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Therapeutic alliance in clinical videoteleconferencing: Optimizing the communication context
Abstract
This chapter addresses methods to establish or bolster therapeutic alliance with patients engaged in clinical videoconferencing (CV). The chapter will present a brief summary of the existing literature on therapeutic alliance to support a discussion of how therapeutic alliance may be impacted when conducting CV services. The chapter will also denote modifications to standard clinical behaviors which have been linked to strong therapeutic alliance in CV settings.
... Of particular interest to mental health practitioners has been the availability of videoconference technology (Berryhill et al., 2019a, b). With the ability to provide real-time audio and visual communication between client and therapist, videoconference software allows for reciprocal communication similar to that experienced in traditional therapeutic settings (Lozano et al., 2015). Promising in terms of convenience and accessibility, the use of telehealth in the provision of mental health care has been identified by a number of governmental agencies as a means of expanding treatment options (Department of Health & Ageing, 2012;Te Pou, 2018;Wozney et al., 2017). ...
... The need to interpret and respond to nonverbal cues may be of less imminent concern to clients, making them more open to the idea of developing a therapeutic relationship via telepresence. Besides non-verbal cues, concerns regarding other aspects of the therapeutic relationship were evident and included anticipated issues with communicating empathy , expressing warmth (Lozano et al., 2015) and impersonality of care (Connolly et al., 2020). ...
... The literature suggests that initial scepticism towards capacity for relationship building tends to diminish after therapists have had a chance to engage with clients via videoconference (Lozano et al., 2015). Békés et al. (2020) provided a recent example of the value of assessing therapist perspectives on the therapeutic relationship post-experience with online care. ...
An integrative literature review was undertaken as a means of drawing together contemporary perspectives on the outcomes and affordances of videoconference-based therapy. This review was conducted in a way which placed emphasis on the need for mental healthcare strategies which are mindful of the cultural and social needs of indigenous and ethnic minority populations, particularly those situated in the Global South. The review was undertaken using an inverse funnelling approach which sought to prioritise literature on videoconference-based therapy literature which specifically focused on indigenous and ethnic minority populations. A series of general and population specific searches across relevant health databases were supplemented by a simultaneous search of Google Scholar. The PICOS search tool was used in developing the search terms, and data was processed using an inductive approach to thematic analysis. A final dataset of 43 articles were included in the review. This body of literature encompassed an international range of studies and included perspectives informed by quantitative, qualitative and mixed methods research. Four key themes were identified across the reviewed literature: indigenous and ethnic minority populations, therapeutic relationships, clinical outcomes and technical and logistical considerations. Based on our findings, there is reason to believe that videoconference-based therapy can be made to be just as effective as offline, face-to-face modes of delivery. However, research into the efficacy, impact and cultural implications of this technology in relation to indigenous and ethnic minority populations represents a significant gap within contemporary literature.
... Ertelt and colleagues (2011) found that when compared to in-person delivery of individuals diagnosed with bulimia nervosa, clinicians reported significantly higher ratings of alliance in the in-person condition as opposed to TVC condition. @BULLET Lozano et al. (2015) and Glueck (2013) reviewed steps to take in order to optimize the therapeutic relationship over TVC. @BULLET Suggestions for optimizing therapeutic relationship: o Using picture in picture (PIP) may be helpful for clinicians to monitor their own reactions and connection with the client. ...
... @BULLET Suggestions for optimizing therapeutic relationship: o Using picture in picture (PIP) may be helpful for clinicians to monitor their own reactions and connection with the client. Disabling the client's PIP may limit client distraction and reduce client self-consciousness (Bouchard et al., 2004; Lozano et al., 2015). o Remove or cover patterned wallpapers or posters, as they can be distorted on camera and distracting to the client (Lozano et al., 2015). ...
... Disabling the client's PIP may limit client distraction and reduce client self-consciousness (Bouchard et al., 2004; Lozano et al., 2015). o Remove or cover patterned wallpapers or posters, as they can be distorted on camera and distracting to the client (Lozano et al., 2015). o For cameras located above the monitor, clinicians should look directly at the camera to appear to have direct eye contact. ...
Poster presented at the American Psychological Association Annual Convention in August, 2015.
... (1) becoming more deliberate in their use of both verbal and nonverbal gestures and mannerisms in order to convey empathy and encouragement, such as through the use of paralanguage and voice tone, tempo, and inflection; (2) becoming more enquiring, seeking more clarification and providing more feedback and therapeutic reflections, while being attuned to changes in clients' facial expressions and gestures; (3) providing a preparatory face-to-face session for those clients who require this in order to ease into the telepsychology relationship and familiarize themselves with aspects of the technology (Bischoff et al. 2004;Manchanda and McLaren 1998); and (4) demonstrating therapeutic flexibility and creativity in the context of developing points of connection and therapeutic support for clients (while maintaining therapeutic boundaries) (Tuerk et al. 2010). Several resources are available for ensuring therapist competence and maximizing client engagement in telepsychology (e.g., Hilty et al. 2018;Lozano et al. 2015;Simpson et al. 2016). ...
... The following case study illustrates some of the key therapeutic issues and the ways in which the therapist can manage these in the context of video-therapy. Further detailed clinical recommendations on the topic of telepsychology etiquette are available through other recent publications (e.g., Lozano et al. 2015;Simpson et al. 2016). ...
Barriers to the equitable provision of evidence-based psychological treatments in rural and regional areas are significant in both developed and developing countries. Psychologists and mental health workers are turning to telehealth as a means of overcoming some of these barriers, including the use of email, telephone, web-based interventions, social media, virtual environments, podcasting, and videoconferencing for therapeutic purposes. Increasingly accessible wireless and hardwired networks, combined with affordable Internet Protocol (IP)-based videoconferencing, provide the greatest potential for psychologists to engage with marginalized residents in remote and rural areas. Evidence suggests that videoconferencing, in particular, is both a clinically and cost-effective means of increasing access to care with high ratings of therapeutic alliance and satisfaction by clients and therapists alike. This chapter outlines ways in which videoconferencing can be used clinically with rural and remote clients and suggests strategies by which organizations and individual practitioners may address some of the challenges of setting up and sustaining videoconferencing-based psychology services in the future. In particular these issues will be illustrated through a rural Australian case study.
... Privacy and time are factors that provide a safe space for patients to share emotional concerns confidentially with their physiotherapist and an appropriate context where the therapeutic alliance can be fostered (Moore et al., 2020;Sønden a et al., 2020). Alternative approaches to achieving therapeutic alliance during remote delivery, for example, using video-conferencing or nuanced communication techniques (Lozano et al., 2015), could further improve PACT treatment. ...
Objectives:
A randomized controlled trial of a new type of Physiotherapy informed by Acceptance and Commitment Therapy (PACT), found that it improved functioning in people with chronic low back pain compared to usual physiotherapy care. Fidelity evaluation is necessary to understand trial processes and outcomes. This study evaluated PACT treatment fidelity including delivery, receipt, and enactment.
Design:
A mixed-methods study nested within a randomized controlled trial was conducted.
Methods:
A total of 72 (20% of total) PACT treatment audio files were independently assessed by two raters, according to a novel framework developed to measure PACT treatment content adherence, therapeutic alliance, ACT competence, and treatment enactment. Interview transcripts from 19 trial participants randomized to PACT were analysed thematically for evidence of treatment receipt and enactment.
Results:
PACT physiotherapists delivered treatment as intended with high content adherence and satisfactory therapeutic alliance, but ACT competence was low. Qualitative findings indicated participant receipt of 11/17 and enactment of 3/17 components; 89% (n = 17) and 47% (n = 9) of participants reported treatment receipt and enactment of at least one component, respectively.
Conclusions:
This mixed-methods study of PACT treatment demonstrated high fidelity reflecting treatment content delivery and receipt, and therapeutic alliance. There was some evidence of treatment enactment in participants with chronic low back pain. Low ACT competence could be addressed through additional support and adaptations to therapeutic processes for delivery by physiotherapists.
... As shown in Table 1, we reviewed content of published instruments from multiple disciplines to determine checklist item content. Items from 12 instruments (Dinh et al., 1999;English et al., 2007;Frankel & Stein, 1999;Hughes et al., 2016;Humphris & Kaney, 2001;Johnson et al., 2014;Kurtz et al., 1998;Lehmann et al., 1990;Lozano et al., 2015;Roter & Larson, 2002;Siassakos et al., 2009;Studer et al., 2010) sufficiently covered the five pre-determined categories of telehealth communication behaviors: preparation, verbal, non-verbal, relationship, and environment. Each category had five to 10 instruments that included related items. ...
While interpersonal skills in telehealth may positively impact clinical practice, patient engagement and outcomes, assessment strategies are lacking. We conducted a multi-stage iterative approach to develop and test validity and reliability of the Teaching Interpersonal Skills in Telehealth checklist (TIPS-TC). First, we identified observable communication behaviors from the literature. Second, we surveyed telehealth managers and researchers (N = 11) to rate appropriateness of potential checklist items. Level of agreement (35%-91%) and Kappa statistic (0.18-0.89) confirmed items to be retained and identified items to modify. Based on response patterns and comments, we reduced 44 items to 12 critical checklist behaviors. Third, student clinicians used the checklist with video telehealth consultations and provided feedback. Fourth, we conducted reliability testing with practitioners and administrators (N = 68) who completed the TIPS-TC for two versions of a telehealth scenario. Strong interrater reliability intraclass correlation coefficient (ICC) and test-retest reliability ICC (both p < .001), along with non-significant findings of order effects supported the checklist as an acceptable instrument to differentiate high skill from low skill telehealth sessions. The TIPS-TC offers an evidence-based approach to assessing interpersonal skills in telehealth to help evaluate clinician competence and tailor learning activities across disciplinary roles.
... In individual online therapy, facial expressions exert a great influence on the therapeutic relationship. Research studies which compared the efficiency of face-to-face (verbal) therapy with Internet-based treatment of various disorders found the two forms of treatment equally helpful (Lozano et al., 2015;Oldenburg et al., 2015). While there have been some references relating to digital DMT (e.g., Goldhahn, 2020;Spooner et al., 2019), we found no research study comparing face-to-face DMT with webcam DMT. ...
Dance/movement therapy (DMT) has been forced to find alternative ways to
operate amid the Coronavirus pandemic. Due to the restrictions of isolation,
therapy sessions have begun to be held through online means, in an attempt to
preserve the therapeutic relationship whilst meetings take place in separate
physical spaces. Inevitably, various components of the therapy session have
been impacted and altered. DMT is based uniquely on an ongoing focus on
body-movements, thus enabling the therapist to gather data on personal and
interpersonal processes and to assess, intervene, and interpret such data. The
shift to webcam-DMT has had an influence on the manner in which the emotional
body-movement ‘text’ of patients is revealed. This article attempts to
illuminate the adversities affecting DMT during the pandemic and to expound
ways to maintain DMT’s unique contribution despite the detriment caused to
body-movement textual space in webcam sessions.
... Bouchard, Robillard, Marchand, Renaud, and Riva (2007) found the feeling of presence predicted the strength of the therapeutic alliance over a course of CBT for panic disorder. Better image and sound quality may promote greater presence (Lozano et al., 2015) and, therefore, the choice of VC platform and the Internet connection quality will be important to consider carefully in future studies. Similarly, training programs for online mindfulness instructors should be developed based on good practice guidelines to meet the challenges of managing group dynamics remotely. ...
Revisión sistemática de la terapia cognitiva basada en la atención plena y la reducción del estrés basada en la atención plena mediante videoconferencia grupal: Viabilidad, aceptabilidad, seguridad y eficacia
La terapia cognitiva basada en la atención plena (MBCT) y la reducción del estrés basada en la atención plena (MBSR) son efectivas para reducir la angustia entre las personas con problemas de salud física o mental. Sin embargo, la implementación está limitada por la provisión geográfica variable, la capacidad de viajar y la necesidad de la prestación de servicios remotos durante la crisis de la enfermedad del coronavirus 2019 (COVID-19). La integración con tecnologías habilitadas para Internet como las videoconferencias potencialmente mejora el acceso. Este artículo informa una revisión sistemática que explora la viabilidad, aceptabilidad, seguridad y eficacia de administrar MBCT / MBSR por videoconferencia (MBCT / MBSR-VC). No se hicieron restricciones sobre la población o el diseño del estudio. Se realizaron búsquedas en once bases de datos en línea y diez estudios cumplieron los criterios de inclusión. Se utilizó la síntesis narrativa debido a la heterogeneidad del estudio. Los artículos presentaban muestras no clínicas de salud física, pero no de salud mental. Tres estudios tuvieron una calidad metodológica moderada-fuerte. Los resultados apoyaron la viabilidad y aceptabilidad de MBCT / MBSR-VC. Las consideraciones de seguridad no se informaron en gran medida. MBCT / MBSR-VC demostró efectos positivos medios en los resultados de salud mental en comparación con los controles inactivos (ds 0,44 –0,71) y poca diferencia en comparación con los controles activos como la entrega en persona (todos los intervalos de confianza cruzaron cero). La evidencia con respecto a la atención plena o la autocompasión como posibles mecanismos de acción no fue concluyente. La investigación de implementación futura debe dirigirse a las poblaciones de salud mental utilizando diseños de no inferioridad. La adaptación de MBCT / MBSR a la entrega remota requerirá el desarrollo de pautas y paquetes de capacitación para garantizar las mejores prácticas en este medio y el cumplimiento de los modelos MBCT / MBSR basados en evidencia.
... Therapists may also enquire more regularly to elucidate meanings associated with facial expressions and body movements/position. (Bischoff, Hollist, Smith, & Flack, 2004;Himle et al., 2006;Lozano et al., 2015;Richardson, 2012;Simpson, 2009;Simpson, Richardson, & Reid, 2016;Tuerk, Yoder, Ruggiero, Gros, & Acierno, 2010). ...
The arrival of the coronavirus (COVID-19) pandemic has confronted us with a global and unprecedented challenge of community-wide psychological distress alongside reduced access to therapeutic services in the traditional face-to-face format, due to the need to self-isolate. This previously unimagineable set of circumstances provides a unique opportunity, and indeed an imperative, for videotherapy to fulfil its potential in addressing mental health and well-being needs from a distance. Historically, the uptake of videotherapy has been hindered by psychotherapist expectations of inferior therapeutic alliance and outcomes, in spite of considerable research evidence to the contrary. Research suggests that videotherapy provides a powerful pathway for clients to experience enhanced opportunities for self-expression, connection and intimacy. This more neutral therapeutic 'space' provides clients with multifarious opportunities for self-awareness, creative experience and collaboration, with potentially a greater sense of agency over their own experience. This paper explores ways in which videotherapy can lead to a revitalisation of the concept of the therapeutic relationship, in order to meet the challenges associated with COVID-19. A number of specific considerations for videotherapy adaptations and etiquette in the midst of COVID-19 are described.
... 6 In fact, troubleshooting around common issues such as poor audio/visual connectivity or dropped calls can improve and maintain a strong therapeutic alliance. 7 While best practices for video-based services have been outlined by various professional organizations, including the National Association of Social Workers 8 and the American Telemedicine Association, 9 the guidelines provided by these organizations focus primarily on quality, cost, ethics, and regulations of conducting telehealth services. While useful, most of these guidelines lack specific and practical information on how to address real-time technological issues that can directly impact the efficacy and acceptability of telehealth services. ...
Background:
Telehealth methods, including video chat counseling, have been growing in popularity within the behavioral health counseling field for over a decade. While video-based counseling methods have been shown to be effective and convenient, they have unique challenges stemming from the technology they use. Technical challenges can negatively impact appointment flow, intervention effectiveness, and the satisfaction of both patients and clinicians.
Methodology:
The Y2TEC (Youth to Text or Telehealth for Engagement in HIV Care) study is a pilot randomized control trial examining the feasibility and acceptability of a video counseling series provided to young adults (ages 18-29) living with HIV. The study's clinicians provided about 500 video-based counseling sessions through the Zoom videoconferencing platform. The study team then developed recommendations for overcoming technical challenges through a review of the best practice literature, insights from the clinicians and study coordinator, engaging in consultations during supervision meetings, receiving verbal feedback from participants, and reviewing logs of technical challenges.
Results:
Through our experience, we have found that quality of video-based counseling services can be greatly improved with minor intentional technological modifications in preparation and provision of services. We provide an overview of common challenges and corresponding recommendations to address them.
Conclusion:
This article can help clinicians improve their quality of telehealth sessions by identifying several common technological challenges that can occur during video chat sessions, exploring the impact of these challenges on session dynamics and providing concise, best practice-based recommendations to mitigate these issues that clinicians face.
... [2][3][4] Also, some patients may feel more comfortable engaging in therapy, or more collaborative within the therapeutic relationship, if a provider is flexible in the ways that he/she is willing to deliver care. [5][6][7][8][9] ...
Video-to-home (VTH) is a patient-centered approach to delivering mental health care that has increased the reach of care to patients who face considerable logistical and sociocultural barriers. Despite high rates of patient satisfaction and acceptance of VTH, scholarly resources for expanding providers' comfort and competence using VTH are limited to emergency preparedness or remotely managing higher risk patients. This article highlights other potential benefits, adaptations, and considerations for providers interested in expanding their use of VTH to engage patients who are difficult to reach or who have complex presentations.
... Overall, the delivery of the TBIconneCT intervention via videoconferencing was feasible and well received by the participants, despite the occurrence of some technical problems. Our positive findings regarding therapeutic alliance were consistent with the findings of previous telehealth studies (48). We were able to retain both participants for the entire study up until follow-up, although there was a difference in the timing of follow-up assessment (3 months versus 9 months). ...
Primary objective: To investigate use of telehealth to deliver social communication skills training (TBIconneCT) to people with severe traumatic brain injury (TBI) and their communication partners (CPs).
Research design: Feasibility study involving single case experimental design with two participants.
Methods and procedures: TBI Express is an established program for improving social interactions between people with TBI and their CPs. To improve access to the program, we developed a modified version called TBIconneCT that can be delivered via videoconferencing. Two participants with TBI and their CPs completed TBIconneCT training. Outcome measures included exchange structure analysis of conversation samples, blinded ratings of conversation samples and self-report measures.
Main outcomes and results: The study indicated positive change on blinded ratings of conversation and self-reported measures for both participants. Exchange structure analysis conducted on session-by-session data did not demonstrate treatment effects due to variability during baseline.
Conclusion: This study indicated potential for using telehealth to provide social communication skills training to people with TBI and their families. The study findings provide a foundation for a phase one clinical trial which will compare in-person with videoconferencing delivery of TBIconneCT.
Introduction:
Clinicians often report technical issues as a barrier to adopting videoconferencing service models. This descriptive study nested within a randomised controlled trial investigated the frequency, nature and impact of technical issues during video consultations.
Methods:
Physiotherapists (n = 15) underwent training to deliver knee osteoarthritis care focussed on education, strengthening and physical activity. In the randomised controlled trial, participants received five physiotherapy consultations either in-person or via videoconferencing (via Zoom) over 3-months; consultations were recorded and physiotherapists documented technical difficulties. In this study, available notes were audited (n = 169 initial and n = 147 final consultations) and nature and frequency of technical issues coded. Based on whether the clinician reported technical difficulties, three subgroups were created for analysis 1) in-person, 2) videoconferencing without technical issues, 3) videoconferencing with technical issues. Forty participants were randomly selected for each subgroup (n = 120). Duration of consultation components (set-up and introduction, assessment, exercise, physical activity, education and wrap-up), total consultation duration and duration of technical issues were compared across subgroups using one-way multivariate analyses of variance with mean differences (MD) and 95% confidence intervals (CIs).
Results:
Technical issues were documented in 37% (initial) and 19% (final) of video consultations. Problems with audio/video were most frequent, occurring in 36-21% (initial) and 18-24% (final) consultations. Audio/video problems were predominantly experienced during set-up, but did not significantly increase videoconferencing consultation duration compared to in-person consultation duration (MD (95% CI) 0.72 (-3.57 to 5.01) minutes).
Discussion:
While technical issues with videoconferencing consultations frequently occur, they are typically minor, transient and resolved quickly.
Telemedicine via videoconferencing rapidly deployed during the COVID-19 pandemic reduces contact and opportunity for virus transmission, with Quadruple Aim benefits of improved population health and associated cost avoidance of COVID-related illness. Patient experience of telemedicine has generally been positive, but widespread use of videoconferencing outside of healthcare has brought growing recognition of associated mental fatigue. Experience in telepsychiatry shows attending to non-verbal communication and maintaining empathic rapport requires increased mental effort, making provider experience more sensitive to cumulative fatigue effects. Since empathy and therapeutic alliance are foundational to all physician-patient relationships, these telepsychiatry findings have implications for telehealth generally. Health leaders and providers planning for sustainable incorporation of videoconferencing into ongoing healthcare delivery should consider the potential for unintended negative effects on provider experience and burnout.
Tips for building rapport with adult clients via telehealth in the age of COVID-19
Clinical video teleconferencing (CVT) is a treatment delivery modality that can be used to provide services to clinical populations that experience barriers to accessing mental health care. Recently, home-based CVT (HBCVT) has been developed in order to deliver treatment via CVT to patients in their homes. A number of clinical considerations, including the appropriate clinical population and individual patient factors, need to be taken into account when delivering CVT. Particular challenges can exist when setting up the home environment for HBCVT. Concerns about maintaining patient privacy while living in shared spaces, ensuring adequate CVT technology in the patient's home, and conducting risk management remotely are important to consider when delivering treatment via CVT. Since treatments delivered via CVT are often conducted across state lines, novel ethical and legal issues such as privacy laws, licensing of providers, prescribing practices, and insurance reimbursements need to be addressed when conducting services via these modalities. Future research on HBCVT will provide researchers and clinicians with information regarding which patients are most appropriate for treatment delivered via this modality and help further develop evidence for the cost-effectiveness of CVT and HBCVT clinical practice guidelines.
This study compared selected process and outcome variables across 3 modes of psychotherapy: face-to-face, real-time video conference, and 2-way audio (analogous to telephone). Results from 80 randomly assigned clients suggested that differences in process and outcome among the 3 treatments were small and clinically promising in comparison with the untreated control group.
Context: Home-based videoconferencing may be a promising vehicle for providing much-needed counseling services to at-risk adolescents with epilepsy and their families. However, there has been only limited research examining differences in user perceptions of telecommunication-mediated counseling versus traditional, office-based counseling. Objective: To examine differences between the perceptions of adolescents with epilepsy and their parents in regard to comfort, distraction, and therapeutic alliance across 3 different modalities: (a) home-based video-system counseling, (b) home-based speakerphone counseling, and (c) videotaped, office-based counseling. Results: Mothers and adolescents reported moderately high levels of comfort and therapeutic alliance and low levels of distraction across all modalities. Adolescents were more comfortable and less distracted than their mothers across all three conditions. Conclusions: These results lend preliminary support to the use of telecommunication-mediated counseling with at-risk adolescents with epilepsy.
The objective of this study was to evaluate patient satisfaction when telemedicine is used for clinical consultations. Patient satisfaction data from 495 real-time interactive telemedicine clinical consultations at the Telemedicine Center at East Carolina University School of Medicine in Greenville, NC were collected and evaluated. Patient satisfaction was examined in relation to patient age, gender, race, income, education, and insurance. Overall patient satisfaction was found to be 98.3%. Because so few patients were dissatisfied with their telemedicine consultation, correlation with the sociodemographic variables was limited. Patients are highly satisfied with consultations through telemedicine, and report that care was easier to obtain. The sample size in this study is larger than other reported telemedicine studies, but its findings are consistent with those of previous studies. In non-telemedicine settings where patient satisfaction has been studied, several significant factors have been correlated with dissatisfaction. These factors include appointment scheduling, travel time, and patient involvement in the physical examination. In telemedicine, the same factors may be associated with higher patient satisfaction rates. To determine correlation between demographic factors and satisfaction, additional studies using different constructs relating to patient satisfaction are needed.
Equal access to mental health services is necessary for healthy individuals and communities. However, due to geographical distances and other barriers, some clients cannot easily access mental health professionals. Technologies such as videoconferencing for clinical purposes (i.e., telemental health) may help to bridge these gaps to connect clients and clinicians at geographically diverse locations. However, despite its potential utility, telemental health has not been widely adopted in Canada. This study is an exploratory investigation into mental health professionals' attitudes toward telemental health, factors that affect the frequency with which they use this technology, and their perceptions of individual characteristics that make clients more or less suitable candidates for telemental health. This study has a particular focus on remote and rural and Operational Stress Injury (OSI) contexts. One hundred sixty mental health workers across Canada participated in an online survey, and 25 mental health workers from Operational Stress Injury clinics across Canada participated in in-person interviews. The data were examined using qualitative and quantitative analysis methods. Findings suggest that mental health workers have overall positive attitudes toward the use of telemental health—particularly for clients in remote and rural locations. Additionally, receiving training in telemental health, being in the mental health field for longer, and perceiving the technology as easy to use are associated with more frequent use of telemental health. Finally, clinicians reported specific client characteristics that they perceive to make some clients unsuitable candidates for telemental health. Implications of these findings and directions for future research are discussed.
Many studies have shown the feasibility of psychiatric consultation in telehealth, and some have addressed the effectiveness of telepsychotherapy. However, outcome studies on telepsychiatry essentially amount to a few case studies, none of which have used an empirically validated psychosocial treatment to treat a specific mental disorder. This article presents the preliminary results of an outcome study on the effectiveness of telepsychotherapy for panic disorder with agoraphobia. Participants received 12 sessions of cognitive-behavior therapy, which is an empirically validated treatment for panic disorder with agoraphobia. The treatment was delivered via videoconference by trained therapists according to a standardized treatment manual. The remote site was located at 130 km north of the local site and both were linked by six ISDN lines. Telepsychotherapy demonstrated statistically and clinically significant improvements on measures of target symptoms (frequency, of panic attacks, panic apprehension, severity of panic disorder, perceived self-efficacy) and measures of global functioning (trait anxiety, general improvement). Of interest was the fact that a very good therapeutic alliance was built after only the first telepsychotherapy session. Factors that may reduce the effectiveness of telepsychotherapy are discussed.
The present review is a comprehensive examination of the therapist's personal attributes and in-session activities that negatively influence the therapeutic alliance from a broad range of psychotherapy perspectives. Therapist's personal attributes such as being rigid, uncertain, critical, distant, tense, and distracted were found to contribute negatively to the alliance. Moreover, therapist techniques such as over structuring the therapy, inappropriate self-disclosure, unyielding use of transference interpretation, and inappropriate use of silence were also found to contribute negatively to the alliance. In addition, this review reveals how therapist's personal qualities and use of technique have a similar influence on the identification or exacerbation of ruptures in the alliance.
The aim of this study was to examine the potential independent and joint impact of 2 specific therapist nonverbal behaviors—eye contact and trunk lean—on perceptions of therapist empathy, the relationship between client and therapist, and the credibility of the treatment. Four different psychotherapists were filmed in 4 combinations of eye contact and trunk lean. Participants rated these therapists after viewing a randomized order of the therapy session videos. Findings indicate that high eye contact and forward trunk lean enhanced perceived therapist empathy, therapeutic alliance, and treatment credibility. These results suggest that therapists could improve their practice by using specific nonverbal behaviors.
Objective: Assess the effects of videoconferencing-based counseling on the psychosocial functioning of rural teenagers with epilepsy. Setting: University and rural communities. Participants: Twenty-two teenagers with epilepsy and their parents. Interventions: Six sessions of home-based video counseling, home-based speakerphone counseling, or office-based counseling. Main Outcome Measures: Problem severity and frequency, Social Skills Rating System, modified Working Alliance Inventory, and treatment adherence. Results: Teenagers and parents reported significant reductions in both problem severity and frequency across all 3 conditions from pre- to post-6th session to the 6-month follow-up. Parents reported significant increases in prosocial behaviors from pre- to post-6th session to follow-up. In contrast, both parents and teachers reported no change in problem behaviors over time. No differences in adherence were found across the 3 modalities. Overall therapeutic alliance was high but varied as a function of family member and treatment. Conclusions: Mode of delivery did not influence initial treatment outcomes or adherence. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The authors predicted that client attachment status would moderate the relationship between counselor experience and client-perceived working alliance. Forty clients from 2 university counseling centers completed measures of attachment and the working alliance. Their counselors were classified according to experience level. Client comfort with intimacy was related to a stronger alliance with the counselors. However, counselor experience was unrelated to client-rated working alliance. Client attachment, specifically comfort with intimacy, moderated the relationship between counselor experience and working alliance. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Current social competencies and memories of attachment bonds with each parent were examined as they related to influences on formation of the working alliance. Female clients (
N = 76) at 4 university and community agencies completed surveys containing the Parental Bonding Instrument, the Self-Efficacy Scale, the Adult Attachment Scale, and the Working Alliance Inventory. Results indicated that parental bonds, especially with fathers, were significantly associated with social competencies. Multiple regression analyses indicated that social competencies (self-efficacy and adult attachment) accounted for 14% of the variance in client working alliance ratings, whereas recalled parental bonds accounted for 23% of the variance. Working alliance was negatively associated with father bonds, positively associated with mother bonds, and (among social competencies) significantly associated with capacity for adult attachment. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Results of 24 studies (based on 20 distinct data sets) relating the quality of the working alliance (WA) to therapy outcome were synthesized using meta-analytic procedures. A moderate but reliable association between good WA and positive therapy outcome was found. Overall, the quality of the WA was most predictive of treatment outcomes based on clients' assessments, less so of therapists' assessments, and least predictive of observers' report. Clients' and observers' rating of the WA appear to be more correlated with all types of outcomes reported than therapists' ratings. The relation of WA and outcome does not appear to be a function of the type of therapy practiced, the length of treatment, whether the research is published, or the number of participants in the study. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The advent of telehealth technology gives psychologists new opportunities to expand their practices in a cost-effective manner, but little is known about telehealth efficacy and costs. This study of 49 neuropsychology clients interviewed using videoconferencing and 49 matched in-person controls yielded no group differences in client ratings of interpersonal factors. Telehealth clients were more likely to want to repeat their experience, but psychologist satisfaction was lower for telehealth sessions. Telehealth costs were significantly lower than in-person costs. Concerns about ethical issues, billing, and licensure must be addressed to help practitioners capitalize on new telehealth opportunities. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Reviews and elaborates the psychoanalytic concept of the working alliance. It is argued that various modes of psychotherapy can be meaningfully differentiated in terms of the kinds of working alliances (WA) embedded in them. Moreover, the strength, rather than the kind of WA, will prove to be the major factor in change achieved through psychotherapy. Strength of alliance will be a function of the goodness of fit of the respective personalities of patient and therapist to the demands of the WA. The WA includes 3 features: agreement on goals, assignment of tasks, and the development of bonds. (36 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Two decades of empirical research have consistently linked the quality of the alliance between therapist and client with therapy outcome. The magnitude of this relation appears to be independent of the type of therapy and whether the outcome is assessed from the perspective of the therapist, client, or observer. Although the strength of the connection between alliance and therapy outcome appears to be relatively uniform throughout therapy, the client's report of the early alliance may be the most clinically useful indicator. In successful treatments, the therapist's and client's assessments of the alliance tend to converge over time. Recent research suggests that the therapist's skills and personal factors both influence the likelihood of developing a good therapeutic alliance with the client. Though the relation between the therapist's level of training and the quality of the alliance is inconsistent, it is likely that the more trained therapists are able to form better alliances with severely impaired clients. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Auditory-Verbal Therapy (AVT) is an effective early intervention for children with hearing loss. The Hear and Say Centre in Brisbane offers AVT sessions to families soon after diagnosis, and about 20% of the families in Queensland participate via PC-based videoconferencing (Skype). Parent and therapist satisfaction with the telemedicine sessions was examined by questionnaire. All families had been enrolled in the telemedicine AVT programme for at least six months. Their average distance from the Hear and Say Centre was 600 km. Questionnaires were completed by 13 of the 17 parents and all five therapists. Parents and therapists generally expressed high satisfaction in the majority of the sections of the questionnaire, e.g. most rated the audio and video quality as good or excellent. All parents felt comfortable or as comfortable as face-to-face when discussing matters with the therapist online, and were satisfied or as satisfied as face-to-face with their level and their child's level of interaction/rapport with the therapist. All therapists were satisfied or very satisfied with the telemedicine AVT programme. The results demonstrate the potential of telemedicine service delivery for teaching listening and spoken language to children with hearing loss in rural and remote areas of Australia.
Despite the great potential videoconferencing holds for providing psychotherapy services to a wide range of individuals, it is presently underused by psychologists. Do psychologists hold negative attitudes that interfere with their willingness to use the technology? What do psychologists think about the impact of the technology on the therapeutic alliance? Thirty clinical psychologists were randomly assigned to watch an identical therapy session, either face-to-face or videoconferencing format. Our prediction that psychologists in the videoconferencing condition would rate the therapeutic alliance significantly lower than would psychologists in the face-to-face condition was supported. We discuss the need to develop appropriate therapist training and improve the general dissemination of information regarding videoconferencing as an important means by which to reduce negative attitudes toward the technology.
Behavioral telehealth is a reasonable solution to the accessibility to mental health care problem that exists in many rural communities. This paper reports the results of a multiple case study of a behavioral telehealth program administered through a marriage and family therapy training program. The results suggest that mental health services can be effectively delivered using existing distance education technology to underserved rural populations. Rural communities have unique barriers to accessing mental health care, some of which can be overcome through the distance delivery of services and some of which cannot. In order to effectively deliver treatment, accommodations to the technology must be made by both therapist and client.
This article summarizes two ongoing randomized controlled trials that compare individual in-person psychotherapy with psychotherapy provided using video teleconferencing for military veterans with posttraumatic stress disorder. We describe training methods, populations, technology, challenges, successes, and lessons learned so far during the trials.
Individuals with mental health problems may face barriers to accessing effective psychotherapies. Videoconferencing technology, which allows audio and video information to be shared concurrently across geographical distances, offers an alternative that may improve access. We conducted a systematic literature review of the use of videoconferencing psychotherapy (VCP), designed to address 10 specific questions, including therapeutic types/formats that have been implemented, the populations with which VCP is being used, the number and types of publications related to VCP, and available satisfaction, feasibility, and outcome data related to VCP. After electronic searches and reviews of reference lists, 821 potential articles were identified, and 65 were selected for inclusion. The results indicate that VCP is feasible, has been used in a variety of therapeutic formats and with diverse populations, is generally associated with good user satisfaction, and is found to have similar clinical outcomes to traditional face-to-face psychotherapy. Although the number of articles being published on VCP has increased in recent years, there remains a need for additional large-scale clinical trials to further assess the efficacy and effectiveness of VCP.
The effects of fear appeals on persuasion were investigated in a factorial experiment that was designed to test a combined model of protection motivation theory and self-efficacy theory. As predicted, the probability of a threat's occurrence and the effectiveness of a coping response both had positive main effects on intentions to adopt a recommended preventive health behavior. More importantly, the findings provided support for self-efficacy expectancy as a fourth component of protection motivation theory: Self-efficacy had a direct influence on intentions and interacted with two other variables of protection motivation theory. The interaction effect was interpreted in terms of two new decision-making strategies that people use when confronted with a fear appeal: a precaution strategy and a hyperdefensiveness strategy. In addition, the results replicated previous findings on the relationship between self-efficacy expectancy and outcome expectancy. A model incorporating protection motivation theory and self-efficacy theory is presented as a possible general model of attitude change.
Patient satisfaction is a widely used health care quality metric. However, the relationship between patient satisfaction and health care utilization, expenditures, and outcomes remains ill defined.
We conducted a prospective cohort study of adult respondents (N = 51,946) to the 2000 through 2007 national Medical Expenditure Panel Survey, including 2 years of panel data for each patient and mortality follow-up data through December 31, 2006, for the 2000 through 2005 subsample (n = 36,428). Year 1 patient satisfaction was assessed using 5 items from the Consumer Assessment of Health Plans Survey. We estimated the adjusted associations between year 1 patient satisfaction and year 2 health care utilization (any emergency department visits and any inpatient admissions), year 2 health care expenditures (total and for prescription drugs), and mortality during a mean follow-up duration of 3.9 years.
Adjusting for sociodemographics, insurance status, availability of a usual source of care, chronic disease burden, health status, and year 1 utilization and expenditures, respondents in the highest patient satisfaction quartile (relative to the lowest patient satisfaction quartile) had lower odds of any emergency department visit (adjusted odds ratio [aOR], 0.92; 95% CI, 0.84-1.00), higher odds of any inpatient admission (aOR, 1.12; 95% CI, 1.02-1.23), 8.8% (95% CI, 1.6%-16.6%) greater total expenditures, 9.1% (95% CI, 2.3%-16.4%) greater prescription drug expenditures, and higher mortality (adjusted hazard ratio, 1.26; 95% CI, 1.05-1.53).
In a nationally representative sample, higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality.
We conducted an online survey and interviews amongst mental health workers in Canada who reported experience in working with rural and remote First Nations (although not necessarily telemental health). Sixty-three respondents (of the 164) to the online survey reported experience in working with clients in remote and rural First Nations. Only 16 of the online survey respondents with remote and rural First Nations experience reported having received training in videoconferencing use. When asked how frequently they used videoconferencing with clients, 51% reported never using it, 19% used it once every few months and 10% reported using it a few times a month. Approximately 50% of participants reported finding it useful. Approximately 38% found the technology easy or very easy to use, and 15% found it very difficult. Individual in-depth interviews were also conducted with professionals who had First Nations telemental health experience specifically (n = 5). A quantitative data analysis was used to explore their perceptions of usefulness and ease of use of telemental health, as well as the relationships among these constructs. Advantages, disadvantages and challenges in using the technology were identified from the qualitative data. Promising ways forward include incorporating traditional practices and the Seven Teachings into telemental health services.
This article reports on a research synthesis of the relation between alliance and the outcomes of individual psychotherapy. Included were over 200 research reports based on 190 independent data sources, covering more than 14,000 treatments. Research involving 5 or more adult participants receiving genuine (as opposed to analogue) treatments, where the author(s) referred to one of the independent variables as "alliance," "therapeutic alliance," "helping alliance," or "working alliance" were the inclusion criteria. All analyses were done using the assumptions of a random model. The overall aggregate relation between the alliance and treatment outcome (adjusted for sample size and non independence of outcome measures) was r = .275 (k = 190); the 95% confidence interval for this value was .25-.30. The statistical probability associated with the aggregated relation between alliance and outcome is p < .0001. The data collected for this meta-analysis were quite variable (heterogeneous). Potential variables such as assessment perspectives (client, therapist, observer), publication source, types of assessment methods and time of assessment were explored.
Video teleconferencing (VTC) is used for mental health treatment delivery to geographically remote, underserved populations. However, few studies have examined how VTC affects individual or group psychotherapy processes. This study compares process variables such as therapeutic alliance and attrition among participants receiving anger management group therapy either through traditional face-to-face delivery or by VTC.
The current study represents secondary analyses of a randomized noninferiority trial (Morland et al., in press) in which clinical effectiveness of VTC delivery proved noninferior to in-person delivery. Participants were male veterans (N = 112) with posttraumatic stress disorder (PTSD) and moderate to severe anger problems. The present study examined potential differences in process variables, including therapeutic alliance, satisfaction, treatment credibility, attendance, homework completion, and attrition.
No significant differences were found between the two modalities on most process variables. However, individuals in the VTC condition exhibited lower alliance with the group leader than those in the in-person condition. Mean self-leader alliance scores were 4.2 (SD = 0.8) and 4.5 (SD = 0.4), respectively, where 5 represents strongly agree and 4 represents agree with positive statements about the relationship, suggesting that participants in both conditions felt reasonably strong alliance in absolute terms. Individuals who had stronger alliance tended to have better anger outcomes, yet the effect was not strong enough to result in the VTC condition producing inferior aggregate outcomes.
Our findings suggest that even if group psychotherapy via VTC differs in subtle ways from in-person delivery, VTC is a viable and effective means of delivering psychotherapy.
Client engagement is an essential yet challenging ingredient in effective therapy. Engaged clients are more likely to bond with therapists and counselors, endorse treatment goals, participate to a greater degree, remain in treatment longer, and report higher levels of satisfaction. This study explored the process of engaging high-risk youth and their parents in a unique home-based family therapy intervention. Qualitative interviews were conducted with 19 families who completed family therapy sessions that included a core component aimed at increasing treatment engagement. Parents' and youths' perceptions of engagement suggest the importance of developing therapeutic alliance with therapists, who facilitated building a shared alliance among family members. Implications for improving client engagement are discussed within the context of alliance building with the therapist and among family members.
The provision of mental health services via videoconferencing tele-mental health has become an increasingly routine component of mental health service delivery throughout the world. Emphasizing the research literature since 2003, we examine: 1) the extent to which the field of tele-mental health has advanced the research agenda previously suggested; and 2) implications for tele-mental health care delivery for special clinical populations. Previous findings have demonstrated that tele-mental health services are satisfactory to patients, improve outcomes, and are probably cost effective. In the very small number of randomized controlled studies that have been conducted to date, tele-mental health has demonstrated equivalent efficacy compared to face-to-face care in a variety of clinical settings and with specific patient populations. However, methodologically flawed or limited research studies are the norm, and thus the research agenda for tele-mental health has not been fully maximized. Implications for future research and practice are discussed.
We investigated the validity and feasibility of online delivery of the Lee Silverman Voice Treatment (LSVT) for the treatment of the speech disorder of a patient with idiopathic Parkinson's disease. The treatment was delivered in 16 sessions to the participant's home, 90 km from the speech language pathologist. A PC-based videoconferencing system was used, operating at 128 kbit/s over the public telecommunications network. The patient achieved substantial improvements in vocal sound pressure levels during sustained vowel phonation (6.13 dB), reading (12.28 dB) and conversational monologue (11.32 dB). There were improvements in the duration of sustained vowel phonation (4 s). Improvements were also perceived in the degree of breathiness and roughness in the voice, and in overall speech intelligibility in conversation. The patient was very satisfied with the audio and video quality of the conferencing, and with the online treatment overall. He reported a preference for online sessions for the future management of his condition, rather than face-to-face treatment. Remote LSVT delivery was found to be feasible and effective.
The advent of telehealth technology gives psychologists new opportunities to expand their practices in a cost-effective manner, but little is known about telehealth efficacy and costs. This study of 49 neuropsychology clients interviewed using videoconferencing and 49 matched in-person controls yielded no group differences in client ratings of interpersonal factors. Telehealth clients were more likely to want to repeat their experience, but psychologist satisfaction was lower for telehealth sessions. Telehealth costs were significantly lower than in-person costs. Concerns about ethical issues, billing, and licensure must be addressed to help practitioners capitalize on new telehealth opportunities.
Objectives:
The first Home-Based Telemental pilot program (HBTMH) in the Department of Veterans Affairs addresses the significant challenge of access to mental health treatment for rural veterans. Though the feasibility of telemental healthcare in clinic-based settings has been well documented, the feasibility of telemental health via webcam and computer in a patient's home or other non-clinic settings is unknown.
Methods:
The HBTMH program, established in December 2009 at the Portland VA Medical Center, delivers a wide range of mental health services into the homes and other non-clinic settings of rural veterans via webcam, secure and encrypted software and veteran-owned personal computers. The program adhered to a Standard Operating Procedure (SOP) Manual, evaluated patients with the Assessment for Suitability for Home Based Telemental Health (ASH-25), utilized a Patient Support Person (PSP), and incorporated a peer technical consultant to provide assistance to veterans. The authors describe satisfaction and safety survey results from the initial 40 veterans enrolled.
Results:
Survey results support the feasibility and safety of using webcams, secure/encrypted software and veteran-owned personal computers for the delivery of mental health services into the home. Veterans report high levels of satisfaction and perceived safety with home-based telemental health. RESULTS also suggest fewer no-show appointments in home-based telemental health compared to clinic-based telemental health.
Conclusions:
The authors discuss the strength and limitations of the program as well as potential areas of future research.
The development of the therapeutic alliance is explored in a prospective study of 33 borderline personality disorder patients. Assessments of the alliance were made by both the patients and their therapists using the Penn Helping Alliance Questionnaire at six weeks, six months, and then annually for up to five years. The major findings were: (1) The alliance was rated highly by both patients and therapists throughout treatment; (2) the alliance showed steady and significant improvement over time (and no significant deterioration at any point); (3) patients and therapists corresponded closely in their assessments; (4) therapists rated the alliance higher than did patients at three and four years; (5) therapist ratings of the alliance at six weeks was predictive of subsequent dropping out; but (6) early alliance scores were not strongly related to subsequent level of change. These results frame issues for future research in this area.
Objective: There continues to be a shortage of clinical staff specialising in the treatment of CFS (ME). In order to access specialist care, many clients have to undertake long or difficult journeys that may exacerbate their symptoms. This exploratory study aimed to reduce these travel problems by the introduction of a Teleconference Review Clinic (TRC). Method: A TRC was booked for six CFS clients who would normally have face-to-face review by specialists 44 miles away. Questionnaires were used to elicit the views of both clients being reviewed and clinicians undertaking the review at a distance. Differences in distances travelled by clients for conventional face to face and telemedicine review were calculated and comments about the teleconference made by clients and therapists were noted. Results: There was general satisfaction with the quality of the pictures and sound during the reviews. Clinicians were able to obtain all the information required to undertake all clinical assessments. For two clients the clinical management was changed after the consultation and for one client an issue was identified that required referral to another clinician. For clients who lived nearer to the teleconference hospital, the journey saved ranged between 1 mile and 85.8 miles, the mean being 64.2 miles. Conclusion: This pilot study does suggest that telemedicine in this area of medicine is logistically viable and effective, and indicates that a larger study is needed.
Telehealth has been around for a long time. Currently, its application is dominated by mental health and predominantly by the discipline of psychiatry. Telepsychology refers to the use of technology-assisted means to provide psychological services. One such technological approach, videoconferencing, enables the provision of psychological services via a live, interactive two-way video-audio system. Videoconferencing is used extensively in Australia but the discipline of psychology is yet to fully embrace the technology. A possible explanation for this is the lack of information and discussion specific to the discipline of psychology as to the effectiveness of the technology and issues relating to its use for provision of psychological services. This paper attempts to provide such information relevant to psychologists as well as a discussion of some of the practical considerations in its use. Specifically, practical guidelines are offered that relate to provision of education and training via videoconferencing, but many of the comments and guidelines equally apply to other psychological services provided via videoconferencing.
The Child and Adolescent Psychological Telemedicine Outreach Service (CAPTOS) in Sydney has been providing telepsychiatry services in New South Wales (NSW) for ten years. Services are provided to over 40 sites in remote and rural NSW. There are eight telepsychiatry clinics a week, providing almost 600 consultations a year. As well as telepsychiatry, three additional services are provided: professional supervision, education and training, and Aboriginal child and adolescent mental health traineeships. The service was re-evaluated in 2004 using a semi-structured interview to obtain information about service satisfaction and effectiveness from hub and rural clinicians. There continues to be a high level of satisfaction with the telepsychiatry service and with other telemedicine services, such as clinical supervision and teaching. Videoconferencing appears to be a highly effective and well accepted method of providing mental health care to remote and rural children, adolescents and families. CAPTOS has developed into an integral part of child and adolescent mental health services in remote and rural New South Wales.
The effects of counsellors’ facial expressions upon the degree of rapport experienced by a Standardized Client (STC) was assessed via examination of 59 counselling interviews conducted by graduate students in counselling. Izard's (197112.
Izard , CE . 1971 . The face of emotion , New York : Appleton-Century-Crofts . View all references) Affex system of classifying facial expressions was used to operationalize the independent variable of facial expression, with STC ratings of rapport on a five-point scale each minute of the interviews constituting the dependent variable. Data indicated that there was significant more (in seconds/minute) counsellor facial expression of the categories “Interest-excitement” and “Enjoyment-joy” during minutes rated as high in rapport than in minutes rated as low in rapport, but that there was significantly less of the counsellor facial expression “Hypothesized Interest” in high rapport minutes. Implications for the development of effective training procedures for counsellors, plus the need to emphasize the building of emotional engagement between counsellor and client are discussed.
Whilst there is substantial evidence of the efficacy of exposure and response prevention in Obsessive-Compulsive Disorder (OCD), little research has focused on delivering treatment in a more cost-effective way. This study investigated the use of brief treatment of a single 45-minute face-to-face treatment session, followed by eight weekly 15-minute telephone therapy sessions, and a final face-to-face session of 30 minutes. Of the four patients included in this small pilot study, of whom all completed treatment, three clients improved and one client made slight improvement. Given these promising results, further investigation of exposure and response prevention delivered in this way is warranted.
Although the relationship between the therapeutic alliance and outcome has been supported consistently across several studies and meta-analyses, there is less known about how the patient and therapist contribute to this relationship. The purpose of this present meta-analysis was to (1) test for therapist effects in the alliance-outcome correlation and (2) extend the findings of previous research by examining several potential confounds/covariates of this relationship.
A random effects analysis examined several moderators of the alliance-outcome correlation. These included (a) patient-therapist ratio (patient N divided by therapist N), (b) alliance and outcome rater (patient, therapist, and observer), (c) alliance measure, (d) research design and (e) DSM IV Axis II diagnosis.
The patient-therapist ratio (PTR) was a significant moderator of the alliance-outcome correlation. Controlling for several potential confounds in a multi-predictor meta-regression, including rater of alliance, research design, percentage of patient Axis II diagnoses, rater of outcome and alliance measure, PTR remained a significant moderator of the alliance-outcome correlation.
Corroborating previous research, therapist variability in the alliance appears to be more important than patient variability for improved patient outcomes. This relationship remains significant even when simultaneously controlling for several potential covariates of this relationship.
The authors are involved in an ongoing trial comparing the efficacy of cognitive behavioural therapy for patients with bulimia nervosa delivered via telemedicine versus delivered via an on-site therapist. The overall purpose of the study is to see if psychotherapy can be delivered effectively via telemedicine, and if such administration is acceptable to patients. This trial evolved out of growing concerns that manual-based psychotherapies for various psychiatric conditions are not widely available, particularly to people in rural areas. Some of the practical aspects of delivering psychotherapy via telemedicine are discussed. Copyright © 2003 John Wiley & Sons, Ltd and Eating Disorders Association.
This study examines the clinical utility of cognitive behavioural therapy delivered via videoconferencing for bulimic disorders, and factors associated with adjustment to this mode of treatment delivery. A single-case-series design was used with six participants with bulimic disorders. Most were living in remote areas in north-east Scotland or Shetland. Therapy sessions were conducted weekly at a bandwidth of ISDN 6 (384 kbytes/sec) via videoconferencing links between local community hospital sites and the eating disorders service in Aberdeen, Scotland. Almost all participants rated high levels of therapeutic alliance and satisfaction with video therapy. Some participants preferred video therapy due to feeling less self-conscious and intimidated, whereas others felt it was less personal than face-to-face sessions would be. It is proposed that video therapy may be particularly suited to the treatment of eating disorders, especially for those with high levels of shame and body-related self-consciousness and those who require greater levels of control in therapy. Copyright © 2005 John Wiley & Sons, Ltd.
This study compared a 12-week behavioral weight-control treatment program conducted over interactive television (N = 133) to a standard therapist-led (in-person) treatment condition (N = 33). Subjects started treatment with an average Body Mass Index (BMI) of 34.9 and lost 7.7 kg over 12 weeks with no difference between conditions noted for weight loss, calorie (− 622 calories per day), or exercise changes (+ 970 calories expended per day). Ratings of the technology were positive and there was no difference in subjects' expectations for change, nor was there any difference by treatment condition in overall attrition. A cost-effectiveness analysis showed that the per-person cost of the interactive technology was higher.
Eye contact is a natural and often essential element in the language of visual communication. Unfortunately, perceiving eye contact is difficult in most video-conferencing systems and hence limits their effectiveness. We conducted experiments to determine how accurately people perceive eye contact. We discovered that the sensitivity to eye contact is asymmetric, in that we are an order of magnitude less sensitive to eye contact when people look below our eyes than when they look to the left, right, or above our eyes. Additional experiments support a theory that people are prone to perceive eye contact, that is, we will think that someone is making eye contact with us unless we are certain that the person is not looking into our eyes. These experimental results suggest parameters for the design of videoconferencing systems. As a demonstration, we were able to construct from commodity components a simple dyadic videoconferencing prototype that supports eye contact
This analogue study examined the relationship between therapists' resolution of therapeutic alliance ruptures and their attachment styles. Seventy-seven clinical psychology graduate student therapists responded to videotaped statements made by role-played patients displaying four different attachment styles (preoccupied, dismissing, fearful, and secure). Therapist responses were rated on empathy and depth of interpretation. Therapist differences in attachment style were assessed on the two dimensions of anxiety and avoidance, derived from a factor analysis of the Relationship Scales Questionnaire. Overall, more anxious therapists tended to respond less empathically, particularly with the fearful and secure patients. There were no therapist differences in depth of interpretation. As a whole, responses to the fearful and preoccupied patients tended to be deeper and more empathic than those to the dismissing and secure patients.
We investigated whether a distance therapeutic alliance occurs when children receive manualized, cognitive-behavioural treatment via telephone, in the absence of face-to-face contact. The therapeutic alliance scores were measured in 55 child-parent pairs. The mean total Working Alliance Inventory child scores were 236 (95% confidence interval [CI]: 232, 240) and the mean parent scores were 245 (95% CI: 242, 247). Parent scores were significantly higher than child scores, although the difference may not be clinically meaningful. This study provides evidence that a strong therapeutic alliance does occur between child-coach and parent-coach pairs when treatment is delivered from a distance by non-professionals. The term 'child' encompasses both children and adolescents.
To compare physician and patient impressions and interphysician diagnostic agreement between live teledermatology and in-person examinations.
Paired video and in-person examinations with different dermatologists.
An urban Veterans Affairs dermatology clinic.
One hundred thirty-nine patients.
Satisfaction questionnaires and interphysician diagnostic agreement.
Patient and physician satisfaction was high. Agreement between video and in-person diagnoses was 80%.
Physicians and patients were satisfied with teledermatology examinations. Diagnostic agreement between in-person and video dermatologists was high.
We conducted a systematic review of literature relating to videoconferencing in therapeutic interventions for chronic conditions. Two hundred articles were reviewed in detail, 35 of which were relevant to the study. Of these, eight were randomized controlled trials (RCTs) and the remainder were service evaluations, pilot studies and case studies. Two major themes emerged, relating specifically to videoconferencing: clinical outcomes and patient satisfaction. There were 14 studies which measured clinical outcomes of interventions for chronic conditions delivered by videoconferencing. A range of evidence, including four RCTs of high quality, indicates that interventions for a variety of conditions, including psychological and physical, delivered by videoconferencing produce similar outcomes to treatment delivered in-person. Evidence suggests that levels of patient satisfaction with telerehabilitation are high and that the formation of a good therapeutic alliance is possible. Several papers reported that clinical staff showed lower levels of satisfaction in using telerehabilitation than patients. It is feasible to use videoconferencing as a means of delivering therapeutic interventions for people with chronic conditions in rural communities.
The relationship between therapeutic outcome and a patient-reported measure of the Rogerian conditions of positive regard, empathy, and genuineness was decomposed into between-therapist effects and within-therapist effects using multilevel modeling. Data were available for 157 depressed outpatients treated by 27 therapists in the cognitive-behavioral therapy, interpersonal therapy, or placebo with clinical management conditions of the Treatment of Depression Collaborative Research Program (Elkin, 1994). Consistent with prior findings of significant between-therapist variability in outcome (e.g., Baldwin, Wampold, & Imel, 2007), patients whose therapists provided high average levels of the perceived Rogerian conditions across the patients in their caseloads experienced more rapid reductions in both overall maladjustment and depressive vulnerability (self-critical perfectionism). Within each therapist's caseload, differences between patients in perceived Rogerian conditions had weaker effects. The results underline the importance of differences between therapists as determinants of outcome in the treatment of depression.
Introduction
National and International telepsychiatry service was established between Denmark and Sweden in order to increase access to cross-cultural expertise. Patient acceptability study was conducted to assess the patients’ attitudes toward the quality, advantages and disadvantages of telepsychiatry service.
Methods
Over a period January 2005-December 2007, 61 patients were treated via telepsychiatry by clinicians that speak patientsrespective mother tongues. Video-conferencing equipment connected the Little Prince Psychiatric Centre in Copenhagen with two hospitals, one asylum seekers’ centre and one social institution in Denmark. These stations were also connected to the Swedish department of the Centre. Number of languages spoken was 9 while the number of nationalities treated was 11. No interpreter assistance has been used.
After the end of the telepsychiatry contact all patients were asked to complete a satisfaction questionnaire.
Results
Patients reported a high level of acceptance and satisfaction with telepsychiatry. They expressed a wish to use telepsychiatry via their mother tongue, rather than interpreter-assisted mental health care in the future.
Discussion
The restricted physical contact and non-verbal communication of telepsychiatry was compensated by the fact that the doctor and patient spoke the same language and had similar cultural and/or national references. The results of the survey may contribute to further development of, primarily, European Telepsychiatry Network. However, this model may be used for conducting of larger international telepsychiatry service capable to provide mental health care toward diversity of patient populations underserved on their mother tongue worldwide.
The authors present a pilot study of 12 veterans diagnosed with combat-related PTSD and treated with prolonged exposure therapy (PE) via telehealth technology. A reference sample of 35 combat veterans treated with in-person PE in the same clinic is also included for a comparison. Feasibility and clinical outcomes of interest include technical performance and practicality of the telehealth equipment, patient safety, treatment completion rates, number of sessions required for termination, and clinical outcomes. Results indicated large statistically significant decreases in self-reported pathology for veterans treated with PE via telehealth technology. Preliminary results support the feasibility and safety of the modality. Suggestions for the implementation of PE via telehealth technology are discussed.