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Review of the current empirical literature on using videoconferencing to deliver individual psychotherapies to adults with mental health problems



Purpose: The COVID-19 pandemic has resulted in a widespread adoption of videoconferencing as a communication medium in mental health service delivery. This review considers the empirical literature to date on using videoconferencing to deliver psychological therapy to adults presenting with mental health problems. Method: Papers were identified via search of relevant databases. Quantitative and qualitative data were extracted and synthesized on uptake, feasibility, outcomes, and participant and therapist experiences. Results: Videoconferencing has an established evidence base in the delivery of cognitive behavioural therapies for post-traumatic stress disorder and depression, with prolonged exposure, cognitive processing therapy, and behavioural activation non-inferior to in-person delivery. There are large trials reporting efficacy for health anxiety and bulimia nervosa compared with treatment-as-usual. Initial studies show applicability of cognitive behavioural therapies for other anxiety and eating disorders and obsessive-compulsive spectrum disorders, but there has yet to be study of use in severe and complex mental health problems. Therapists may find it more difficult to judge non-verbal behaviour, and there may be initial discomfort while adapting to videoconferencing, but client ratings of the therapeutic alliance are similar to in-person therapy, and videoconferencing may have advantages such as being less confronting. There may be useful opportunities for videoconferencing in embedding therapy delivery within the client's own environment. Conclusions: Videoconferencing is an accessible and effective modality for therapy delivery. Future research needs to extend beyond testing whether videoconferencing can replicate in-person therapy delivery to consider unique therapeutic affordances of the videoconferencing modality. Practitioner points: Videoconferencing is an efficacious means of delivering behavioural and cognitive therapies to adults with mental health problems. Trial evidence has established it is no less efficacious than in-person therapy for prolonged exposure, cognitive processing therapy, and behavioural activation. While therapists report nonverbal feedback being harder to judge, and clients can take time to adapt to videoconferencing, clients rate the therapeutic alliance and satisfaction similarly to therapy in-person. Videoconferencing provides opportunities to integrate therapeutic exercises within the person's day-to-day environment.
Psychology and Psychotherapy: Theory, Research and Practice (2021)
©2021 The Authors. Psychology and Psychotherapy: Theory, Research and Practice
published by John Wiley &Sons Ltd
on behalf of British Psychological Society.
Invited Article
Review of the current empirical literature on using
videoconferencing to deliver individual
psychotherapies to adults with mental health
Neil Thomas*
, Caity McDonald
, Kathleen deBoer
Rachel M. Brand
, Maja Nedeljkovic
and Liz Seabrook
National eTherapy Centre, Swinburne University of Technology, Melbourne,
Victoria, Australia
Centre for Mental Health, Swinburne University of Technology, Melbourne, Victoria,
Alfred Hospital, Melbourne, Victoria, Australia
School of Health and Behavioural Sciences, University of the Sunshine Coast, Sippy
Downs, Qld, Australia
Abstract. Purpose. The COVID-19 pandemic has resulted in a widespread adoption of
videoconferencing as a communication medium in mental health service delivery. This
review considers the empirical literature to date on using videoconferencing to deliver
psychological therapy to adults presenting with mental health problems.
Method. Papers were identified via search of relevant databases. Quantitative and
qualitative data were extracted and synthesized on uptake, feasibility, outcomes, and
participant and therapist experiences.
Results. Videoconferencing has an established evidence base in the delivery of cognitive
behavioural therapies for post-traumatic stress disorder and depression, with prolonged
exposure, cognitive processing therapy, and behavioural activation non-inferior to in-
person delivery. There are large trials reporting efficacy for health anxiety and bulimia
nervosa compared with treatment-as-usual. Initial studies show applicability of cognitive
behavioural therapies for other anxiety and eating disorders and obsessivecompulsive
spectrum disorders, but there has yet to be study of use in severe and complex mental
health problems. Therapists may find it more difficult to judge non-verbal behaviour, and
there may be initial discomfort while adapting to videoconferencing, but client ratings of
the therapeutic alliance are similar to in-person therapy, and videoconferencing may have
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and
reproduction in any medium, provided the original work is properly cited.
*Correspondence should be addressed to Neil Thomas, Centre for Mental Health, Swinburne University of Technology, PO
Box 218, Hawthorn, Vic. 3122, Australia, (e-mail:
advantages such as being less confronting. There may be useful opportunities for
videoconferencing in embedding therapy delivery within the client’s own environment.
Conclusions. Videoconferencing is an accessible and effective modality for therapy
delivery. Future research needs to extend beyond testing whether videoconferencing can
replicate in-person therapy delivery to consider unique therapeutic affordances of the
videoconferencing modality.
Practitioner points
Videoconferencing is an efficacious means of delivering behavioural and cognitive therapies to adults
with mental health problems.
Trial evidence has established it is no less efficacious than in-person therapy for prolonged exposure,
cognitive processing therapy, and behavioural activation.
While therapists report nonverbal feedback being harder to judge, and clients can take time to adapt to
videoconferencing, clients rate the therapeutic alliance and satisfaction similarly to therapy in-person.
Videoconferencing provides opportunities to integrate therapeutic exercises within the person’s day-
to-day environment.
One of the notable impacts of the COVID-19 pandemic on psychological therapy delivery
has been the use of videoconferencing becoming widespread. Telehealththe use of
telecommunication technology to deliver servicesincludes a range of networked
communication modalities, also including telephone, email, and text chat messaging.
With improvements in online videoconferencing software and internet speeds, products
such as Skype, FaceTime, and Zoom had already entered mainstream personal and
business communication usage prior to the pandemic, and by incorporating video offer a
close approximation to being in-person. While in-person services had been slow to adopt
digital technologies prior to the pandemic, substantial potential was already seen in
making services more accessible, and the necessity to minimize in-person interaction has
catalysed the adoption of this technology in psychotherapy delivery (Chen et al., 2020;
Shore, Schneck, & Mishkind, 2020; Torous, Myrick, Rauseo-Ricupero, & Firth, 2020;
Wind, Rijkeboer, Andersson, & Riper, 2020).
Videoconferencing has been researched as a medium for therapy delivery over the past
three decades, adopting contemporaneous communication technologies such as televi-
sion-based telemedicine equipment, videophones, and Internet-based webcam systems
(Simpson, 2009). While therapists report concerns about technical difficulties and the
potential impact of videoconferencing on the therapeutic alliance (Connoly, Miller,
Lindsay, & Bauer, 2020; Simpson & Reid, 2014), they make adaptations such as
emphasizing their own non-verbal behaviour and clarifying the client’s own responses,
and overall are positive about the technology (Connoly et al., 2020). Backhaus et al. (2012)
conducted a systematic review of 65 papers across a range of populations, concluding that
videoconferencing was feasible, associated with good user satisfaction and similar clinical
outcomes to in-person therapy delivery. Recent systematic reviews by Berryhill, Culmer,
et al. (2019), and Berryhill, Halli-Tiemey, et al. (2019) have confirmed that there are
significant post-therapy effects on the most commonly used outcome measures of anxiety
and depressive symptoms aggregated across different clinical groups.
Findings of overall acceptability and efficacy of videoconferencing have informed the
implementation of videoconferencing within services, particularly for programmes
delivered to geographically isolated or dispersed individuals (Morriss et al., 2019; Muir
et al., 2020; Varker, Brand, Ward, Terhaad, & Phelps, 2018). Now adoption is more
2Neil Thomas et al.
widespread, practitioners and clients may need to choose between video and in-person as
more equally available options. To inform clinical decision-making, it is now important to
consider when, and for whom, this mode of therapy delivery may be applicable. This is
particularly important when weighing up choices against pandemic-related health risks
associated with transit and in-person contact, which can be avoided by remote therapy
This review considers the literature to date on how videoconferencing can be utilized
for the delivery of psychological therapy to adults presenting with mental health
problems. Extending upon previous reviews, which have considered outcomes and
satisfaction with videoconferencing across studies as a whole, we consider the following
For which mental health populations and psychological interventions is there current
evidence for psychological therapy being acceptable and efficacious when delivered
via videoconferencing?
What are client and therapist experiences of psychological therapy delivered by
videoconferencing, including perceived benefits, challenges and opportunities?
Primary research studies were identified via the databases PubMed, Medline, PsycINFO,
and EMBASE in July 2020. Search terms included combinations of the search terms
videoconferencing, telehealth telemedicine, telemental health, telepsychology, telepsy-
chiatry, telepsychotherapy, or telecounselling; psychological therapy, psychotherapy,
counselling, psychological intervention, or cognitive behaviour; and mental disorder,
mental health, mental illness, anorexia, anxiety, bipolar, bulimia, depression, eating
disorder, mood disorder, obsessivecompulsive, personality disorder, post-traumatic
stress, psychosis, and schizophrenia. Database searches were supplemented by review of
reference lists of included papers and previous review papers.
Studies were included which focused on adult populations experiencing adult mental
disorders or clinically significant symptoms of mental disorder. Studies were excluded that
focused on children and/or adolescents; people with mental health problems secondary
due to physical illness, substance abuse and/or addictions, neurocognitive disorders,
learning difficulties, or intellectual disabilities; healthy populations at risk of developing
mental health difficulties; and families of people with mental health difficulties. Studies
were included that used one-to-one psychological interventions delivered via videoconfer-
encing. This excluded group-based, couple or family interventions; simulated therapy
sessions; self-help; general psychiatric care; asynchronous psychological therapy delivered
via recorded video. Studies were included that reported quantitative or qualitative data
relevant to understandingoutcomes or experiences of therapy. Case studies were excluded,
as were studies that did not disaggregate psychological therapy results from broader
findings, but multiple baseline case series were included.
Abstracts were screened by CM, and full papers were independently reviewed against
the inclusion criteria by CM and NT. Each author led extraction of data for a component of
the review, with all data extraction checked and verified by NT. Data on outcomes and
acceptability were extracted and considered within diagnostic groupings, with a main focus
on randomized controlled trial findings, and pre-to-post studies and case series findings
considered when they added to the trial literature. Client and practitioner experiences of
Using videoconferencing to deliver psychological therapy 3
videoconferencing were considered across the literature, prioritizing systematically
collected data reported by papers, but also including anecdotal participant comments. A
thematic synthesis (Lucas, Baird, Arai, Law, & Roberts, 2007) was conducted with a lens of
identifying the prominent benefits, challenges, and considerations in delivery.
The literature search identified 1637 papers once duplicates were removed, with a total of
69 papers reporting on 54 discrete studies meeting inclusion criteria (see Table 1). These
included 21 randomized controlled trials (RCTs), 20 pre-to-post and non-randomized
comparison trials, 6 case series, 4 stand-alone qualitative studies, and 3 studies examining
rates of uptake. Of the RCTs, 7 examined efficacy compared with a non-therapy control,
and 15 included a head-to-head comparison with in-person therapy, of which 9 conducted
formal non-inferiority or equivalence analyses (detailed in Table 2). No studies contrasted
videoconferencing with other remote communication modalities (e.g., telephone).
The most frequently studied diagnostic groups were post-traumatic stress disorder
(PTSD; 14 studies), and depression (10), for which there were a number of well-powered
RCTs, followed by anxiety disorders (6), obsessivecompulsive spectrum disorders (6)
and eating disorders (6). Twelve additional studies examined mixed diagnosis populations
including a large RCT. Across these studies, a number examined implementations to
specific populations, with a large number, particularly PTSD studies, conducted with
veterans or military personnel, and others focusing on populations with difficulties
attending clinic settings in person, including people with difficulties leaving the home,
people living in rural or remote areas, prison inmates, and geographically dispersed
members of migrant populations. Less than half of studies were conducted within the
person’s home/residence, with many especially older studies, involving visiting a local
clinic using telehealth equipment to connect with a therapist in a different location. The
types of technology used for videoconferencing included dedicated telemedicine
hardware, analogue videophones, and, increasingly, using Internet-based videoconfer-
encing software on computers or smartphones. Many studies provided participants with
equipment such as laptop or tablet computers, but more recent studies have used
participants’ own devices.
Across the full range of studies, therapy was found feasible to deliver via videocon-
ferencing, clients were satisfied with therapy, and expected improvements in targeted
symptoms occurred. We consider the findings for specific populations in detail
(summarized in Table 3), followed by broader findings about use of videoconferencing
across all studies.
Application of videoconferencing with different populations
Post-traumatic stress disorder
PTSD was the most researched mental health diagnosis. In addition to small prepost
studies and pilot RCTs, the search identified 7 well-powered RCTs of videoconferencing
therapy for PTSD, covering a range of treatment protocols, including cognitive processing
therapy (CPT), prolonged exposure (PE), and behavioural activation.
Two trials examined the use of the eight-to-twelve session PE protocol to treat PTSD in
veterans (Acierno et al., 2017, also reported on in Gros, Allan, Lancaster, Szafranski, &
Acierno, 2018; Gros, Lancaster, L
opez, & Acierno, 2018; and Yuen et al., 2015), and one
4Neil Thomas et al.
Table 1. Included studies
Study Population Country Design Comparison NTherapy Location System
and alliance
Acierno et al. (2016),
Strachan et al.
(2012), Gros et al.
Veterans with
USA RCT IP (NI) 232 BA-TE Home Own device +provided software,
or videophone (Viterion 500)
Acierno et al. (2017),
Gros, Allan, et al.
(2018), Gros,
Lancaster, et al.
Veterans with
PTSD and
USA RCT IP (NI) 150 PE Home Own device +AK Summit software
or provided tablet or videophone
Franklin et al. (2017) Veterans with
USA RCT TAU 27 PE Home or clinic Computer +provided software,
or iPhone +Tango
CAPS, PDS Preferred therapy
Germain et al. (2009),
Germain et al.
(2010), Marchand
et al. (2011)
PTSD Canada
NRCT IP 68 CBT Clinic Tandberg 2500 VC units MPSS WAI, SEQ, DCCS,
Gros et al. (2011) Veterans with
USA NRCT IP 89 PE Clinic Tandberg 1000 MXP VC units PCL-M IIRS
Hassija and Gray
Women with
PTSD from
prepost - 15 PE or CPT Clinic Polycom VSX3000 VC units PCL, CES-D Satisfaction
Liu et al. (2019) Veterans with
PTSD, male
and female
USA RCT IP (NI) 207 CPT Clinic Not stated CAPS, PCL-S,
Luxton et al. (2015) Active military
and veterans
with PTSD
USA prepost - 10 BA Home Laptop +Cisco Jabber CAPS, PCL-M,
Maieritsch et al.
Veterans with
USA RCT IP (E) 90 CPT Clinic Not stated CAPS, PCL WAI
Using videoconferencing to deliver psychological therapy 5
Table 1. (Continued)
Study Population Country Design Comparison NTherapy Location System
and alliance
Morland et al. (2015) Women with
civilians and
USA RCT IP (NI) 149 CPT Clinic Not stated CAPS WAI, CPOSS-VA,
Olden et al. (2017) PTSD in
USA prepost - 11 PE Home or clinic Polycom VC units (clinic)
or own device (home)
Tuerk et al. (2010) Veterans with
NRCT IP 47 PE Clinic Tandberg 1000 MXP VC units PCL-M, BDI -
Yuen et al. (2015) PTSD, combat
USA RCT IP (NI) 52 PE Home Own device/tablet +VC software or
Ziemba et al. (2014) PTSD USA RCT IP 18 CT Clinic Polycom VC units CAPS Satisfaction survey
Arnaert et al. (2007) Older adults
qualitative - 4 PST Home Videophone - Interviews
Jang et al. (2014) Korean
USA prepost - 12 CBT ‘Place
to client’
Laptop +Vidyo PHQ-9 CSQ
Lazzari, Egan, and
Rees (2011)
Depression Australia prepost - 3 BA Clinic Not stated GDS Satisfaction
Choi, Hegel, et al.
(2014), Choi, Marti,
et al. (2014), Choi
et al. (2013)
adults over
50 with
USA RCT IP, TAU 158 PST Home Laptop +Skype HRSD,
TEI, interviews
Deen et al. (2013) Primary care
with positive
USA uptake study - 179 CBT Home Not stated Uptake of
6Neil Thomas et al.
Table 1. (Continued)
Study Population Country Design Comparison NTherapy Location System
and alliance
Egede et al. (2015) Veterans with
USA RCT IP (NI) 241 BA Home Videophone BDI, GDS,
Luxton et al. (2016),
Smolenski et al.
(2017), Pruitt et al.
USA RCT IP (NI) 121 BA Home Laptop +Cisco Jabber BDI, BHS IASMHS
Sayal et al. (2019) Young adults
with self-
harm and
UK RCT TAU 22 PST Not stated Mobile phone or video calling (WebeX) BDI Interviews
Lichstein et al. (z2013) Comorbid
USA prepost - 5 CBT Clinic Laptop +Skype HRSD, CSD,
WAI, session
ratings, feedback
Scogin et al. (2018) Comorbid
USA (rural) RCT TAU 40 CBT Clinic Computer +Skype HRSD, CSD,
Anxiety disorders
et al. (2015)
GAD Canada MBCS - 5 CBT Clinic Tandberg 2500 VC system PSWQ -
Watts et al. (2020) GAD Canada RCT IP (S) 115 CBT Clinic Computer +Tandberg MXP software Not yet
Bouchard et al. (2000) Panic disorder/
Canada prepost - 8 CBT Clinic Tandberg 2000 VC system P&A WAI, session
Bouchard et al. (2004) Panic disorder/
NRCT IP 21 CBT Clinic Tandberg 2500 VC system
Using videoconferencing to deliver psychological therapy 7
Table 1. (Continued)
Study Population Country Design Comparison NTherapy Location System
and alliance
Daily diaries,
WAI, treatment
Morriss et al. (2019) Health anxiety UK RCT TAU 156 CBT Clinic WebeX or telephone SHAI -
Yuen et al. (2013) Social anxiety USA prepost - 24 ABBT Home Own device +Skype SPAI, LSAS,
therapist survey
Fitt and Rees (2012) OCD Australia MBCS - 4 MCT Clinic Computer +Polycom PVX v 8.0.2 Y-BOCS WAI
Himle et al. (2006) OCD USA MBCS - 3 CBT Not stated Polycom Viewstation VC units Y-BOCS WAI, VTS,
Goetter et al. (2014) OCD USA prepost - 15 ERP Home Not stated Y-BOCS RTQ, WAI, CSS,
Vogel et al. (2014) OCD Norway RCT SH, TAU 30 ERP Clinic Computer/tablet +FaceTime ADIS-IV, Y-
Muroff and Steketee
Hoarding USA case series - 7 CBT Home Own device +VC software HRS-I, SI-R WAI
Lee et al. (2018) Trichotillomania USA RCT
TAU 22 ACT +HRT Home VSee software
(device not
Eating disorders
Abrahamsson et al.
Binge eating
disorder and
case series - 5 CBT Not stated Mobile device +VC software Meal
Giel et al. (2015) Anorexia
Germany prepost - 16 MM Not stated Laptop +Cisco VC software BMI, SCID
Satisfaction ratings
Hamatani et al. (2019) Japan prepost - 7 CBT Home Cisco WebEx (device not stated) EDE WAI
8Neil Thomas et al.
Table 1. (Continued)
Study Population Country Design Comparison NTherapy Location System
and alliance
nervosa or
binge eating
Mitchell et al. (2008);
Ertelt et al. (2011);
Marrone et al.
nervosa or
USA RCT IP 128 CBT Clinic Telemedicine equipment (model not
Simpson et al. (2005,
nervosa or
UK (remote) case series - 6 CBT Clinic Sony 1600 VC units +VC software SEDS, BEI-II,
ARM, satisfaction
survey, interview
Yu et al. (2020) Binge eating
USA RCT IP 18 CBT Not stated Own device +Fruit Street EQE, EAT,
Satisfaction ratings
Mixed diagnoses
Brunnbauer et al.
Australia prepost - 20 Individualized Not stated Not stated CORE-10,
Dunstan and Tooth
Mood or
Australia prepost - 8 Individualized Clinic Video monitor +VC software SUDS, DASS,
Griffiths et al. (2006) Mood or
prepost - 15 CBT Clinic Computer +VC software MHI, HoNOS Satisfaction rating
Gonzalez and
Brossart (2015)
USA (rural) prepost - 52 Individualized Clinic Not stated CORE, PHQ-
9, SF-12
Lindsay et al. (2015) USA (rural) qualitative - 93 Individualized Home Not stated -
Using videoconferencing to deliver psychological therapy 9
Table 1. (Continued)
Study Population Country Design Comparison NTherapy Location System
and alliance
and client
Matsumoto et al.
(2018, 2020)
Japan prepost - 30 CBT Home iPad Mini +Cisco WebEx Y-BOCS,
Morgan et al. (2008) People in
prison or
USA RCT IP 186 Individualized Prison/
Not stated - WAI, SEQ, CSQ
Simpson et al. (2001),
Simpson (2001)
People living in
a remote
area, mixed
UK (remote) qualitative - 10 Individualized Clinic Computer +VC software Interview PHAS
Simpson et al. (2015) Psychology
Australia qualitative - 6 CBT Clinic Computer +Cisco C20 endpoint Interview,
Stubbings et al. (2013) Australia RCT IP 26 CBT Clinic Computer +iChat DASS, QLESQ WAI, CSQ, TSQ
10 Neil Thomas et al.
Table 1. (Continued)
Study Population Country Design Comparison NTherapy Location System
and alliance
Mood or
Valentine, Donofry,
and Sexton (2020)
USA uptake/
- 250 CBT Clinic/ home Not stated Uptake of VC -
Yang et al. (2019) Psychotherapy
with post-
mood or
Canada uptake (RCT
IP 38 CBT Home Own device +VC software Uptake of VC,
TSQ, patient
reported costs
Note. VC videoconferencing. Populations: EDNOS =eating disorder not otherwise specified; GAD =generalized anxiety disorder; OCD =obsessivecompulsive disorder; PTSD =post-traumatic stress disorder. Design: MBCS =multiple
baseline case series; NRCT =non-randomized controlled trial; RCT =randomized controlled trial. Comparison: IP =in-person; IP (E) =in-person, including an equivalence analysis; IP (NI) =in-person, including a non-inferiority analysis.
TAU =treatment-as-usual or enhanced treatment-as-usual condition; SH =self-help. Therapies: ABBT =acceptance-based behaviour therapy; BA =behavioural activation; BA-TE =behavioural activation and therapeutic exposure;
CPT =cognitive processing therapy; CT =cognitive therapy; HRT =habit reversal therapy; MM =Maudsley model; PE =prolonged exposure; ERP =exposure and response prevention; MCT =metacognitive therapy; PST =problem-solving
therapy. Measures: ACQ =Agoraphobic Cognitions Questionnaire; ADIS-IV =Anxiety Disorders Interview for DSM-IV; BDI Beck =Depression Inventory; BHS =Beck Hopelessness Scale; BITE =Bulimic Investigatory Test; BMI =body mass
index; BSQ =Body Sensation Questionnaire; CAPS =Clinical Administered PTSD Scale; CES-D =Centre for Epidemiology Scale for Depression; CORE =Clinical Outcomes Routine Evaluation; CPOSS =Charleston Psychiatric Outpatient
Satisfaction Scale; CSD =Consensus Sleep Diary; CSQ =Client Satisfaction Questionnaire; CSS =Client Satisfaction Survey; DASS =Depression Anxiety Stress Scale; DCCS =Distance Communication Comfort Scale; EAT =Eating Attitude
Test; EDE =Eating Disorder Examination; EPDS =Edinburgh Postnatal Depression Scale; ETO =Expectancy of Therapeutic Outcome; GDS =Geriatric DepressionScale; HPRS =Hill Process Rating System; HRSD =Hamilton Rating Scale for
Depression; HRS-I =Hoarding Rating Scale-Interview; IASMHS =Inventoryof Attitudes Toward Seeking MentalHealth Service; ISI =Insomnia Severity Index; LSAS =Liebowitz Social Anxiety Scale; MGH-HPS =Massachusetts General Hospital
Hair Pulling Scale; MHI =Mental health Inventory; MI =Mobility Inventory for Agoraphobia; MPSS =Modified PTSD Symptom Scale; OQ45 =Outcome Questionnaire 45; P&A =Panic and Agoraphobia Scale, PCL PTSD Checklist (M Military
version) ; PDS =Posttraumatic Diagnostic Scale; PDSS =Panic Disorder Severity Scale; PEAS =Patient EX/RP AdherenceScale; PHAS =Penn Helping Alliance Scale; PHQ-9 =Patient Health Questionnaire for Depression; PSWQ =Penn State
Worry Questionnaire; QLESQ =Quality of Life Enjoyment and Satisfaction Questionnaire-18 item; RTQ =Reaction to Treatment Questionnaire; SCID =Structured Clinical Interview for DSM; SDPQ =Service Delivery Perception
Questionnaire; SEDS =Survey for Eating Disorders; SEQ =Session Evaluation Questionnaire; SHAI =Short Health Anxiety Inventory; SI-R =Saving Inventory Revised; SPAI =Social Phobia and Anxiety Inventory; SUDS =Subjective Units of
Distress Scale; TEI =Treatment Evaluation Inventory; TEQ =Treatment Expectancy Questionnaire; TFEQ =Three-Factor Eating Questionnaire; TSAS =Telemedicine Satisfaction and Acceptance Scale; TSC =Treatment Session Checklist;
TSQ =Telehealth Satisfaction Questionnaire; VOCI =Vancouver Obsessional Compulsive Inventory; VTF =Videoconference Therapy Questionnaire; VTS =Videoconferencing Telepresence Scale; WAI =Working Alliance Inventory;
WHODAS =World Health Organization Disability Scale; YAFS =Yale Food Addiction Scale; Y-BOCS =Yale-Brown ObsessiveCompulsive Scale.
Using videoconferencing to deliver psychological therapy 11
Table 2. Between group differences in working alliance, primary outcomes, dropout, and satisfaction in large randomized controlled trials involving direct
comparisons with in-person therapy
Study Population NTherapy Therapeutic alliance Primary outcome Dropout/satisfaction
Acierno et al. (2016) PTSD and depression,
232 BA-TE - PCL-M, BDI: VC non-inferior to IP at
post-therapy, and 3 and 12 months
Rate of completion of both therapy and
post-treatment assessment: no
difference (VC 82%, IP 77%)
Acierno et al. (2017),
Gros, Allan, et al. (2018)
PTSD and depression,
150 PE - PCL-M: VC non-inferior to IP at post-
therapy, 3 months and 6 months;
BDI: VC non-inferior to IP at 6 months,
inconclusive at post and 3 months
No difference in number of sessions
attended (VC 7.6, IP 8.6) or
completion of a minimum dose of 6
sessions, but discontinuation
occurred earlier in VC over sessions
Liu et al. (2019) PTSD, veterans 207 CPT - CAPS: VC non-inferior to IP at
6 months, but not at post-therapy;
PCL: VC non-inferior to IP at post and
6 months. PHQ-9: VC non-inferior to
IP at post and 6 months
No difference in study dropout (VC 23%,
IP 28%)
Maieritsch et al. (2016) PTSD, veterans 90 CPT WAI client ratings show equivalence CAPS, PCL: inconclusive but trend for
equivalence between groups (p<.10)
High rates of treatment dropout (43%
overall) but no difference by group
Morland et al. (2015) PTSD, female,
civilians and veterans
149 CPT WAI client ratings: VC inferior to IP at
session 2, but difference small (d=
0.07), and no difference at session 6
or 12; therapist ratings: no difference
at any time point. Homework
completion: no difference (VC 77%, IP
CAPS: VC non-inferior to IP at post-
treatment, 3 and 6 months.
Therapy completion rate: no
difference (10 sessions: VC 76%, IP
79%). Treatment expectations: no
Satisfaction ratings: both groups rated
service highly on global ratings, with
no difference, but VC inferior to IP on
CPOSS ratings of broader service
delivery (d=0.24)
Yuen et al. (2015) PTSD, combat-related 52 PE No difference on ratings of how
comfortable feel talking with therapist
or quality of communication
CAPS: VC non-inferior to IP; PCL:
neither group superior but non-
inferiority analysis inconclusive
SDPQ: 100% satisfied with treatment in
both VC and IP
Choi, Hegel, et al. (2014),
Choi, Marti, et al. (2014)
Depression, housebound
adults over 50
158 PST - HAMD: neither group superior at 12 or
24 weeks; VC superior to IP at
36 weeks; WHODAS: neither
superior at any time point
Treatment Evaluation Inventory: VC
superior to IP
Egede et al. (2015) Depression, veterans 241 BA - BDI, GDS, SCID: VC non-inferior at
4 weeks (mid), 8 weeks (post) and
3 months.
No difference in full therapy completion
rate (VC 81%, IP 79%)
Luxton et al. (2016) Depression, military
121 BA - BDI: VC non-inferior to IP at mid-
therapy and 12 weeks, but not at post-
therapy; BHS: VC non-inferiority not
CSQ: high satisfaction, no difference
between groups.
12 Neil Thomas et al.
Table 2. (Continued)
Study Population NTherapy Therapeutic alliance Primary outcome Dropout/satisfaction
established at any time point, and
found to be inferior to IP at post-
Attitudes to seeking mental health
treatment: no difference between
groups. No difference in full therapy
completion rate (VC 64%, IP 71%)
Watts et al. (2020) Generalized anxiety disorder 115 CBT WAI: Across 8 time points, VC superior
to IP in client ratings; neither group
superior on therapists’ ratings.
Mitchell et al. (2008),
Ertelt et al. (2011),
Marrone et al. (2009)
Bulimia nervosa or EDNOS 128 CBT WAI: no difference in client ratings, VC
inferior to IP in therapist ratings.
EDE: neither group superior for
abstinence from bingeing and/or
purging. VC inferior to IP for
reduction in binge eating frequency
across time points.
Client ratings of treatment suitability,
client expectation of success, and
number of sessions completed: no
Morgan et al. (2008) People in prison or secure
forensic psychiatric hospital
186 Individualized
WAI: no difference in client ratings. - No differences on CSQ, or ratings of
session depth, smoothness, positivity
or distress.
Note:. Only includes randomized controlled trials sufficiently powered to detect large between group effects (N52 at 80% power). If no primary outcome
specified, symptoms of target disorder listed. Superiority/inferiority refers to group differences observed versus a null hypothesis of no difference;non-inferiority (one
tailed test) and equivalence (two-tailed test) refer to whether or not the confidence interval for the difference includes a null hypothesis of the groups differing by the
minimum clinically significant difference. PTSD =post-traumatic stress disorder; EDNOS =Eating disorder not otherwise specified. Therapies: BA =behavioural
activation; BA-TE =behavioural activation and therapeutic exposure; CBT =cognitive behavioural therapy; CPT =cognitive processing therapy; PST =problem-
solving therapy. Groups: IP =in-person; VC =videoconferencing. Measures: BDI =Beck Depression Inventory; CAPS =Clinician Administered PTSD Scale;
CGI =Clinical Global Impression; CPOSS =Charleston Psychiatric Outpatient Satisfaction Scale; CSQ =Client Satisfaction Questionnaire; EDE =Eating
Disorders Examination; GDS =Geriatric Depression Scale; HAMD =Hamilton Rating Scale for Depression; SCID =Structured Clinical Interview for DSM
diagnosis; SCL-90R =Hopkins Symptom Checklist; SDPQ =Service Delivery Perceptions Questionnaire; SEQ =Session Evaluation Questionnaire;
WAI =Working Alliance Inventory.
Using videoconferencing to deliver psychological therapy 13
trial combined behavioural activation with exposure therapy to treat both PTSD and
depression (Acierno et al., 2016; Gros et al., 2012; Strachan, Gros, Ruggiero, Lejuez, &
Acierno, 2012). All compared videoconferencing to in-person delivery and had samples
that were over 90% male. Videoconferencing showed similar rates of therapy completion
(Acierno et al., 2016, 2017; Yuen et al., 2015) and satisfaction (Gros, Allan, et al., 2018;
Yuen et al., 2015) and was non-inferior to in-person for PTSD, depression, and anxiety
(Acierno et al., 2016, 2017; Yuen et al., 2015).
Four trials examined CPT delivered by videoconferencing in comparison with in-person
therapy (Glassman et al., 2019; Lui et al., 2019; Maieritsch et al., 2016;Morland et al., 2015).
Participants were again predominantly veterans, with one study also including civilians
(Morland et al., 2015), but females were better represented in CPT studies (Lui et al., 2019:
45% female, Morland et al., 2015: 100% female). Delivery by videoconferencing was found
to be non-inferior to in-person in reducing PTSD symptoms in all studies other than Lui et al.
(2019) who found that videoconferencing was inferior at post-treatment, but equivalent at
6-month follow-up. All studies found no significant differences in dropout or satisfaction
between videoconferencing and in-person conditions.
Overall, the generally positive findings of acceptability and efficacy of videoconfer-
encing for exposure-based therapies are noteworthy, suggesting this modality is able to
support this emotionally challenging, experientially focused, treatment. It has also been
observed that videoconferencing clients rate the therapeutic alliance as highly for
exposure-based sessions as other CBT-based sessions (Germain, Marchand, Bouchard,
Guay, & Drouin, 2010).
We identified 3 well-powered RCTs of videoconferencing therapy for depression, 3
smaller RCTs, and 4 studies using other designs. Two studies, including one of the RCTs
(Yang, Vigod, & Hensel, 2019), primarily reported on uptake of videoconferencing.
Intervention models included problem-solving therapy, behavioural activation and
combined CBT protocols for depression with insomnia, and for depression with self-
harm. Overall, results suggested participants were satisfied with therapy, and ratings of
acceptability and efficacy appeared similar to in-person delivery.
Problem-solving therapy was examined in a three-arm RCT which compared
videoconferencing or in-person delivery with a supportive weekly care-call control
condition in 158 housebound adults over the age of 50 with depression (Choi, Hegel, et al.,
2014; Choi, Marti, et al., 2014). On the Hamilton Rating Scale for Depression (HRSD), both
videoconferencing and in-person problem-solving therapy were superior to the control
condition at 12 weeks, 24 weeks, without differing from each other, and videoconfer-
encing was superior to both conditions at 36 weeks (Choi, Marti, et al., 2014).
Videoconferencing-based behavioural activation has been examined in two RCTs,
both conducted with veterans. Luxton et al. (2016) conducted an RCT of an 8-session
behavioural activation intervention delivered by telehealth or in-person to 121 military
personnel and veterans with depression. Both conditions showed significant post-
treatment improvements on the Beck Depression Inventory (BDI) as the primary
outcome, and non-inferiority analyses showed videoconferencing was non-inferior at mid-
treatment and 12-week follow-up, but not immediately post-therapy. Egede et al. (2015)
obtained more conclusive results in a larger non-inferiority trial with 241 older veterans
with major depression. Comparing videoconferencing delivery using a videophone
system with in-person delivery, non-inferiority was established with no significant
14 Neil Thomas et al.
Table 3. Summary of evidence for feasibility, acceptability, and efficacy by population
Therapy models found feasible to deliver using
videoconferencing Outcomes of videoconferencing delivery
PTSD BA-based exposure therapy, CPT, prolonged
6 of 7 RCTs found non-inferior to in-person
therapy, with the other finding
videoconferencing inferior at post-treatment and
non-inferior at follow-up
Depression BA, CBT, problem-solving therapy 1 RCT found superior to routine care. 3 RCTs
compared with in-person therapy, finding few
differences between modalities, and 1 trial
establishing non-inferiority.
Anxiety disorders CBT, including focused therapies for GAD, panic
disorder, social anxiety and health anxiety
1 RCT, with health anxiety, found superior to
routine care. Prepost studies show
improvements following therapy for other
anxiety disorders. No non-inferiority trials
conducted, but 1 small RCT (mixed diagnoses)
found similar outcomes to in-person delivery.
Obsessivecompulsive disorders CBT, ERP; CBT for hoarding; habit reversal
therapy for trichotillomania
No fully powered RCTs. Prepost studies show
improvements following therapy.
Eating disorders CBT; Maudsley Model-based relapse prevention 1 RCT (bulimia nervosa) comparing to in-person
therapy, finding few differences. Prepost
improvements observed for both bulimia
nervosa and anorexia nervosa
Psychotic disorders No studies identified -
Bipolar disorder No studies identified -
Personality disorders No studies identified -
Note:.BA=behavioural activation; CBT =cognitive behaviour therapy; CPT =cognitive processing therapy; ERP =exposure and response prevention;
RCT =randomized controlled trial.
Using videoconferencing to deliver psychological therapy 15
differences observed in trajectories of improvement on the BDI and Geriatric Depression
Scale, with rates of recovery similar between conditions.
Smaller studies have additionally demonstrated feasibility and acceptability of
delivering CBT-based therapies via videoconferencing to specific populations such as
women with post-partum depression or anxiety (Yang et al., 2019) and Korean migrants
with depression (Jang et al., 2014). Among other notable studies, Scogin et al. (2018)
conducted a small RCT of a 10-session CBT-based treatment for comorbid depression and
insomnia delivered via Skype, which found superiority over usual care on a measure of
insomnia, but not the HRSD. Finally, in treating self-harm, Sayal et al. (2019) commenced a
small RCT (N=22) of problem-solving therapy for young adults following presentation
for self-harm and mild depression. However, this was discontinued due to recruitment
difficulties (an analysis of which did not attribute these to the use of videoconferencing).
Anxiety disorders
Anxiety disorders have been less fully studied than depression. Nonetheless, anxiety
disorders feature as a major group in a number of mixed diagnosis studies, which have
demonstrated that CBT-based therapies can be satisfactorily delivered (e.g., Brunnbauer
et al., 2016; Dunstan & Tooth, 2012; Griffiths, Blignault, & Yellowlees, 2006; Matsumoto
et al., 2018, 2020; Stubbings et al., 2013). Among these, an RCT design was used by
Stubbings, Rees, Roberts, and Kane (2013) in a study of 26 people with mainly anxiety
disorders. Reductions on all subscales of the Depression Anxiety Stress Scale (DASS) were
observed following videoconferencing CBT, and, while underpowered, no differences in
the magnitude of effect were observed between videoconferencing and an in-person
comparison group. The feasibility of applying videoconferencing to deliver therapies to
other specific populations is indicated by the following, mainly small, studies.
Generalized anxiety disorder (GAD)
A multiple baseline case series by Th
eberge-Lapointe, Marchand, Langlois, Gosselin, and
Watts (2015) showed evidence for successful cognitive behavioural treatment of GAD,
with five participants no longer meeting diagnostic criteria post-therapy and 3 months
later, and this outcome persisting to 12 months after treatment in all but one case. At the
time of writing, initial results from a large RCT of CBT for GAD (N=115), focusing on
working alliance, have been reported by Watts et al. (2020), with clients rating the
working alliance more highly for videoconferencing than in-person therapy across time
points, although therapists rated both modes of delivery similarly.
Panic disorder and agoraphobia have only been studied in small pre-to-post studies,
all of CBT. Bouchard et al. (2000) found significant improvements across all measures,
reporting that five out of the eight participants no longer experienced panic attacks after
the 12-week treatment. Bouchard et al. (2004) delivered the same intervention to a further
10 videoconferencing cases, compared with a non-randomized in-person delivery group.
Nearly all participants achieved remission at the end of treatment, maintained six months
later, a similar to in-person delivery. Matsumoto et al. (2018) also found significant
reductions in panic symptoms among 10 participants with panic disorder in their pre-to-
post study of CBT.
16 Neil Thomas et al.
Social anxiety. Modality of delivery is of particular interest for social anxiety, where
communication itself is a source of anxiety. Yuen et al. (2013) examined 12 sessions of
acceptance-based behaviour therapy for 24 individuals with SAD. Therapists rated the use
of videoconferencing as feasible, and there were post-therapy improvements on several
questionnaire measures of social anxiety, maintained and at the 3-month follow-up, as well
as changes on observer-rated social behaviour; participants indicated that they were
satisfied with the treatment. Likewise, Matsumoto et al. (2018) found reductions in social
anxiety following videoconferencing-based CBT in their small sample of 10 social anxiety
Health anxiety. The largest study for a specific anxiety disorder has been for health
anxiety: Morris et al. (2019) conducted an RCT comparing CBT delivered via videocon-
ferencing or telephone with routine care in 156 participants. Supporting the use of
videoconferencing, health anxiety was reduced in the therapy group relative to routine
care at 6-, 9-, and 12-month time points.
Obsessivecompulsive and related disorders
Research into videoconferencing-delivered psychological treatments in obsessive
compulsive and related disorders was limited, with studies limited to case series and
small sample single-arm open trials and pilot RCTs. Nevertheless, there is an emerging
support for the acceptability and effectiveness of videoconferencing for a range of
intervention types across OCD, hoarding and trichotillomania.
Matsumoto et al. (2018) reported on a standard 16-week CBT treatment for their 10
OCD patients. Symptom reduction prepost treatment, strong therapeutic alliance, high
rates of satisfaction with treatment, and 100% retention, supported the effectiveness and
feasibility of the intervention. Further, two studies (Goetter, Herbert, Forman, Yuen, &
Thomas, 2014; Vogel et al., 2014) successfully used exposure and response prevention
(ERP) to treat OCD via videoconferencing, with post-treatment symptom reductions.
Vogel et al. (2014) noted high engagement with treatment, an ability to observe exposure
exercises as they occur in participants’ natural environments, and an opportunity to
involve family members and carers, thus addressing family accommodation to rituals
where appropriate.
Emerging investigations in hoarding and trichotillomania provide support for its
effectiveness, feasibility, and that it provides additional benefits when compared to
existing treatments. Muroff and Steketee (2018) delivered a structured CBT treatment for
seven patients with hoarding. Six of the seven patients experienced improvements in
symptoms post-treatment, with five maintaining the gains at 3-month follow-up. The
ability to use portable devices to move around rooms was noted as an important facilitator
in the treatment. In relation to trichotillomania, Lee, Haeger, Levin, Ong, and Twohig
(2018) conducted an RCT comparing videoconferencing-based ACT-enhanced Habit
Reversal Therapy to waitlist control in 22 trichotillomania patients. The study had high
retention rates with only one dropout in each condition, and high levels of participant
satisfaction and therapeutic alliance. Statistically and clinically significant improvements
in trichotillomania symptoms were noted among the treatment group.
Using videoconferencing to deliver psychological therapy 17
Eating disorders
In the treatment of eating disorders, there has been a single large RCT, which examined
CBT for bulimia nervosa and related disorders (Ertelt et al., 2011; Marrone, Mitchell,
Crosby, Wonderlich, & Jollie-Trottier, 2009; Mitchell et al., 2008). Although bulimia
symptoms reduced for both videoconferencing and in-person delivery, and rates of
abstinence from bingeing and/or purging showed were similar, the reduction in binge
eating frequency was less for videoconferencing participants across multiple time points
(Mitchell et al., 2008). Working alliance was rated similarly by clients for each of the
conditions, but therapists rated the alliance less strongly in the videoconferencing
condition (Ertelt et al., 2011).
Most other studies identified by the search examined smaller single group samples for
bulimia and related disorders, reporting reductions in bulimic symptoms (Abrahamssom,
Ahlund, Ahrin, & Alfonsson, 2018; Hamatani et al., 2019; Simpson et al., 2006) and
satisfaction with the online modality (Abrahamssom et al., 2018; Simpson et al., 2005).
For anorexia nervosa, Giel et al. (2015) conducted a single group pilot study examining
a relapse prevention intervention based on the Maudsley model (Schmidt, Magill, &
Renwick, 2015) in 16 individuals. Eight sessions were delivered via videoconferencing,
bookended by two in-person sessions. Three-quarters of participants completed therapy,
rating high satisfaction, and at post-intervention body mass index had increased by an
average of 1.1 points, eating concerns were reduced, and two participants were in
complete remission.
Other populations
No studies were identified providing data on videoconferencing therapy delivery to
persons with psychotic disorders, bipolar disorder, or personality disorder.
Client and practitioner experience
Overall acceptability
Every RCT comparing at-home videoconferencing with in-person delivery at a clinic
reported no group differences on questionnaire measures of satisfaction (see Table 2).
Differences in satisfaction or dropout were only seen in two studies overall, both
delivering interventions within the same environment: Morland et al. (2015) reported
lower satisfaction ratings primarily related to negative experiences of the clinic setting
that was attended for videoconferencing (also used in the in-person condition),
suggesting specificity to the potentially impersonal experience of attending a clinic for
a video-based appointment. Conversely, Choi, Hegel, et al. (2014) found that housebound
people with depression receiving in-home therapy via videoconferencing were more
satisfied than those being visited by a therapist. Overall, this demonstrates that satisfaction
with videoconferencing-based therapy is as high as traditional forms of delivery.
In terms of therapy dropout, nearly all comparisons with in-person therapy revealed no
group differences (see Table 2). An exception was a follow-up analysis of discontinuation
in the trial by Acierno et al. (2017) reported that early dropout tended to arise more often
with videoconferencing (Gros, Allan, et al., 2018), even though overall session attendance
rates were similar. While dropout seems to only arise in a small number of people, other
studies report discomfort with videoconferencing being cited by participants as a reason
for dropout, so this may be an issue with a small number of people, although at this stage
18 Neil Thomas et al.
there is a lack of information on what contributes to this (Germain, Marchand, Bouchard,
Drouin, & Guay, 2009; Lichstein et al., 2013; Simpson, Bell, Knox, Mitchell, & Eating,
It should be noted that individual comments expressing a preference for in-person
therapy were often noted from videoconferencing participants (Choi, Wilson, Sirrianni,
Marinucci, & Hegel, 2013; Lichstein et al., 2013; Simpson et al. 2005, 2006). Among
qualitative client reports, a period of early discomfort and adaptation to using
videoconferencing technology was also an experience reported by participants across
studies (Choi, Hegel, et al., 2014; Dunstan & Tooth, 2012; Fitt & Rees, 2012; Germain et al.,
2009; Lichstein et al., 2013; Simpson et al., 2005, 2006; Simpson et al., 2015; Yuen et al.,
2015). For some participants, attitudes towards videoconferencing (including scepticism,
anxiety, unfamiliarity) were linked to the experiences of discomfort in early sessions
(Arnaet, Klooster, & Chow, 2007; Choi, Hegel, et al., 2014; Fitt & Rees, 2012; Simpson
et al., 2005, 2006). For most, this early discomfort was reduced over time, as participants
got more comfortable with the technology (Choi, Hegel, et al., 2014; Dunstan & Tooth,
2012; Simpson et al., 2005, 2006; Simpson et al., 2015) or their interactions with their
therapist became more ‘natural’ (Yuen et al., 2015), although this did not always occur
(Choi, Hegel, et al., 2014; Choi et al., 2013; Lichstein et al., 2013; Simpson et al., 2005).
Therapists reported similar experiences of initial apprehension and discomfort, before
becoming more confident in using videoconferencing technology and adapting to the
modality (Dunstan & Tooth, 2012; Michell et al., 2008). This is balanced by other reports
of participants embracing the novelty and use of technology in therapy delivery (e.g.,
Aranaet et al., 2007; Choi, Hegel, et al., 2014; Choi et al., 2013; Dunstan & Tooth, 2012). It
should be noted that many of these studies were conducted before the widespread day-to-
day use of videoconferencing platforms, and less adaptation may be required in the 2020s.
Facilitating access
One of the presumed benefits of videoconferencing is that it facilitates access. As shown in
Table 1, many of the studies reviewed targeted participants in rural or geographically
remote areas, and some involved applications to potentially isolated groups (e.g.,
housebound older adults; victims of domestic violence, migrants). Participant reports
indicated that many people receiving videoconferencing therapy would otherwise have
been unable to access any therapy (Choi et al., 2013; Hassija & Gray, 2011), while others
included references to challenges of travel distance and its associated financial impact
(Abrahamsson et al., 2018; Simpson et al., 2005; Simpson et al. 2015). Some studies also
referred to the opportunity to provide specialist services for a specific issue to people over
a broad area (Hassija & Gray, 2011; Lee et al., 2018).
Even when not an absolute barrier, the increased accessibility appeared valued. The
post-partum mental health study by Yang et al. (2019) examined uptake when the option
to use videoconferencing in place of in-person psychotherapy sessions was offered: 74%
used videoconferencing for at least one therapy session, with 21% doing all therapy via
video; Time and cost savings were identified, and participants reported being able to
attend more frequently. In other studies, participants spoke of convenience, such as
fitting therapy into busy life schedules (Abrahamsson et al., 2018; Choi, Hegel, et al., 2014;
Choi et al., 2013; Lee et al., 2018; Yuen et al., 2015), and being able to access therapy from
home (Choi, Hegel, et al., 2014). Continuity of care independent of location was also
highlighted, both in relation to moving house (Simpson et al., 2005, 2006), and being
released from prison (Morgan, Patrick, & Magaletta, 2008).
Using videoconferencing to deliver psychological therapy 19
Symptoms of anxiety, concerns about stigma, and negative thought processes also
featured as potential barriers to accessing in-person services that videoconferencing was
able to circumvent (Abrahamsson et al., 2018; Bouchard et al., 2000; Simpson, Guerrini, &
Rochford, 2015). For example, in the trichotillomania study by Lee et al. (2018), 40% of
participants reported that they would not have entered treatment in an in-person setting
due to shame. Privacy for persons in small or rural communities was also referred to
(Simpson et al., 2005; Simpson et al., 2015). Nonetheless, privacy was not always assured
by videoconferencing with concerns about privacy from others within the person’s own
home being raised by some participants (Abrahamsson et al., 2018; Choi, Hegel, et al.,
2014; Franklin, Cuccurullo, Walton, Arseneau, & Petersen, 2017). Notably, concerns
about privacy from use of networked digital technology did not tend to be reported.
Client factors predicting uptake and satisfaction
Studies of client variables predicting uptake, engagement and completion of therapy have
identified relatively few predictors. In considering predictors of uptake among American
primary care attendees with a positive depression screen, Deen, Fortney, and Schroeder
(2013) found that uptake of videoconferencing-based CBT was predicted by perceiving
illness to be persisting, believing that treatment would be effective, and reporting
geographic barriers to attending; Time barriers, financial barriers, perceived stigma, and
other beliefs about depression were unrelated to uptake. In a mixed diagnosis veteran
sample offered therapy, Valentine et al. (2020) found that videoconferencing therapy
uptake, and sessions completed, were each unrelated to age, race, gender, and marital
Several studies have examined predictors of differential satisfaction with, or dropout
from, videoconferencing therapy. In most studies, completion of therapy appears
unrelated to baseline demographic (age, gender, ethnicity, income) and clinical variables
(Choi, Hegel, et al., 2014; Germain et al. 2009; Luxton et al., 2016; Watts et al., 2020),
although unreplicated findings reported by single studies include greater completion
rates for mood rather than anxiety disorders (Valentine et al., 2018), lower baseline PTSD
and absence of disability status (Gros, Allan, et al., 2018), and, among veteran samples,
being an older, Vietnam-era veteran (Gros, Yoder, Tuerk, Lozano, & Acierno, 2011). Pruitt
et al. (2019) also found that satisfaction with therapy was higher for older military,
although, in their sample, this was confounded with serving vs veteran status, with active
military needing to travel off base to access videoconferencing facilities. Analyses of
predictors of outcome have been limited, but in a military sample, Smolenski, Pruitt,
Vuletic, Luxton, and Gahm (2017) found greater baseline anxiety and loneliness predicted
participants having a better outcome from in-person than from videoconferencing-based
Among their participants with depression, Choi, Hegel, et al. (2014) found no
relationship between ratings of treatment acceptability and computer/Internet owner-
ship, or network quality. Similarly, in an analysis of PTSD trial data, Price and Gros (2014)
observed that outcome of PTSD treatment via telehealth was unrelated to prior
experience with, or expressed comfort with, telehealth at the outset of treatment. This
suggests that prior experience is not a requirement to benefit. However, prior experience
of therapy appears to predict completion. In their study of uptake, Deen et al. (2013)
found predictors of treatment completion were different from those for uptake, and
completion was most related to engagement with other treatments: receipt of prior
20 Neil Thomas et al.
counselling and being prescribed antidepressant medication. Watts et al. (2020) also
found prior therapy experience predicted completion.
Technical issues
Most studies referred to technical issues as an experience impacting on the delivery of
therapy. These included difficulties establishing connection, disconnection, suboptimal
audio and visual quality, and bandwidth and connection stability issues resulting in lag and
frozen images. Participants considered minor disruptions such as lag as a frustrating and
distracting disadvantage of videoconferencing, but, overall, this did not negatively impact
on participant engagement (Abrahamsson et al., 2018; Choi et al., 2013; Dunstan & Tooth,
2012; Lichstein et al., 2013). Studies resolved these issues through in-session trou-
bleshooting or reconnection. Severe technical issues (e.g., disconnection and inability to
re-establish connection) were managed by postponing or cancelling scheduled sessions,
or by utilizing a back-up communication method (e.g., telephone) (Abrahamsson et al.,
2018; Germain et al., 2010; Hassija and Gray, 2011; Lee et al., 2018; Luxton, Pruitt,
O’Brien, & Kramer, 2015; Olden et al., 2017; Yu et al., 2020; Vogel et al., 2014; Watts et al.,
To proactively manage technical issues, test calls or in-person training were often
provided to therapists to resolve potential technical issues at the outset (Acierno et al.,
2016, 2017; Choi, Hegel, et al., 2014; Choi, Marti, et al., 2014; Goetter et al., 2014; Gros,
Allan, et al., 2018; Gros, Lancaster, et al., 2018; Luxton et al., 2015, 2016; Yuen et al., 2013,
2015), and many studies arranged for technical support to be available as part of the study
design (Acierno et al., 2016, 2017; Germain et al., 2009, 2010; Liu et al., 2019; Olden et al.,
2017; Scogin et al., 2018; Watts et al., 2020; Yuen et al., 2013). Yuen et al. (2013, 2015)
observed that technical difficulties reduced over the course of the study, in part due to
participants becoming proficient at troubleshooting. Overall, while technical issues were
encountered in most studies, participant feedback and reports from the study authors
indicate that disruptions were not sufficiently impactful to detract from therapy.
Therapy relationship and process
On both formal measures and in qualitative reports, studies consistently reported that the
videoconferencing clients were typically able to develop a positive connection with the
therapist (Simpson et al., 2005, 2006; Simpson et al., 2015; Choi et al., 2013; Dunstan &
Tooth, 2012; Fitt & Rees, 2012; Yuen et al., 2015), although some individual reports found
a reduced sense of the therapist’s presence (e.g., Arnaet et al., 2007; Choi, Marti, et al.,
2014). Furthermore, nearly all well-powered RCTs that directly compared client ratings of
the therapeutic relationship with in-person delivery found no significant differences
(Table 2), consistent with observations in smaller studies (e.g., Morgan et al., 2008; Scogin
et al., 2018). Additionally, in an analysis of equivalence, Maieritsch et al. (2016) found
confidence intervals for the working alliance fell within a priori bounds of equivalence in
their trial of CPT. An exception to these findings is the CPT trial by Morland et al., (2015),
which found statistically, but marginally, lower ratings for videoconferencing in the
second session, with no differences at later time points. It is notable that, mirroring the
adaptation to discomfort reported in some studies, some studies have also observed that
videoconferencing clients rate a stronger alliance as sessions progress (Ertelt et al., 2011;
Germain et al., 2010).
Using videoconferencing to deliver psychological therapy 21
The converse finding of a stronger alliance in the videoconferencing condition by
Watts et al. (2020) corresponds to qualitative comments in other studies to there being
potential advantages of videoconferencing for the therapeutic relationship. Participants
discussed finding therapy easier through having a greater sense of control (i.e., of
emotion, of context, of the ability to leave) and the creation of a less intense therapy
environment (Dunstan & Tooth, 2012; Fitt & Rees, 2012; Simpson, 2001; Simpson, Deans,
& Brebner, 2001, Simpson et al. 2005; Simpson et al. 2006; Simpson et al. 2015).
Participants discussed the ability to ‘talk more freely’, being less self-conscious, finding it
easier to communicate and feeling less pressured or intimidated in videoconferencing
than they might be in-person (Fitt & Rees, 2012; Simpson et al., 2005, 2015; Yuen et al.,
Two of the three well-powered studies that included both client and therapist ratings
(Ertelt et al., 2011; Morland et al., 2015; Watts et al., 2020) identified differences of
perspective: videoconferencing clients rated a stronger alliance than in-person clients,
while therapists rated the conditions the same (Watts et al., 2020), or clients rated the
conditions similarly when therapists rated videoconferencing as inferior (Ertelt et al.,
2011). These quantitative findings correspond to therapist reports of some difficulties in
detecting emotion and ability to read body language through videoconferencing (Dunstan
& Tooth, 2012; Simpson et al., 2005; Yu et al., 2020; Yuen et al., 2013). This highlights that
therapists and clients may have discrepant experiences of videoconferencing therapy and
that therapists can find the process of therapy more challenging, without that necessarily
being reflected in client experience.
Adaptations of therapy
To deliver therapy via videoconferencing, several studies reported adaptations to therapy
protocols. Most commonly, the practical logistic changes to how components of therapy
were delivered involved using other technologies to share documents (e.g., mailing,
faxing, emailing, or screen sharing worksheets and homework) (Gros et al., 2011; Himle
et al., 2006; Lindsay et al., 2017; Luxton et al., 2015; Matsumoto et al., 2018; Turek, Yoder,
Ruggiero, Gros, & Acierno, 2010). Clinical variations included removing situation-specific
in vivo exposure exercises from videoconferencing sessions and asking participants to
complete exposure as homework only (Gros et al., 2011; Yuen et al., 2013), or creatively
adapting or restricting exposure exercises so that they would be suitable for delivery
within the virtual environment (e.g., talking on the phone to someone; Yuen et al., 2013).
While feasible, for some clients, exposure tasks via videoconferencing were perceived to
be less real and less engaging when compared with in-person (Yuen et al., 2013).
Conversely, where videoconferencing was delivered by smartphone, opportunities were
identified in using the portability of the device to observe and conduct exposure activities
within the person’s environment (Franklin et al., 2017; Turek et al., 2010; Vogel et al.,
2012, Vogel et al., 2014).
Clients also reported that some activities translated less well such as meditation
(Linsday et al., 2017) and use of imagery (Simpson et al., 2005) and that sensitive topics
may be easier to discuss in person than over videoconferencing (Lindsay et al., 2017). It is
notable that the studies surveyed used primarily behaviour al models of treatment, so more
reflective therapies are relatively less tested.
In addition to facilitating exposure tasks, the opportunity to see the person in their
home environment was mentioned by some practitio ners as helpful in contextualizing the
person’s experiences (Lindsay et al., 2017) and potentially altering the power balance by
22 Neil Thomas et al.
seeing the person in their own territory (Simpson et al., 2005). However, environmental
distractions arose more frequently within the home environment were also noted, and
some clients treated the session less formally (e.g., smoking, attending wearing pyjamas),
sometimes requiring boundary setting to maintain focus (Franklin et al., 2016; Lindsay
et al., 2017; Yu et al., 2020). When contrasting with therapy delivered in-person within the
home, even greater distractions were noted when the therapist is in the home
environment, and videoconferencing was noted to help to formalize the interaction
and help clients stay focused (Choi, Hegel, et al., 2014).
Discussion and conclusions
The literature to date shows consistent positive findings about the suitability of the
videoconferencing modality for delivery of psychological therapies, with consistent
findings that videoconferencing does not differ from in-person therapy on outcome,
satisfaction, therapy completion, and client experiences of the therapeutic alliance.
Advantages include accessibility, particularly to persons without local in-person services,
but also in terms of convenience, reducing time and financial costs, and circumventing
stigma, self-consciousness and privacy concerns. Disadvantages include therapists finding
it harder to judge body language, both clients and therapists experiencing initial
discomfort with the modality while adapting to it, and interruptions arising from
inevitable technical issues. However, it appeared that these concerns became less as
clients and therapists adjusted: It may be that these issues become less of a concern as
familiarity with videoconferencing grows across the population.
In considering the clinical populations for whom videoconferencing-based therapy is
most evidenced, conclusions primarily reflect the availability of trial data, rather than
patterns of superior or inferior efficacy being observed. That withstanding, the
videoconferencing modality has its most established evidence base in the delivery of
cognitive behavioural therapies for PTSD and depression, where multiple trials have
determined non-inferiority to in-person therapy. Across anxiety, obsessivecompulsive
spectrum and eating disorders, there is also emergent evidence supporting use. Notably,
there was a lack of study of videoconferencing therapy delivery to people with psychosis
(although see Santestaban-Echarri et al., 2020, for findings of broader service delivery,
such as psychiatry appointments, being acceptable to this population).
Among therapy modalities, CPT, PE, and behavioural activation all have evidence of
non-inferiority, so can be considered the best supported for delivery in this modality. It is
notable that trauma-focused therapies, as some of the most confronting therapeutic
approaches, are the best evidenced, which suggests that an in-room presence is not
required to deliver quite challenging therapies. Nonetheless, studies with available data
have primarily utilized behavioural therapies. This leaves it unknown how therapies that
use greater Socratic dialogue and reflection may operate within a videoconferencing
environment, where some of the technical issues such as lag may prove more interruptive
to the therapy process. Likewise, it is not known whether therapies for complex
presentations, such as personality disorder and psychosis, which require more careful
monitoring of in-session rapport, would be equally successful.
A further caveat is that most large-scale studies have been conducted in American
veteran/military populations, with predominantly male participants, raising questions of
generalizability. Of note, the clearest finding of videoconferencing having slightly poorer
outcomes than in-person therapy was in a trial for bulimia nervosa with a predominantly
Using videoconferencing to deliver psychological therapy 23
female group (although also using older telemedicine technology). On the other hand, the
female-only study by Morland et al. (2015) also found non-inferiority and broadly similar
results and observed that outcomes were in fact better among civilians compared with
veterans. Nonetheless, these limitations in the available data urge some caution in
assuming that videoconferencing therapies will function as well as in-person therapy with
all therapies and populations. It should also be noted that we did not aggregate and meta-
analyse mean scores for variables across studies, so there may be small between group
differences that individual trials were not powered to detect.
In considering areas for further research, it is notable that since the COVID-19
pandemic, new questions have emerged as in-person therapy has not always been the
most important reference point. We did not identify any studies that contrasted
videoconferencing with telephone as the other widely accessible communication
modality. While, in a non-clinical client group, Day and Schnier (2002) failed to find any
advantages of video counselling over telephone on process or outcome measures,
considering the contrasting uses of these two widely accessible platforms, and
understanding whether visual non-verbal feedback facilitates maintaining rapport, is
needed in clinical populations. Further study also needs to be directed at examining the
opportunities that may be presented by using videoconferencing as a therapeutic
medium. Observations suggest there are particular affordances of video, allowing access
to the home environment and potentially for portability, which may have advantages in
better connecting with the person’s daily life, and developing more ecologically valid
therapeutic exercises. Rather than considering videoconferencing second to a presumed
gold standard of in-person therapy, attention to these affordances is needed to evolve
videoconferencing-based therapy practice in its own right.
This research received no specific funding.
Conflict of interest
All authors declare no conflict of interest.
Author contributions
Neil Thomas (Conceptualization; Data curation; Formal analysis; Investigation; Method-
ology; Supervision; Writing original draft; Writing review & editing) Caity McDonald
(Conceptualization; Data curation; Formal analysis; Investigation; Writing review &
editing) Kathleen de Boer (Data curation; Formal analysis; Investigation; Writing original
draft; Writing review & editing) Rachel M. Brand (Investigation; Writing original draft;
Writing review & editing) Maja Nedeljkovic (Investigation; Writing original draft;
Writing review & editing) Liz Seabrook (Conceptualization; Data curation; Formal
analysis; Investigation; Writing original draft; Writing review & editing).
24 Neil Thomas et al.
Data availability statement
The data that support the findings of this study are available from the corresponding author
upon reasonable request.
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... Broadly, the identified benefits and challenges of remote delivery have been captured by the telepsychiatry literature outside of ASD (Chiauzzi et al., 2020;Stoll et al., 2020;Thomas et al., 2021), except the YP's difficulties navigating a new social system. In addition, the reasons for the intensity of the social interaction feeling reduced and controllable remotely differed in some respects. ...
... In addition, the reasons for the intensity of the social interaction feeling reduced and controllable remotely differed in some respects. While YP considered it to be less pressurising, felt they could talk more freely, and could be in a comforting environment with increased control, as reported previously (Thomas et al., 2021), YP in this study voiced additional reasons that included reduced eye contact and sensory familiarity. These missed aspects may thus be ASD-associated, especially since they appear to pertain to the social communication impairments and sensory sensitivities at the core of ASD (APA, 2013). ...
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Recently, therapy has been delivered at a distance (i.e. remotely) to help control the spread of coronavirus. Clinicians have voiced concerns that remote delivery is unsuitable for certain individuals, including those who are autistic, but they have also highlighted potential benefits for autistic individuals. Benefits include some individuals feeling more comfortable receiving therapy at home. This is the first study to interview autistic individuals about their experience of remote therapy. Participants were six young people aged 15-18 years and eight clinicians. Participants described their experience of remote delivery, including challenges, benefits, and suggestions. Most of these supported previous research findings, but some were new or provided further insight into those already identified. A newly identified challenge was knowing online social etiquette. All participants found aspects of the experience challenging, but all identified benefits and most voiced that remote sessions should be offered to young people. Participants further identified individual characteristics that may make someone less suited to remote delivery (e.g. shyness). They also identified ways of making the experience of remote delivery easier (e.g. sitting with a pet). Young people's and clinicians' views were similar overall, with only subtle differences. For example, young people uniquely voiced that remote delivery was similar to in-person, that benefits were hard to identify, and provided distinct reasons for the social interaction feeling less intense remotely. Findings may be used to improve remote delivery, for guiding future research, and as a case for continuing to offer it to those who may most benefit.
... Several reviews [6][7][8][9][10] and meta-analyses[11,13] of TMH-based treatments for OCD have found that VCbased treatment is useful, but they have only included a few trials of VC-ERP for OCD. Similarly, metaanalyses[25, 45,46] and reviews[17, [47][48][49][50] that have found VC-based treatments to be effective for psychiatric disorders have included a limited number of VC-ERP studies of OCD. This is not surprising because there are only three randomized-controlled trials (RCTs) of VC-ERP in OCD [51][52][53]. ...
Background: The existing literature indicates that psychotherapeutic treatment, especially exposure and response prevention (ERP) is efficacious in treating obsessive-compulsive disorder (OCD). The coronavirus disease 2019 pandemic adversely impacted many patients with OCD and disrupted their usual treatment. Moreover, the pandemic forced a global switch to telemental health (TMH) services to maintain the standards and continuity of care. Consequently, clinicians are increasingly using TMH-based psychotherapeutic treatments to treat OCD. However, several challenges have made it difficult for them to implement these treatments in the changed circumstances imposed by the pandemic. Aim: To describe the formulation, implementation, feasibility, and usefulness of videoconferencing-based ERP (VC-ERP) treatment for OCD during the coronavirus disease 2019 pandemic. Methods: This prospective, observational study was conducted in the psychiatric unit of a multi-specialty hospital in north India over 12 mo (July 2020-June 2021). All patients with OCD were assessed using the home-based TMH services of the department. The VC-ERP protocol for OCD was the outcome of weekly Zoom meetings with a group of clinicians involved in administering the treatment. After a systematic evaluation of the available treatment options, an initial protocol for delivering VC-ERP was developed. Guidelines for clinicians and educational materials for patients and their families were prepared. The protocol was implemented among patients with OCD attending the TMH services, and their progress was monitored. The weekly meetings were used to upgrade the protocol to meet the needs of all stakeholders. Feasibility and efficacy outcomes were examined. Results: All patients were diagnosed with OCD as a primary or a comorbid condition according to the International Classification of Diseases, 10th version criteria. Out of 115 patients who attended the services during the study period, 37 were excluded from the final analysis. Of the remaining 78 patients, VC-ERP was initiated in 43 patients. Six patients dropped out, and three were hospitalized for inpatient ERP. Eleven patients have completed the full VC-ERP treatment. One patient completed the psychoeducation part of the protocol. VC-ERP is ongoing in 22 patients. The protocol for VC-ERP treatment was developed and upgraded online. A large proportion of the eligible patients (n = 34/43; 79%) actively engaged in the VC-ERP treatment. Drop-out rates were low (n = 6/43; 14%). Satisfaction with the treatment was adequate among patients, caregivers, and clinicians. Apart from hospitalization in 3 patients, there were no other adverse events. Hybrid care and stepped care approaches could be incorporated into the VC-ERP protocol. Therefore, the feasibility of VC-ERP treatment in terms of operational viability, service utilization, service engagement, need for additional in-person services, frequency of adverse events, and user satisfaction was adequate. The VC-ERP treatment was found to be efficacious in the 11 patients who had completed the full treatment. Significant reductions in symptoms and maintenance of treatment gains on follow-up were observed. Conclusion: This study provided preliminary evidence for the feasibility and usefulness of VC-ERP in the treatment of OCD. The results suggest that VC-ERP can be a useful option in resource-constrained settings.
... Literature contrasts patients' and psychologists' satisfaction with the separate settings that VCP imposes [1,18]. According to studies conducted during the COVID-19 pandemic, patients treated by VCP tend to not perceive the psychologist's presence as intimidating as in FTF therapy, and they interact more spontaneously with the psychologist; in contrast, psychologists evaluate VCP as difficult in perceiving patients' physical and emotional signals [1,[19][20][21][22]. Psychologists have felt uncertain about VCP adoption during the entire duration of the pandemic [23,24], but at present, they appear more open to the use of VCP than before the pandemic [25]. ...
Background The COVID-19 pandemic caused a surge in the use of telehealth platforms. Psychologists have shifted from face-to-face sessions to videoconference sessions. Therefore, essential information that is easily obtainable via in-person sessions may be missing. Consequently, therapeutic work could be compromised. Objective This study aimed to explore the videoconference psychotherapy (VCP) experiences of psychologists around the world. Furthermore, we aimed to identify technological features that may enhance psychologists’ therapeutic work through augmented VCP. Methods In total, 17 psychologists across the world (n=7, 41% from Australia; n=1, 6% from England; n=5, 29% from Italy; n=1, 6% from Mexico; n=1, 6% from Spain; and n=2, 12% from the United States) were interviewed. We used thematic analysis to examine the data collected from a sample of 17 psychologists. We applied the Chaos Theory to interpret the system dynamics and collected details about the challenges posed by VCP. For collecting further information about the technology and processes involved, we relied on the Input-Process-Output (IPO) model. Results The analysis resulted in the generation of 9 themes (input themes: psychologists’ attitude, trust-reinforcing features, reducing cognitive load, enhancing emotional communication, and engaging features between psychologists and patients; process themes: building and reinforcing trust, decreasing cognitive load, enhancing emotional communication, and increasing psychologist-patient engagement) and 19 subthemes. Psychologists found new strategies to deal with VCP limitations but also reported the need for more technical control to facilitate therapeutic processes. The suggested technologies (eye contact functionality, emergency call functionality, screen control functionality, interactive interface with other apps and software, and zooming in and out functionality) could enhance the presence and dynamic nature of the therapeutic relationship. Conclusions Psychologists expressed a desire for enhanced control of VCP sessions. Psychologists reported a decreased sense of control within the therapeutic relationship owing to the influence of the VCP system. Great control of the VCP system could better approximate the critical elements of in-person psychotherapy (eg, observation of body language). To facilitate improved control, psychologists would like technology to implement features such as improved eye contact, better screen control, emergency call functionality, ability to zoom in and out, and an interactive interface to communicate with other apps. These results contribute to the general perception of the computer as an actual part of the VCP process. Thus, the computer plays a key role in the communication, rather than remaining as a technical medium. By adopting the IPO model in the VCP environment (VCP-IPO model), the relationship experience may help psychologists have more control in their VCP sessions.
Objective Digital supplements to tele-psychotherapy are increasingly needed. The purpose of this retrospective study was to investigate the association between outcomes and the use of supplemental video lessons based on the Unified Protocol (UP), an empirically supported transdiagnostic treatment. Methods Participants included 7,326 adults in psychotherapy for depression and/or anxiety. Partial correlations were calculated between number of UP video lessons completed and change in outcomes after 10 weeks, controlling for number of therapy sessions and baseline scores. Then, participants were divided into those who did not complete any UP video lessons (n = 2355) and those who completed at least 7/10 video lessons (n = 549), and propensity-matched on 14 covariates. Repeated measures analysis of variance compared these groups (n = 401 in each group) on outcomes. Results Among the entire sample, symptom severity decreased as the number of UP video lessons completed increased, with the exception of lessons on avoidance and exposure. Those watching at least 7 lessons showed significantly greater reduction in both depression and anxiety symptoms than those who did not watch any. Conclusion Viewing supplemental UP video lessons in addition to tele-psychotherapy had a positive and significant association with symptom improvement and may provide an additional tool for clinicians to implement UP components virtually.
Background: People would prefer to have psychotherapy as treatment over medication for major depression. There is evidence that psychotherapy does not require in-person delivery to be effective. Other modes of delivery, such as videoconferencing teletherapy, may make it a more accessible treatment. Method: The aim of this review was to identify the characteristics of effective psychotherapy delivered by videoconference for adults in primary care with a primary diagnosis of depression. A quantitative systematic review was conducted and reported according to PRISMA guidelines. Results: There were 8 studies included in the review. The therapies studied were tele problem-solving therapy, behavioural activation and cognitive behavioural therapy. All studies had a medium to high risk of bias. Six were randomized controlled trials, one was a pragmatic retrospective cohort study and one was an open-label design. Four studies found similar outcomes to the in-person comparators, one study found tele problem-solving therapy was more effective than behavioural activation, and one study found cognitive behavioural therapy to be similar to usual care. Limitations: The search identified only 8 studies. Due to the heterogeneity of outcome measures and comparators, a meta-analysis could not be conducted. Conclusions: No definitive conclusions can be drawn about the effectiveness of teletherapy in primary care based on this review, however, there is emerging evidence to suggest it has similar outcomes to in-person therapy for people with a primary diagnosis of depression. There is no evidence regarding the superiority of one model of therapy over the others.
The internet offers important ways for UK clinical psychologists to engage the global community of aspiring psychologists. Increasing and diversifying the use of social media and internet-based platforms to target this audience may increase access and inclusion in clinical psychology.
Purpose This paper aims to evaluate service user (SU) and clinician acceptability of video care, including future preferences to inform mental health practice during COVID-19, and beyond. Design/methodology/approach Structured questionnaires were co-developed with SUs and clinicians. The SU online experience questionnaire was built into video consultations (VCs) via the Attend Anywhere platform, completed between July 2020 and March 2021. A Trust-wide clinician experience survey was conducted between July and October 2020. Chi-squared test was performed for any differences in clinician VC rating by mental health difficulties, with the content analysis used for free-text data. Findings Of 1,275 SUs completing the questionnaire following VC, most felt supported (93.4%), and their needs were met (90%). For future appointments, 51.8% of SUs preferred video, followed by face-to-face (33%), with COVID-related and practical reasons given. Of 249 clinicians, 161 (64.7%) had used VCs. Most felt the therapeutic relationship (76.4%) and privacy (78.7%) were maintained. Clinicians felt confident about clinical assessment and management using video. However, they were less confident in assessing psychotic symptoms and initiating psychotropic medications. There were no significant differences in clinician VC rating by mental health difficulties. For future, more SUs preferred using video, with a quarter providing practical reasons. Originality/value The study provides a real-world example of video care implementation. In addition to highlighting clinician needs, support at the wider system/policy level, with a focus on addressing inequalities, can inform mental health care beyond COVID-19.
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The introduction chapter describes the scope and purpose of this book and summarizes key topics regarding online therapy. We explain that the book addresses most of the main approaches and schools of psychotherapy that are prevalent in the therapeutic field nowadays. Thus, in addition to exploring how each of them adjust to online therapy, we also have created a collection of the most practiced therapeutic approaches nowadays. Beyond the theories, we describe why flexibility and creativity are among the main factors that contribute to the success of online therapy. Also discussed briefly are skills and training required for the successful provision of online therapy. The introduction also presents the current research about online therapeutic alliance, elements influencing the therapeutic alliance such as the setting and rupture and repair, and the outcome of online therapy. We show that there is enough evidence that online therapy is beneficial no less than in-person. We address the question whether it is suitable for everyone, and summarize how the factors that unify all psychodynamic approaches can be applied online.
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Background: Face-to-face individual cognitive behavioral therapy (CBT) and internet-based CBT (ICBT) without videoconferencing are known to have long-term effectiveness for obsessive-compulsive disorder (OCD), panic disorder (PD), and social anxiety disorder (SAD). However, videoconference-delivered CBT (VCBT) has not been investigated regarding its long-term effectiveness and cost-effectiveness. Objective: The purpose of this study was to investigate the long-term effectiveness and cost-effectiveness of VCBT for patients with OCD, PD, or SAD in Japan via a 1-year follow-up to our previous 16-week single-arm study. Methods: Written informed consent was obtained from 25 of 29 eligible patients with OCD, PD, and SAD who had completed VCBT in our clinical trial. Participants were assessed at baseline, end of treatment, and at the follow-up end points of 3, 6, and 12 months. Outcomes were the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Panic Disorder Severity Scale (PDSS), Liebowitz Social Anxiety Scale (LSAS), Patient Health Questionnaire-9 (PHQ-9), General Anxiety Disorder-7 (GAD-7), and EuroQol-5D-5L (EQ-5D-5L). To analyze long-term effectiveness, we used mixed-model analysis of variance. To analyze cost-effectiveness, we employed relevant public data and derived data on VCBT implementation costs from Japanese national health insurance data. Results: Four males and 21 females with an average age of 35.1 (SD 8.6) years participated in the 1-year follow-up study. Principal diagnoses were OCD (n=10), PD (n=7), and SAD (n=8). The change at 12 months on the Y-BOCS was -4.1 (F1=4.45, P=.04), the change in PDSS was -4.4 (F1=6.83, P=.001), and the change in LSAS was -30.9 (F1=6.73, P=.01). The change in the PHQ-9 at 12 months was -2.7 (F1=7.72, P=.007), and the change in the GAD-7 was -3.0 (F1=7.09, P=.009). QALY at 12 months was 0.7469 (SE 0.0353, 95% Cl 0.6728-0.821), and the change was a significant increase of 0.0379 (P=.01). Total costs to provide the VCBT were ¥60,800 to ¥81,960 per patient. The set threshold was ¥189,500 ($1723, €1579, and £1354) calculated based on willingness to pay in Japan. Conclusions: VCBT was a cost-effective way to effectively treat Japanese patients with OCD, PD, or SAD. Trial registration: University Hospital Medical Information Network Clinical Trials Registry UMIN000026609;
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As interest in and use of telehealth during the COVID-19 global pandemic increase, the potential of digital health to increase access and quality of mental health is becoming clear. Although the world today must "flatten the curve" of spread of the virus, we argue that now is the time to "accelerate and bend the curve" on digital health. Increased investments in digital health today will yield unprecedented access to high-quality mental health care. Focusing on personal experiences and projects from our diverse authorship team, we share selected examples of digital health innovations while acknowledging that no single piece can discuss all the impressive global efforts past and present. Exploring the success of telehealth during the present crisis and how technologies like apps can soon play a larger role, we discuss the need for workforce training, high-quality evidence, and digital equity among other factors critical for bending the curve further.
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Background Videoconferencing psychotherapy (VCP) is a growing practice among mental health professionals. Early adopters have predominantly been in private practice settings, and more recent adoption has occurred in larger organizations, such as the military. The implementation of VCP into larger health service providers in the public sector is an important step in reaching and helping vulnerable and at-risk individuals; however, several additional implementation challenges exist for public sector organizations. Objective The aim of this study was to offer an implementation model for effectively introducing VCP into public sector organizations. This model will also provide practical guidelines for planning and executing an embedded service trial to assess the effectiveness of the VCP modality once implemented. Methods An iterative search strategy was employed, drawing on multiple fields of research across mental health, information technology, and organizational psychology. Previous VCP implementation papers were considered in detail to provide a synthesis of the barriers, facilitators, and lessons learned from the implementation attempts in the military and other public sector settings. Results A model was formulated, which draws on change management for technology integration and considers the specific needs for VCP integration in larger organizations. A total of 6 phases were formulated and were further broken down into practical and measurable steps. The model explicitly considers the barriers often encountered in large organizational settings and suggests steps to increase facilitating factors. Conclusions Although the model proposed is time and resource intensive, it draws on a comprehensive understanding of larger organizational needs and the unique challenge that the introduction of VCP presents to such organizations.
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Background: A major problem in providing mental health services is the lack of access to treatment, especially in remote areas. Thus far, no clinical studies have demonstrated the feasibility of internet-based cognitive behavioral therapy (ICBT) with real-time therapist support via videoconference for bulimia nervosa and binge-eating disorder in Japan. Objective: The goal of the research was to evaluate the feasibility of ICBT via videoconference for patients with bulimia nervosa or binge-eating disorder. Methods: Seven Japanese subjects (mean age 31.9 [SD 7.9] years) with bulimia nervosa and binge-eating disorder received 16 weekly sessions of individualized ICBT via videoconference with real-time therapist support. Treatment included CBT tailored specifically to the presenting diagnosis. The primary outcome was a reduction in the Eating Disorder Examination Edition 16.0D (EDE 16D) for bulimia nervosa and binge-eating disorder: the combined objective binge and purging episodes, objective binge episodes, and purging episodes. The secondary outcomes were the Eating Disorders Examination Questionnaire, Bulimic Investigatory Test, Edinburgh, body mass index for eating symptoms, Motivational Ruler for motivation to change, EuroQol-5 Dimension for quality of life, 9-item Patient Health Questionnaire for depression, 7-item Generalized Anxiety Disorder scale for anxiety, and Working Alliance Inventory–Short Form (WAI-SF). All outcomes were assessed at week 1 (baseline) and weeks 8 (midintervention) and 16 (postintervention) during therapy. Patients were asked about adverse events at each session. For the primary analysis, treatment-related changes were assessed by comparing participant scores and 95% confidence intervals using the paired t test. Results: Although the mean combined objective binge and purging episodes improved from 47.60 to 13.60 (71% reduction) and showed a medium effect size (Cohen d=–0.76), there was no significant reduction in the combined episodes (EDE 16D –41; 95% CI –2.089 to 0.576; P=.17). There were no significant treatment-related changes in secondary outcomes. The WAI-SF scores remained consistently high (64.8 to 66.0) during treatment. Conclusions: ICBT via videoconference is feasible in Japanese patients with bulimia nervosa and binge-eating disorder. Trial Registration: UMIN Clinical Trials Registry UMIN000029426;
The COVID-19 pandemic has dramatically transformed the U.S. healthcare landscape. Within psychiatry, a sudden relaxing of insurance and regulatory barriers during the month of March 2020 enabled clinicians practicing in a wide range of settings to quickly adopt virtual care in order to provide critical ongoing mental health supports to both existing and new patients struggling with the pandemic's impact. In this article, we briefly review the extensive literature supporting the effectiveness of telepsychiatry relative to in-person mental health care, and describe how payment and regulatory challenges were the primary barriers preventing more widespread adoption of this treatment modality prior to COVID-19. We then review key changes that were implemented at the federal, state, professional, and insurance levels over a one-month period that helped usher in an unprecedented transformation in psychiatric care delivery, from mostly in-person to mostly virtual. Early quality improvement data regarding virtual visit volumes and clinical insights from our outpatient psychiatry department located within a large, urban, tertiary care academic medical center reflect both the opportunities and challenges of virtual care for patients and providers. Finally, we provide clinical suggestions for optimizing telepsychiatry based on our experience, make a call for advocacy to continue the reduced insurance and regulatory restrictions affecting telepsychiatry even once this public health crisis has passed, and pose research questions that can help guide optimal utilization of telepsychiatry as mainstay or adjunct of outpatient psychiatric treatment now and in the future.
Telepsychotherapy represents a promising solution to problems pertaining to specialized mental health services accessibility, including when delivering psychotherapy to people who do not have access to care due to the COVID-19 pandemic. The quality of the working alliance established in such a therapeutic context remains often questioned. Moreover, no study has comparatively examined the evolution of the alliance over telepsychotherapy and conventional, face-to-face, psychotherapy. This study assesses the impact of cognitive–behavioral therapy administered via telepsychotherapy or face-to-face on the quality of the working alliance. One hundred and 15 participants suffering from generalized anxiety disorder (GAD) took part in this randomized controlled trial, 50 of whom were assigned to telepsychotherapy in videoconference and 65 of whom were assigned to conventional psychotherapy. Each client and their psychotherapist completed the Working Alliance Inventory every 2 sessions. In the current sample, telepsychotherapy did not interfere with the establishment of the working alliance over the course of the treatment for GAD. On the contrary, clients showed a stronger working alliance in telepsychotherapy delivered in videoconference than in conventional psychotherapy. Clients seemed to be more comfortable with telepsychotherapy than psychotherapists. The clinical implications of these findings are discussed.
Background: There has been increasing interest in using videoconferencing in health care, but limited research was conducted in Binge Eating Disorder (BED) patients. This 3-month pilot study aimed to assess the feasibility, acceptability, and preliminary efficacy of a videoconferencing (VC)-based treatment program in overweight and obese females with BED. Methods: Eighteen participants, aged 20-73, were diagnosed and randomized into either a face-to-face (F2F) group or a VC-based group. In the F2F group, participants received 12 one-on-one weekly counseling sessions from a Licensed Mental Health Counselor and Registered Dietitian Nutritionist. In the VC group, participants received the same counseling through an online telemedicine software. Measured outcomes include retention, adherence to treatment, and attitudinal and behavioral changes of participants. Results: In the end of study, of the 9 participants randomized into each group, 8 (88.9%) F2F participants and 4 (44.4%) VC participants completed the study. On average, F2F finishers attended 94.8% of sessions and completed 66.2% of dietary diaries. VC finishers attended 95.8% of sessions and completed 55.4% of diaries. No changes in weight and binge eating episode were observed in either group. F2F finishers had significant improvement on uncontrolled eating (p = 0.01), emotional eating (p = 0.004), food addiction diagnosis (p = 0.04), loss of control (p = 0.04), and clinical significance (p = 0.04). VC finishers observed significant improvements in eating disorder examination shape concern (p = 0.03) and global score (p = 0.03). Conclusion: VC-based treatment program is feasible and could be effective for BED patients. Long-term large-scale randomized clinical trials are warranted to further assess the efficacy.
Telemental health conducted via videoconferencing (TMH‐V) has the potential to improve access to care, and providers’ attitudes toward this innovation play a crucial role in its uptake. This systematic review examined providers’ attitudes toward TMH‐V through the lens of the unified theory of acceptance and use of technology (UTAUT). Findings suggest that providers have positive overall attitudes toward TMH‐V despite describing multiple drawbacks. Therefore, the relative advantages of TMH‐V, such as its ability to increase access to care, may outweigh its disadvantages, including technological problems, increased hassle, and perceptions of impersonality. Providers’ attitudes may also be related to their degree of prior TMH‐V experience, and acceptance may increase with use. Limitations and implications of findings for implementation efforts are discussed.