Is therapy delivered by phone effective? Is it even therapy? How does using the phone as a medium impact on factors such as therapeutic alliance, disclosure, empathy, attentiveness and participation? A recent study has looked at this area, and its results might surprise you.
Poll a hundred therapists, and the chances are that you’ll get a wide range of opinion and attitude about and towards the idea of providing therapy by phone. At one end will be those who are well disposed to the idea and may have been doing it for years. At the other will be those who question whether it’s possible to do effective work without eyeballs on the client, and therefore the word ‘therapy’ needs quote marks either side.
On the Believer – Agnostic – Atheist spectrum, I am a believer, but I didn’t start there. I was agnostic at best, but circumstances at a particular point in my professional career left me with few choices.
A question of expediency
Back in the day, when I managed the counselling service at the Royal College of Nursing, I faced a seemingly impossible challenge as a new manager. How was I, with a staff complement that then numbered around four WTE, to provide a counselling service with national reach to the college’s 300,000 plus members?
Short of cloning, there was no possibility that we might (even with additional staff) provide a comprehensive service across the RCN’s 17 or so regional and national offices. Even were we able to, travel to their nearest office would have been impractical for many if not most of our members.
I concluded that the only viable option was to provide a mix of face-to-face and telephone-based work, and keep my fingers crossed that the latter wouldn’t prove to be a low-rent version of the former. So, in 1995, that’s what we did. The rest is history, but I will say more in a moment about what our evaluation of their relative effectiveness found.
How does the medium affect the process of therapy?
I think it’s safe to say that we were early pioneers of phone counselling at the RCN. Having worked this way for the best part of 25 years, I’ve heard of lot of opinions about it, some more favourable than others. The notion that without being able to see visual cues afforded by face-to-face work the quality of our interaction suffers, is a very common one.
Given my background then, I was intrigued when I came across a recent paper exploring the interactional differences between telephone and face-to-face psychological therapy. Conducted as a systematic review of comparative studies, it set out to answer the following research question:
What is known, empirically, about differences in interactional features of psychotherapeutic encounters conducted face-to-face vs. by telephone?
The authors were interested in the process features of therapeutic interactions, rather than their outcomes. They looked at a range of interactional variables, some of which we know from research to underpin the foundations of effective therapy. These variables were grouped into six over-arching headings:
The duration of sessions
Therapeutic alliance
Client disclosure
Empathy
Attentiveness
Client participation
The review identified 15 studies that used comparative approaches to explore these interactional aspects of telephone and face to face therapy. Not all studies examined each of the six variables, but together there was sufficient material to draw conclusions.
What are the differences between phone and face to face therapy?
First, two headlines.
The outcomes of both phone and face-to-face based interventions are broadly comparable. While the study did not set out to study outcomes specifically, the literature review led the authors to conclude the following:
“Evidence from both trial and service settings suggests that telephone-delivered psychological therapy leads to symptom improvement for subthreshold depression, mild to moderate depression and anxiety, and Obsessive Compulsive Disorder, and that similar clinical outcomes can be achieved via the telephone as are obtained in face-to-face intervention.”
The review found no evidence of significant differences between the modes for any of the variables save for, wait for it………the duration of sessions. Any differences between the modes for the other variables were non-significant. Even as a believer in phone-based therapy, the lack of significance surprised me.
Here is a brief flavour of the detail for each of the variables.
The duration of sessions
The seven studies which recorded session duration consistently found that telephone sessions were shorter than those delivered face-to-face, with three reporting statistically significant differences between the two modes.
Therapeutic alliance
Five studies considered patient and/or therapist ratings of therapeutic alliance across telephone and face-to-face therapy sessions, using versions of the Working Alliance Inventory (WAI). They included two in which clients were randomised to one or other intervention.
A meta-analysis on the data from the studies found (perhaps contrary to expectation) better ratings for phone interventions, though the differences did not reach the level of significance.
Client disclosure
For the purposes of the review, the term ‘client disclosure’ encompassed the revelation of personal or sensitive information by the client; client self-exploration; enabling the client to discuss personally relevant material in specific and concrete terms, and the extent to which the client talked about affective feelings during sessions.
No significant differences were found between the two modes, although in one study, a post-intervention questionnaire revealed that 78% of clients felt their self-exploration was better facilitated in the face-to-face mode. Conversely, introverted clients were found to be significantly more inclined to reveal feelings in telephone interviews than in face-to-face encounters.
Empathy
Two studies used third-party ratings of therapists’ empathy for phone vs. face-to-face modes. Neither reported findings of significance between the two. Interestingly, however, in one of those studies therapists reported feelings of inferiority or inadequacy of the phone mode, suggesting they needed more visual cues from seeing the client.
Attentiveness
Two studies explored how well the therapists listened or attended, both using client ratings. One found no significant differences between the modes on how well clients perceived their therapist had listened.
The other used a composite measure to capture how much their therapist listened to them, how caring the therapist was, and how much the client liked their therapist. This measure received significantly higher ratings from clients receiving telephone-based interventions.
Client participation
Two studies considered clients’ degree of participation in the therapy session. One, which used a single item question, found no difference between the modes on either client or therapist-reported participation. The other, using a scale which rated clients’ activity level, initiative, trust, spontaneity and disinhibition found that clients participated significantly more actively in both video and audio modes than in face-to-face work.
Making sense of the findings
I am not in the slightest bit surprised by the findings from research that the outcomes of the two modes are comparable. We came to the same conclusion at the RCN when evaluating the relative effectiveness of our phone and face-to-face offerings.
Our experience at the RCN also showed, however, that not all members of the team were equally comfortable with both modes. Some showed a much stronger preference for one over the other. Especially if we’ve been used to working face-to-face, starting to deliver therapy by phone and other alternative modes takes us out of our comfort zones.
It’s very easy to imagine (assuming of course that we are sighted) not having the client sat in front of us and feeling that we will be deprived of vital cues, without thinking about what else might occupy that space.
But would we assume that the outcomes of blind and partially sighted colleagues are inferior to those of us who are sighted? I sincerely hope not.
I think this imagined deficit becomes a story that we tell ourselves, based on what we are familiar with in terms of our therapeutic ‘bandwidth’. In my experience bandwidth doesn’t shrink, however, it merely adjusts. I know I listen differently when I’m working on the phone with a client. Most of the time my eyes will be closed. I will pick up things I would probably miss in a face-to-face session. My bandwidth, however, remains the same.
Therapy delivered by phone isn’t for everyone, however, and I wouldn’t dream of forcing anyone down that route. If you don’t believe in it, it’s not going to work. Moreover, it will become a self-fulfilling and self-reinforcing prophesy.
But is it therapy? For my money, if it looks like therapy, it smells like therapy, and it achieves comparable outcomes, then I guess it must be therapy.
What’s your experience? If you have no experience of phone-based work, are there any thoughts, beliefs, or even ancient prejudices you’d care to share?
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Interesting. I had to deliver telephone counselling before it was a thing many years ago too: the client didn’t have a home phone, and at his end therapy was received in a phone box (and occasionally with rather irate people outside waiting!) He couldn’t afford the travelling expenses to and from the office I worked at every time.
I always used to ask, and he always said it worked for him – usually with a surprised tone.
Lots of other cases too.
Very well-timed at the moment. I think I’ll be having sessions with a number of clients either on the phone or using a secure online portal like VSee over the coming weeks.
Thanks David. I love your tale about the phone box. It shows what’s possible when the need arises. Feels like a reframe of the old saying about the location of church? Where two or more shall come together in the name of therapy……? Cheers! Barry
Interesting and timely article, thanks.
In my experience, therapy over the phone can go just as well, and produce just as favourable outcomes, as working face to face. Admittedly, this has been when phone has been the client’s preferred (or only viable) channel so they’ve come to it pretty willingly and, presumably, without major concerns that it’ll be a barrier to effective work.
In the current corona-circumstanes, it may be we end up working over video call or phone with clients who see these channels as second or third best – in which case, this could present problems for the therapy. No doubt we’ll learn a lot more about this in the next couple of months.
Hi Paul and I really appreciate your post. As you say, with the current coronavirus situation we may be left with little choice for a period but to work differently. Your comment about the client’s preferred channel puts me in mind of how clear evidence is for the impact of client preferences on outcomes. As you say, no doubt we’ll learn more soon!
Thanks again, Barry
Thank you Barry for this synopsis of research comparing face to face and telephone counselling.
I have been working with RCN Direct telephone counselling service for past 9 months. I have been pleasantly surprised at how effective telephone counselling can be and how I have adapted to this mode. The contract and structure of the RCN counselling service in offering brief therapy really enhances the whole process. Core results and client feedback have indicated a high level of effectiveness in helping clients achieve their goals.
Having worked face to face and longer term for most of my career I note that client self exploration 78% better in face to face is noted.
I realise my “bandwidth” too has adjusted as I’m learning to be present and listen intently, without the visual non verbals.
As a former nurse myself and given the current pandemic crisis it is a privilege to work in this area.
Hi Marie and great to hear from you. I’m so pleased that you and the RCN are still championing the phone as a means of delivering effective therapy to those that in other circumstances just might not, or not be able, to access it.
Keep up the great work!
Barry