“Going the Extra Mile”: Satisfaction and Alliance Findings from an Evaluation of Videoconferencing Telepsychology in RuralWestern Australia Lisa… [631995]

ORIGINAL ARTICLE
“Going the Extra Mile”: Satisfaction and Alliance Findings from
an Evaluation of Videoconferencing Telepsychology in RuralWestern Australia
Lisa Richardson, Corinne Reid, and Suzanne Dziurawiec
School of Psychology and Exercise Science, Murdoch University
Objective: Technology is changing how we behave, communicate, and process information, and this has significant implications for mental
health care. Telepsychology has appeal as a solution to obstacles of distance and access in rural and regional areas; however, few servicesappear to provide telepsychology as a routine service component for psychotherapeutic exchanges. The primary research goal of a multi-yearPhD project was to explore and explain the disconnect between research and practice in telepsychology, and to investigate, among other things,how telepsychology changes the clinician’s usual practice or the client’s behaviour.Methods: Eight adult participants were seen for 68 hours of direct videoconferencing telepsychology over 11 months, and 53 separate points
of data for each client that included the perspectives of both the client and therapist were collected. Clients completed technical, process, andtherapy-based satisfaction surveys after each session, in addition to standardised clinical symptom rating.Results: This manuscript will summarise some of the project’s research findings in relation to specific practice techniques, with a particular focus
on therapeutic alliance and satisfaction.Conclusions: In possible contrast to the opinions of those less familiar with telepsychology, we conclude that if telepsychology is not treated
apologetically it can achieve therapeutic results, albeit via a different route, favourably comparable to those achieved in face-to-face encounte rs.
Key words: alliance; clinicians; rural; telepsychology; therapeutic; videoconference.
What is already known on this topic
1 Telepsychology is recognised as a potential solution to access to
care barriers in rural and regional areas.
2 The results of telemental health studies indicate strong evi-
dence for high patient satisfaction and therapeutic alliance for arange of health services, regardless of therapy orientation.
3 Despite positive satisfaction and effectiveness evidence, practi-
tioners still appear to be reluctant to use telepsychology.What this paper adds
1 The conditions of “artificiality” of transmissions, for example,
from low bandwidth, poor camera resolution, and colour/pictureor sound distortion, appear to not impede the client’s satisfac-tion, or clinical outcomes.
2 Despite technical problems, there appeared little impact on par-
ticipants’ overall satisfaction or on the development of thera-peutic alliance or clinical outcomes.
3 In some circumstances, the distancing provided by the
telepsychology medium can also offer a sense of safety andsanctuary for clients who are dealing with shame-based issues.
Introduction
Telepsychology, or psychological services delivered viavideoconferencing, may be one response to reducing the obsta-cles of remote mental health care delivery in a mushroomingbattery of telehealth technologies and distance delivery (Duncan,
Velasquez, & Nelson, 2014; Maheu, Pulier, McMenamin, &Posen, 2012). The appeal of telepsychology is that its real-timesynchronous visual interface is most akin to traditional clinicalpractice, and thus is most familiar to novice practitionersand clients. The research described in this article focuses onvideoconferencing telepsychology.
Telepsychology studies indicate strong evidence for high
patient satisfaction for a range of services, regardless of therapyorientation. Moderate evidence also supports the effectivenessof telepsychology to treat specific mental health diagnoses, suchas depression and anxiety disorders, with clinical outcomes thatare comparable to those achieved in face-to-face environments(for reviews, see Backhaus et al., 2012; Boydell et al., 2014;
Correspondence: Lisa Richardson, School of Psychology and
Exercise Science, Murdoch University, South Street, Murdoch, WA 6150,Australia. Fax: 9347 6324; email: lisakrichardson@bigpond.com.au orlisa.richardson@health.wa.gov.au
Accepted for publication 19 February 2015doi:10.1111/ap.12126bs_bs_banner
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Gros et al., 2013; Hilty et al., 2013; Richardson, Frueh,
Grubaugh, Egede, & Elhai, 2009; Simpson, 2009). In addition toreducing issues of distance and professional shortages (Simpson& Reid, 2014a, 2014b), telepsychology has also been demon-strated to reduce costs and save resources (Godleski, Darkins, &Peters, 2012; Shore, Brooks, Savin, Manson, & Libby, 2007).However, despite its many benefits, telepsychology is not uni-versally accepted, and therapeutic telepsychology remains anexception rather than a core practice in many services(Germain, Marchand, Bouchard, Guay, & Drouin, 2010; Rees &Stone, 2005; Richardson, 2011; Simpson & Reid, 2014a).
This article describes a small component of a larger PhD
clinical intervention study (Richardson, 2011) that investi-gated the processes of conducting routine psychotherapeutictelepsychology in a rural context. The specific focus of thisarticle is on satisfaction and therapeutic alliance, which aredeemed important given the primacy of therapeutic alliance topositive clinical outcomes in psychotherapy (Horvath &Symonds, 1991; Lambert & Barley, 2001). Moreover, dimin-ished quality of therapeutic alliance is an oft-cited reason fornot utilising telepsychology options in practice and as one ofthe main therapist-reported reasons for lower satisfaction withits use.
Broadly, therapeutic alliance is described as the collaborative
and affective bond between a therapist and his/her patient(Martin, Garske, & Davis, 2000), and can include empathy,rapport, acceptance, warmth, client and provider expectationsand beliefs, as well as generic clinical communication skills.These factors are deemed to be present in all effective psycho-therapy interactions, regardless of the therapist’s theoretical ori-entation (Horvath & Luborsky, 1993).
Perceived Shortcomings of Telepsychology
For some time, research literature has reported that cliniciansoften have lower expectations about the use and value oftelepsychology. These complaints contrast with the experiencesof some clients who receive the service. There is now researchevidence to suggest that some clients prefer telepsychology overits face-to-face counterpart, and for telepsychology offeringadvantage for some special populations over face-to-face treat-ment (e.g., Boydell, Volpe, & Pignatiello, 2010; Dunstan &Tooth, 2012; Mitchell, Myers, Swan-Kremeier, & Wonderlich,2003; Richardson, 2011; Simpson, Bell, Knox, & Mitchell,2005). Given the consumer-driven immersion of technologyinto our broader lives, these clients are not outliers but a likelyexpanding subgroup of mental health consumers. Notably, thereare similar emerging findings for special population clients whoprefer computerised e-mental health distance approaches toface-to-face approaches (e.g., Klein & Cook, 2010; Waller &Gilbody, 2009).
In psychotherapy research, face-to-face delivery of psycho-
logical intervention is assumed, for the most part, to be the goldstandard (Richardson, 2011; Simpson & Reid, 2014a). Theassumption underpinning the high status of face-to-face inter-vention is that the relationship between practitioner and clientis best developed when each participant is within direct physicalproximity in the same physical space (May et al., 2001). Clini-cians have been reported as complaining that telepsychologyresults in reduced ability to observe body language, difficulty in
discerning the subtleties of non-verbal communication, andadditional concerns regarding privacy and confidentiality (forreview, see Castelnuovo, Gaggiolo, Manntovan, & Riva, 2003).Clinicians have also suggested that because of the artificiality ofthe transmission image and environment, engaging participantsis harder, communication is less spontaneous, and the potentialfor therapeutic alliance to be ruptured or underdeveloped isgreater (Austen & McGrath, 2006; Germain et al., 2010; Rees &Haythornthwaite, 2004; Rees & Stone, 2005). Some researcherssuggest that the technological necessity of discrete turn-takingduring a telepsychology session may force the clinical interac-tion to become more task-oriented, less spontaneous, and moremechanised (May et al., 2001; Miller, 2003; Wootton & Darkins,1997). However, others suggest that such a constraint maymake interactions more efficient and focused, and enhancecommunication (Dunstan & Tooth, 2012; Urness, 2003).
Studies investigating the optimal technical and environmen-
tal conditions in which to conduct telepsychology consultationshave consistently demonstrated that clinician’s complaintsabout the artificiality of sessions are not borne out. The condi-tions of “artificiality” of transmissions as a consequence of lowbandwidth, poor camera resolution, colour, picture, or sounddistortions, limited previous experience with the technology, ornegative expectations, appear not to impede the development oftherapeutic alliance, satisfaction with the service, the accuracyof assessments, the reliability of evaluations or the clinical out-comes for clients in emergency, clinical, or research consulta-tions (Cruz et al., 2004; Germain et al., 2010; Gros, Veronee,Strachan, Ruggiero, & Acierno, 2011; Hyler, Gangure, &Batchelder, 2005). Some studies have also reported that distrac-tion from the technology was so absent that clients and thera-pists both forgot they were not in the same room during therapy(e.g., Bouchard et al., 2004; Goetter et al., 2013; Porcari et al.,2009). Positive findings in relation to alliance and satisfactionwere also evident in our research and are described furtherbelow.
Our Study: The Impact of Technology on Alliance
and Satisfaction
Numerous telepsychology studies have attempted to evaluate
technical factors specific to the process of conducting transmit-ted communications, which may directly influence the devel-opment of therapeutic alliance and subsequent ratings ofsatisfaction by patients and providers (for reviews, see Glueck,2013; Richardson et al., 2009; Simpson & Reid 2014a).
One of the goals of this research was to determine if the
absence of interpersonal contact and physical presence precludedor impeded the development of telepresence (i.e., the sense ofbeing present in a mediated virtual environment; Lombard &Ditton, 2006), and the degree to which this impacted on thedevelopment of rapport or alliance, clinical outcomes, and con-sumer satisfaction. To answer such questions, our investigativetools emphasised the measurement of interpersonal and rela-tional characteristics in the therapeutic encounter, such as com-munication, practice accommodations, technique, clinical skills,and telepresence. Assessment of satisfaction included ease oftalking with the therapist, usefulness of the session, and degree ofL Richardson et al . Alliance in telepsychology
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influence over the session. Therapeutic alliance was also evalu-
ated in more detail than in previous studies by using the Agnewrelationship measure (client and therapist, ARM; Agnew-Davies,Stiles, Hardy, Barkham, & Shapiro, 1998) to consider therapist–client bond, partnership, confidence, openness, and client initia-tive as functional elements of a strong alliance. A person-centredresearch framework was also utilised (Reid, 2013) to ensure thatthe experience of both client and therapist became the primarypoint of the investigation rather than the technical aspects ofvideoconferencing.
At the time of our intervention, the telepsychology connec-
tions were made over a closed video system via IntegratedServices Digital Network at an average of 256 kbps, resulting inapproximately 80% quality of television broadcast. Numeroustechnical difficulties beset the therapeutic intervention transmis-sions, although fortunately these were intermittent and rarelylasted more than a minute or two. Technical problems includedminor picture pixellated and intermittent blurring; occasionalsound/picture synchronisation problems; complete brief sounddisconnections during two sessions for less than 2 min; ambientsound problems (e.g., trucks outside); issues with echoing thatwere addressed by reducing the volume of the speakers at bothsites; and adjustments to camera and microphone placement andfrequent sound cancellation when participants and the therapistspoke at the same time.
Over the 11 months of direct intervention, eight participants
(six women, two men), aged between 27 and 52 years, with arange of 7–14 years of schooling were seen for telepsychologypsychotherapy. Sixty-eight hours of direct videoconferencingtelepsychology was conducted (average 11.2 sessions per client)capturing 53 separate points of data for each client that includedthe perspectives of both the client and the therapist. Clientscompleted technical, process, and therapy-based satisfactionsurveys after each session, in addition to standardised clinicalsymptom ratings (see Richardson, 2011, for detailed descriptionof study methods). The ARM (Agnew-Davies et al., 1998) wasadministered after every session to assess therapeutic alliance.
Results
Clinical Effectiveness
All assessment results were collapsed across eight interventioncases, and scores on standardised questionnaire baseline meas-ures were compared with their matched follow-up measures.On all clinical symptom measures, seven out of the eight par-ticipants demonstrated reduced symptoms of depression andanxiety to non-clinical levels.
Therapeutic Alliance
On the ARM, baseline levels of alliance were high for the thera-pist, although slightly lower for the clients, which would beconsistent with what might be expected from clients in a newtherapy environment, compared with therapists’ experience inthis environment. Over the course of treatment, both the clientand therapist ratings of therapeutic alliance indicated strength-ening over time. Mean client alliance rating scores improved toa level of clinical significance; however, therapist ratings did not,and changed minimally, although positively, over the measure-
ment occurrences. Overall, the client ratings indicated anincrease in positive feelings towards the therapist, the workingrelationship, and the intervention generally.
In contrast, only the therapist’s ratings of openness (i.e., feel-
ings that the client was fully disclosing all thoughts, feelings,and concerns to the therapist) increased from the first to the lastsession. This change may have captured a genuine increase infeelings of trust and disclosure, or may simply represent thechange in level of familiarity that comes with months of therapysessions.
Satisfaction
This study’s satisfaction survey asked participants to rate theirsatisfaction with separate technical aspects of the telepsychologyexperience (i.e., picture clarity, sound clarity, distraction fromthe technology, comfort with use) and the therapeutic experi-ence (e.g., ease of talking with the therapist, usefulness of thesession, and degree of influence over the session), in addition toan overall rating of satisfaction with the telepsychology experi-ence and other environmental questions (e.g., backgroundcolours, clothing contrasts). For all items, participants rated on aLikert scale from 0 =poor quality to 4 =good quality (highest
number =most positive rating). Results indicated that partici-
pants found the sound issues described above to be minimallydisruptive (mean ratings for sound clarity =3.0/4), suggesting
that, despite the problems described above, clients were mini-mally affected and remained generally satisfied. Picture qualitywas rated marginally higher than sound across all sessions andacross all participants (mean picture quality rating =3.1/4). The
blurriness and pixellation, described above, are responsible forthese lower ratings.
The lowest mean satisfaction rating (3.0/4) was for picture
clarity and usefulness of the session; the highest was 3.8/4 forease of use of the technology and overall satisfaction. Thefigures also demonstrate small improvements in ratings fromfirst to last session in picture and sound clarity (e.g., 3.1–3.3 forsound). While this amount may not reflect a statistically signifi-cant improvement in technical quality, it does demonstrate thatparticipants respond to even small changes in a technical aspectof the environment. It is these small changes, which, when incombination with other issues (such as ease of use or satisfac-tion with the therapist), that can significantly alter overallratings of satisfaction.
Related to sound and picture quality, another item on the
satisfaction survey asked participants to what extent they weredistracted by the telepsychology technology. Figure 1 showsthat this item was consistently rated high (mean score 3.4, with0=extremely distracting and 4 =I don’t notice it at all ) Only one
participant comment specifically alluded to issues related to thetechnology being distracting: “I’m not sure why [I prefertelepsychology], it’s a bit surreal.”
Client Comments about Telepsychology
Notably, sound and picture quality did not seem salient toclients when considering satisfaction, as evidenced by very fewcomments being made by participants about these issues. Per-ceptions of satisfaction seemed more global. When given severalAlliance in telepsychology L Richardson et al .
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forced-choice questions, many chose telepsychology over tel-
ephone counselling, while there was a 50% split preference forface-to-face versus telepsychology. Comments included:
I prefer [videotherapy] to telephone counselling because you can
relate better to someone you can see.
Thank you . . .—it was great; the picture was a bit funny sometimes,
and the sound, but all-in-all, as beneficial as a one-on-one session.
telephone is definitely too impersonal, video is a good in-between,
face-to-face I find too confronting.
For all but one of the subjects, results from the satisfaction
survey and the comments suggested that as time went on sat-isfaction improved with all aspects of the telepsychology expe-rience. Of note is the acknowledgement by participants that thetechnology was not perfect, but that regardless they found valueand positive outcomes with the telepsychology experience. Itwould appear that the criticism that technology impacts nega-tively on therapy has been further undermined by the findingsin our research. Despite technical problems, participants intelepsychology are optimistic about the outcomes, tolerate thetechnical problems, and possibly become accustomed to theaccommodations that they have made during telepsychology, tosuch an extent that the impact on their overall satisfaction or onthe development of therapeutic alliance and subsequent clinicaloutcomes is negligible.
When Telepsychology Is Better Than Face-to-face:
A Client Example
In our study, at least one client experienced very positive ben-
efits of a reduced sense of “proximity” (both emotionally andphysically) between us. In the case of a 40-year-old man withdepression and social anxiety, the client was extremely anxiousand avoidant around women, and depressed as a result.Throughout the sessions, and in the satisfaction and allianceassessments, the client expressed his gratitude that he was notsharing a physical space with the female therapist, and that he
could not smell perfume or find any of the therapist’s fallenhairs on his clothes, as these would be potentially panic-triggering stimuli at worst, or distracting, at best. The clientfrequently noted that he was conscious of the physical distancebetween himself and the therapist during the telepsychologysession, but this perceived physical distance did not impede thedevelopment of good therapeutic rapport, which ultimatelyresulted in significant intimate disclosures and good clinicaloutcomes. The telepsychology “distance” allowed him to sharepersonal information with a female therapist when normally hewould not have been able to share a room with a woman. Thesessions provided opportunistic graded exposure conditions,and the client made consistently high ratings of alliance andsatisfaction over the treatment.
Taken together, these findings highlight how multifactorial
the assessment of satisfaction is. Despite frequent reports in theliterature about how consistently telepsychology is rated satis-factory by clinicians and clients, in reality numerous factors arebeing assessed by satisfaction surveys, and not all assessmentselucidate the source of that satisfaction.
Some Personal Observations
During this study, it became apparent that telepsychologywas a satisfactory way of interacting with most clients,although it occasionally felt different from a face-to-face inter-vention. For one participant, the therapist often felt uncom-fortable in the technological environment and struggled tomake adequate accommodations to the technological limita-tions of the medium from the first meeting to the last. Thisclient had been diagnosed with challenging personality traitsand lived in an unstable home environment, and the clientoften presented to the sessions in a new state of psychosocialcrisis. For each of the other study participants, there werevarious sessions during which the therapist felt acutely awareof the limitations of the telepsychology medium, and specu-lated whether that particular session might have workedbetter in a face-to-face environment. This feeling tended tooccur in sessions where there was high expressed emotion,complex countertransference reactions, high-risk disclosures,or when transfer of hard copy information between sites, suchas worksheets, diaries etc, was needed beyond that which hadbeen sent pre-session.
Given the significant improvement in technology hardware
and high-speed internet since that time, it is unlikely thatpresent or future clinicians will need to manage with suchlow-tech environments and their inherent shortcomings.Current research presages the likelihood that future usersof face-to-face psychology services may also receivetelepsychology interventions via Skype, home-based webcams,and “smart” mobile technology augmented by computer-mediated communications, such as email, text, chat application-based, and virtual interventions (Castelnuovo et al., 2003;Maheu et al., 2012). Although this study is small in sample size,and generalisability is limited by its reduced power, the conclu-sions are multilayered and triangulated, and are based on areal-life clinical population and service delivery framework, asopposed to a controlled laboratory model. Importantly, the00.511.522.533.544.5Mean ra/g415ngs 0–4 range
First session Final session
Figure 1 The Mean Results From the Client Satisfaction Survey
Sampled at the First Session and the Final Session, and Collapsed AcrossAll Participants.L Richardson et al . Alliance in telepsychology
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“less-than-ideal” technology and scenario reported in this study
were “state of the art” at their time. This further emphasises thevery positive nature of the outcomes that were obtained, despitethe presence of significant technological interruption and lack ofexposure to the technology, and contextualises the buildingblock achievements of the past into the evolving world of theyoung technological native, who embraces telepsychology andother telemental health approaches as natural adjunctiveplatforms for receiving remote mental health services(Duncan et al., 2014; Maheu et al., 2012). In other words, iftelepsychology worked well in the disadvantaged environmentsof the recent past, it is likely to work better in the enrichedtechnological worlds of the present and future.
Less than a decade ago, technology hardware, software, and
transmission costs were significant barriers, and large organisa-tions, like government public health departments and universi-ties, were the main providers and users of the technology. Thesebarriers have been supplanted by organisation and discipline/clinician-based barriers, such as organisational attitude,reimbursement, referral pathways, multidisciplinary and multi-service collaboration, and client ownership (Castelnuovo et al.,2003), and now individuals have their own access tovideoconference networks, as well as a myriad of e-mentalhealth services.
In the future, with greater user exposure, targeted training,
adequate reimbursement structures, robust encryption and datasecurity frameworks, and more consumer-driven streamlinedintegration of multiplatform and home-based interactive tech-nology (e.g., Skype and other application-based communicationtools, “smart” mobile biofeedback monitoring, cloud computingand virtual worlds), the increased technoliteracy of both clini-cians and clients (Duncan et al., 2014) is likely to minimise thedegree of psychological distance experienced, such that con-cerns regarding the quality of therapeutic engagement aresilenced. Our hope is that contemporary distance therapists, nolonger fearful of the erosion of their role as specialty providers oftherapy and assessment skills, will embrace these augmentativetechnologies as de rigueur in their practice, and may view tradi-
tional two-chair/single room practices as quaint, althoughsomewhat under-resourced. Perhaps with the appropriate train-ing, data security, and professional practice safeguards in place,government departments and universities that once providedthe expensive technology infrastructure may come to supportapp-based or Skype-delivered clinical services, and can focustheir efforts back to training the providers and providing goodclient-centred health care.
As the literature attests, telepsychology does create chal-
lenges for the practitioner and the client; however, these chal-lenges appear to be overcome with preparation, flexibility, andtime. Moreover, one need not assume that all clients prefer, orbenefit from, a face-to-face intervention every time. In somecircumstances, the distancing provided by the telepsychologymedium can also offer a sense of safety and sanctuary forclients who are dealing with shame-based issues and may alsobe facilitative of better clinical and process outcomes for par-ticular client groups (Richardson, 2011; Simpson, 2009;Simpson & Reid, 2014a).
This research indicated that the same issues surrounding the
development and maintenance of client–therapist relationshipexist in telepsychology as they do in traditional forms of
therapy. The therapeutic relationship can be challenged by thetechnological constraints of telepsychology, but the process of“reaching out” through the telepsychology medium, of “goingthe extra mile,” to provide a service for isolated clients, andproblem-solve collaboratively through the technical glitches,can also be a very bonding experience for practitioner andclient. Furthermore, working out both the technological processas well as the therapeutic process is bidirectional and makesboth parties more committed to the sessions and being “in ittogether.” We would argue that the client is also “going theextra mile” to work in this way. Consequently, we should notunderestimate the power of choice in change—if clients make acommitment to the process of therapy (made more explicitbecause of choosing to continue with telepsychology sessionsdespite challenges), they are more likely to commit to personalchange and succeed in their efforts. While the clinician who usesthe technology to conduct psychotherapeutic interventions mayalways be conscious of being separated from their clients by aphysical distance, they will feel less separated by the emotionaldistance, which tends to feel similar to that in face-to-facetherapy. Accordingly, telepsychology feels different to a typicalface-to-face therapy session, but does not necessarily feel betteror worse.
Conclusion
Ultimately, telepsychology users benefit from remembering thatall new psychotherapy techniques need practice and familiari-sation, and that these techniques remain a dynamic part of atherapist’s intervention repertoire. The assumption that newtechniques can function the same as currently existingapproaches, or that they should not require dynamic reworkingof their implementation as their use becomes mainstream, isnaive and, potentially, ethically irresponsible. Thus, the previ-ously documented “criticism” that telepsychology requireschanges to usual practice is borne out by the findings of thisstudy; however, this change has neither an inherently negativenor positive connotation. A more accurate understanding of thesituation might be that the clinicians who persevere with thetechnology long enough to feel confident to accommodate to itand capitalise on its strengths are satisfied with it. When there isa mismatch between the intervention approach, the client, andthe technology, they become dissatisfied. If telepsychology is nottreated apologetically or defensively, like face-to-face therapy’s“poor cousin,” it can achieve positive therapeutic results.Encouragingly, it would seem that by staying in our offices andpushing our experiential limits, by “going the extra digital mile,”
we can be clinically effective and powerfully motivating for ourclients and ourselves.
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