Research roundup: Telepsychology
By Practice Research and Policy Staff
July 30, 2012—Telepsychology refers to the provision of psychotherapy or other psychological services through technology media that can accommodate geographical distance between healthcare providers and patients, such as telephone, e-mail, internet-based communications, and videoconferencing. It offers an innovative strategy to avert some of the obstacles people face in accessing and adhering to needed care. Technological advancement is fast-paced and inherently new, teeming with challenges and opportunities. This issue’s Research Roundup reviews recent research on telepsychotherapy that highlights some of these challenges and opportunities.
Yuen, E. K., Goetter, E. M., Herbert, J. D., & Forman, E. M. (2012). Challenges and opportunities in internet-mediated telemental health. Professional Psychology: Research and Practice, 43(1), 1-8.
Yuen and colleagues summarize some of the latest professional literature and highlight challenges and opportunities for psychologists in the realm of telepsychology. Internet-based services have the potential to bridge the gap created by logistical barriers to healthcare, such as scheduling conflicts, transportation, childcare, location and lack of services, lack of access to services, disabilities, incarceration, and stigma. This would yield pivotal benefits to a wide range of individuals currently unable to attain the psychological care they need. Technology’s rapid growth presents the opportunity to remotely administer consultations, treatments, assessments, and even supervision and training for mental health professionals via videoconferencing, websites, and handheld mobile devices.
Though limited, studies have thus far found encouraging evidence for the effectiveness of internet-mediated telepsychotherapy, with results comparable to in-person treatments. Websites can be used to educate and inform patients, and have been shown to support symptom reduction in anxiety disorders, depression, and behavioral health problems. Likewise, videoconferencing has proven beneficial in treating social anxiety disorders, anxiety in cancer patients, and depression in adolescents and children. Handheld devices used in telepsychology include landline telephones, mobile phones, and increasingly smartphones, which may facilitate videoconferencing, internet access, and downloadable applications.
With any of these options come new challenges: finding a secure and private internet/telephone connection, access to technology, need for encryption and password protection when transferring confidential written material (assessments, homework assignments, etc.), and limited observation (body language, micro-expressions, hygiene, eye contact, physiological responses, etc.). Advances in technology will soon likely eliminate some of these challenges, but until then it is imperative that the therapist and patient fully understand the potential threats to privacy, the proper use of the technology, and how to address connection failures and maintain the flow of the session.
When used efficiently, telepsychology resources will increase convenience for both patient and therapist, but only if proper training and necessary adjustments are made to maintain quality care. Psychologists may need to become more familiar with data security within computerized formats, and larger practices should consider utilizing an information technology specialist.
Smith, R. E., Fagan, C., Wilson, N. L., Chen, J., Corona, M., Nguyen, H., Racz, S., & Shoda, Y. (2011). Internet-based approaches to collaborative therapeutic assessment: New opportunities for professional psychologists. Professional Psychology: Research and Practice, 42(6), 494-504.
Technology has the ability to improve the speed, consistency, and convenience of collaborative assessment, which involves the client as an active participant in therapeutic activities, such as ongoing tracking of psychological symptoms, journaling and other homework assignments, and graphic feedback in and outside sessions. One tool being developed at the University of Washington comprises over 30 assessments that can be completed on a computer, tablet, or smartphone. A computerized diary system provides a secure and confidential mechanism for the client to communicate daily entries to the clinician, and allows clients to choose from a variety of formats: rating scales, checklists, free text, and any combination.
Prior to sessions, clinicians can use client feedback to make therapeutic adjustments as necessary. During sessions, clinicians will be able to provide concise feedback to patients by pointing out patterns and highlighting elements of the entries. Moreover, access to real-time out-of-session client feedback (such as homework assignments), will enable clinicians to better assess progress and improve session planning, thus increasing assessment efficiency and effectiveness.
While the benefits to a system like this may be substantial, there are issues that arise with the use of telepsychology. For example, clients in lower socioeconomic groups or rural locations may have difficulty obtaining internet access as frequently as is required. This could be especially counterproductive to treatment if it becomes a source of stress or frustration for the client.
Using Internet-based collaborative assessments, clinicians will be able to better utilize their expertise to design session plans addressing the client’s most current state. Using technology to provide an ongoing platform for assessment could aid the clinician in ways not previously possible, not only as a supplemental therapeutic tool, but also as a convenient source of pre-treatment patient feedback to ease the discomfort and unfamiliarity of a client’s first session.
Mohr, D. C., Ho, J., Duffecy, J., Reifler, D., Sokol, L., Burns, M.N., Jin, L., & Siddique, J. (2012). Effect of telephone-administered vs face-to-face cognitive behavioral therapy on adherence to therapy and depression outcomes among primary care patients. The Journal of the American Medical Association, 307(21), 2278-2284.
Among primary care patients diagnosed with depression, most indicate a preference for psychotherapy over antidepressant medication. However, many patients do not or cannot participate in psychotherapy due to access barriers.
In this study, 325 primary care patients diagnosed with Major Depressive Disorder were randomized to receive cognitive behavior therapy from a psychologist either by telephone (T-CBT) or face-to-face. The T-CBT group had a significantly lower attrition rate (20.9 percent) than the face-to-face CBT group (32.7 percent). For both groups, therapist-rated and self-reported symptoms of depression showed significant improvements post treatment, when compared to baseline. However, at a six-month follow-up, patients who had received face-to-face CBT were significantly less depressed than those who had received T-CBT, suggesting that while T-CBT may increase adherence to psychotherapy, the effects of face-to-face psychotherapy may be more durable over time.
Telephone CBT can be effective for typical patients in primary care, and it appears to reduce some of the barriers to regular psychotherapy attendance. However, this study does not identify characteristics of patients who are more likely to sustain gains over time—a better understanding of these factors will enable psychologists to determine whether phone psychotherapy is likely to benefit a particular individual. T-CBT is a reasonable option to improve access and provide therapy to underserved individuals who otherwise cannot or will not access psychotherapy. However, the benefits appear to diminish over time compared to face-to-face psychotherapy, and psychologists will want to evaluate alternate methods to enhance gains post-treatment.
Mohr, D.C., Carmody, T., Erickson, L., Jin, L., &Leader, J. (2011). Telephone- administered cognitive behavioral therapy for veterans served by community-based outpatient clinics. Journal of Consulting and Clinical Psychology, 79(2), 261-265.
In a trial examining the efficacy of telephone-administered cognitive behavioral therapy (T-CBT) in treating depression, 85 veterans (mean age 55.9 years) with Major Depressive Disorder (MDD) from six rural community-based out-patient clinics (CBOCs) in California and Illinois were randomized into one of two treatment conditions: T-CBT, or treatment as usual (TAU) through the CBOC. None of the participants included in this study had previously received psychotherapy. In the T-CBT condition, three licensed psychologists, trained in CBT with experience working with veterans in the VA, delivered sixteen 45-50 minute sessions over the course of 20 weeks (allowing four extra weeks for session cancellations). In the TAU condition, participants were free to access all of the available mental health services offered by the CBOCs, yet over the 20 week course of the study, little care was sought by participants in this condition. This resulted in a TAU condition that was fairly minimal compared to typical TAU conditions, which often require regular participation, such as ongoing community based psychotherapy.
Over the course of study, therapist-reported measures of patient change showed significant time effects from baseline through week 20, but they did not show significant treatment effects. While both groups showed a similar reduction in levels of depression, both the client-rated and the therapist-rated measures produced average scores that still fell in the clinically depressed range. No differences were found between veterans using T-CBT as compared to TAU for patient-reported measures, or standardized psychiatric interviews assessing major depressive episodes; there were also no significant time by treatment interactions; and, there were no significant differences between the treatments at a six-month follow-up. Given that the TAU condition was so minimal, researchers questioned whether patient expectations of therapy within this population may have affected the outcomes. In contrast to this study, prior research suggests that T-CBT can be an effective treatment for depression. The researchers discuss three main reasons why this study’s findings seem to diverge from others: non-significant trials may be under-published, therefore, the benefits of T-CBT may be overestimated; published randomized clinical trials often have small effect sizes, thus it may not be possible to detect a difference between T-CBT and TAU in real world treatment settings with less stringent controls; and, it is possible that veterans are less amenable to telephone psychotherapy than other populations that have been studied.
The divergence between this study and other published research evaluating telephone psychotherapy for depression indicates that more research must be done to determine which populations might benefit from T-CBT. A patient’s aptitude for technology and their expectations for psychotherapy may moderate the benefits of technology-delivered or technology-aided therapy.
Warmerdam, L., Van Straten, A., Twisk, J., Riper, H., & Cuijpers, P. (2008). Internet- based treatment for adults with depressive symptoms: Randomized controlled trial. Journal of Medical Internet Research, 10(4).
Internet-based CBT was compared to a short intervention concentrating on problem solving therapy for the treatment of depressive symptoms among adults. In the study, 263 participants who met the minimum score requirement on a depressive symptoms scale were randomized to one of three treatments: Internet-based cognitive behavioral therapy (CBT), Internet-based short-intervention problem-solving therapy (PST), or waitlist (WL).
The internet interventions were both highly structured, self-administered programs supplemented by supporting emails from Masters-level students of clinical psychology detailing weekly assignments, and providing assignment feedback. PST consisted of one session per week for five weeks; it focused on strategizing solutions for problems the participant categorized as “solvable,” and creating a plan for the future. CBT consisted of one session per week for eight weeks, plus a ninth session at twelve weeks; it followed a highly structured psycho-educational model specific to CBT for depression, which views problems as learned or unlearned behavioral/cognitive patterns that are modified by using coping skills and increasing pleasant activities.
Questionnaires assessing depression, anxiety, and quality of life were completed by participants before treatment, and at five, eight and twelve weeks. After five weeks of treatment, the PST group showed significant improvements in all three questionnaire scores compared to WL.
After eight weeks, as compared to the WL, both CBT and PST showed significant improvements, which was maintained after twelve weeks. No significant differences were found between the CBT and PST on the assessment scores at weeks eight and twelve, but patients who received PST exhibited a significantly faster response to treatment than CBT, by having significantly improved scores at week five. There was a high attrition rate for both CBT (61.4 percent) and PST (62.5 percent); and those who adhered to the treatment had significantly higher levels of education and significantly lower depression scores at baseline than those who did not complete treatment.
Internet-based psychotherapy is designed to be completed entirely from home (or other desired internet-accessible location) with minimal client-therapist interaction. However, the high attraction rate indicates that this approach may only be effective for self-motivated individuals who adhere to the program.
A clinician must consider the patient’s level of independence and need for personal contact with the therapist, and discuss these issues with the patient, when considering whether or not to suggest a program like Internet-based CBT or PST. This form of treatment may be ideal for some patients, but for others it may not provide sufficient interactions with the treatment provider.
Rees, C. S., & Stone, S. (2005). Therapeutic alliance in face-to-face versus videoconferenced psychotherapy. Professional Psychology: Research and Practice, 36(6), 649-653.
Videoconferencing is another form of telepsychology that can reduce barriers to psychotherapy, but few psychologists offer or provide it as an option. It is possible that psychologists’ traditional understanding of the therapeutic alliance, and the environment in which it is created, prompts wariness regarding the use of videoconferencing.
Based on previous research, which concluded that psychologists harbor negativity toward the use of videoconferencing in therapy, researchers hypothesized that psychologists would rate therapeutic alliance as being higher when psychotherapy is provided face-to-face versus via videoconferencing. Thirty clinical psychologists were randomly assigned to watch a twenty minute excerpt from a therapy session conducted in one of two formats: face-to-face or videoconferencing.
Other than the format, the sessions in each condition were identical. The psychologists then rated the therapeutic alliance between the therapist and client for each format using an instrument designed to be completed from the perspective of a third party observer. The instrument’s total score is the sum of two scores: the bond from the client’s point of view (such as therapist’s warmth, kindness, sincerity), and how well the therapist and patient work together to understand and abate the issue at hand. The group of psychologists who viewed the videoconferencing session had a significantly lower mean total score (M = 61.05) than the group who viewed the face-to-face session (M = 69.08). Additionally, the psychologists viewing the videoconferencing session rated the bond from the client’s point of view as significantly lower than those who viewed the face-to-face session. However, there was not a significant difference between the session formats on the psychologists’ ratings of how well the therapist and patient worked together.
The quality of the therapeutic alliance is a prominent concern many psychologists have regarding telepsychology, and specifically whether it is possible to establish the as strong an alliance via technology as in person. This article, though several years old, is still a relevant examination of the effects of psychologists’ perceptions about the therapeutic alliance. So, it would be interesting to see whether or not these results have changed with the rapid growth in technology use since 2005. Although psychologists rated the therapeutic alliance higher for face-to-face versus videoconferencing psychotherapy, the reasons for this are unclear. More study is needed to determine if there is a true difference, or if psychologists have a bias in favor of face-to-face psychotherapy, as the authors propose. Regardless, given the importance attributed to therapeutic alliance as a predictor of treatment response and adherence, psychologists using videoconferencing for psychotherapy may want to use a client-rated measure of the therapeutic alliance, or otherwise pay particular attention to the client’s impression of the therapist, to gage the therapeutic bond and maximize treatment response.
Telepsychology has the potential to improve access to services, the quality of mental health care, and convenience of treatment for both providers and clients. More research is necessary to understand the limitations inherent in telepsychology and to address the challenges for patients and providers.
Before providing an intervention via technology, psychologists should consider whether it is the best route for the patient and the clinician—this includes attention to current inter- and inner state laws regarding the specific uses of telepsychology, how session layout and involvement translate and adjust to the new format, and to issues of payment/reimbursement for services that may differ by format.
For more information on payment and reimbursement, see Reimbursement for Telehealth (PDF, 792KB) Services in the Spring 2011 issue of Good Practice.