Evidence
Alert

Therapists and patients have good quality interactions during telephone sessions

The quality of interactions between therapists and their patients is as good by telephone as in face-to-face sessions. A review of the evidence found little difference in the interaction regardless of how therapy was delivered. Telephone sessions were shorter but measures such as empathy and attentiveness, as well as patients’ readiness to disclose information, was similar in both settings. 

Traditionally, psychological therapy is delivered face-to-face but increasingly it is delivered in new formats including by telephone, video and online. There is already evidence, from clinical trials and observational evaluations, that telephone therapy is as successful as face-to-face treatment in treating mild to moderate mental health problems. Despite this, both therapists and patients remain concerned about the use of telephone therapy. 

With recent policy moves to increase the amount of therapy offered by telephone, as well as the current restrictions placed on therapists and patients due to the COVID-19 pandemic, the findings of this review could provide reassurance that this form of therapy does not hinder the relationship between therapist and patient.

What’s the issue?

Educational materials tend to focus on face to face interactions. Therapists often claim that a lack of visual cues in telephone-based therapy sessions may be detrimental to their interaction with patients. There is little evidence to support this belief. 

Telephone-delivered psychological interventions are recommended by the National Institute of Health and Care Excellence (NICE) for the treatment of anxiety and depression. Reviews of previous scientific studies show that telephone and face-to-face therapy have comparable benefits for depression in primary care. 

The NHS now offers a service called Improving Access to Psychological Therapy (IAPT) for people with depression and anxiety. Many sessions are carried out by telephone in line with NICE guidelines. This service is valuable, but many therapists say they do not feel they have adequate training in working over the phone. 

What’s new?

This study was part of a larger project, Enhancing the Quality of Psychological Interventions Delivered by Telephone (EQUITy), which is designed to support the improvement of psychotherapy delivered by telephone. In light of the COVID-19 pandemic, the design of the study is being enhanced to ensure findings are made available quickly. 

The researchers searched databases for papers comparing telephone-delivered and face-to-face therapy for mental health problems. They carried out a systematic review of 15 papers which focused on the interaction between therapist and patient. 

Telephone sessions were shorter than face-to-face therapy, but there was no evidence of differences in the way therapists and patients rated their interactions, the amount of information a patient disclosed, empathy, attentiveness or participation. 

One study found introverted individuals were more likely to discuss their emotions by telephone than when face-to-face. The researchers said this demonstrated one area where there could be potential benefits to therapy delivered via telephone, at least for some groups. 

Why is this important?

Telephone-based psychological therapy for anxiety and depression already forms part of clinical guidelines in the UK. Even prior to the current COVID-19 pandemic, a growing proportion of psychological therapy was being delivered by telephone and other remote methods. This study supports the case for telephone treatment being both acceptable and effective. The implications are less about changing guidelines and more about making patients and practitioners feel confident that they can achieve all the core ingredients of a good psychological therapy session on the telephone. 

Many patients and therapists have been forced to switch to telephone-based therapy due to the restrictions imposed during the pandemic. But telephone psychological therapy will continue to have an important role even when lockdown ends. There are many other reasons why people can find the telephone better suited to their needs, such as issues with mobility, caring responsibilities, or living in rural areas.

What’s next?

The research itself demonstrated a lack of studies that directly compare telephone and face-to-face therapy. More studies comparing different types of therapy such as cognitive behavioural therapy (CBT) and psychoanalysis are needed. It will also be important to look at different patient groups.  

Video therapy was not included in this review but could be an important area for further study as more people are using video tools for therapy during the COVID-19 pandemic. 

You may be interested to read

The full paper: Irvine A, and others. Are there interactional differences between telephone and face-to-face psychological therapy? A systematic review of comparative studies. J Affect 2020;265:120-131

The EQUITy programme project page, by the University of Manchester, which includes practical suggestions on delivering telephone therapy for practitioners

Related paper by the same group: Rushton K, and others.  A case of misalignment: the perspectives of local and national decision-makers on the implementation of psychological treatment by telephone in the Improving Access to Psychological Therapies ServiceBMC Health Service Res. 2019;19:997

Related paper by the same group: Rushton K, and others. ‘I didn’t know what to expect’: Exploring patient perspectives to identify targets for change to improve telephone-delivered psychological interventions. BMC Psychiatry 2020;20:156

Hammond GC, and others. Comparative effectiveness of cognitive therapies delivered face-to-face or over the telephone: An observational study using propensity methods. PLoS ONE 2012;7:e42916.

Conflict of interest

The authors declare no conflicts of interest.

Funding

This research is part of the Enhancing the Quality of Psychological Interventions Delivered by Telephone (EQUITy) study, a project funded by the NIHR Programme Grants for Applied Research NIHR Programme

Commentaries

Study author

The results were interesting and ran counter to common perceptions that alliance and rapport are more difficult to achieve over the phone. What I find most thought-provoking and challenging is how we unpick the matter of people nevertheless feeling that interactions are somehow different – and perhaps compromised – over the phone; these feelings are still important because they have implications for patient and practitioner uptake and engagement, without which opportunities for clinical success are hindered.

Annie Irvine, Research Associate, University of York

Therapist

I was previously reluctant to offer interventions by telephone, partly because during my training consultations were all face to face. I also thought that telephone-based interventions were being actively promoted due to a lack of resources and rooms.

With the COVID-19 pandemic, we suddenly had no choice but to work via the telephone and I am surprised by how similar it is to working face to face. I have made some changes to my practice. I always explain that I am in a quiet space at home and that I am alone, and I ask about a client’s environment. One advantage has been that I can make a brief note of the exact words they use or the name of a friend or child they mention. I would never stop to write when I am working face to face and I may not retain that level of information. I have found that having these details helps to build rapport when I am reflecting back difficulties or changes.

I have no doubt that I will continue to offer telephone therapy after the pandemic is over. In my experience, it has not been inferior at all. It will help make our service accessible to people at work, those who cannot afford to travel, or postnatal mums who have a baby with them. People like this might choose not to have treatment if they had to come to my office.

Kerry Ardern, Psychological Wellbeing Practitioner, Sheffield