What do we know about interaction in telephone therapy?
by Annie Irvine & Rebecca McNaughton
The EQUITy programme is exploring how mental health services can be helped to increase patient engagement in telephone-delivered psychotherapy. Although telephone treatment has been shown to be as effective as face-to-face treatment in improving symptoms of anxiety and depression, some mental health practitioners are concerned about the impact that the telephone has on their interactions with patients.
One worry is that, if patients and practitioners cannot see each other, the positive working relationship between patient and therapist – often referred to as the ‘therapeutic alliance’ – may not be as strong as when treatment is face-to-face. Can a bond be built and can practitioners demonstrate empathy and understanding without the use of facial expressions and body language?
Another worry is that it will be more difficult to assess and understand patients’ emotions. And although some people may find it easier to talk about sensitive personal issues when they have the anonymity of the telephone, there is also a concern that patients may not disclose important information if they do not get to know their therapist face-to-face.
As we set out on the EQUITy programme, we wanted to understand what research evidence there was to support these reservations about the quality of interaction in telephone therapy sessions. We explored the existing research literature using the systematic review method – searching bibliographic databases for all research studies that had looked specifically at this question.
Our wide-ranging search of the research literature found 15 papers reporting studies that had compared telephone and face-to-face therapy and had looked, in particular, at the interaction between patients and mental health practitioners. These studies had been conducted between 1971 and 2015, mostly within the USA but also in Australia, Canada, Mexico and the UK.
The 15 papers looked at a range of interactional aspects of therapy, including: therapeutic alliance, disclosure, empathy, attentiveness, participation and the duration of therapy sessions. For almost all of these interactional features, the research found no evidence that telephone therapy led to less positive ratings or outcomes. In fact, some studies found higher ratings of therapeutic alliance in telephone-based treatments compared to face-to-face.
The only significant difference was in the duration of therapy sessions, where telephone sessions were typically shorter than those carried out face-to-face.
So it seems that perhaps mental health practitioners do not need to worry so much about the effect that the telephone might have on their interactions with patients. Our findings do raise the question, however, of whether longer face-to-face sessions necessarily indicate ‘better’ therapy, or whether it might be that telephone sessions are somehow more efficient and hence offer good value to services and to patients.
Reflections from lived experience:
Having worked as a therapist at Step 3 of an IAPT service, I remember my own reluctance to offer sessions by phone. I had an intuitive sense that ‘therapy by phone’ was somehow inferior to face-to-face work; less ‘personal’ and less intimate. I also recall a niggling concern that the offer of telephone therapy was part of a political move to ‘do more for less’ i.e. demanding a greater ‘output’ and ‘throughput’ by therapists. This may signify ‘perceptions [which] can be extremely influential and persist even in the absence of evidence’ and the need for ‘nuanced forms of intervention … to effect change in practitioner attitudes and behaviours’ whilst recognising that ‘barriers to change lie not only at the individual or interpersonal level, but also at the systems level’.
I now work for Childline where no face-to-face contact is offered and yet one young person every 25 seconds makes contact with the service by phone or on-line. For many of these young people, the anonymity and convenience of the service are the things that enable them to seek help. And yet for me, during two years of weekly face-to-face psychotherapy, I needed to be recognised not anonymous. And the effort (often begrudging and rarely convenient) of getting to weekly therapy was an important part of the process. This illustrates the importance of client choice, the fact that ‘one size’ will never ‘fit all’ and gives some clues, perhaps, to the ways in which the ‘actual, interactive process of therapeutic alliance formation’ occurs. My relationship with my therapist saved my life; over time and with rupture, repair, blood, sweat and tears. Now, when I fall into darkness, I picture my therapist. I imagine being safely cocooned in his sky-blue lambs-wool jumper; a thing I never touched (and which could be cheap acrylic). For those people who experience telephone therapy, what do they take away beyond words and how is this provided? Questions like this are what excite me about the EQUITy study and I look forward to continuing to contribute as a member of the Lived Experience Advisory Panel.