat deployment: effects on military children and at-home
spouses. J Am Acad Child Adolesc Psychiatr 49(4): 310–320. DOI: 10.1097/
00004583-201004000-00006.
20. Myers BJ, Smarsh TM, Amlund-Hagen K, Kennon S (1999) Children of
incarcerated mothers. J Child Fam Stud 8(1): 11–25.

7

February 2011 | Volume 6 | Issue 2 | e17129

Video Communication with Young Children

21. Quaker United Nations Office (2009) Children need dads too: Children with
fathers in prison. Available: http://www.quno.org/geneva/pdf/humanrights/
women-in-prison/CNDT%20internet-1.pdf. Accessed 2009 Nov 17.
22. Farrell A (1998) Mothers offending against their role: An Australian experience.
Women Crim Justice 9(4): 47–67. DOI: 10.1300/J012v09n04_02.
23. Troseth GL, Saylor MM, Arche AH (2006) Young children’s use of video as
a source of socially relevant information. Child Dev 77(3): 786–799. DOI:
10.1111/j.1467-8624.2006.00903.x.

PLoS ONE | www.plosone.org

24. Ainsworth MDS, Bell SM, Stayton D (1971) Individual differences in Strange
Situation behavior of one-year-olds. In: Schaffer HR, ed. The origins of human
social relations. London: Academic Press. pp 17–57.
25. Van Ijzendoorn MH, Vereijken CMJL, Bakermans-Kranenburg MJ, RiksenWalraven JM (2004) Assessing attachment security with the attachment Q sort:
Meta-analytic evidence for the validity of the observer AQS. Child Dev 75(4):
1188–1213. DOI: 10.1111/j.1467-8624.2004.00733.x.
26. Ainsworth MS (1979) Infant-mother attachment. Am Psychol 34(10): 932–937.
DOI: 10.1037/0003-066X.34.10.932.

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Exhibit 6
Léon Digard, Jessi LaChance, and Jennifer Hill, Closing the Distance: The Impact of Video
Visits in Washington State Prisons (August 2017)

Vera
INSTITUTE OF JUSTICE

August 2017

Closing the Distance
The Impact of Video Visits in Washington State Prisons
Léon Digard, Jessi LaChance, and Jennifer Hill

This study was supported by Award Number 2012-IJ-CX-0035, awarded by the National Institute of Justice, Office of
Justice Programs, U.S. Department of Justice. The opinions, findings, and conclusions or recommendations expressed
in this publication are those of the authors and do not necessarily reflect those of the U.S. Department of Justice.

From the Director
Research has shown that continued connection to
family and friends is a critical factor in incarcerated
people’s successful post-prison outcomes. Because many
prisons around the country are in remote locations,
far from the communities where the majority of
incarcerated people live, in-person visits present ofteninsurmountable logistical and financial challenges. For
corrections officials looking to keep those in prison
in touch with those in the community, video visiting
offers a new route. Given its ability to bridge physical
separation, this technology lends itself to addressing the
difficulties incarcerated people and their loved ones in
the community face to keep in touch.
In 2016, the Vera Institute of Justice (Vera) published a
national study of state corrections systems’ adoption of
video telephony as a way to visit incarcerated people.
The study found that many state prison systems
were weary of adopting video visiting, given security
concerns and implementation costs. One early adopter
of the technology was the Washington State Department
of Corrections, which introduced video visiting using
computers in its prisons in 2014.
The current study examines the impact of video visiting
in Washington on incarcerated people’s in-prison
behavior and analyzes their experience of the service.
The principle finding was that using the service had a
positive impact on the number of in-person visits the
video visit users received. In at least one significant
sense, the findings follow what we know about the
digital divide: Younger people tended to adopt the new
technology more than older people. And video visit
users also had the most in-person visits both before
and after introduction of the service, suggesting that

those with strong social bonds tend to sustain them
in as many ways as possible. Vera’s researchers found
no significant correlation between video visiting and
people’s in-prison behavior, as measured by the number
of infractions they committed during the period under
study.
Overall, the analysis drew a sobering big picture:
Nearly half of the people in Washington’s prisons do
not have visitors of any kind. And those who do don’t
have many. One factor was constant across sub-groups:
The distance from home had a negative effect on
visiting. Travel is expensive and time-consuming; video
calls, while cheaper, cost more than a lot of people
can spend and are rife with technical glitches. Those
who used the service despite its costs and limitations
told poignant stories of its benefits: the opportunity
for parents and children to bond; the possibility for
people in prison to show their families and friends that
they are doing well; the chance to talk in a setting less
stressful than a prison.
Given the importance of sustained human ties for
people reentering the community from prison, it
behooves corrections officials and policymakers to
devote ongoing attention to promoting successful
family and community ties while reducing the factors
that strain these vital connections.

Fred Patrick
Director, Center on Sentencing and Corrections
Vera Institute of Justice

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Vera Institute of Justice

Contents
4

Introduction

6

Methodology

9	The use of video visits and their impact on
in-person visiting rates
12

The video visit experience

15

In-prison behavior and video visits

16

In-person visits in Washington State prisons

21

Conclusion

22

Appendices

31

Endnotes

Closing the Distance: The Impact of Video Visits in Washington State Prisons

3

Introduction

O

f the many difficulties incarcerated people face, losing contact
with loved ones may be among the most damaging. Research
has shown that maintaining community ties can improve their
health and well-being, decrease their sense of isolation, reduce symptoms
of anxiety and stress, and improve their feelings of control and involvement
in family life.1 Furthermore, research suggests that receiving any visit at
all during incarceration reduces the risk of someone committing a new
offense or violating conditions of parole when they are released.2 Thus, visits
with loved ones form a lifeline to the outside world for incarcerated people
and help pave the way back into society. As the number of visits a person
receives increases, so do their chances of success in the community.3

One of the most significant barriers
to prison visits may be the long distances
visitors generally have to travel
to the facilities where their loved
ones are incarcerated.
Despite the value of in-person visits, people in prison receive few. A
survey conducted in 2003 and 2004 by the federal Bureau of Justice Statistics
(BJS) showed that in any given month, nearly 70 percent of incarcerated
people in state prisons had no visitors.4 There are many reasons why loved
ones do not or cannot visit incarcerated people, including the financial
strain (such as the cost of travel, missed workdays, and childcare); rules and
regulations governing visits (such as ID requirements, limited visiting hours,
and background checks); and the anxiety-producing experience of enduring
metal detectors and personal searches.5 One of the most significant barriers
to prison visits may be the long distances visitors generally have to travel to
the facilities where their loved ones are incarcerated. According to the same
survey by BJS, approximately 63 percent of state prison inmates were held
over 100 miles from their residence at arrest.6

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More recently, departments of corrections have been turning to
computer-based video technology to try to ameliorate the burden of
those distances and create opportunities for families to stay in touch
with incarcerated loved ones. However, opinions about the value of video
visiting to date are mixed. Some corrections professionals and advocates
for incarcerated people have expressed concern that the technology may
replace in-person visits—an outcome that could have negative impacts on
both incarcerated people and their loved ones in the community.7 In many
local jail systems, those fears have been realized: they have eliminated inperson visits in favor of on-site video links.8
In 2016, the Vera Institute of Justice (Vera) reported on the availability of
video visitation in state prisons, and the process and cost of implementing
the system by one recent adopter: the Washington Department of Corrections
(WADOC).9 Vera’s research showed that, at the time of implementation in
2014, Washington was one of 15 state corrections agencies deploying this
technology. WADOC reported that it did not intend video visits to replace
in-person visits, and hoped that, by enabling more sustained contact between
incarcerated people and their loved ones, the introduction of video visits
might even increase in-person visit rates. Video calls to people incarcerated
in Washington State prisons are made by pre-approved visitors using a home
computer or public terminals set up in the community. (At the time of the
study, video calls were not available via smartphones or tablets.)
A private vendor, JPay, provides the service. Washington’s decision
to provide video visits to increase contact opportunities for incarcerated
people seemed prudent in its attempt to address the needs of a
geographically dispersed population: 50 percent of respondents to a survey
Vera conducted of people incarcerated in Washington State prisons in 2014
were in facilities at least 129 miles from their home communities.10
Since the publication of that survey’s findings, Vera’s researchers have
been studying the use of video visits in Washington State prisons to
understand whether it is successfully providing a means for incarcerated
people to contact loved ones more regularly, and whether its use has
affected the number of in-person visits that they receive. Below, Vera
presents the findings of this recent study.
First, the study sought to assess who received video visits and how
frequently. Next, researchers assessed whether participating in video
visits affected in-person visit rates, and whether it affected incarcerated
people’s in-prison behavior. Interviews with incarcerated people about
the experience and perceived benefits and challenges of the video visit

Closing the Distance: The Impact of Video Visits in Washington State Prisons

5

system supplemented the data analyses. Last, to contextualize the findings
of the evaluation and to identify the unmet visitation needs of incarcerated
people, the study looked at the prevalence and frequency of in-person
visits across the system. While previous studies have noted that distance
from home may inhibit in-person visits, Vera sought to identify the specific
nature of the relationship between being housed far from home and
incarcerated people’s ability to maintain contact with their loved ones.11

Methodology
Vera set out to answer the following research questions using the
methods and sources outlined below. (A detailed description of the study’s
methodology can be found in Appendix A.)

Did video visit use affect in-person
visit rates?
To understand who received video visits in Washington State prisons, and
how often they received them, Vera researchers analyzed administrative
data from both WADOC and JPay. WADOC introduced video visits in its
prisons gradually throughout 2013. Vera researchers identified the date on
which video visitation was first made available to each incarcerated person,
from a full dataset that included people incarcerated for any length of time
between January 1, 2012, and November 30, 2015. To estimate the impact
of using the video visit service, Vera researchers compared pre- and postvideo visit implementation outcomes of service users and nonusers. For
the analysis, the researchers chose all 9,217 people who were in WADOC
custody for at least one year prior to and at least one year following service
implementation. From this sample, the researchers identified 1,058 users of
the video visit service. Under the assumption that people who rarely used
the service were unlikely to be affected by it, the researchers identified a
group of 459 very low users—people averaging fewer than 1.5 video visits
per year during the study period—and removed them from the analysis.
They also identified a group of high users, comprising those who were
in the 90th percentile of service use, each receiving an average of nine or

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more video visits per year. This resulted in a total sample of 8,758 people,
divided into three groups: 8,159 nonusers; 488 users; and 111 high users.
The researchers compared nonusers, users, and high users of the
service to identify demographic differences between the groups; Vera then
used two statistical methods to estimate the impact of participating in
video visits on subsequent in-person visits, while controlling for those
differences—Inverse Probability of Treatment Weighting, with Difference
in Differences tests (IPTW/DID) and Bayesian Additive Regression
Trees (BART). Using two methods allows the researchers to have greater
confidence in the findings when the results of the analyses agree. The first
method, IPTW/DID, reweighted the control group so that it looked like the
treatment group, and then compared changes in in-person visits over time
between the groups. The second method, BART, capitalizes on a machinelearning-based approach to adjust for the sample characteristics. The BART
analysis allowed the researchers to predict, for each person who had
video visits, how many in-person visits they would have received if they
had not participated in the program. See Appendix A for a more detailed
description of these methods and the variables controlled for.

What were the strengths and weaknesses
of the video visit experience?
To better understand how users of the video visit system experienced the
service, Vera conducted interviews with 20 incarcerated people who had
used the service within the previous month. The participants (10 men
and 10 women) were asked open-ended questions about their satisfaction
with the service, why they chose video visits, and their perceptions of the
benefits and challenges associated with using the system.

Did video visits affect users’ in-prison
behavior?
Using the same sample and methods used to determine the impact of
video visits on service-users’ in-person visit rates, Vera researchers
conducted analyses to determine whether using the service affected
in-prison behavior. Researchers compared the groups to identify any
significant changes between the periods of time before and after video

Closing the Distance: The Impact of Video Visits in Washington State Prisons

7

visits were introduced in the overall number of infractions of prison rules
service users committed, the number of serious infractions (as defined by
WADOC policy), or the number of general infractions they committed. To
supplement these analyses, they drew upon the experiences of incarcerated
people, as reflected in the 20 interviews described above.

How frequently did people have in-person
visits?
To understand how often people in Washington State prisons received
in-person visits and determine the extent to which long distances from
home created a barrier to such visits, Vera analyzed administrative data
from WADOC about all people who were incarcerated during a one-year
period (11,524 people incarcerated from November 30, 2014 to November
30, 2015). The data included demographic information, home ZIP Codes,
and information on in-person visits. Vera analyzed the data to describe
demographic variation in visit rates and conducted statistical analyses to
identify the relationship between being incarcerated far from home and
in-person visit rates.

Video visitation in Washington State prisons
People incarcerated in Washington State prisons can make
video visits in addition to their standard phone-call allowance,
which varies by their security level. A video visit takes place
at a kiosk installed in a housing-unit day room. Depending on
the prison’s security level, the kiosks may look like computer
monitors, with a webcam and a headset for the person to
speak into and listen to his or her visitor. The visit, which an
approved visitor must schedule in advance, lasts 30 minutes
at a cost to the person who is incarcerated of $12.95. For
an additional $12.95, participants can extend the visit to an
hour at the time of the call if no one else has reserved the
kiosk for that time slot. While the hours during which people
can access kiosks vary by prison facility, some visits take
place as late as 10 p.m., substantially expanding the time for
families to connect beyond in-person visiting hours. The visitor

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Vera Institute of Justice

participates in the visit using any computer with Internet
access and a webcam. The vendor records all video visits,
which the WADOC staff can review following completion of the
visit. Corrections staff can also opt to monitor the visits in real
time, and can end a call immediately if they witness prohibited
behaviors or interactions, such as gang signs or nudity.
The first video visitation pilot began in February 2013 at the
Washington Corrections Center for Women. By June 2014, all
12 of the state’s adult prison facilities offered video visitation.
JPay, a private vendor that also provides prison services
such as e-mail, music, and commissary accounts, operates
the video visitation program. Securus Technologies, a large
criminal-justice technology and prison telecommunications
company, acquired JPay in July 2015.

The use of video visits and their
impact on in-person visiting rates
Video visit rates
Overall use rates were low. In Vera’s sample, 11.5 percent of incarcerated
people (1,058) participated in at least one video visit. On average, people
who used video visits had 3.6 video calls per year. However, a substantial
proportion of this group could be considered very low users; the researchers
averaged each person’s video visits over the time the option was available to
them and found that 43 percent (459) of people who tried the service made
fewer than 1.5 video visits per year. Of Vera’s total sample (N=9,217), only
6.5 percent (599) could therefore be considered regular users of the service.
Possible reasons for the low usage rate are described below. The 459 verylow users were dropped from the impact analysis.

User demographics
The researchers observed some notable differences between nonusers,
users, and high users.12

Table 1

Demographics
Nonusers (n=8,159)

Users
(n=488)

High users (n=111)

34 years

28 years

27 years

Black

19%

39%

43%

Member of a security threat
group (a gang)

29%

54%

56%

Average age when admitted

Closing the Distance: The Impact of Video Visits in Washington State Prisons

9

As Table 1 shows, users of the video visit service tended to be slightly
younger than nonusers when they were admitted to custody for their current
sentence (though all groups had, on average, been in custody for similar lengths
of time—seven years—at the time of the study). It is possible that younger people
are more familiar with the technology and have greater experience and ease
connecting to people through video. It is also possible that people incarcerated
at a younger age are leaving behind stronger or larger social networks. Users and
very high users of the system were slightly less likely to have used mental health
services (14 percent and 12 percent, versus 28 percent of nonusers), were less
likely to be white and more likely to be black, and were more likely to have been
identified as belonging to a security threat group (a gang).
There were also clear differences in the sample members’ incarceration
experiences in the year prior to the introduction of video visits. (See Table
2.) Users of the service were moved between facilities more often and held,
on average, further from home than nonusers. It is noteworthy that, despite
these challenges, during the year prior to implementation, service users
already received more in-person visits from more visitors. In the year before
implementation of video visits, nonusers had an average of seven in-person
visits per year, while moderate users received over double this rate of visits,
averaging 15.6, and high users had an average of 19 visits. From the data available,
the researchers were unable to determine the cause of these differences. It is
possible that financial capacity accounted for the relationship between in-person
visit rates and subsequent video visit use—that is, family members who could
afford the cost of the video service were also better able to handle the expense of
traveling to their loved one’s facility. The higher rate of in-person visits may also
Table 2

Pre-exposure variables
Nonusers (n=8,159)

Users
(n=488)

High users (n=111)

5.3

6.6

7.8

128.3

149.4

160.6

Average number of in-person
visits per year

7.0

15.6

19.3

Average number of in-person
visitors per year

12.4

26.8

31.6

Average number of
facility moves
Weighted average distance from
home (miles)

Note: “Average number of visits” refers to the number of visit “events” that a person experienced, regardless of how many visitors were present at the
same time. A “person visit” means that the same person is counted each time he or she visits during the year.

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Table 3

Pre-exposure conduct
Nonusers (n=8,159)

Users
(n=488)

High users (n=111)

Average number of general
infractions (all)

1.9

2.1

2.0

Average number of serious
infractions

0.8

0.8

0.8

Average number of segregation
infractions

0.4

0.4

0.5

indicate that users of the video service had stronger relationships with people
in the community before video visits were introduced. (See “The effect of video
visits on in-person visiting rates” below for more information.)
There were few meaningful differences in the average number
of infractions committed by people during the year prior to service
implementation. The average number of infractions, serious infractions, and
infractions that resulted in a segregation sanction (commonly known as
“solitary confinement”) were low for all subgroups (see Table 3, above).

The effect of video visits on in-person
visiting rates
Vera researchers conducted two analyses to determine whether engaging
in video visits affected the number of in-person visits incarcerated people
received. They used two analytic techniques to control for the differences
between users and nonusers and to allow for an apples-to-apples
comparison. In both analyses, users and high users of the video service
saw a significant increase in the number of in-person visits they received
following implementation of the service, as compared to nonusers. The
IPTW/DID analyses show that use of the service resulted in a 40 percent
increase in the number of in-person visits, while very high use resulted
in a 49 percent increase. The results of the BART analysis were similar
(finding a 48 percent increase for users and a 49 percent increase for
very high users). For both users and high users, these findings held true
regardless of how far from home people were incarcerated. (See Appendix
B for the results of the IPTW/DID and BART.)

Closing the Distance: The Impact of Video Visits in Washington State Prisons

11

The video visit experience

T

o help understand the results of the data analyses, Vera interviewed
20 people (10 men and 10 women) incarcerated in Washington State
prisons who had used the video service within the previous month. The
information the interviewees provided illuminates how the system benefited
users and what mechanisms might explain the increase in in-person visits
Vera identified. The interviewees stressed the system’s technical challenges
and costs, which may account, at least in part, for the low use rates.13

Seeing and connecting
While Vera’s data analysis suggested that users of the video visit service
were already better connected to the community than nonusers, there was
still a high level of need among this group for more contact with loved ones.
Video visits helped ameliorate this need. Interviewees spoke expansively of
the video service’s benefits, and 18 of the 20 participants reported that they
would continue to use it. Video visits allowed users to connect with people
who would otherwise struggle to make an in-person visit because of the
distance. Participants noted long travel times, gas and hotel expenses, loss
of earnings, and child-care requirements as significant barriers to in-person
contact. Loved ones with limited mobility or in poor health faced additional
challenges to in-person visits. Indeed, one participant who was incarcerated
far from home reported that, prior to his first video visit, he had not had any
form of visit for 19 years.
While most interviewees preferred in-person visits to video calls, they
still found the opportunity for greater contact with loved ones to be highly
meaningful. Video visits allowed incarcerated parents to participate in and
connect to their children’s lives. One mother said that her young daughter
had not recognized her at the start of in-person visits for the first few years
of her incarceration. The more consistent visual contact made possible
through video visits helped to relieve the estrangement: “Now she does
[recognize me] and writes more and talks on the phone more.” Incarcerated
parents felt that opportunities to stay actively involved in their children’s
lives were mutually beneficial. As another woman said, “This would be
harder for both of us without [video visits]. I get to see my little monsters

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Video visits provided loved ones
with visual reassurance that they were
physically and emotionally well—something
phone calls and letters could not do.
grow.” Another participant reported that, through video visits, he could
counsel and support his son, who was struggling with drug addiction.
Interviewees said that video visits were a more comfortable mode of
communication for young children than phone calls. A father explained that
his young daughter, who struggled to talk over the phone, had started asking
questions about his prison sentence: “It’s easier to answer her questions
face-to-face—to look at her when I’m talking to her.” Via video, he said, his
daughter played while they talked and showed her father her room, toys,
and drawings: “I get to see her grow.” Similarly, participants noted that video
visits provided loved ones with visual reassurance that they were physically
and emotionally well—something phone calls and letters could not do.

Video visits built a foundation for
in-person visits
Interviewees described video visits as providing a space to reconnect with
loved ones that was free from many of the pressures and stresses of in-person
visiting. They described in-person visits as highly important, but also as an
emotionally difficult experience—especially for young children, who had to
endure long travel times and who may have been overwhelmed by the noise
and stress of the prison environment. The relative ease of video visits removed
some of these pressures. A male interviewee said that he found in-person
visits with his family to be “very emotional because they’re all nice people,”
while he considered himself to be “the bad apple.” He went on to say, “I like
that video visits aren’t like that—there’s not enough time to go into that. It’s all
laughs and giggles.” Video visits provided a less pressured medium through
which people could relax in each other’s virtual company. As one interviewee
explained, “Having the opportunity to video visit can make the first in-person
visit less awkward, particularly for women like me who’ve been separated

Closing the Distance: The Impact of Video Visits in Washington State Prisons

13

from their kids for a long time.” Video visits created a safe space for people to
strengthen their bonds before moving on to in-person visits.
Additionally, for loved ones in the community who were uncertain
about visiting an incarcerated person, video visits may have been a
medium for the incarcerated person to demonstrate why they should visit.
One man said that through participation in cognitive-behavioral group
therapy while in custody, he had developed as a person since he last saw
his family. Video visits allowed him to communicate this to them. “Contact
is important,” he concluded. “I try to let people know that I’ve changed.”

Users faced significant technical
challenges
Through its 2014 survey of people incarcerated in Washington State’s
prisons, Vera identified high levels of dissatisfaction with both the cost
and quality of the video visiting system.14 While the interviews described
here happened a year after the survey, most participants reported frequent
problems with their video visits’ picture and sound quality. Twelve of the
20 interviewees said they had experienced occasional or frequent problems
with the picture quality: Sometimes the image would flash, sometimes it
would freeze, and sometimes there would be no picture at all. Seventeen
participants reported poor audio quality, with voice delays making it
difficult to have a natural conversation. Interviewees said that if they lost
the connection entirely, they could usually get credit toward another visit.
These technical problems were a source of great frustration and upset
for the interviewed incarcerated people and their families, potentially
undermining the positive aspects of the service. As one interviewee
recounted, “When it didn’t work, my husband told me that my son was
sitting outside in the yard, totally crushed.” Another explained that, “When
I talk to my younger kids, sometimes they think I’m mad because I’m not
saying anything, but it’s because I can’t hear.”
The interviewees expressed dissatisfaction with the service cost,
especially given the problems with its quality. As one person said, “For what
we’re actually getting, it’s ridiculous.” Nine of the 20 interviewees said that
they would use the service more if it were more affordable. Nevertheless,
another person concluded, “It seems pretty expensive, but it’s all we’ve got.”

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In-prison behavior
and video visits

W

hile research has demonstrated the positive impact of inperson visits on post-release recidivism rates, fewer studies
have questioned whether in-person visits similarly influence
incarcerated people’s behavior while in custody. One recent study of people
incarcerated in Florida state prisons showed mixed results, including
short-lived and quickly reversed decreases in infraction rates associated
with the anticipation of a visit.15
Using the same methodology described above to identify the impact
of video-visit use on in-person visit rates, Vera researchers sought to
determine whether video visits affected the number of infractions people
in the sample committed. The researchers conducted BART and IPTW/
DID analyses to determine whether regular users of the service exhibited a
change in the number of infractions they committed, the number of serious
infractions they committed (as defined by WADOC policy), or the number of
general, non-serious infractions during the year following the video service’s
implementation. Neither analysis found any significant impact of video
visiting on any of the outcomes. It should be noted, however, that infraction
rates were already very low for all groups prior to implementation.
Infraction rates are a narrow and limited metric with which to assess
people’s conduct; they do not capture increases in positive behavior.
However, the interviews with incarcerated people suggest that video visits
may have some positive impacts. One interviewee explained, “[Video
visiting] makes you reconnect with society… Even though it’s only a
video, it makes you remember there’s something outside of here.” Other
interviewees suggested that these glimpses into life outside of the prison,
into the daily lives and homes of their loved ones, motivated them to
improve their lives; as one participant stated, video visiting “supports my
positive change, it reminds me why I’m trying to be a better person… even
though I’ve got life without parole, there is still a chance for me.”
Yet some participants cautioned that frustrations with video service
glitches could worsen people’s behavior. As one interviewee said, “When
you’re incarcerated and you expect something and don’t get it, it can be really
bad. If you let it get to you, you can end up back in [solitary confinement].”

Closing the Distance: The Impact of Video Visits in Washington State Prisons

15

Additional research can help to clarify the positive or negative effects
of both video and in-person visits on video service users’ in-prison
behavior. Vera’s analysis shows, as the findings below reveal, that during
the study period both video visit and in-person visit rates were low
throughout Washington’s prison system. Furthermore, visit rates varied
by the demographic characteristics of the people who were incarcerated.
Because staying connected with supportive people in the community
fosters good post-prison outcomes, the disparate visit rates for various
groups in the Washington prison population merit further scrutiny.

In-person visits in
Washington State prisons

V

era’s analysis established that participating in video visits increased
the number of in-person visits that incarcerated people received,
but also showed that only a small proportion of the prison
population used the service. To give context to these findings, Vera
analyzed the statewide prevalence and frequency of in-person visits in the
year following the implementation of the video visit service.
The analysis of WADOC administrative data revealed that nearly half
(45 percent) of incarcerated people did not receive in-person visits during
the year ending November 2015. As described below, visit rates varied:
Women and people under 45 were more likely to receive visits than men
and older incarcerated people. For all groups, however, the further people
were held from their homes, the fewer visits they received.16

In-person visits, from few to none
Nearly 45 percent of people incarcerated in Washington State’s prisons had
no visits during the year-long study period. Of those who had in-person
visits, the average number per person was between eight and nine. As
Figure 1 shows, over 13 percent of the sample received one to two inperson visits, 11 percent received three to five, and 18 percent received
more than 12 in-person visits during this one-year period.

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Figure 1

Number of in-person visits received between
November 30, 2014 and November 30, 2015

> 12 visits
18%

10-12
visits
4%

0 visits
45%

6-9 visits
8%
3-5 visits
11%
1-2 visits
14%

n = 11,524

Demographic disparities in visit rates
Vera analyzed the demographics of people who received in-person visits
during the study period. The findings below show that many of the people
who were least likely to receive video visits—such as older people or those
with mental health needs—were also less likely to receive in-person visits,
meaning the service was not benefiting those who needed it the most.

Women had more in-person visits than men
While 54 percent of men in the sample received visits during the year, 74
percent of the women had visits. Consistent with national trends, women
received more visits on average than men—12.5 per year compared to 8.3.17
Vera’s analysis found that women received more visits than men independent
of the distance they were held from their homes. However, Washington
State’s two women’s prisons are located near Seattle and Tacoma—the state’s
largest and third-largest cities, respectively—making them more accessible
than the more remote male facilities. Factors such as the availability of public
transport or direct routes to the facilities may correlate with the number of
visits people receive, in addition to physical proximity.

Closing the Distance: The Impact of Video Visits in Washington State Prisons

17

Figure 2

Average number of in-person visits by gender and race

T T

14

Female

Male

14

10
9.5
8.6

7.8

Number of visits

8.4

7
6.5

0
Black

Hispanic

Native American

White

n = 11,524

There were racial disparities in visiting rates
among women
White women, on average, received about 14 in-person visits throughout
the year, while black women received 9.5, and Hispanic women received
approximately seven in-person visits. This disproportionate pattern was
less pronounced for men.

Younger people received more in-person visits
The average number of in-person visits decreased among people over the
age of 45.18 People in age groups under 45 received an average of between
nine and 10 in-person visits; however, those over 45 received six in-person
visits on average. (See Figure 3.)

People with mental health disorders received fewer visits
On average, people living with mental health disorders received six inperson visits during the year, compared to members of the general prison
population who did not have a diagnosed disorder, who received between
nine and 10 visits on average.19

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Figure 3

Average number of in-person visits by age

I•
10

9.2

10

9.3

I•

I•

46-55

56+

5.9

6

0
25 and under

26-35

36-45

n = 11,524

Visit rates were higher for people who had been
incarcerated for long sentences
Researchers found a slight upward trend in the number of visits that
people received in relation to the length of time that they had been
incarcerated. Those in the first year of their sentence received an average
of eight in-person visits, while those who had already served 10 or more
years received an average of 10 in-person visits a year. (See Figure 4.)

People received fewer visits the further they were
incarcerated from their homes
Vera found that, in Washington State, the mean distance from home for
incarcerated people was nearly 130 miles (median = 113 miles)—about a twohour car ride. Because Vera researchers calculated distance using straightline measurements (or “as the crow flies”), actual distances by road and the
associated travel times are greater. Further, for people without access to a
car who rely on public transportation, with the constraints of timetables and
fixed routes, traveling this distance would likely take even longer.

Closing the Distance: The Impact of Video Visits in Washington State Prisons

19

Figure 4

Average number of in-person visits by length of incarcertion
I
~

10

I

10

~

t".l
7.5

t".l

0-1 year

1-3 years

9

8.3

t".l
8.5

0
3-5 years

5-10 years

10+ years

n = 11,524

Vera researchers created a model that would test the significance of the
relationship between in-person visits and individual-level characteristics,
including distance from home, gender, race, age, mental health status,
and length of incarceration. Each of these variables was found to be
significantly correlated to the number of visits people received (p<0.001).
The model is presented in Appendix C.
The model shows that the number of in-person visits people received
decreased by about 1 percent for every additional mile in distance from
home they were incarcerated. For men, all else being equal, the predicted
average number of visits for someone held 58 miles from home is eight per
year; for men held 184 miles from home, this number drops to three, and at
327 miles from home the model predicts 1.5 visits per year.
Gender differences in visiting rates remained even when controlling for
distance from home, with women being more likely than men to receive visits.
Consistent with the descriptive statistics presented above, the model also
found that, for every year increase in a person’s age, the rate of in-person visits
decreases by about 2 percent. However, there was a 2 percent increase in the
number of visits received for every year a person had been incarcerated.

20

Vera Institute of Justice

Conclusion

S

taying connected to loved ones outside of prison is important to the
well-being and success of incarcerated people in leading safe and
crime-free lives after release. Video visits provide another avenue for
incarcerated people to reconnect with family and friends. Vera’s analysis
shows that use of the service may strengthen people’s relationships to those
on the outside, as demonstrated by a subsequent increase in the number of
in-person visits they received. However, only a small portion of incarcerated
people used the service during the period under study, and even those who
did reported that the service’s cost limited their use. Although the $12.95 fee
is less than the cost of a long-distance trip, the calls are short and the sound
and video quality are often poor. Furthermore, $12.95 is a significant sum for
incarcerated people, who may rely on friends and family to send them money
to supplement the small amounts they can earn in prison-based jobs.
In-person visit rates were low across the state, and the small proportion
of incarcerated people who used video visits on a regular basis indicated that
the service alone cannot be relied on to increase contact with their loved
ones. Further, Vera’s analysis of in-person visits shows that some of the very
groups within the prison population who may be most in need of additional
support from family and friends, such as older people and those with mental
illness, received both the fewest in-person visits and the fewest video visits.
It does not appear that video visits themselves can reverse disparities in
outside support for some of the most vulnerable people in prison.
While research has demonstrated that in-person visits can benefit
incarcerated people, their families, and the wider community by increasing
well-being and decreasing recidivism, structural factors in U.S. corrections
systems impede efforts to encourage this connection. Throughout most
of the country, people convicted of crimes wind up incarcerated in
facilities in remote locations. The fact that typically people are held at
great distances from their home communities continues to be a significant
barrier to meaningful contact. Although video visits contribute to easing
the separation, it would be far preferable if corrections departments
nationwide eliminated this factor entirely. Housing people in their custody
in facilities that are close to, and accessible from, their home communities
could go a long way toward supporting people during their incarceration
and as they reenter society and seek to build stable, connected lives.
Closing the Distance: The Impact of Video Visits in Washington State Prisons

21

Exhibit 7
Susan D. Phillips, Ph.D., Video Visits for Children Whose Parents are Incarcerated: In Whose
Best Interest? (Oct. 2012)

Video Visits for Children
Whose Parents Are
Incarcerated:
In Whose Best Interest?
Susan D. Phillips, Ph.D.
October 2012

For further information:
The Sentencing Project
1705 DeSales St., NW
8th Floor
Washington, D.C. 20036
(202) 628-0871
www.sentencingproject.org

This report was written by Susan D. Phillips, Ph.D., research analyst
at The Sentencing Project.
The Sentencing Project is a national non-profit organization engaged
in research and advocacy on criminal justice issues.
The work of The Sentencing Project is supported by many individual
donors and contributions from the following:
Morton K. and Jane Blaustein Foundation
Ford Foundation
Bernard F. and Alva B. Gimbel Foundation
General Board of Global Ministries of the United Methodist Church
Herb Block Foundation
JK Irwin Foundation
Open Society Institute
Public Welfare Foundation
David Rockefeller Fund
Elizabeth B. and Arthur E. Roswell Foundation
Tikva Grassroots Empowerment Fund of Tides Foundation
Wallace Global Fund
Working Assets/CREDO
Copyright @ 2012 by The Sentencing Project. Reproduction of this
document in full or in part, and in print or electronic format, only by
permission of The Sentencing Project

1

VIDEO VISITS FOR CHILDREN WHOSE PARENTS ARE INCARCERATED | IN WHOSE BEST INTEREST?

“If video visits are an addition [to in-person visits] they will be a help to all and a God-send to
many. But, if video visits are a replacement for the current visitation, their implementation
would be a painful unwelcomed change that would be impersonal and dehumanizing.” 1

O

n any given day, approximately 2.6 million children (or about 1 in every
33) have a parent in jail or prison. 2 Until relatively recently, few people
paid attention to what happens to children when their parents are
incarcerated, but as the number of parents in jails and prisons grew
during the 1980s and 1990s there began to be an appreciation that incarcerating
parents can have a profound and enduring effect on their children. 3
The circumstances and experiences of individual children whose parents are sent to
jail or prison differ markedly, 4 but collectively this group of children experience
greater childhood adversity on average than other children. The causes of that
adversity are varied, including parental (e.g., addiction, mental illness), familial (e.g.,
poverty, violence, disrupted ties), and community problems (e.g., community
violence, exposure to drug markets, inadequate schools, delinquent peers). 5, 6 , 7
Sending parents to jail or prison can exacerbate the adversity in children’s lives and
negatively affect their well-being independent of other factors. For example, the
arrest and incarceration of parents can affect children’s ability to form relationships
with other people, precipitate feelings of grief and anxiety, and spawn symptoms of
post-traumatic stress. 8, 9 , 10 A parent’s incarceration can also result in children being
socially isolated from peers, contribute to disruptive behaviors, reduce school
performance, and exacerbate poverty and instability within families and
communities. 11, 12 , 13
As a society, we recognize the need for children who are separated from their
parents to maintain personal relations and have direct contact with their parents on a
regular basis unless compelling evidence indicates that doing so is contrary to a
child’s best interests. 14 But children whose parents are sent to jail or prison are
treated differently than children who are separated from their parents for other
reasons such as divorce, hospitalization, death, adoption, foster care placement, or
military deployment. The loss of a parent to jail or prison is often overlooked,

2

VIDEO VISITS FOR CHILDREN WHOSE PARENTS ARE INCARCERATED | IN WHOSE BEST INTEREST?

unacknowledged, and dismissed. There are no rituals to mark the child’s loss and no
outpouring of community concern when a parent is incarcerated. 15
In the last 20 years, there have been growing efforts to support and nurture children
when their parents are incarcerated. Those efforts include, among other things,
facilitating opportunities for children to visit their parents in jails and prisons,
increasing opportunities for children to have physical contact with their parents
during visits, and instituting programs that allow children to take part in normal
parent-child activities with their parents during visits. 16, 17 , 18

BARRIERS TO CHILDREN VISITING THEIR PARENTS
It is not easy for children to visit their incarcerated parents, particularly if their
parents are in prison rather than in local jails. A majority of parents in prison are
housed more than 100 miles from their children. 19 Distance, along with the high
costs of transportation, food, lodging, and the time involved make it difficult for
families to take children to visit their parents. 20, 21 Roughly half of all parents in
prison (59% of those in state prison and 45% in federal prison) have never had a
visit from any of their children. 22
Security procedures can make visiting stressful. Visitation procedures are often strict,
arbitrarily enforced, and include subjecting children to searches. In some facilities,
children can only communicate with their parents through a glass barrier. In others,
they meet with their parents in crowded, noisy visiting rooms. Interactions between
children and their parents are strictly regulated, with watchful correctional officers
close by causing parents concern that their children’s normal behaviors might
unintentionally violate rules. 23, 24 Some facilities have special programs for a limited
number of parents that allow children and parents to visit together in child-friendly
environments and engage in normal parent-child activities, but these are not the
norm. 25
The opportunity for children to visit their parents is further limited by facility visiting
hours. Many facilities only have daytime visiting hours, making it difficult for schoolage children and people who are employed to visit their family members. 26

“Growing Up with a Father in Prison: Part II”
Emani Davis, http://youtube/8DlfwLRtmjQ
“You never get used to it and you always know you don’t have any control
over anything so there’s just a level of anxiety that’s always going to be there.
Are they going to give me a hard time about these shoes? Am I allowed to do
this? Is there going to be a problem if I wear this? Even though you know
what the rules are, they can be interpreted however they want depending on
the day and the officer at the front.”

3

VIDEO VISITS FOR CHILDREN WHOSE PARENTS ARE INCARCERATED | IN WHOSE BEST INTEREST?

THE ADVENT OF VIDEO VISITATION
Even as advocacy groups and community organizations are pushing to remove
barriers to children visiting their incarcerated parents, changes are occurring in
correctional visitation practices: jails and prisons are shifting to video visitation –
visitation using real-time video conferencing technology similar to Skype.
Correctional facilities have been using video systems since the 1990s. Based on
interviews with system vendors, criminal justice officials, legal experts, and news
reports, the New York Times estimates that correctional facilities in at least 20 states
already have video capability or have plans to adopt the technology. 27
The benefits of video visitation for correctional facilities are described as reducing
the risk of contraband entering facilities, cost savings because fewer staff are needed
to oversee visits and, in some cases, increased revenue from fees paid by inmates or
visitors. 28,29 In Idaho, Sheriff Gary Raney of the Ada County Sheriff’s Office claims
that the virtual visitation system put in place there will have produced over $2 million
in revenue over the course of two years. 30 The companies that provide the
equipment and software that correctional facilities need to retool for and manage
video visitation are also benefiting. In fact, these companies have been referred to as
“the newest player in the prison-industrial complex.” 31
But, what about the 2.6 million children whose parents are in jail or prison? Are they
benefiting?
Possibly.
Children may benefit from video visitation if it increases opportunities for them to
communicate with their parents. But video visitation is not a substitute for in-person
contact visits, particularly for infants and young children.

POTENTIAL BENEFITS AND LIMITING FACTORS OF VIDEO
VISITATION FOR CHILDREN
To the best of our knowledge, children’s experiences visiting their incarcerated
parents via video have not yet been studied, but video visitation has been used to
help children maintain relations with parents who are absent under other
circumstances. Military families, for example, use video calls and other forms of ecommunication to help children stay connected with their parents when they are
deployed. 32 Family courts also sometimes include virtual visitation in divorce decrees
as a way for children to maintain relations with their absent noncustodial parents. 33,34
Experience in these areas suggests that video visitation may make separation from a

4

VIDEO VISITS FOR CHILDREN WHOSE PARENTS ARE INCARCERATED | IN WHOSE BEST INTEREST?

parent who is incarcerated more tolerable by reducing family stress and helping
parents and children stay connected, 35 but that it is not a substitute for face-to-face
contact. 36
Children stand to benefit from correctional facilities transitioning to video visitation
if such visitation increases the frequency with which they can communicate with
their parents. Video visitation policies, however, vary markedly with respect to
whether visitors are required to travel to facilities to visit via video or can visit from
their homes or communities, the frequency and duration of visits, and costs.
Facility versus community based visits
In some instances (typically jails) families have to take children to correctional
facilities to visit via video. Rather than parents being brought to a visiting area to
meet with their children, parents remain on their units and children see and speak to
them via video. 37, 38 , 39
In other jurisdictions, families are able to visit via computers in their homes 40 or
other community locations. 41,42 Some jurisdictions make arrangements with
community organizations (e.g., churches, not-for-profit organizations, bail bond
companies) to host computer stations so families without internet access are not
excluded from video visitation. 43 In Pinellas County, Florida, the Sheriff’s Office
outfitted a bus with video visitation equipment, which travels to four cities. 44 Some
community organizations that host video visitation couple visits with other
“Visiting a Detainee in DC is Now Done by Video”

P. Hermann, July 28, 2012, The Washington Post
“When Ciara Jackson visited her boyfriend at the D.C. jail three weeks ago,
her 5-year-old daughter Talia reached out and touched the glass partition
separating her from her father. He pressed back from the other side.
‘It seemed real,’ said Jackson, 20.
That intimacy, though restricted is now gone. Jackson and other visitors must
chat by video, with cameras aimed at detainees in the jail and at their loved
ones a few hundred yards away in a building attached to the former D.C.
General Hospital Complex in Southeast D.C.
Prisoner rights groups complain that the video visits – a growing trend at jails
across the country – deprive the detained of interacting with flesh-and-blood
people and contradict a long-held philosophy that family visits are vital to
rehabilitation and morale.”

5

VIDEO VISITS FOR CHILDREN WHOSE PARENTS ARE INCARCERATED | IN WHOSE BEST INTEREST?

programming for children and their incarcerated parents so that the visit becomes a
supportive, therapeutic intervention to improve parent-child relationships. 45 , 46
Fees
Anyone with a computer or cell phone with a camera and an internet connection can
make video calls at no cost using readily available free software such as Skype, but
some correctional facilities and community sites charge fees for video visitation. 47,48
In some cases the fees go to the correctional facility and in others they go to the
community organizations that host remote visitation sites. 49
Fees vary widely. The Ada County Jail in Idaho allows visitors to register for two free
25-minute video visits per week and charges a small fee for additional visits. 50 In
contrast, Indiana’s Rockville Correctional Facility charges families $12.50 for 30
minutes of virtual visitation, which is only slightly less than the $15 charge for a 30minute local phone call. 51
The Virtual Visitation Program in Pennsylvania allows one 55-minute virtual visit a
month for $15, with the fee going to the not-for-profit hosting the program. Priority
for virtual visitation is given to inmates who participate in parenting skills classes and
other family-oriented programs. 52 In Virginia, the Department of Corrections
recently expanded its virtual visitation program and charges $15 for a 30-minute and
$30 for a 60-minute visit with the fees going to community churches that host
visiting sites. 53

SUMMARY
Jail and prison administrators are often attracted to video visitation for its potential
cost savings and profits as well as security benefits. Video visitation can be managed
with fewer personnel than regular visitation and the risk of contraband entering
facilities is reduced. Video visitation is also a potential source of revenue for facilities
and for the companies that provide video visitation equipment and software. Renovo
Software, a company that specializes in video communication software, frames the
use of virtual visitation as a profitable business venture complete with the potential
to use advertisements on the computer stations. 54
The potential for video visitation to benefit children will largely depend on the
policies of the facilities in which their parents are housed. Video visitation can be
expected to have the greatest benefits when:
•
•

used as an adjunct to rather than a replacement for other modes of
communication, particularly contact visits;
children can visit from their homes or nearby sites;

6

VIDEO VISITS FOR CHILDREN WHOSE PARENTS ARE INCARCERATED | IN WHOSE BEST INTEREST?

•
•

facility policies allow for frequent visits; and
fees are not cost prohibitive.

The Vermont Legislative Research Services office cut to the heart of the matter
when it concluded:
Corrections administrators should be cognizant that traditional contact visitation is the
best means of communication between children and their incarcerated parent; however, in
many circumstances it is impractical for families to visit their loved ones in prison.
Virtual visitation helps if the prison is too far, transportation is too expensive, or the
prison environment is inappropriate for a child. In-person visitation is regarded as the
most effective form of child-incarcerated parent visitation. 55

Beazar, C. (2008) Video Visitation. The Real Cost of Prisons Project.
http://realcostofprisons.org/writing/beazer_video.html
2 Estimate uses data published by the Bureau of Justice Statistics (Glaze, L.E. & Maruschak, L.M.
[2008], Parents in prison and their minor children, and Glaze, L.E. [2011], Correctional populations, 2010). An
estimated 53% of all people in prison are parents with an average of 2.1 children. The total number
of children with incarcerated parents (2.6 million) was derived by applying these estimates to the total
number of people in jails and prisons in 2010 (2.3 million). That number was then divided by the
number of children under age 18 based on 2010 Census estimates (74.1 million) to arrive at the
estimated percentage of children with parents in jail or prison (3.1%).
3 Murray, J. (2008). Longitudinal research on the effects of parental incarceration on children. In
Eddy, J. M. & Poehlmann, J. (Eds). Children of incarcerated parents: A handbook for researchers and
practitioners (pp. 55-74). Washington, DC: Urban Institute Press.
4 Maruschak, L. M., Glaze, L.E., & Mumola, C.J. (2010). Incarcerated parents and their children:
Findings from the Bureau of Justice Statistics. In Eddy, J. M. & Poehlmann, J. (Eds). Children of
incarcerated parents: A handbook for researchers and practitioners (pp. 33-52). Washington, DC: Urban
Institute Press.
5 Johnson, E. I., & Waldfogel, J. (2002). Children of incarcerated parents: Cumulative risk and
children's living arrangements. New York: Columbia University.
6 Phillips, S. D., Burns, B.J., Wagner, H.R. & Barth, R.P. (2004). Parental arrest and children involved
with child welfare services agencies. Journal of Orthopsychiatry, 2, 174-186.
7 Phillips, S.D., Burns, B.J., Wagner, H.R., Kramer, T.L. & Robbins, J.M. (2002). Parental
incarceration among adolescents receiving mental health services. Journal of Child and Family Studies, 11,
385–399.
8 Poehlmann, J. (2005). Representation of attachment relationships in children of incarcerated
mothers. Child Development, 76, 679-696.
1

7

9Walker,

VIDEO VISITS FOR CHILDREN WHOSE PARENTS ARE INCARCERATED | IN WHOSE BEST INTEREST?

C.A. (2005). Children of incarcerated parents: Full report. Pittsburgh: Pittsburgh Child Guidance
Center. http://www.foundationcenter.org/grantmaker/childguidance/linked_files/incarcerated.pdf
10 Ibid. 7
11 Cho, R.M. (2009) The impact of maternal imprisonment on children’s education achievement:
Results from children in Chicago Public Schools. Journal of Human Resources, 44, 772-797.
12 Phillips, S.D., Erkanli, A., Keeler, G.P., Costello, E.J., & Angold, A. (2006). Disentangling the risks:
Parent criminal justice involvement and children’s exposure to family risks. Criminology and Public
Policy, 5, 677-702.
13 Rose, D. R., & Clear, T. R. (1998). Incarceration, social capital, and crime: Implications for social
disorganization theory. Criminology, 26, 441-478.
14 Boudin, C. (2011). Children of incarcerated parents: The child’s constitutional right to the family
relationship. The Journal of Criminal Law and Criminology, 101, 77-118.
15 Bocknek, E.L., Sanderson, J. & Britner, P.A. (2009). Ambiguous loss and posttraumatic stress in
school-age children of prisoners. Journal of Child and Family Studies, 18, 323-333.
16 Block, K. J. (1999). Bringing scouting to prison: Programs and challenges. Prison Journal, 79, 215.
17 Snyder, Z.K., Carol, T.A., & Mullins, M.M. (2001). Parenting from prison: An examination of a
children's visitation program at a women's correctional facility. Marriage and Family Review, 32, 33-62.
18 Tennessee Department of Corrections: Child Visitation Program
http://www.tn.gov/correction/institutions/child.html
19 Mumola, C. (2000). Incarcerated parents and their children. Washington, D.C.: Bureau of Justice Statistics.
20 Christian, J. (2005). Riding the bus. Journal of Contemporary Criminal Justice, 21(1), 31-48.
21 Monroe, A. (nd). Effects of prison location on visitation.
http://scholarworks.boisestate.edu/cgi/viewcontent.cgi?article=1109&context=mcnair_journal
22 Glaze, L. E., & Maruschak, L. M. (2008). Parents in prison and their minor children (NCJ 222984).
Washington, DC: Bureau of Justice Statistics.
23 Dunn, E. & Arbuckle, J.G. (2002). Children of incarcerated parents enhanced visitation programs: Impacts of
the Living Interactive Families (LIFE) Program. University of Columbia, Missouri.
http://extension.missouri.edu/4hlife/guide/4HLIFE_guide_appendix_09.pdf
24 Parke, R., & Clarke-Stewart, A. (2002). Effects of parental incarceration on young children. Washington,
D.C.: The Urban Institute.
25 Girl Scouts of the USA. (2008). Third year evaluation of Girl Scouts Beyond Bars. NY: Author.
http://www.girlscouts.org/research/pdf/gsbb_report.pdf
26 Ibid. 24
27 Emmanuel, A. (2012). In-person visits fade as jails set up video units for inmates and families. New
York Times.
http://query.nytimes.com/gst/fullpage.html?res=9401E1D91039F934A3575BC0A9649D8B63
28 Eickhoff, T. (2010). Video visitation: Evolving revenue streams. Corrections One News.

8

VIDEO VISITS FOR CHILDREN WHOSE PARENTS ARE INCARCERATED | IN WHOSE BEST INTEREST?

Gresko, J. (2009). Families visit prison from comfort of their homes
http://www.azcentral.com/offbeat/articles/2009/07/02/20090702ArmchairPrison.html#ixzz24hY8
4ff3
30 Corrections One News. Internet video visitation: Why and how to make the switch.
http://www.correctionsone.com/products/facility-products/inmate-visitation/articles/2075432Internet-video-visitation-Why-and-how-to-make-the-switch/
31 Russia Today, Video Visits: The Latest Player in the Prison-Industrial Complex
http://www.youtube.com/watch?v=IVNHRxPotSI
32 Parent’s guide to the military child during deployment and reunion.
http://www.usarak.army.mil/crisisassistance/Documents/Parents_Guide_Deployment_Reunion.pdf
33 Gramlich, J. (2009). States expand video conferencing. Stateline.
34 Welsh, D., (2008). Virtual parents: How virtual visitation legislation is shaping the future of custody
law. Journal of Law and Family Studies, 11, 215-224.
35 Van Pelt, J. (2011) Parental deployment and child mental health. Social Work Today, 11, 30.
36 Graham v. Graham, 794 A.2d 912, 915 (Pa. Super. Ct. 2002).
37 Hermann, P., J. Visiting a Detainee in D.C. is Now Done by Video. July 28, 2010, The Washington
Post.
38 Inmates, visitors benefit from new jail visitation system.
http://youtube.com/watch?v=Svz8HnEVWoM
39 Hillsborough County Sheriff’s Office. Video visitation center rules and regulations.
http://www.hcso.tampa.fl.us/getdoc/987260f8-1fa5-4eff-ac70-c21963f97031/Video-VisitationCenter.aspx
40 Quinn, R. (2009) Video prison visits bring inmates home. Newser.
http://www.newser.com/story/63373/video-prison-visits-bring-inmates-home.html
41 Ibid. 28
42 Assisting Families of Inmates, Inc. http://www.prisoneducation.com/prison-educationnews/2012/3/10/assisting-families-of-inmates-inc.html.
43 Ibid. 28
44 Video visitation bus connects jail inmates to families http://www.govtech.com/public-safety/VideoVisitation-Bus-Connects-Jail-Inmates.html
45 Crabbe, M. (2002). Virtual visitation program uses video conferencing to strengthen prisoner
contacts with families and children. Offender Program Report, 6, 35-36, 47.
https://www.ncjrs.gov/App/Publications/abstract.aspx?ID=197834
46 PB&J Family Services, TVCP (Tele-Visitation for Children of Prisoners).
http://pbjfamilyservices.org/prisonrelated.html
47 Maryland General Assembly, Department of Legislative Services. Fiscal and Policy Note HB 796 –
Bringing Maryland Families Together Act. http://mlis.state.md.us/2012rs/fnotes/bil_0006/hb0796.pdf
29

9

VIDEO VISITS FOR CHILDREN WHOSE PARENTS ARE INCARCERATED | IN WHOSE BEST INTEREST?

Vermont Legislative Research Services. Prison Video Conferencing. The University of Vermont, James
M. Jeffords Center.
http://www.uvm.edu/~vlrs/CriminalJusticeandCorrections/prison%20video%20conferencing.pdf
49 Virginia Department of Corrections. Video Visitation.
http://www.vadoc.state.va.us/offenders/prison-life/videoVisitation.shtm
50 Ada County Jail Video Visitation. http://www.youtube.com/watch?v=eOcgTKsz4pE
51 Ibid. 29
52 Crabbe, M. (2002). Virtual visitation program uses video conferencing to strengthen prisoner
contacts with families and children. Offender Program Report, 6, 35-36, 47.
https://www.ncjrs.gov/App/Publications/abstract.aspx?ID=197834
53 Ibid. 48
54 Ibid. 28
55 Ibid. 48
48

FURTHER READING AVAILABLE AT www.sentencingproject.org:
Fact Sheet: Parents in Prison
Incarcerated Parents and Their Children: Trends 1991-2007
Women in the Criminal Justice System

1705 DeSales Street, NW, 8th floor
Washington, DC 20036
Tel: 202.628.0871 • Fax: 202.628.1091
www.sentencingproject.org

Exhibit 8
Stacie Anne Deslich, MA, MS; Timothy Thistlethwaite, MD; Alberto Coustasse, DrPH, MD,
MBA, MPH, Telepsychiatry in Correctional Facilities: Using Technology to Improve Access and
Decrease Costs of Mental Health Care in Underserved Populations, The Permanente Journal
(Summer 2013).

REVIEW ARTICLE

Telepsychiatry in Correctional Facilities: Using Technology
to Improve Access and Decrease Costs of Mental Health Care
in Underserved Populations
Stacie Anne Deslich, MA, MS; Timothy Thistlethwaite, MD; Alberto Coustasse, DrPH, MD, MBA, MPH

Perm J 2013 Summer;17(3):80-86
http://dx.doi.org/10.7812/TPP/12-123

Abstract
Objective: It is unclear if telepsychiatry, a subset of telemedicine, increases access to mental health care for inmates in
correctional facilities or decreases costs for clinicians or facility
administrators. The purpose of this investigation was to determine
how utilization of telepsychiatry affected access to care and
costs of providing mental health care in correctional facilities.
Methods: A literature review complemented by a semistructured interview with a telepsychiatry practitioner. Five electronic
databases, the National Bureau of Justice, and the American
Psychiatric Association Web sites were searched for this research,
and 49 sources were referenced. The literature review examined
implementation of telepsychiatry in correctional facilities in
Arizona, California, Georgia, Kansas, Ohio, Texas, and West
Virginia to determine the effect of telepsychiatry on inmate access to mental health services and the costs of providing mental
health care in correctional facilities.
Results: Telepsychiatry provided improved access to mental health services for inmates, and this increase in access is
through the continuum of mental health care, which has been
instrumental in increasing quality of care for inmates. Use of
telepsychiatry saved correctional facilities from $12,000 to
more than $1 million. The semistructured interview with the
telepsychiatry practitioner supported utilization of telepsychiatry
to increase access and lower costs of providing mental health
care in correctional facilities.
Conclusions: Increasing access to mental health care for this
underserved group through telepsychiatry may improve living
conditions and safety inside correctional facilities. Providers, facilities, and state and federal governments can expect increased
savings with utilization of telepsychiatry.

Introduction
Substantial growth in technology has improved the delivery of
medical care and increased access for patients seeking care. One
area in which technology has made meaningful contributions is
telemedicine, the delivery of health care across distance via the
use of technology and communication modalities.1 Telemedicine has been used for medical information interchange and
to facilitate diagnosis, referral, monitoring, and interventions

to offset higher costs associated with hard-to-access patients.2
Telepsychiatry has been one area of telemedicine that has continued to grow and improve. Telepsychiatry has been defined as
using telecommunication modalities, including teleconferencing
software, hardware, and supporting infrastructure, to provide
mental health care.3 Telepsychiatry has the potential to improve
patient access to care and lower costs of providing mental health
care.4 This technology has been shown to be used effectively in
rural areas, schools, forensic practices, and correctional facilities.5
This subspecialty of telemedicine has shown potential for
expanded use in correctional settings such as jails and prisons.6
The nation’s correctional facilities in 2007 held approximately
7.1 million inmates, and around half of these inmates had some
sort of mental illness.7 As the number of incarcerated individuals increases, the need for effective and appropriate psychiatric
treatment has continued to grow as well. Telepsychiatry has
begun to fill this need.8
Inmates in correctional facilities have long received substandard health care, including mental health care.9 Lack of proper
psychiatric services has led to untreated mental illnesses such
as depression, anxiety, bipolar disorders, and schizophrenia being common in the inmate population.7 Access to appropriate
psychiatric care has been limited in correctional facilities for
several reasons. In some cases, such as in West Virginia, Ohio,
and Georgia, various providers have been hesitant to provide
mental health treatment inside correctional facilities because of
safety concerns.3 In addition, costs for providers traveling to
distant facilities have been a deterrent to providing adequate
care to inmates. Besides transportation costs, there is an “opportunity cost” of not seeing more patients in the clinic because
of the long trip to the prison.10
It can be noted, however, that cases do exist in which the
practice of psychiatry in the correctional systems in some states,
such as California, is lucrative enough to offset such limitations. It
has been reported that 1 psychiatrist earned more than $820,000
in 2011 working for 1 prison in California. Also according to the
same authors, 14 prison psychiatrists earned more than $400,000
in this state, a level matched by only 12 other states.11
Transporting inmates outside correctional facilities for treatment has not been effective, either. The costs of transporting
an inmate, in actual transportation costs, person hours, and

Stacie Anne Deslich, MA, MS, is a Master of Science in Healthcare Administration, Graduate School of Business at
Marshall University in South Charleston, West Virginia. E-mail: deslich1@marshall.edu. Timothy Thistlethwaite, MD, is a
Psychiatrist and Medical Director of PSYMED Corrections, LLC, in Charleston, West Virginia. E-mail: timmyt114@yahoo.com.
Alberto Coustasse, DrPH, MD, MBA, MPH, is an Associate Professor of Healthcare Administration in the Graduate School
of Management at Marshall University in South Charleston, West Virginia. E-mail: coustassehen@marshall.edu.

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increased risk to public safety and security, have been a major
barrier to bringing inmates to providers for treatment. Additionally, prisons usually use two prison staff members to transport
inmates, which generates a need to replace those two officers
in the prison to avoid a security risk because of understaffing
the facility. Furthermore, many providers have been unwilling to
provide treatment to inmates in a private practice setting because
of increased danger to the providers and the other patients.12
Telepsychiatry in correctional facilities has been effective in
overcoming these barriers.
The National Bureau of Justice has reported that more than
50% of inmates in correctional facilities had a diagnosable mental
illness, including substance abuse.7 Recidivism, or reoffending
and reentering the correctional system within 3 years of release,
has been high among offenders with mental illness; approximately 25% of those inmates surveyed by the Bureau of Justice
who had been incarcerated 3 or more times had diagnosable
mental illnesses, specifically mania, depression, or a psychotic
disorder.7 With so many mentally ill inmates being released and
reoffending, correctional system administrators and providers
have had to examine ways to effectively treat mental illness and
to decrease recidivism among the mentally ill. Telepsychiatry
has been examined for its potential to do that.10
Several studies have examined the efficacy of telemedicine,
and telepsychiatry in particular, in correctional settings.1,9,13,14
Less research has been performed to examine the effect of
telepsychiatry on inmate access to mental health treatment or
the impact of telepsychiatry on costs of providing mental health
treatment in correctional facilities. This may have been because
of the difficulty in quantifying access or cost in providing this
treatment.15 The research that has been done, however, has indicated that telepsychiatry may play a pivotal role in providing
psychiatric treatment inside correctional facilities.16
Methods
The purpose of this review was to determine the effect of
telepsychiatry utilization on inmate access to mental health
services and on the cost of providing mental health care in
correctional facilities.
The method used was a literature review complemented
with a semistructured interview of the second author, Timothy
Thistlethwaite, MD, an experienced practitioner of telepsychiatry
who has used telepsychiatry in correctional facilities for more
than 17 years (see Sidebar: Questions asked in semistructured
interview of telepsychiatrist). This interview was tape recorded,
and only relevant answers were used to support the information found in the literature review to provide a contextualized
and more comprehensive overview of this technology and its
utilization in prisons.
Electronic databases of PubMed, Academic Search Premier,
ProQuest, PsycARTICLES, and Google Scholar were searched for
the terms telepsychiatry or tele mental health and prison or access
or cost. Reputable Web sites of the National Bureau of Justice
and the American Psychiatric Association were also mined. Only
articles that were written in English were included for review.
In an attempt to stay current in research, all articles that were
older than 12 years (starting from 2000) were eliminated from

The Permanente Journal/ Summer 2013/ Volume 17 No. 3

the search. References were reviewed and determined to have
satisfied the inclusion criteria if the material provided accurate
information about telepsychiatry with a particular focus on
prison mental health.
The results presented were extracted from journal articles,
case studies, and different Web sites from diverse sources, as
well as from the semistructured interview, to illustrate several
aspects of telepsychiatry in prisons that should be considered,
such as inmate access to mental health care and costs involved
with it. Academic articles and practitioner health information
technology sources were analyzed, and relevant categories
were identified.
Results
Forty-nine sources were selected for this review. Findings are
presented in the categories of access and savings.
Increased Access
Leonard17 cited limited access to appropriate mental health
care as a difficulty faced by many inmates. Inadequate access to
care has often led to prisoners having untreated mental illness,
which, in turn, has increased rates of violent behavior in correctional facilities as well as substantially increased recidivism.18
According to the World Health Organization Mind Project, 24%
of inmates with a mental illness have assaulted another inmate
in a correctional facility, and those with mental illness are 2
times more likely to be injured in a fight than inmates without
mental illness.19 On the other hand, Hilty et al20 found that using
telepsychiatry as the means for mental health treatment increased
access in rural, suburban, and urban settings. Similar results have
been supported in a 2005 study of telepsychiatry in a correctional
setting in New York as well.21 Furthermore, telepsychiatry has
been shown to increase access to mental health treatment for
patients in schools and for veterans.22,23
Questions asked in semistructured
interview of telepsychiatrista
• How have you implemented telepsychiatry into your practice
in correctional facilities?
• What method do you use to provide telepsychiatry to your
patients in prisons, ie, software, hardware, and Internet
connections?
• Who is involved in a typical telepsychiatry session
in a correctional facility?
• What services are provided via telepsychiatry?
• How have inmates reacted to the utilization of telepsychiatry?
• How has telepsychiatry benefited your practice?
• How has the utilization of telepsychiatry affected inmate
access to mental health care?
• How has the utilization of telepsychiatry affected the cost of
providing mental health services to inmates in your practice?
• Are there any other significant advantages or disadvantages
to telepsychiatry utilization in correctional facilities that we
have not discussed?
a

Timothy Thistlethwaite, MD, on March 28, 2012.

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Utilization of telepsychiatry has been shown to overcome
travel and cost barriers, allowing inmates to meet with a treating
psychiatrist via teleconference, thus allowing greater access to
treatment for the inmate and continuity of care without compromising public safety and security or incurring
increased transportation costs.24
… use of
Mental health treatment teams in correctional
telepsychiatry
settings
in the US normally include a psychiatrist,
in conjunction
psychologists,
therapists, and psychiatric nurses.
with electronic
Access to the team is facilitated by living-unit
medical records
supervisors and correctional caseworkers who
that have been
have direct contact with the general population
implemented
of the prison. The psychiatrist provides telepsyin correctional
chiatric services from a remote setting to inmates
facilities has
in the penitentiary. Services provided include
allowed for
psychiatric consultation, initial treatment evaluations, crisis intervention, medication management,
more effective
and patient education.25 Psychotherapy, although
provision of
available via telecommunications devices, is often
health care to
provided face to face by a therapist or psycholoinmates.
gist in the facility.
Several states have effectively implemented
telepsychiatry programs into their correctional facilities and have
been able to increase access to appropriate mental health care
for inmates. Arizona, California, Georgia, Kansas, Ohio, and West
Virginia have begun to use telepsychiatry in their correctional
facilities with some success (Table 1).
The Ohio State University Medical Center in Columbus, OH,
has partnered with the Ohio Department of Rehabilitation and
Correction to provide telepsychiatry services to inmates in Ohio
prisons, providing evaluation, patient education, and medication
management to more than 4000 inmates each year since 1998.26
Similarly, as of 1997, St Mary’s Hospital and the University of Arizona in Tucson have collaborated with the Arizona Telemedicine
Program to provide telemedicine and telepsychiatry to the Arizona
Department of Corrections. The University of Arizona Medical
Center and Maricopa Medical Center in Phoenix, AZ, provided
the base for this program to use telepsychiatry in rural prisons in
the state, thus reaching more inmates and encouraging increased
access to inmates who otherwise would have had lengthy waits
for mental health services and evaluations for treatment.27

In 1998, the University of Kansas Center for Telemedicine &
Telehealth implemented a telepsychiatry program that has served
the state prison system since then and has provided an average
of 70 telepsychiatry consultations each month. Telepsychiatrists
have provided care and been reimbursed on a fee-for-service basis,
and have delivered psychiatric services such as evaluation, treatment planning, medication management, and crisis intervention.14
In California, the California Department of Corrections and
Rehabilitation Division of Correctional Health Care Services
implemented a telepsychiatry program using contracted providers to meet the mental health needs of the inmates in 27
of the prisons in that state, and more than 4000 inmates have
received appropriate psychiatric care annually.28 This program
has increased public safety by preventing inmate transports,
decreased costs associated with those transports, and increased
inmate access to effective psychiatric treatment in the form of
psychiatric evaluations, medication management, and crisis
intervention.28 Johnston and Solomon29 found that the implementation and utilization of this telepsychiatry program saved
about $850 in inmate transportation costs, a savings of $4 million
in 2004 because of decreased travel and transportation costs,
as well as decreased costs for providing correctional officers to
facilitate the transport.
The University of Texas Medical Branch at Galveston has a
telemedicine program, in service since the early 1990s, providing
telepsychiatry services including medication management and
crisis intervention to correctional facilities at the county, state,
and federal levels in Texas. The program has grown to be one
of the largest providers of telepsychiatry worldwide (S Shelton,
MBA PA-C, personal communication, June 11, 2012).a This program, while providing vital services to the inmate population
in Texas, faces funding difficulties. Survival of the program will
depend on adequate and appropriate funding (S Shelton, MBA,
PA-C, personal communication, June 11, 2012).a
In West Virginia, mental health services are provided to inmates housed in the state’s prisons by an independent subcontractor, PsiMed Corrections LLC, under the contract of Wexford
Health Services with the state of West Virginia.30 PsiMed has
used a telepsychiatry system set up in the state’s only maximum
security prison to provide telepsychiatric care such as initial
treatment evaluation, medication management, crisis interven-

Table 1. States that implemented telepsychiatry programs in correctional facilities

82

Author, year
Nelson et al,14 2004

State
Kansas

Venable,33 2005
Ohio Department of Rehabilitation
and Correction,26 2006
California Legislative Analyst’s
Office,28 2007

Georgia
Ohio

Hincapie et al,27 2011
PsiMed Corrections LLC,31 2012

Arizona
West Virginia

California

Provider
University of Kansas Center for Telemedicine
& Telehealth
Augusta Correctional and Medical Institute
Ohio State University Medical Center
Office of Telemedicine Services, California
Department of Corrections and Rehabilitation
Division of Correctional Health Care Services
Arizona Telemedicine Program
PsiMed Corrections LLC

Population treated
Treatment provided to 1 jail in a pilot
program with all 62 participating inmates
Treatment provided to 5 prisons
Treatment provided to > 5000 inmates
annually
Treatment provided to 4400 inmates
annually in 27 prisons
Treatment provided to 11 rural prisons
Treatment provided to 4200 inmates
annually in 31 correctional facilities across
West Virginia

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Telepsychiatry in Correctional Facilities: Using Technology to Improve Access and Decrease Costs of Mental Health Care in Underserved Populations  

tion, and education about mental health to inmates throughout
31 of West Virginia’s correctional facilities.30 From 2003 to 2007,
PsiMed Corrections’ telepsychiatry program effectively provided
psychiatric treatment to more than 4000 inmates annually, thus
increasing inmate access to mental health treatment and decreasing travel costs for the treating psychiatrist.31
Gramlich32 identified that approximately 70% of telemedicine visits provided in the Georgia correctional system were
for mental health treatment. Georgia’s telepsychiatry program
has increased access to psychiatric care in 5 prisons in Georgia
since the mid-1990s.33
According to Dr Thistlethwaite, the interviewed telepsychiatric
practitioner, this technology has provided increased access to
mental health services for inmates, and this increased access,
in turn, has been instrumental in improving quality of care for
inmates by ensuring no disruption in continuity of care. Incarcerated individuals have experienced greater consistency with
medication management and have had less delay in receiving
appropriate care. As inmates are transferred from facility to
facility, psychiatric care and medication management can be
disrupted. Telepsychiatry can prevent such disruptions.
Inmates have further experienced greater access to care
because practitioners and clinical staff involved in patient care
have been able to use the same videoconferencing capabilities
to coordinate care. For example, in the central hub, a psychiatrist and an assistant gather information about an inmate, while
a counselor, psychologist, or nurse in the facility sits with the
inmate to facilitate communication between the treating psychiatrist and the inmate. This increase in communication has been
beneficial when more than one provider is involved in inmate
care, because the clinicians also have utilized teleconferencing
to communicate with each other and to provide better quality
and continuity of care. Furthermore, use of telepsychiatry in
conjunction with electronic medical records that have been
implemented in correctional facilities has allowed for more
effective provision of health care to inmates. Not only are two
treating mental health care practitioners able to communicate via
teleconference, psychiatrists and internists or specialists are also
able to utilize this technology to discuss ongoing care of inmates.
PsiMed Corrections uses Polycom Solutions, a high-definition
videoconferencing technology package (Polycom, Polycom
Inc, San Jose, CA) for each telepsychiatric session, which is
encrypted for privacy and for compliance with the Health Insurance Portability and Accountability Act (HIPAA). The contract
with the prison system is managed with a private contract that
the state bids out for medical care every three years. PsiMed
gets its reimbursement as a subcontractor on a capitation basis.
It has been the experience of the psychologist first author of
this review (SD) that the telepsychiatric session differs from a
face-to-face psychiatric session in only the method of delivery.
Most telepsychiatric interactions occur with a mental health
practitioner present with the inmate. Only in cases of particularly
violent or dangerous inmates are correctional officers present
during the session. Inmates have been provided identical treatment via telepsychiatry as they would have in a more traditional
setting. Additionally, more prisoners have been able to be seen,
as travel time has been decreased. These inmates have been able

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to discuss medication management as well as ongoing mental
health treatment issues with the psychiatrist and the prison medical team. Inmates have been able, via telepsychiatry, to continue
to receive psychiatric services from the same provider, regardless
of the prison in which they have been incarcerated, thus avoiding
a period of adjusting to and developing therapeutic rapport with
a different provider after transfer to a different prison.
According to Thistlethwaite, drawbacks to utilization of telepsychiatry in correctional facilities are mostly technical. Many
providers who use the correctional facilities’ Internet access
must gain access past the facilities’ firewalls. This demands the
ongoing cooperation of the prison administrators, which has not
always been offered,32,34 as well as an adept team in the information technology department. Furthermore, Gramlich32 notes that
the prison servers are not always reliable, and connections may
be inadequate for providing telepsychiatric care. Lee35 noted
concerns of some researchers, such as lack of nonverbal communication or confidentiality issues. Thistlethwaite disagreed
with this, noting that proper placement of the videoconferencing
equipment to adequately capture the movements of the inmate
allows for visual identification of clinically significant motor
movements and body language, and confidentiality agreements
are signed, as well as informed consent to treatment, upon
inmates entering a facility.
Thistlethwaite also noted that inmate satisfaction has not
appeared to suffer with the use of telepsychiatry. In fact, in his
personal experience, many inmates seem to prefer this form of
treatment because of increased access to the psychiatrist. The
notion that the use of telepsychiatry is supported by inmates
has been reinforced by findings in the literature. Lexcen et al36
found, in a study of 72 patients in a forensic setting, similar
scores of satisfaction and outcomes using telepsychiatry as with
face-to-face interventions. Similarly, Tucker et al37 found that
inmates were satisfied with telepsychiatry treatment for services
including consulting, initial treatment evaluation, medication
management, and psychotherapy. In addition, inmates actually
preferred telepsychiatry in some situations, such as treatment
for sexual abuse and sexual dysfunction.37 As inmates have little
confidentiality or privacy in general, it has been found that patient acceptance of and satisfaction with providers and multiple
staff being involved in treatment via telepsychiatry remain high
in comparison with face-to-face treatment.36 Thistlethwaite noted
that treatment confidentiality is no more at risk than in face-toface interactions in mental health care in correctional facilities
because secure software and Internet connections are used to
provide this service.
Additionally, Ross et al38 and Morland et al39 examined patient
outcomes of telepsychiatry and found them to be equivalent to
those of face-to-face psychiatric treatment. At times, telepsychiatry was found to be more effective in treating mental illnesses
such as depression.40
Increased Savings
Several studies have explored the financial benefits of implementing telepsychiatry programs. Cost-benefit analysis has been
recommended as the most efficient and effective economic
evaluation used for telepsychiatry implementation41 (Table 2).

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Although initial costs to start a telepsychiatry practice may
reach several thousand dollars to acquire the software, hardware,
and required infrastructure, these programs have been shown to
cut overall costs by reducing travel for the provider, decreasing
overutilization of other medical services such as laboratory work,
increasing medication compliance, and speeding diagnosis via
reduced waiting or consultation time.41
A literature review by Hyler and Gangure42
identified seven studies that indicated substantial
… inmates were
cost savings via the utilization of telepsychiatry.
satisfied with
One study found increased costs, and three
telepsychiatry
studies identified situations in which utilization
treatment for
of telepsychiatry had similar costs as face-to-face
services including
psychiatric treatment. The seven studies that idenconsulting,
tified savings with the implementation and use
initial treatment
of telepsychiatry prompted these researchers to
evaluation,
determine that the utilization of telepsychiatry has
led to a decrease in cost for providing psychiatric
medication
treatment in some settings.42
management, and
Similarly, in a prospective test-retest (pretestpsychotherapy.
posttest) design study, Shore et al43 determined that
utilization of telepsychiatry for clinical interviews
saved more than $12,000 compared with face-to-face clinical interviews over an 11-month period in 2006.
Harley, in 2006, examined the cost of providing tertiary
mental health care via telepsychiatry compared with traditional
methods.44 It was found that initial costs to begin a telepsychiatry
service were around $6800; however, after providing telepsychiatric care for 6 months, costs remained under $7000 total for
providing telepsychiatric services. The author estimated that the
costs to provide traditional face-to-face psychiatric services to the
same population over the same period would have been more
than $25,000, primarily because of travel expenses.44
These findings have been supported by actual utilization of
telepsychiatry in correctional facilities. For example, the aforementioned Arizona Telemedicine Program reported a savings of
more than $1 million in transportation costs since its inception
in 1996, and a savings of $106,000 between July 2003 and December 2003 alone.45 The program identified further savings in
administrative costs, as well as an added benefit of government
incentives for the utilization of telemedicine. These savings and
benefits amounted to approximately $2.6 million.45

An examination of the actual costs of providing services—
specific and individual costs of sessions—using telepsychiatry vs
using traditional face-to-face methods yielded results. Reimbursement for telepsychiatry has been typically on a fee-for-service
basis and does not cover maintenance and infrastructure costs.
These extra costs often have been covered by grant funding to
the provider’s organization.46 A review of the costs of providing
telepsychiatric services have indicated substantial savings, even
when hardware costs are figured in. It was found in a randomized controlled trial in 2006 that a face-to-face psychiatric session
cost providers $315 per visit, whereas a telepsychiatric visit had
a cost of $265, a savings of $50 per visit.47
Discussion
The purpose of this research was to determine the effect of
utilization of telepsychiatry on inmate access to mental health
services and on the cost of providing mental health care in
correctional facilities. The results of this review suggest that
telepsychiatry has had a positive impact on mental health care in
prisons by increasing access for inmates to effective psychiatric
treatment and by maintaining continuity of care. In addition,
substantial savings for providers and facilities was noted.
With a high prevalence of mental illness among inmates,
adequate psychiatric care is imperative. In fact, appropriate care
may have reduced aggressive inmate behavior inside correctional
facilities, and well-managed mental illness has been shown to
decrease recidivism upon release, as well as decrease victimization inside the facility.48 Telepsychiatry is a way to provide this
much needed care that is cost-effective, easily implemented, and
accepted by providers and inmates.
As noted, a number of states, including Arizona, California,
Georgia, Kansas, Ohio, Texas, and West Virginia, have implemented telepsychiatry programs in their correctional facilities with
much success, both in increasing inmate access to providers and
in decreasing costs. Furthermore, New Mexico and Michigan have
also begun using telepsychiatry in prisons and have found similar
positive results as in the other states.49 Whereas the literature
review identified one study that found increased costs with the
implementation of telepsychiatry, the other studies reviewed found
either similar costs as with face-to-face treatment or an increase in
savings.42 Studies examining the effect on access to care have all
demonstrated substantial increase in inmates’ access to care.26,27,30,32

Table 2. Studies of cost-effectiveness of telepsychiatry programs in US correctional facilities

84

Author, year
Hyler & Gangure,41 2003

Study design
Literature review

Harley,43 2006

Prospective design

O’Reilly et al,46 2007

Case-control design

Shore et al,42 2007

Prospective test-retest design

Johnston & Solomon,29 2008

Review of government documents

Outcome of utilization
of telepsychiatry
Decrease in costs in some
settings
Savings of $18,000
Decreased costs from $315 to
$265, a savings of $50 per visit
Savings of > $12,000
Savings of $850 per visit, or $4
million annually

Methods by which
savings were achieved
Decreased provider travel, decreased
use of other medical services
Decreased provider travel, greater
medication management
Decreased provider travel
Decreased provider travel, decreased
client travel
Decreased inmate transportation costs,
decreased provider travel

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Telepsychiatry in Correctional Facilities: Using Technology to Improve Access and Decrease Costs of Mental Health Care in Underserved Populations  

The semistructured interview with a telepsychiatric practitioner (TT) supported some of the findings of this review, including the advantages of increased access and decreased costs with
the utilization of telepsychiatry, and potential disadvantages
of lack of support by prison administration32,34 and technical difficulties. The involvement of the correctional facilities’
administration and their cooperation has been imperative for
effective mental health treatment to take place via telepsychiatry. Thistlethwaite contradicted, however, some of the potential
drawbacks identified in previous research studies such as lack
of nonverbal communication or confidentiality issues.
This study was limited by the restrictions in the search
strategy used, such as the number of databases searched, and
publication bias may have affected the availability and quality of
the research identified during the search. In addition, although
much research exists about telepsychiatry in general, and a large
number of studies have examined telepsychiatry in prisons,
most of those studies have examined efficacy or acceptance
of telepsychiatry. Research about the benefits or drawbacks of
utilization on inmate access or cost to provide care is sparse.
Also, the quality of care received through telepsychiatry was
not measured through the reporting of any use of standardized
scales or assessments.
Telepsychiatry can be “the wave of the future” in psychiatric
care in correctional facilities because it can decrease the cost
for facilities and increase access for inmates; however, further
research in this area is needed. A prospective case-control
examination of the cost to provide care via telepsychiatry in
corrections compared with face-to-face psychiatric treatment
would be beneficial. A comparison of the types and quantity of
services provided to inmates through the use of telepsychiatry
also would advance this new field of psychiatry.
Conclusion
Telepsychiatry has been demonstrated to have substantial
ability to transform the way psychiatric services are delivered
in mental health care. This literature review has revealed that
utilization of telepsychiatry in correctional facilities has increased
access to effective mental health care for inmates and has decreased the costs of providing such care. v
a

S Shelton, MBA, PA-C, Assistant Vice President for Community Outreach
Program Director, Texas East Area Health Education Center, Office of the
Provost, and Office of Health Policy and Legislative Affairs, University of
Texas Medical Branch, 301 University Blvd, Galveston, TX.

Disclosure Statement
The author(s) have no conflicts of interest to disclose.
Acknowledgment
Kathleen Louden, ELS, of Louden Health Communications provided
editorial assistance.
References

1. Tucker W, Olfson M, Simring S, Goodman W, Bienenfeld S. A pilot survey
of inmate preferences for on-site, visiting consultant, and telemedicine
psychiatric services. CNS Spectr 2006 Oct;11(10):783-7.
2. Hill R, Luptak M, Rupper RW, et al. Review of Veterans Health Administration telemedicine interventions. Am J Manag Care 2010 Dec;16(12 suppl
HIT):e302-10.

The Permanente Journal/ Summer 2013/ Volume 17 No. 3

3. Saleem Y, Taylor MH, Khalifa N. Forensic telepsychiatry in the United Kingdom.
Behav Sci Law 2008;26(3):333-44. DOI: http://dx.doi.org/10.1002/bsl.810
4. Chee JJ. Telepsychiatry and internet prescribing: a legal overview and case
investigation [monograph on the Internet]. Washington, DC: Center for
Telehealth and e-Health Law; 2012 Aug [cited 2012 Feb 5]. Available from:
www.ctel.org/research/Telepsychiatry%20and%20Internet%20Prescribing%20A%20legal%20Overview%20and%20Case%20Investigation.pdf.
5. Melaka A, Edirippulige S. Psych-technology: a systematic review of the
telepsychiatry literature. Psychiatry On Line, The International Forum for
Psychiatry [serial on the Internet]. 2009 [cited 2012 Feb 5]. Available from:
http://espace.library.uq.edu.au/view/UQ:196610.
6. Emerson R. Telehealth in corrections [slide show on the Internet]. Presented to
the Maine Corrections Alternatives Advisory Committee 2006 Dec; Augusta,
ME. Slide Serve; 2006 [cited 2011 Dec 12]. Available from: www.slideserve.
com/gwenllian/telehealth-in-corrections.
7. James DJ, Glaze LE. Bureau of Justice Statistics special report: mental health
problems of prison and jail inmates [monograph on the Internet]. Washington, DC: US Department of Justice, Office of Justice Programs; 2006 Sep
[cited 2012 Feb 20]. Available from: http://bjs.ojp.usdoj.gov/content/pub/
pdf/mhppji.pdf.
8. Raimer BG, Stobo JD. Health care delivery in the Texas prison system: the
role of academic medicine. JAMA 2004 Jul 28;292(4):485-9. DOI: http://
dx.doi.org/10.1001/jama.292.4.485
9. Leonard S. The successes and challenges of developing a prison telepsychiatry service. J Telemed Telecare 2004;10 Suppl 1:69-71. DOI: http://dx.doi.
org/10.1258/1357633042614375
10. Morgan RD, Patrick AR, Magaletta PR. Does the use of telemental health
alter the treatment experience? Inmates’ perceptions of telemental health
versus face-to-face treatment modalities. J Consult Clin Psychol 2008
Feb;76(1):158-62. DOI: http://dx.doi.org/10.1037/0022-006X.76.1.158
11. Klopott F, Yap R, Dopp T. California psychiatrists paid $400,000 shows bidding war [monograph on the Internet]. New York, NY: Bloomberg; 2012 Dec
11 [cited 2012 Feb 14]. Available from: www.bloomberg.com/news/2012-1212/california-psychiatrists-paid-400-000-shows-bidding-war.html.
12. Magaletta PR, Patry MW, Gross NR, et al. Clinical practice in corrections:
providing service, obtaining experience. Psychol Serv 2011;8(4):343-55.
DOI: http://dx.doi.org/10.1037/a0025315
13. Larsen D, Stamm BH, Davis K, Magaletta PR. Prison telemedicine and
telehealth utilization in the United States: state and federal perceptions
of benefits and barriers. Telemed J E Health 2004;10 Suppl 2:S-81-9. DOI:
http://dx.doi.org/10.1089/tmj.2004.10.S-81
14. Nelson EL, Zaylor C, Cook D. A comparison of psychiatrist evaluation
and patient symptom report in a jail telepsychiatry clinic. Telemed J
E Health 2004;10 Suppl 2:S-54-9. DOI: http://dx.doi.org/10.1089/
tmj.2004.10.S-54
15. Antonacci DJ, Bloch RM, Saeed SA, Yildirim Y, Talley J. Empirical evidence
on the use and effectiveness of telepsychiatry via videoconferencing:
implications for forensic and correctional psychiatry. Behav Sci Law
2008;26(3):253-69. DOI: http://dx.doi.org/10.1002/bsl.812
16. Doarn CR, Justis D, Chaudhri MS, Merrell RC. Integration of telemedicine practice into correctional medicine: an evolving standard.
J Correct Health Care 2005 Apr;11(3):253-70. DOI: http://dx.doi.
org/10.1177/107834580401100304
17. Leonard S. The development and evaluation of a telepsychiatry service for
prisoners. J Psychiatr Ment Health Nurs 2004 Aug;11(4):461-8. DOI: http://
dx.doi.org/10.1111/j.1365-2850.2004.00747.x
18. Myers KM, Valentine JM, Melzer SM. Feasibility, acceptability, and sustainability of telepsychiatry for children and adolescents. Psychiatr Serv 2007
Nov;58(11):1493-6. DOI: http://dx.doi.org/10.1176/appi.ps.58.11.1493
19. Mental health and prisons [monograph on the Internet]. Geneva,
Switzerland: World Health Organization; 2007 Sep [cited 2012 Oct
20]. Available from: www.who.int/mental_health/policy/development/
MH&PrisonsFactsheet.pdf.
20. Hilty DM, Marks SL, Urness D, Yellowlees PM, Nesbitt TS. Clinical and
educational telepsychiatry applications: a review. Can J Psychiatry 2004
Jan;49(1):12-23.
21. Manfredi L, Shupe J, Batki SL. Rural jail telepsychiatry: a pilot feasibility study. Telemed J E Health 2005 Oct;11(5):574-7. DOI: http://dx.doi.
org/10.1089/tmj.2005.11.574
22. Morland LA, Hynes AK, Mackintosh MA, Resick PA, Chard KM. Group
cognitive processing therapy delivered to veterans via telehealth: a
pilot cohort. J Trauma Stress 2011 Aug;24(4):465-9. DOI: http://dx.doi.
org/10.1002/jts.20661
23. Shore JH, Bloom JD, Manson SM, Whitener RJ. Telepsychiatry with
rural American Indians: issues in civil commitments. Behav Sci Law
2008;26(3):287-300. DOI: http://dx.doi.org/10.1002/bsl.813

85

REVIEW ARTICLE
Telepsychiatry in Correctional Facilities: Using Technology to Improve Access and Decrease Costs of Mental Health Care in Underserved Populations  

24. Khalifa N, Saleem Y. Stankard P. The use of telepsychiatry within
forensic practice: a literature review on the use of videolink. J Forens Psychiatry Psychol 2008 Mar;19(1):2-13. DOI: http://dx.doi.
org/10.1080/14789940701560794
25. Vought RG, Grigsby RK, Adams LN, Shevitz SA. Telepsychiatry: addressing mental health needs in Georgia. Community Ment Health J 2000
Oct;36(5);525-36.
26. Telemedicine [Web page on the Internet]. Columbus, OH: Ohio Department
of Rehabilitation and Correction; updated 2006 Mar 13 [cited 2012 Feb 5].
Available from: www.drc.ohio.gov/web/telemed.htm.
27. Hincapie A, Warholak TL, Armstrong EP. Socioeconomic impact of mandated health coverage for telemedicine in the state of Arizona [monograph on
the Internet]. Tucson, AZ: The University of Arizona, College of Pharmacy;
2011 Nov 1 [cited 2012 Feb 4]. Available from: http://crh.arizona.edu/sites/
crh.arizona.edu/files/Telemedicine%20Report%20V12Ana-1.pdf.
28. California Legislative Analyst’s Office. Judicial and criminal justice: 2006-07
analysis [monograph on the Internet]. Sacramento, CA: Legislative Analyst’s
Office; 2006 [cited 2012 Feb 14]. Available from: www.lao.ca.gov/analysis_2006/crim_justice/crimjust_anl06.pdf.
29. Johnston B, Solomon NA. Telemedicine in California: progress, challenges,
and opportunities [monograph on the Internet]. Oakland, CA: California
Healthcare Foundation; 2008 Jul [cited 2012 Feb 14]. Available from: www.
chcf.org/publications/2008/07/telemedicine-in-california-progress-challenges-and-opportunities.
30. Offender Programs [Web page on the Internet]. Charleston, WV: West Virginia Division of Corrections; c2007-13 [cited 2012 Mar 5]. Available from:
www.wvdoc.com/wvdoc/OffenderPrograms/tabid/121/Default.aspx.
31. Telemedicine [Web page on the Internet]. South Charleston, WV: PSIMED
Inc; c2013 [cited 2012 Mar 5]. Available from: www.psimedinc.com/#!__
services/telemedicine.
32. Gramlich J. States expand videoconferencing in prisons [monograph on
the Internet]. Washington, DC: Stateline, The Pew Charitable Trusts; 2009
May 12 [cited 2012 Feb 5]. Available from: www.stateline.org/live/details/
story?contentId=399298.
33. Venable SS. A call to action: Georgia must adopt new standard of care,
licensure, reimbursement, and privacy laws for telemedicine. Emory Law
Journal 2005 Spring;54(2):1183-218.
34. Menachemi N, Burke DE, Ayers DJ. Factors affecting the adoption of telemedicine—a multiple adopter perspective. J Med Syst 2004 Dec;28(6):61732. DOI: http://dx.doi.org/10.1023/B:JOMS.0000044964.49821.df
35. Lee S. Contemporary issues of ethical e-therapy. Journal of Ethics in Mental
Health [serial on the Internet]. 2010 Nov;5(1):1-5 [cited 2013 May 1]. Available from: www.jemh.ca/issues/v5n1/documents/JEMH_Vol5_No1_Contemporary_Issues_of_Ethical_E-Therapy.pdf.
36. Lexcen FJ, Hawk GL, Herrick S, Blank MB. Use of video conferencing for
psychiatric and forensic evaluations. Psychiatr Serv 2006 May;57(5):713-5.
DOI: http://dx.doi.org/10.1176/appi.ps.57.5.713

37. Tucker W, Olfson M, Simring S, Goodman W, Bienenfeld S. A pilot survey
of inmate preferences for on-site, visiting consultant, and telemedicine
psychiatric services. CNS Spectr 2006 Oct;11(10):783-7.
38. Ross JT, TenHave T, Eakin AC, Difilippo S, Oslin DW. A randomized
controlled trial of a close monitoring program for minor depression and
distress. J Gen Intern Med 2008 Sep;23(9):1379-85. DOI: http://dx.doi.
org/10.1007/s11606-008-0663-4
39. Morland LA, Pierce K, Wong MY. Telemedicine and coping skills
groups for Pacific Island veterans with post-traumatic stress disorder:
a pilot study. J Telemed Telecare 2004;10(5):286-9. DOI: http://dx.doi.
org/10.1258/1357633042026387
40. Fortney JC, Pyne JM, Edlund MJ, et al. A randomized trial of telemedicine-based collaborative care for depression. J Gen Intern Med 2007
Aug;22(8):1086-93. DOI: http://dx.doi.org/10.1007/s11606-007-0201-9
41. Dávalos ME, French MT, Burdick AE, Simmons SC. Economic evaluation of
telemedicine: review of the literature and research guidelines for benefitcost analysis. Telemed J E Health 2009 Dec;15(10):933-48. DOI: http://
dx.doi.org/10.1089/tmj.2009.0067
42. Hyler SE, Gangure DP. A review of the costs of telepsychiatry. Psychiatr Serv
2003 Jul;54(7):976-80. DOI: http://dx.doi.org/10.1176/appi.ps.54.7.976
43. Shore JH, Brooks E, Savin DM, Manson SM, Libby AM. An economic evaluation of telehealth data collection with rural populations. Psychiatr Serv 2007
Jun;58(6):830-5. DOI: http://dx.doi.org/10.1176/appi.ps.58.6.830
44. Harley J. Economic evaluation of a tertiary telepsychiatry service to
an island. J Telemed Telecare 2006;12(7):354-7. DOI: http://dx.doi.
org/10.1258/135763306778682378
45. Arizona telemedicine [monograph on the Internet]. Tucson, AZ:
Arizona Telemedicine Program; 2004 Summer [cited 2012 Mar 5].
Available from: www.learningace.com/doc/1547990/bf26fa9b1edec0237efbe07824d3d522/telemed_newsltr_smr041#.
46. McGinty KL, Saeed SA, Simmons SC, Yildirim Y. Telepsychiatry and e-mental
health services: potential for improving access to mental health care.
Psychiatric Q 2006 Winter;77(4):335-42. DOI: http://dx.doi.org/10.1007/
s11126-006-9019-6
47. O’Reilly R, Bishop J, Maddox K, Hutchinson L, Fisman M, Takhar J. Is telepsychiatry equivalent to face-to-face psychiatry? Results from a randomized
controlled equivalence trial. Psychiatr Serv 2007 Jun;58(6):836-43. DOI:
http://dx.doi.org/10.1176/appi.ps.58.6.836
48. Neal TS, Clements CB. Prison rape and psychological sequelae: a call for
research. Psychol Public Policy Law 2010;16(3):284-99. DOI: http://dx.doi.
org/10.1037/a0019448
49. Michigan department of corrections reduces costs with Polycom Solutions
[monograph on the Internet]. Pleasanton, CA: Polycom Inc; 2009 [cited
2012 Apr 1]. Available from: http://docs.polycom.com/global/documents/
company/customer_success_stories/government/michigan_corrections_
cs.pdf.

Healing That Can Last
When depression, hopelessness, and lack of help do hurt,
healing that can last may still be achieved by a kindly word.
— Johan Wolfgang von Goethe, 1749-1832, German author, artist, and politician

86

The Permanente Journal/ Summer 2013/ Volume 17 No. 3

Exhibit 9
Substance Abuse and Mental Health Services Administration, Telehealth for the Treatment
of Serious Mental Illness and Substance Use Disorders at pp. 20-23 (2021)

EVIDENCE-BASED RESOURCE GUIDE SERIES

Telehealth for the
Treatment of Serious
Mental Illness and
Substance Use
Disorders

Telehealth for the Treatment of Serious
Mental Illness and Substance Use Disorders
Acknowledgments

This report was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA)
under contract number HHSS283201700001/ 75S20319F42002 with SAMHSA, U.S. Department of Health
and Human Services (HHS). Donelle Johnson served as contracting officer representative.
Disclaimer

The views, opinions, and content of this publication are those of the authors and do not necessarily reflect
the views, opinions, or policies of SAMHSA. Nothing in this document constitutes a direct or indirect
endorsement by SAMHSA of any non-federal entity’s products, services, or policies, and any reference to
non-federal entity’s products, services, or policies should not be construed as such.
Public Domain Notice

All material appearing in this publication is in the public domain and may be reproduced or copied
without permission from SAMHSA. Citation of the source is appreciated. However, this publication
may not be reproduced or distributed for a fee without the specific, written authorization of the Office of
Communications, SAMHSA.
Electronic Access

This publication may be downloaded from http://store.samhsa.gov
Recommended Citation

Substance Abuse and Mental Health Services Administration (SAMHSA). Telehealth for the Treatment
of Serious Mental Illness and Substance Use Disorders. SAMHSA Publication No. PEP21-06-02-001
Rockville, MD: National Mental Health and Substance Use Policy Laboratory. Substance Abuse and Mental
Health Services Administration, 2021.
Originating Office

National Mental Health and Substance Use Policy Laboratory, Substance Abuse and Mental Health Services
Administration, 5600 Fishers Lane, Rockville, MD 20857, Publication No. PEP21-06-02-001.
Nondiscrimination Notice

SAMHSA complies with applicable federal civil rights laws and does not discriminate on the basis of race,
color, national origin, age, disability, or sex.
SAMHSA cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de
raza, color, nacionalidad, edad, discapacidad o sexo.
Publication No. PEP21-06-02-001
Released 2021

Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders
Acknowledgments

I

FOREWORD

Evidence-Based Resource Guide
Series Overview

The Substance Abuse and Mental Health Services
Administration (SAMHSA), and specifically, its
National Mental Health and Substance Use Policy
Laboratory (Policy Lab), is pleased to fulfill the charge
of the 21st Century Cures Act to disseminate information
on evidence-based practices and service delivery models
to prevent substance misuse and help people with
substance use disorders (SUDs), serious mental illness
(SMI), and serious emotional disturbances (SEDs) get
the treatment and support they need.

A priority topic for SAMHSA is increasing access to
treatment for SMI and SUD using telehealth modalities.
This guide reviews literature and research findings
related to this issue, examines emerging and best
practices, discusses gaps in knowledge, and identifies
challenges and strategies for implementation. While this
guide is focused on the needs of people experiencing
SMI and SUD, readers can broadly apply its resources
and lessons from the field for the treatment of any
mental illness.

Treatment and recovery for SUD, SMI, and SED can
vary based on several factors, including geography,
socioeconomics, culture, gender, race, ethnicity, and
age. This can complicate evaluating the effectiveness
of services, treatments, and supports. Despite these
variations, however, there is substantial evidence to
inform the types of resources that can help reduce
substance use, lessen symptoms of mental illness, and
improve quality of life.

Expert panels of federal, state, and non-governmental
participants provided input for each guide in this series.
The panels included accomplished scientists, researchers,
service providers, community administrators, federal and
state policy makers, and people with lived experience.
Members provided input based on their knowledge of
healthcare systems, implementation strategies, evidencebased practices, provision of services, and policies that
foster change.

The Evidence-Based Resource Guide Series is a
comprehensive set of modules with resources to improve
health outcomes for people at risk for, experiencing,
or recovering from SMI and/or SUD. It is designed for
practitioners, administrators, community leaders, and
others considering an intervention for their organization
or community.

Research shows that implementing evidence-based
practices requires a comprehensive, multi-pronged
approach. This guide is one piece of an overall
approach to implement and sustain change. Readers are
encouraged to visit the SAMHSA website for additional
tools and technical assistance opportunities.

Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders
Evidence-Based Resource Guide Series Overview

II

Content of the Guide
This guide contains a foreword and five chapters. The chapters stand alone
and do not need to be read in order. Each chapter is designed to be brief
and accessible to healthcare providers, healthcare system administrators,
community members, policy makers, and others working to meet the needs of
people at risk for, experiencing, or recovering from SMI and/or SUD.
The goal of this guide is to review the literature on the effectiveness of
telehealth modalities for the treatment of SMI and SUD, distill the research into
recommendations for practice, and provide examples of how practitioners use
these practices in their programs.

FW

Evidence-Based Resource Guide Series Overview
Introduction to the series.

1

Issue Brief
Overview of the current landscape of telehealth, including its
need, benefits, and challenges for the treatment of SMI and
SUD among adults.

2

What Research Tells Us
Current evidence on effectiveness of integrating telehealth
modalities for the treatment of SMI and SUD among adults across
a continuum of services, including screening and assessment,
treatment, medication management, case management, recovery
support, and crisis services.

3

FOCUS OF THE GUIDE
SMI and SUD impact millions of
Americans. Barriers to accessing
care include access to appropriate
services and providers, stigma
associated with SMI or SUD,
and competing priorities (e.g.,
employment and caregiving
responsibilities).
Telehealth is the use of two-way,
interactive technology to provide
health care and facilitate clientprovider interactions. Telehealth
modalities for SMI or SUD may
be synchronous (live or real
time) or asynchronous (delayed
communication between clients
and providers).
Telehealth has the potential
to address the treatment gap,
making treatment services more
accessible and convenient,
improving health outcomes, and
reducing health disparities.

Guidance for Implementing Evidence-based
Practices
Practical information to consider at the individual client and
provider, provider-client, organizational, and regulatory levels
when selecting and implementing telehealth modalities.

4

Examples of Telehealth Implementation in
Treatment Programs
Examples of programs that have implemented telehealth
modalities for the treatment of SMI and SUD among adults.

5

Resources for Evaluation and Quality Improvement
Guidance and resources for evaluating telehealth-delivered
practices, monitoring outcomes, and improving quality.

Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders
Evidence-Based Resource Guide Series Overview

III

The framework below provides an overview of this guide. The guide addresses the use of telehealth to provide SMI and
SUD treatment. The review of these treatments in Chapter 2 of the guide includes specific outcomes, practitioner types,
and modes of delivery.

Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders
Evidence-Based Resource Guide Series Overview

IV

1
C HAPTER

Issue Brief
Telehealth is the use of telecommunication
technologies and electronic information to provide
care and facilitate client-provider interactions. It is
comprised of two forms:
1. Two-way, synchronous, interactive clientprovider communication through audio
and video equipment (also referred to as
telemedicine)
2. Asynchronous client-provider interactions
using various forms of technology (further
described in the chart below)1, 2
Serious mental illness (SMI) is defined as a
mental, behavioral, or emotional disorder among
adults aged 18 and older resulting in serious
functional impairment, which substantially interferes
with or limits one or more major life activities.3
Substance use disorder (SUD) is a diagnosis that
applies when the recurrent use of alcohol or drugs
causes clinically significant impairment, including
health problems, disability, and failure to meet
major responsibilities at work, school, or home.4
Co-occurring disorder (COD) refers to the
coexistence of both a substance use and mental
disorder.4

Telehealth is a mode of service delivery that has been
used in clinical settings for over 60 years and empirically
studied for just over 20 years.5-7 Telehealth is not an
intervention itself, but rather a mode of delivering
services. This mode of service delivery increases access
to screening, assessment, treatment, recovery supports,
crisis support, and medication management8, 9 across
diverse behavioral health and primary care settings.
Practitioners can offer telehealth through synchronous
and asynchronous methods.

Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders
Issue Brief

1

Asynchronous

Synchronous

Timing

Application

Technology Options

Real-time interactive client Clinical assessments, ongoing care and treatment, and
and provider interactions. triage of emergency service needs (e.g., for clients with
suicidal ideation).10

Telephone, video calls,
and web-conferencing
platforms.11

Sharing of health
information that is
collected at one point in
time and responded to or
interpreted at a later time
to direct the next steps of
a client’s treatment or care
plan and complement
synchronous treatment.12

Web-based portals
(i.e., client portals),
email messages, text
messages, mobile
applications, symptom
management tracking,
sensors, peripherals,
client education modules,
or electronic medical
record data.13-19

Methods can be
interactive (i.e., the
client actively sending
information to the
provider) or passive (i.e.,
client data transmitted to
providers through portals,
sensors, or peripherals).

Clinical assessments, symptom management, client
education, and treatment reminders that complement
synchronous client-provider interactions and inform
updates to treatment plans through methods such as:
•

Store and forward (i.e., client uploads and transfers
medical information, such as health histories, to
identify or refine a treatment plan)

•

Remote client monitoring (i.e., collecting medical
and health data in one location and transmitting to
another)

•

mHealth (i.e., capture of health information by
the client and transmission of the information to a
provider through mobile applications, mobile devices,
smartphones, tablets, or computers)

•

Client education (e.g., online psychoeducation
sessions and workbooks)

While telehealth is used in health care for a broad range
of ages and presenting problems, this guide focuses on
synchronous, direct to consumer (sometimes referred to
as “D to C”) applications of telehealth for the treatment
of SMI and SUD among adults.20
Furthermore, this guide focuses on the needs of people
experiencing SMI and SUD, but readers can broadly
apply its resources and lessons for the treatment of any
mental illness.

Background
Telehealth can connect clients and providers in multiple
locations such as at a home, private space in a clinical
setting, or another location in the community. The
graphic below depicts examples of ways to connect
using telehealth, but there are many ways to deliver and
receive care that address connectivity barriers and client
preferences.

Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders
Issue Brief

2

A variety of providers (e.g., psychiatrists, primary care
providers, mental health counselors, social workers,
psychologists, addiction counselors, case managers,
opioid treatment providers, peer workers) can implement
telehealth methods. In addition, practitioners can
use telehealth with a hybrid approach for increased
flexibility. For instance, a client can receive both inperson and telehealth visits throughout their treatment
process depending on their needs and preferences.
Telehealth methods can be implemented during public
health emergencies (e.g., pandemics, infectious disease
outbreaks, wildfires, flooding, tornadoes, hurricanes)21-25
to extend networks of providers (e.g., tapping into outof-state providers to increase capacity). They can also
expand capacity to provide direct client care when inperson, face-to-face interactions are not possible due to
geographic barriers or a lack of providers or treatments
in a given area. However, implementation of telehealth
methods should not be reserved for emergencies or
to serve as a bridge between providers and rural or
underserved areas. Telehealth can be integrated into an
organization’s standard practices, providing low-barrier
pathways for clients and providers to connect to and
assess treatment needs, create treatment plans, initiate
treatment, and provide long-term continuity of care.
SMI and SUD impact millions of Americans. However,
for a variety of reasons and despite a perceived need,
many do not seek treatment.
•

Among adults aged 18 or older in 2019, 5.2
percent (13.1 million people) had an SMI. Of
those, 47.7 percent (6.2 million people) reported
an unmet need for mental health services in the
past year.

•

Among people aged 12 or older in 2019,
7.4 percent (20.4 million people) reported
experiencing a SUD. Among people aged 12 or
older in 2019, 7.8 percent (21.6 million people)
needed substance use treatment in the past year.
Of these 21.6 million people, 12.2 percent (2.6
million) received substance use treatment at a
specialty facility.26

health disparities. Clients experiencing SMI and SUD
have traditionally been excluded from both treatments
delivered through telehealth and research evaluating the
efficacy of telehealth among people experiencing SMI
and SUD. However, telehealth is a tool that providers
can use for all clients.
Appropriate and additional upfront work, providerclient agreements, and safeguards can ensure that clients
experiencing SMI and SUD benefit from services
delivered via telehealth. Providers can use assessments
(further discussed in Chapter 3) to identify their
clients’ specific barriers to participating in telehealth
appointments (e.g., access and comfort with technology,
ability to have private or confidential conversations,
safety of the home environment) and inform
conversations with their clients on strategies to address
these barriers.
Implementation and use of telehealth as a
mode of service delivery has been increasing in
recent years. Between 2016 and 2019, use of
telehealth doubled from 14 to 28 percent.9 This
trend continued between 2019 and 2020, due in
large part to the COVID-19 pandemic. Telehealth
visits for mental health increased by 556 percent
between March 11 and April 22, 2020.27
The use of telehealth was steadily increasing prior
to the COVID-19 pandemic. Between 2016 and
2019, SUD treatment offered through telehealth
increased from 13.5 to 17.4 percent. Greater
adoption of telehealth was associated with rural
locations, as well as those that provided multiple
treatment settings, offered pharmacotherapy, and
served both adult and pediatric populations.28
Telehealth visits increased among rural Medicare
beneficiaries, including a 425 percent increase
for mental health appointments between 2010
and 2017. Among these beneficiaries, people
living with schizophrenia or bipolar disorder in
rural areas were more likely to use telehealth
for mental health care than those with any other
mental illness or those living in urban areas.29

Telehealth has the potential to address this treatment
gap, making treatment services more accessible and
convenient, improving health outcomes, and reducing

Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders
Issue Brief

3

Benefits of Telehealth
Telehealth supports team-based care and its interrelated
care objectives. The Quadruple Aim is a conceptual
framework to understand, measure, and optimize health
system performance. The Quadruple Aim organizes
benefits of telehealth into four categories:30
•
•
•
•

Improved provider experience
Improved client experience
Improved population health
Decreased costs

1. Provider experience. Providers may improve the
quality of care they provide and experience the
following benefits from implementing telehealth
methods:
•

•

•
•

Provision of timely client care. Providers
may have increased flexibility in appointment
scheduling by using telehealth. They can extend
care beyond a clinic’s normal operating hours
and its four walls and leverage “virtual walk-in
visits.” Increased flexibility can help clinics to
more effectively manage client “no-shows” and
cancellations.34-37
Effective and efficient coordination of care. An
estimated 40 to 60 percent of civilian clients (not
inclusive of military populations) with mental
and substance use disorders are currently treated
in primary care offices rather than specialty
care settings.31 Providers can use telehealth
methods for tele-consultation, tele-supervision,
and tele-education to coordinate, integrate, and
improve care (e.g., through the “hub and spoke”
model).11, 38-40
Reduction in workforce shortages. This is
especially true for underserved and rural areas.7-9, 41
Ability to assess client’s home environment.
Rather than rely on a client’s report of their
home and living conditions, telehealth makes it
possible for providers to see, with appropriate
permission, inside a client’s home, meet family
support systems, and determine if an in-person
visit at a person’s home is needed.42

Rural Workforce Shortages
Approximately 80 percent of rural areas in
the United States are classified as medically
underserved and in health professional shortage
areas (HPSAs). These regions are lacking the
physicians, dentists, registered nurses, and other
health professionals needed to care for a client
throughout the lifespan. HPSAs also often have
shortages in behavioral health providers (including
psychiatrists, psychologists, and therapists).31
Shortages in the rural healthcare landscape
disproportionately impact rural Americans who
tend to be older, have lower socioeconomic
status, are more reliant on public insurance, and
have worse health outcomes.32, 33

•

•

•

Ability to share information for
psychoeducation and assessment.
Psychoeducation, or the didactic communication
of information to the client about therapeutic
intervention or diagnosis, can be done through
screensharing, thus allowing the clinician to
seamlessly display videos, slideshows, and
other visuals to the client. Mental health and
substance use assessments can also be done this
way, allowing the clinician to track the client’s
responses in real-time.43
Efficient connections to crisis services. In
emergencies, telehealth providers can instruct
clients to call emergency response systems (e.g.,
911, 988) while the providers remain connected
via telephone or video. Enhanced 911 (E911)
automatically provides emergency dispatchers
with the location of the client, rather than the client
needing to provide their address to the dispatcher.
Reductions in provider burnout. Provider
burnout is a pervasive issue in the healthcare field
and exacerbated by numerous factors, including
time pressures, fast-paced environments,
family responsibilities, and time-consuming
documentation.44 Telehealth may lead to
reductions in provider stress and burnout through
promoting more manageable schedules, greater
flexibility, and reductions in commute time.44-46

Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders
Issue Brief

4

2. Client experience. Clients may experience many
benefits receiving mental health and substance use
treatment by telehealth:
Increased access to experienced providers
and high-quality care. Through telehealth,
clients can access experienced providers that
may be geographically distant from their homes.
Through telehealth modalities, clients can access
providers with expertise in their particular
conditions and treatment plans that can provide
care appropriate for their culture, race, gender,
sexual orientation, and lived experience.20, 47, 48
Improved access to and continuity of care.
Telehealth provides a mechanism to increase
access to quality care and reduce travel costs for
clients, increasing the likelihood that clients will
see their provider regularly and attend scheduled
appointments.36, 49
Increased convenience that removes
traditional barriers to care, including:
− Geographic barriers (e.g., transportation
and distance to providers). Telehealth
increases the opportunity for individuals
in remote locations to access the care they
need.8, 9, 50-55
− Psychological barriers. Clients who
experience anxiety about leaving their
homes to access treatment (e.g., clients
experiencing panic disorder or agoraphobia)
are able to receive care in a safe
environment.56, 57

•

•

•

−

−

−

−

Accessibility. Individuals with physical,
visual, or hearing impairments and clients who
are isolated (e.g., older adults) or incarcerated
are able to access needed health care through
use of telehealth.8, 58
Employment. The use of telehealth allows
clients to receive care while not requiring them
to take significant leave from employment or
other essential activities.37, 38
Childcare and caregiver responsibilities.
Receiving home-based telehealth can help to
reduce the burden of finding childcare.59 For
family caregivers, telehealth technologies,
such as remote monitoring, can relieve
some caregiver responsibilities, thereby
decreasing stress and improving quality of
life.60
Team-based services and group-based
interventions. Team-based and coordinated
care is critical to high-quality client
treatment. However, geographic distances
between providers and clients can limit
communication. Telehealth enhances teambased care across geographic barriers by
remotely connecting multiple providers with
a client, promoting provider collaboration
and the exchange of health information.61
Similarly, telehealth improves access
to group-based interventions, which
demonstrate similar treatment outcomes as
in-person groups.62

Health Equity and Telehealth
While telehealth has many benefits, concerns around access to telehealth and telemedicine services, especially
for those with low technology literacy or disabilities, remain.71-73
•

Americans aged 65 and older (18 percent of the population) are most likely to have a chronic disease,
but almost half (40 to 45 percent) do not own a smartphone or have broadband Internet access.71

•

People experiencing poverty report lower rates of smartphone ownership (71 percent), broadband
Internet access (59 percent), and digital literacy (53 percent) compared to the general population.74, 75

•

People who are Black or Hispanic report having lower computer ownership (Black: 58 percent; Hispanic:
57 percent) or home broadband Internet access (Black: 66 percent; Hispanic: 61 percent) than White
respondents (82 and 79 percent, respectively), although smartphone access is nearly equal (Black: 80
percent; Hispanic: 79 percent; White: 82 percent).76

Due to these limitations, some clients may not benefit from telehealth.77, 78

Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders
Issue Brief

5

−

−

Reduction in stigma associated with
experiencing SMI and SUD and accessing
treatment. Through telehealth, clients
can disclose their SUD and/or SMI from
the privacy of their own home.63 In rural
communities with fewer behavioral health
providers, telehealth can connect clients
with providers in other geographic locations,
which can increase their privacy and protect
their anonymity when accessing care.38, 64-66
Satisfaction with care consistent with
in-person treatment. Despite some initial
client hesitancy towards using telehealth,
clients often report comparable satisfaction
between telehealth and in-person care.67-70

3. Population health. Treatments delivered through
telehealth have been shown to improve health
outcomes, including improved quality of life and
access to health care. For people experiencing SMI,
telehealth has the potential to improve quality of
life and general mental health, reduce depressive
symptoms, build more confidence in managing
depression, and increase satisfaction with mental
health and coping skills (when compared to treatment
offered in-person only).8, 79-83 For people experiencing
SUD, treatments delivered through telehealth have
resulted in reductions in alcohol consumption,
increased tobacco cessation, and increased engagement
and retention in opioid use disorder treatment.84
4. Costs. In rural communities in particular,
implementing telehealth services reduces
organizational costs by replacing the budget for a
full-time, onsite behavioral health provider with as
needed hourly fees.36

Implementation of Telehealth
While the use of telehealth as a mode of service delivery
is increasing, providers, clients, and healthcare settings
continue to experience challenges related to adoption
and implementation. For example, uptake of telehealth
can be hindered by disparities in access to appropriate
and needed technology.
Recent advances in technology and access to personal
computing devices and mobile phones have led to a
rapid increase in the application of telehealth across the
continuum of care (i.e., assessment, treatment, medication
management/monitoring, recovery supports). Both
providers and clients need access to appropriate technology
to benefit from synchronous or asynchronous telehealth.
Practitioners can provide synchronous SMI and SUD
treatment through relatively low-tech options, including
telephones, smartphones, tablets, and laptops.10, 14
The age, usability, and functionality of clients’
devices may inhibit their use (e.g., ability to utilize
various mHealth applications, appropriate data plans).
Additionally, clients may be sharing devices with family
members or others in a household, limiting the types
of data a client would want to store or share through
a device. For providers, some clinics struggle to have
enough laptops to support staff working from home or
outside of typical shared office space,73, 85-88 and may
not have updated devices or software systems to utilize
available telehealth applications.
Barriers associated with access to technology are
compounded by challenges experienced on multiple,
interrelated levels (further discussed in Chapter 3).

Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders
Issue Brief

6

Level

Additional Challenges

Individual client and provider

•

Increasing access to and comfort using telehealth

Interpersonal client-provider relationships

•

Preparing clients to use telehealth

•

Building a therapeutic relationship

•

Assessing organizational needs

•

Increasing organizational readiness and workforce capacity to
participate in telehealth

•

Ensuring security and confidentiality

•

Complying with federal, state, and local regulations

Organizational

Regulatory and reimbursement environments

Future of Telehealth
The use of telehealth has increased substantially in
recent years and has accelerated rapidly with the
COVID-19 pandemic. While the landscape of telehealth
is continually evolving, and provider, client, population,

and cost benefits are emerging, the practices and
programs included in Chapter 2 have demonstrated
efficacy in improving client mental health and SUD
outcomes in multiple settings and contexts.

Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders
Issue Brief

7

Medication management via telehealth ranges from
automated, non-specific text messages to adherence
counseling conducted over the telephone.7, 30 Examples
of telehealth modalities for conducting medication
management are described below:
•

•

•

•

Text message interventions, designed to remind
clients to take their medication, have been found
to be effective for people experiencing SMI
even if the messages were not customized or
specific to the dosage, timing, or medication
prescribed.31, 32
Smart pill containers remind clients to take
their medication, provide alerts about taking the
wrong medication, and are linked to programs
for the client to report side effects to providers.
Used together with telephone support, smart pill
containers have shown statistically significant
improvement in medication adherence.33
mHealth apps have been used in combination
with smart pill containers, in-home dispensing
devices, or other systems to dose medications.
These apps remind clients to take medications
and communicate medication use information
to their healthcare provider through a client
portal.34
Treatment support over the phone from case
managers, nurses, or other health professionals
offers clients prescribed medications for SMI
and SUD information and adherence support.
These approaches have shown statistically
significant improvements on medication
adherence rates.35-37

Medication monitoring, including both support for
medication adherence of the prescribed treatment and
prevention of non-prescribed or illicit substance use
that may cause dangerous interactions, is an essential
component of MAT. Clinics or other agencies without a
local, trained MAT provider have used telehealth to link
clients to a remote MAT provider. The local clinic and
agency can provide in-house medication monitoring and
urine toxicology screening while providing space for the
client to meet with the MAT provider using telehealth
technology.25 In some treatment models, monitoring
visits are conducted using telehealth, but the client is
required to report in-person for regular urine toxicology
screening.20, 23, 38

Behavioral Therapies
Practitioners can implement psychotherapy39 and
behavioral therapies through synchronous telehealth
modalities while adhering to clinical specifications and
producing clinical improvements similar to treatment
outcomes from in-person care.40
This evidence review identified four interventions that
met evidence review criteria (described above and in
Appendix 2) and improved health outcomes for people
experiencing SMI, including Behavioral Activation
(BA) Therapy, Cognitive Behavioral Therapy (CBT),
Cognitive Processing Therapy (CPT), and Prolonged
Exposure (PE) Therapy. Each behavioral therapy is
described below, including associated health outcomes,
populations that may benefit, and other important
information for implementing these therapies using
telehealth.

Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders
What Research Tells Us

19

Behavioral Activation (BA) Therapy via telehealth

BA is a treatment component based on changing behavior to change one’s mood. It involves identifying, scheduling, and
completing positive reinforcement activities.41, 42 Behavioral Activation-Therapeutic Exposure (BA-TE) is an integrated,
evidence-based treatment for Post-Traumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD). BA-TE
combines BA with exposure-based therapy. It involves weekly BA activities along with situational exposure to clients’
avoided stimuli and imaginal exposure to past traumatic events.42, 43
Health outcomes

•
•
•

Telehealth-specific
outcomes

When compared to in-person treatments:

Populations that
benefit from the
treatment

People experiencing MDD, including:

•
•

•
•
•
•

Reduction in depression41 and major depression42, 43 symptoms
Reductions in PTSD symptoms42, 43
Reduction in anxiety42
Reduction in Veteran’s Affairs health utilization costs one-year post-telehealth intervention44
Similar rates reduction in PTSD symptoms (e.g., disturbing memories/thoughts about military
experience, avoidance of external stimuli, nightmares, and re-experiencing)43, 45
Older veterans (58+)41
Rural veterans41
Black/African American veterans41
Male veterans41

People experiencing PTSD, including:

Providers who can
offer intervention
services

•

Male and female veterans of Operation Enduring/Iraqi Freedom43 and the Vietnam War, the
Persian Gulf War, and Operation New Dawn43

•

Master’s-level clinicians with over five years of experience who participate in a two-day
training and who receive weekly supervision throughout the trial41
Master’s-level counselors who completed an eight-hour workshop and shadowed a seniorlevel clinician administering the treatment43
Mental health therapists who completed a week-long training, shadowed a senior-level
clinician, and received weekly supervision42

•
•

Technology used

•
•
•

In-home videoconferencing technology, set up via an analogue telephone41
Computer, tablet, or smartphone with encrypted videoconferencing software similar to Skype
or FaceTime42, 43
A landline-based videoconferencing program which functions like a typical touch-phone but
includes an adjacent video screen42, 43

Intensity, duration,
and frequency

•

Eight 60- to 90-minute weekly sessions42, 43

Lessons learned
transitioning from
in-person care to
telehealth

•

Telehealth treatment was effective even though the in-home videoconferencing technology
used in the studies has become somewhat obsolete; researchers believe new technology
can only improve communication between clients and providers, thus easing future
implementation41
Home-based telehealth has potential advantages over hub-and-spoke models (e.g., where
a client is treated in an office setting by providers at another office setting) for addressing
treatment barriers, including cost, stigma, and travel logistics46

•

Four studies met criteria for review (three RCTs and one single sample pre-post), resulting in a rating of Strong Support
for Causal Evidence.

Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders
What Research Tells Us

20

Cognitive Behavioral Therapy (CBT) via telehealth

CBT is a goal-oriented psychotherapy that seeks to modify an individual’s thought patterns, beliefs, and behaviors. CBT
programs use a variety of cognitive and behavioral techniques in group and individual settings while remaining structured
and time-limited.46 Through cognitive restructuring, CBT may be used to help clients re-evaluate their negative thought
patterns that include overgeneralizing or catastrophizing negative outcomes.47, 48 CBT techniques can be used to help
clients address traumatic experiences and develop more effective thought patterns and realistic perspectives on the
trauma.47
Health outcomes

•
•
•

Reduction in severity of depression symptoms49, 50
Reduction in symptoms of PTSD51
Reductions in self-reported depressive and general anxiety symptoms51

TelehealthWhen compared to enhanced usual care (defined as conversations with primary care physicians):
specific outcomes • Higher level of client satisfaction50, 51
• No significant difference in therapeutic working alliance between provider and client51
When compared to in-person treatment:
•

Higher level of treatment completion49

Populations that
benefit from the
treatment

People experiencing major depressive disorder, including:
•
•
•

Primary care clients49
Rural, Latino/Latina clients50
People experiencing PTSD, including:
− College women who are survivors of rape51

Providers
who can offer
intervention
services

•
•
•
•

Doctoral-level therapists49, 51
Students working towards master’s in social work degree 50
Master’s-level social workers50
Licensed social workers50

Technology used

•
•

Telephone49, 50
Computer-based online program facilitated by a therapist51

Intensity,
duration, and
frequency

•

Participants were offered 8 to 18 sessions of CBT; sessions (offered in both English and
Spanish) were designed to be 45 to 50 minutes49, 50
Through an online, therapist-facilitated CBT program, clients completed nine modules over the
course of 14 weeks51

•

Lessons learned
•
transitioning from •
in-person care to
telehealth
•
•

Lack of telephones was not a significant barrier to participation50
Providing culturally tailored CBT via telephone has the potential to enhance access to care for
Latinas/Latinos living in rural areas50
Providers and clients developed a strong therapeutic working alliance despite the largely
asynchronous nature of communication51
Future research is needed to assess the effectiveness of delivering similar therapist-facilitated
online programs to diverse populations and in multiple practice settings51

Four studies met criteria for review (four RCTs), resulting in a rating of Strong Support for Causal Evidence.

Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders
What Research Tells Us

21

Cognitive Processing Therapy (CPT) via telehealth*

CPT is a trauma-focused cognitive therapy aimed at reducing symptoms of PTSD.52 CPT has been found to be effective
in reducing symptoms of PTSD developed as a result of experiencing traumatic events, such as child maltreatment,
sexual assault, and military-related stressors.53-55 CPT consists of four main components: 1) Education; 2) Processing;
3) Challenging thoughts about the trauma to restructure thought patterns; and 4) Focus on trauma-related themes of
safety, trust, power and control, esteem, and intimacy.55-57
Health outcomes

•
•

Greater or equivalent reduction in severity of PTSD symptoms 55, 58-60
Reduction in symptoms of depression59, 60

TelehealthWhen compared to in-person treatments:
specific outcomes • Increased access to care for underserved rural populations58
• No significant difference in client treatment adherence (homework completion) and retention55, 58
• No significant difference in client satisfaction55, 58
• No significant difference in therapeutic alliance between provider and client55, 58, 60
Populations that
benefit from the
treatment

People experiencing PTSD, including:
•
•
•

Veterans55, 59, 60
Civilian women55
Male combat veterans living in rural areas58

Providers
who can offer
intervention
services

•
•
•
•
•

Licensed psychologists59
Doctoral-level psychologists58, 60
Licensed social workers59
Master’s-level and doctoral-level social workers58, 60
Family therapists59

Although formal CPT training is not required for practitioners, resources are available, including a
program delivery manual and certification trainings52
Technology used

•

Videoconference55, 58-60

Intensity,
duration, and
frequency

•

Participants received CPT over 12 sessions, conducted once or twice a week for
approximately 50 to 90 minutes each 55, 58-60

Lessons learned
•
transitioning from •
in-person care to
telehealth
•

Videoconference is a familiar format for many users59
Participants encountered few disruptions using videoconferencing (e.g., no sessions were
canceled due to technological difficulties)58
Smaller technology screens may reduce rapport and communication59

Four studies met criteria for review (four RCTs), resulting in a rating of Strong Support for Causal Evidence.
*
Originally, the primary version of CPT was administered with a written account of trauma and cognitive-only CPT was administered
without a written account of trauma. Research comparing the efficacy of the two versions found that both versions are as effective, and,
notably, the cognitive-only version led to a decrease in dropout rate. As a result, the terminology changed and CPT without a written
account of trauma became the primary version implemented. For the purpose of this evidence review, this guide uses the terminology as
CPT delivered with or without a written account of trauma.

Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders
What Research Tells Us

22

Prolonged Exposure (PE) Therapy via telehealth

PE is a type of CBT that focuses on helping individuals confront their fears from traumatic experiences.61 First developed
as an intervention to treat sexual assault survivors suffering from PTSD, PE has been shown as effective for treating
survivors of varied traumas, including combat, accidents, and disasters.62 Through weekly sessions of PE, individuals learn
how to gradually approach their trauma-related memories and feelings.61, 63 Exposure therapy through imaginal exposure
(describing the traumatic event) and in vivo exposure (confronting feared stimuli) also helps reduce symptoms of PTSD.48,61
Health outcomes

•
•
•

Reduction in the severity of PTSD symptoms64-69 (compared with both no treatment and inperson PE therapy)
Reductions in symptoms of anxiety64, 68, 69
Reductions in symptoms of depression64-69

TelehealthWhen compared to in-person treatments:
specific outcomes • Increased access to care for rural veterans68
• No statistical differences in client satisfaction, although participants in the in-person group
reported a higher level of comfort when communicating with their therapist than participants in
the telehealth group64
• High acceptability of telehealth modalities66
• Reductions in the extent to which PTSD interferes with activities of daily living (including
health, diet, and work)69
Populations that
benefit from the
treatment

People experiencing PTSD, including:
•
•

Veterans, predominantly male 64-67, 69
Rural veterans68

Providers
who can offer
intervention
services

•
•
•
•
•
•

Clinical psychologists66, 68,69
Psychiatrists68
Master’s-level therapists and counselors64, 65, 67
Master’s-level social workers68, 69
Psychology interns/fellows68
Although formal PE training is not required, practitioners of PE often received training and
supervision in the form of:
− Weekly supervision from a licensed clinical psychologist who was a certified PE trainer64
− 32-hour workshop training program in PE65
− Observation of a senior-level clinician through a complete course of prolonged exposure,
both in-person and via telehealth65
− Recordings of therapy sessions for treatment fidelity67
− Extensive training and supervision in exposure therapy for PTSD69

Technology used

•

Videoconferencing via computer64-69 or smartphone68

Intensity,
duration, and
frequency

•

Participants received PE once a week ranging from approximately 60 to 90 minutes;65-69 they
were typically offered between 6 to 12 sessions depending on treatment response,64, 65, 67-69
and up to 21 sessions in one case66

Lessons learned
•
transitioning from •
in-person care to
telehealth
•

•

Clients express general interest and acceptability in using PE delivered via videoconferencing68
Telehealth-delivered PE can help overcome geographic barriers to care and help providers
reach underserved populations68, 69
Providers can make small adaptations to telehealth-delivered care to increase adherence to
PE; some small, yet useful changes in care include using smartphone calendar reminders,
scheduling an initial in-person client meeting to build rapport, and using the PE Coach app to
augment and supplement treatment66, 68
During telehealth visits, the quality and positioning of video cameras and monitors can reduce
providers’ ability to notice and respond to clients’ nonverbal communications69

Seven studies met criteria for review (four RCTs, two QEDs, and one single sample pre-post), resulting in a rating of
Strong Support for Causal Evidence.
Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders
What Research Tells Us

23

Exhibit 10
American Psychiatric Association, Committee on Psychiatric Dimensions of Disaster and
COVID-19 and the Council on Psychiatry and Law, The Impact of COVID-19 on
Incarcerated Persons with Mental Illness (2020)

COVID-19 Pandemic Guidance Document

THE IMPACT OF COVID-19 ON INCARCERATED
PERSONS WITH MENTAL ILLNESS
Prepared by the Committee on Psychiatric Dimensions of Disaster and COVID-19 and the Council on
Psychiatry and Law

The findings, opinions, and conclusions of this guidance document do
not necessarily represent the views of the officers, trustees, or all
members
of
the
American
Psychiatric
Association.

© Copyright 2020, American Psychiatric Association, all rights reserved.

The findings, opinions, and conclusions of this guidance document do not necessarily represent the views of the officers, trustees, or all
members of the American Psychiatric Association.

THE IMPACT OF COVID-19 ON INCARCERATED PERSONS WITH MENTAL ILLNESS
Background
The presence of mental illness leads to more frequent incarceration, on average, as well as longer
periods of incarceration when compared to those without mental illness.
Prior to the COVID-19 pandemic, persons with mental illness (PwMI), and people of color with mental
illness in particular, were disproportionately represented in the jail and prison system.
The COVID-19 pandemic has exacerbated the systemic inequalities that lead to PwMI being treated
differently than other prison populations. The opportunities for system improvement suggested in this
document, while focused on the impact of COVID-19, may have more generalized application beyond
the pandemic.

Issues
1. Courts and parole panels have been recessed, and because PwMI have fewer access to
resources needed to pay for bail, PwMI remain incarcerated at higher rates relative to other
prison populations.
2. In many correctional settings, therapeutic groups have been canceled, access to routine care is
reduced or eliminated, and greatly needed admissions to psychiatric inpatient facilities are even
more limited than prior to the advent of COVID-19.
3. In addition, crowding and movement restrictions in jails and prisons may exacerbate mental
illness leading to symptomatic exacerbation.
4. Access to reliable technology/wi-fi/cell phone service has been limited, affecting all who are
incarcerated and work in these settings.
5. Rapid turnover of inmates and generally reduced access to stable care in jails have been
currently exacerbated.
6. Prejudice and discrimination related to COVID-19 contagion is especially directed towards
PwMI and jail and prison staff, exacerbating preexisting stigma associated with religious, ethnic,
gender, and racial minority status.

Opportunities
Diversion of PwMI:
1. Develop protocols to prevent incarceration for those unable to pay bail/bond.
2. Implement functional crisis teams for referral at time of police contact and expand
technology for such teams.
3. Expand or create crisis respite/drop-in centers.
4. Eliminate incarceration for misdemeanor convictions.
5. Implement expanded electronic monitoring as an alternative to incarceration.

© Copyright 2020, American Psychiatric Association, all rights reserved.

2

The findings, opinions, and conclusions of this guidance document do not necessarily represent the views of the officers, trustees, or all
members of the American Psychiatric Association.

6. Develop infection control protocols to enable community programs (e.g., supported
housing, group homes, shelters) to continue accepting new referrals from court or
prison/jail.
7. Ease challenges for meeting parole or probation requirements and eliminate incarceration
for technical or non-violent violations of parole or probation.
8. Increase use of court diversion programs.
Treatment of PwMI who remain incarcerated:
1. Ensure updated and accurate information is actively given to all incarcerated people and
correctional setting staff members on preventative measures to reduce the spread of COVID-19.
2. Institute enhanced cleaning protocols, following CDC guidelines, for all correctional institutions
to reduce the presence of the coronavirus on surfaces inside the jails or prisons.
3. Establish formal disaster planning protocols; implement rapid COVID-19 screening, triage,
containment (e.g., alternate housing areas) and management protocols.
4. Ensure that jails and prisons have adequate PPE for both staff and inmates stored in the event of
a pandemic and that the supplies are up-to-date.
5. Coordinate care within facilities and significantly expand telehealth wherever possible and
clinically appropriate.
6. Allow visitation via video visits, including professional visits for court-ordered psychiatric
evaluations.
7. Where possible, modify mental health programming to conform with infection control measures
(e.g., smaller groups for a shorter time in order to accommodate social distancing) rather than
cancelling.
8. Ensure continued access to acute psychiatric and medical hospitalization for patients who need
that level of care.
9. Establish written protocols and provide training for collaboration by mental health staff, medical
personnel, and custody/operations staff to ensure adequate, timely, and appropriate
assessment and treatment services.
10. Balance infection control measures (e.g., social distancing, group cancellations) with measures
to maintain psychiatric stability, recognizing that in some cases the exacerbated mental illness
may pose a greater threat than COVID-19.
Early release:
1. Establish criteria for PwMI who have reached their minimum dates and are now parole-eligible,
including a presumption of parole for individuals who have been free of misconduct for a
designated time or have demonstrated rehabilitation in other measurable ways. Expedite parole
hearings for all incarcerated PwMI. Waive hearings for PwMI meeting the categories of
presumption of parole.
2. Utilize video hearings to avoid delays in necessary legal proceedings.
3. Implement emergency measures to release those with severe mental illness with lower level
charges, including those found incompetent to stand trial, as quickly and safely as possible.

© Copyright 2020, American Psychiatric Association, all rights reserved.

3

The findings, opinions, and conclusions of this guidance document do not necessarily represent the views of the officers, trustees, or all
members of the American Psychiatric Association.

Transition to community:
1. Coordinate with local health and mental health services for community-based care prior to
release.
2. Include emergency measures to make sure people released from incarceration have access to
enhanced re-entry support, including housing and other critical supports.
3. Facilitate Medicaid suspension, rather than termination, to reduce delays in accessing
healthcare and healthcare benefits upon release.
4. Improve medical record exchange between the correctional institution and the community
provider.
5. Provide COVID-19 screening upon release.

REFERENCES
Prevalence of Serious Mental Illness Among Jail Inmates.
https://pdfs.semanticscholar.org/f1b4/7a87b8c0e11bc3a46e46280e346c9cb5ec4c.pdf (Accessed June
29, 2020).
The Prevalence of Mental Illnesses in State Prisons: A Systematic Review.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4182175/ (Accessed June 29, 2020).
Indicators of Mental Health Problems Reported by Prisoners and Jail Inmates, 2011-12.
https://www.bjs.gov/index.cfm?ty=pbdetail&iid=5946 (Accessed June 29, 2020).
Jail Diversion: The Miami Model
https://pubmed.ncbi.nlm.nih.gov/32195644/ (Accessed June 29, 2020).

© Copyright 2020, American Psychiatric Association, all rights reserved.

4

 

 

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