Justice Without the Commute: What the Research Says About Telehealth in Forensic Psychology

Telehealth was once viewed primarily as a practical solution for emergencies, rural communities, or patients who could not travel. It is now an established method for delivering many psychological and psychiatric services. Its role has also expanded into forensic practice, including psychological evaluations, fitness-to-stand-trial evaluations, fitness-for-duty assessments, independent psychological examinations, fitness restoration, medication management, and individual counseling.

The central question is no longer simply whether these services can be provided remotely. The more important question is whether telehealth can produce clinically sound, legally useful, and ethically defensible results.

The growing research literature suggests that it often can. The strongest applications are those in which the clinician carefully considers the examinee, the legal question, the assessment methods, the available technology, and the limitations of the remote format. The evidence is especially persuasive when telehealth is viewed not as an automatic substitute for in-person care, but as one well-supported option within a flexible continuum of forensic services.

Can Forensic Evaluations Be Reliable by Telehealth?

A forensic evaluation involves much more than observing someone in the same physical room. A comprehensive evaluation typically integrates a clinical interview, mental-status examination, psychological testing when appropriate, records, collateral information, behavioral observations, and analysis of the relevant legal standard. Many of these components can be completed effectively through secure videoconferencing.

One of the strongest reviews of the broader evidence examined 57 studies involving 4,336 patients or examinees. Videoconference-based mental health treatment generally produced outcomes comparable to in-person services. More importantly for forensic evaluators, remote assessments did not appear to produce meaningfully different clinical decisions from assessments conducted in person, although the authors noted limitations in the number and methodological quality of the available studies. (PubMed)

A 2024 systematic review examined 35 studies comparing live telehealth interviews with face-to-face psychiatric assessment. Across varied populations and standardized diagnostic instruments, remote assessment demonstrated good agreement and reliability for conditions that included depression, bipolar disorder, posttraumatic stress disorder, social anxiety disorder, and autism spectrum disorder. The authors appropriately cautioned that the evidence was stronger for some diagnoses and populations than for others. (PubMed)

Earlier controlled research likewise found that diagnoses such as major depression, bipolar disorder, panic disorder, and alcohol dependence could be made through remote structured interviews with reliability comparable to in-person interviewing. (PubMed)

Taken together, these findings do not establish that every forensic evaluation should occur remotely. They do show that physical presence is not automatically necessary for a clinician to obtain meaningful diagnostic information, assess relevant psychological functioning, and formulate a supportable forensic opinion. That conclusion is particularly important in fitness-to-stand-trial cases, where delays in evaluation can have immediate consequences for defendants and court systems.

Telehealth and Fitness-to-Stand-Trial Evaluations

Fitness or competency evaluations are especially well suited to careful study because they address a defined legal question: whether a defendant has a sufficient factual and rational understanding of the proceedings and can meaningfully assist counsel.

In a Washington State program, clinicians completed 50 competency-evaluation interviews through secure videoconferencing across jails, state hospitals, restoration facilities, and forensic offices. Psychotic symptoms did not prevent the interviews from being completed, although technical difficulties occurred in some sessions. The program offered initial evidence that videoconferencing could be a feasible and safe method for improving access to fitness evaluations. (PubMed)

This finding is especially relevant amid what researchers have described as a national competency crisis. Courts and public mental health systems have faced increasing referrals, lengthy waiting lists, and delays in both evaluation and restoration. Appropriately implemented telehealth programs can help systems use limited forensic evaluators more efficiently and reach defendants who might otherwise remain in jail or travel long distances for an examination. (PubMed)

Telehealth may also allow attorneys, interpreters, institutional staff, and other authorized participants to join when necessary without requiring everyone to travel to one location. In the Washington program, attorneys could participate through a three-way connection. (PubMed)

The feasibility of a remote interview, however, does not automatically answer every assessment question. Psychological testing requires its own analysis because the suitability of remote administration varies substantially from one instrument to another.

Psychological Testing by Telehealth: What Works and What Does Not

Remote interviewing and remote psychological testing are related but distinct practices. Some self-report instruments can be administered securely online with relatively little change from their standardized format. Other measures require physical materials, direct manipulation of objects, precisely controlled conditions, close observation, or specialized equipment. Results may also be affected by screen size, audio quality, internet instability, distractions, or uncertainty about whether someone outside the camera's view is assisting the examinee.

Forensic psychologist Kirk Heilbrun has emphasized that remote testing should be considered measure by measure. The clinician must determine whether remote administration preserves the instrument's standardized procedures, psychometric properties, security, and relevance to the forensic question. (JAAPL)

Accordingly, telehealth should not be treated as permission to administer every test remotely. Depending on the referral question and the available evidence, a responsible evaluator may:

• Complete the interview remotely but arrange in-person testing.

• Use measures supported for remote administration instead of tests that require physical materials or direct observation.

• Employ an on-site technician or proctor when permitted and appropriately trained.

• Qualify the interpretation when administration differs from standard procedures.

• Recommend an in-person supplemental examination when the remote data are insufficient.

The appropriate question is not, "Can this test appear on a computer screen?" It is, "Will this method produce information that is sufficiently reliable and valid for the opinion being offered?" Once an evaluation identifies the functional deficits that require intervention, telehealth can also become a vehicle for providing restoration services rather than merely assessing the need for them.

Expanding Fitness Restoration Through Telehealth

Fitness restoration is not simply a legal vocabulary class. Effective restoration may require psychiatric stabilization, individualized education, cognitive remediation, symptom management, development of communication skills, and repeated assessment of the defendant's ability to apply legal information to the individual case.

Research on restoration programs supports the use of structured instruction, visual aids, individualized teaching, repetition, and deficit-focused intervention. Outpatient restoration programs have used clinicians, multimedia instruction, structured measures, visual materials, and individualized education to teach courtroom procedures and improve adjudicative functioning. (PubMed)

Controlled restoration research has also found improvement in defendants' understanding and appreciation of legal proceedings after structured intervention. (PubMed)

Through videoconferencing, restoration providers can teach and assess:

• Courtroom roles and responsibilities

• Common legal terminology

• The sequence of criminal proceedings

• Pleas and possible case outcomes

• Appropriate courtroom behavior

• The role of defense counsel

• How to communicate relevant information to an attorney

• How symptoms may interfere with rational participation

Telehealth also permits providers to share diagrams, courtroom images, written materials, hypothetical scenarios, quizzes, and other interactive resources directly on the screen. State forensic specialists can use these tools to deliver focused legal education, monitor progress, reassess fitness-related abilities, and prepare reports for the court. This approach can extend specialized forensic expertise to communities that may not have a local restoration provider.

The evidence specific to a fully remote restoration model remains less developed than the literature on general telepsychiatry or in-person restoration. The current rationale is therefore strongest at the component level: research supports structured fitness education and individualized remediation, while the broader telehealth literature supports delivering psychiatric and psychological interventions by videoconference. Larger studies directly comparing remote, in-person, and hybrid restoration models are still needed. (PubMed)

Legal education alone, however, is unlikely to restore a defendant whose hallucinations, delusions, severe mood symptoms, or cognitive disorganization remain uncontrolled. For many defendants, telehealth must therefore connect restoration education with timely psychiatric treatment.

Telepsychiatry for Medication Management and Psychiatric Stabilization

Many defendants found unfit to stand trial have serious mental illnesses, including psychotic and mood disorders. Education about the court process may accomplish little when active symptoms prevent the defendant from learning, reasoning, communicating with counsel, or applying legal information to the case.

Telepsychiatry can allow a psychiatrist to assess symptoms, review medication response, monitor side effects, provide education, evaluate adherence, and coordinate care with on-site medical, correctional, or community-based staff. It can also reduce interruptions when a patient moves between a jail, hospital, residential program, and community placement.

A meta-analysis of 32 randomized trials involving 3,592 participants across 11 psychiatric conditions found that telepsychiatry was generally comparable to face-to-face psychiatric treatment. These findings support telepsychiatry as a legitimate treatment modality rather than merely a temporary substitute for office-based care. (PubMed)

Telehealth does not eliminate the need for local medical support. Laboratory monitoring, vital signs, neurological examinations, emergency intervention, injectable medication, and assessment of certain adverse effects may still require in-person personnel. The strongest programs combine remote psychiatric expertise with reliable local observation, medication administration, and medical coordination.

Medication management may reduce the symptoms that interfere with adjudicative functioning, but symptom stabilization is only part of the restoration process. Individual counseling can help defendants sustain engagement, improve coping, address treatment barriers, and strengthen their ability to work effectively with counsel.

Effective Individual Counseling Through Video

Individual counseling may address anxiety, depression, trauma reactions, anger, substance misuse, medication adherence, adjustment to incarceration, or the psychological barriers preventing a defendant from participating meaningfully in treatment and the legal process.

Meta-analytic research comparing live video psychotherapy with in-person psychotherapy has found little meaningful difference in treatment outcomes. One analysis included 56 within-group studies and 47 comparative studies. Video-delivered psychotherapy produced substantial improvement and differed negligibly from in-person treatment, with particularly strong findings for cognitive-behavioral treatment of anxiety, depression, and PTSD. (PubMed)

Another meta-analysis found videoconference-based mental and behavioral health services broadly comparable to in-person care across numerous treatment outcomes and patient populations. (PubMed)

Therapeutic rapport can develop through a screen. For some patients, participating from a familiar or less intimidating setting may make it easier to disclose symptoms and engage in treatment. Others may feel less connected remotely or become distracted. As with in-person treatment, the clinician must evaluate the quality of engagement rather than assume that one format works equally well for everyone.

When remote evaluation, restoration education, psychiatric care, and counseling are coordinated, their benefits extend beyond the individual clinical encounter. They can improve the efficiency, reach, and continuity of the broader forensic system.

The Practical Benefits of Telehealth in Forensic Settings

When used appropriately, telehealth can offer several important advantages:

• Faster access. A qualified specialist can evaluate or treat an individual without waiting for travel arrangements, institutional transportation, or a local provider with the necessary expertise.

• Geographic reach. Courts, jails, hospitals, attorneys, and examinees in rural or underserved areas can access specialists who may be hundreds of miles away.

• Continuity of care. The same clinician may be able to continue treatment when a defendant changes facilities or returns to the community.

• Reduced transportation and security demands. Remote services may decrease the need to transport incarcerated individuals, coordinate multiple officers, or arrange security in a private office.

• Greater scheduling flexibility. Attorneys, collateral informants, interpreters, and institutional personnel may participate without traveling to a single site.

• Access to specialized expertise. Telehealth allows the legal system to select an evaluator or treatment provider based on qualifications and experience rather than proximity alone.

These advantages are not merely matters of convenience. Timely evaluation and treatment can affect liberty interests, case progression, institutional stability, public expenditures, and a defendant's ability to participate meaningfully in the legal process. (PubMed)

The greatest potential may be realized when states apply these practical benefits at a systems level. In jurisdictions confronting long forensic-bed waitlists and limited outpatient restoration capacity, telehealth can help reorganize services around the actual needs of defendants rather than around the location of scarce specialists.

Telehealth as a Systems-Level Response to the Fitness Crisis

Telehealth offers states a practical and scalable way to help address the growing fitness-to-stand-trial crisis. By allowing evaluations, psychiatric consultations, medication monitoring, restoration education, counseling, and court reporting to begin while defendants remain in jail or in the community, states can reduce avoidable delays, use scarce forensic beds more efficiently, and reserve inpatient placement for individuals who genuinely require hospital-level care.

Telehealth can also substantially expand the reach and efficiency of outpatient fitness-restoration programs. State forensic specialists can remotely provide focused education about courtroom roles, legal terminology, pleas, trial procedures, and the responsibilities of defense counsel. Those specialists can also monitor restoration progress, reassess fitness-related abilities, consult with local providers, and prepare reports for the court. This allows a relatively small group of forensic experts to serve defendants across multiple counties without requiring repeated travel or duplicating specialized programs in every community.

At the same time, local community mental health centers can concentrate on their core clinical strengths: stabilizing psychiatric symptoms, managing medications, promoting treatment adherence, providing counseling, addressing substance use, and coordinating community-based supports. Under this collaborative model, state forensic experts address the specialized legal and evaluative components of restoration, while local clinicians address the psychiatric and psychosocial conditions that prevent the defendant from functioning effectively. Each part of the system does what it is best equipped to do.

This division of responsibility can make outpatient restoration more accessible and efficient, particularly in rural and underserved areas. It can also allow services to begin sooner, reduce unnecessary admissions, shorten the time defendants spend waiting in jail, improve the timeliness of court reports, and create a clearer pathway for stepping defendants up to inpatient care only when clinically necessary.

Telehealth will not eliminate the need for forensic hospitalization. When integrated into a coordinated continuum of care, however, it can help shorten waitlists, expand outpatient restoration, accelerate case resolution, and ensure that defendants receive the right level of care sooner. Telehealth is therefore not simply a convenient alternative. It is an essential systems-level strategy for building a more efficient, humane, and responsive forensic mental health system.

A persuasive case for telehealth does not require ignoring its limitations. On the contrary, a well-designed system must be equally clear about the circumstances in which remote methods are insufficient and in-person services are necessary.

Knowing When Telehealth Is Not the Right Choice

Telehealth is a tool, not a universal solution. An in-person examination or treatment encounter may be preferable when:

• The examinee cannot reliably use the technology.

• Audio or video quality prevents adequate observation or communication.

• Privacy cannot be maintained.

• Severe agitation, intoxication, medical instability, or acute dangerousness requires on-site intervention.

• Cognitive, hearing, visual, or communication limitations substantially interfere with remote participation.

• The evaluation requires testing that cannot be validly administered remotely.

• There is concern that someone is coaching or influencing the examinee outside the camera's view.

• Subtle motor behavior, hygiene, gait, physical condition, or neurological signs are central to the referral question.

• The evaluator cannot obtain adequate records, collateral information, or institutional assistance.

Research has suggested that remotely obtained verbal symptom reports may be more reliable than behavioral ratings that depend heavily on subtle visual observation. This finding underscores the importance of high-quality video, careful behavioral documentation, and recognition of the modality's observational limits. (PubMed)

Recognizing these limitations does not weaken the case for telehealth. It defines responsible use. The defensibility of a remote forensic service depends less on the physical distance between clinician and examinee than on whether the clinician preserves the rigor, security, transparency, and professional standards required by the referral question.

What Makes a Tele-Forensic Service Defensible?

A high-quality telehealth evaluation should reflect the same professional rigor expected in person. The evaluator should verify identity and physical location, explain the nature and limits of confidentiality, confirm who is present, assess privacy, establish an emergency plan, use secure technology, document material technical disruptions, and determine whether applicable licensing and jurisdictional requirements have been satisfied.

The clinician should also disclose in the report that the examination occurred remotely and identify any limitations that affected the data, testing, observations, or opinions. When remote methods are inadequate, the evaluator should say so and recommend an in-person or hybrid approach rather than force the case into a format that cannot support a reliable opinion.

Professional telepsychology guidance emphasizes competence, informed consent, privacy, data security, documentation, testing standards, interjurisdictional practice, and emergency planning. Psychology-law recommendations likewise emphasize adapting telepsychology procedures to the distinctive demands of legal and forensic work. (PubMed)

When these safeguards are built into the process, telehealth can preserve forensic rigor while extending services to people and communities that would otherwise face significant delays or limited access.

The Bottom Line: Expanding Access Without Sacrificing Rigor

Telehealth should not be viewed as automatically inferior to an in-person forensic service. The evidence indicates that videoconferencing can support reliable diagnostic assessment, feasible fitness evaluations, effective psychotherapy, psychiatric treatment, and many important components of fitness restoration.

Quality still depends on thoughtful case selection. The clinician must know when remote methods are sufficient, when their limitations must be acknowledged, and when an in-person or hybrid approach is necessary. The most defensible position is neither "telehealth is always adequate" nor "forensic work must always occur in person." The method should be selected according to the examinee, the legal question, the available evidence, and the professional judgment of the evaluator.

Used in that manner, telehealth can do more than reproduce an office visit on a screen. It can connect courts with specialized evaluators, bring psychiatric and psychological treatment into underserved settings, expand outpatient fitness restoration, reduce avoidable detention and travel, and help states use limited forensic resources more intelligently. Telehealth can broaden access without sacrificing the rigor that courts, attorneys, agencies, and examinees have a right to expect.

Selected References

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101944. (PubMed)

Hagi, K., et al. (2023). Telepsychiatry versus face-to-face treatment: Systematic review and meta-analysis of randomized controlled trials. British Journal of Psychiatry, 223, 407- 414. (PubMed)

Heilbrun, K. (2022). Psychological testing in forensic contexts conducted remotely. Journal of the American Academy of Psychiatry and the Law, 50, 529-532. doi:10.29158/JAAPL.

220083-22. (JAAPL)

Luxton, D. D., & Niemi, J. (2020). Implementation and evaluation of videoconferencing for forensic competency evaluation. Telemedicine and e-Health, 26, 929-934. doi:10.1089/

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Mueller, C., & Wylie, A. M. (2007). Examining the effectiveness of an intervention designed for the restoration of competency to stand trial. Behavioral Sciences & the Law, 25, 891- 900. doi:10.1002/bsl.775. (PubMed)

Norwood, C., Moghaddam, N. G., Malins, S., & Sabin-Farrell, R. (2021). Live psychotherapy by video versus in person: A meta-analysis of efficacy. Clinical Psychology & Psychotherapy, 28, 1175-1190. doi:10.1002/cpp.2594. (PubMed)

Joint Task Force for the Development of Telepsychology Guidelines for Psychologists. (2013). Guidelines for the practice of telepsychology. American Psychologist, 68, 791-800. doi:10.1037/a0035001. (PubMed)

Van der Merwe, M., Atkins, T., Scott, A. M., & Glasziou, P. (2024). Diagnostic assessment via live telehealth versus face-to-face assessment for psychiatric conditions: A systematic review. Journal of Clinical Psychiatry. (PubMed)