Staying connected: Telehealth and the therapeutic relationship

As the number of providers forced to shift from face-to-face care to conducting sessions remotely continues to increase, a number of practice-specific experiences related to telehealth have emerged as hot topics in the conversation about mental healthcare.

Providers and patients alike have questions about what this shift means for treatment, particularly in regard to how changing mediums will impact communication and the therapeutic relationship. At a time of unprecedented and rapidly growing use of telehealth, a recent review published in the Journal of Affective Disorders offers timely insight into this topic of building and sustaining therapeutic relationships at a distance.

The systematic review compares modes of therapy, specifically regarding changes in provider-patient communication when care takes place over the phone. Researchers focused primarily on differences in the process features of therapeutic encounters, rather than treatment outcomes. Specifically, the review examined six areas or themes of interaction: duration, alliance, disclosure (which included openness, revealing of sensitive information, self-exploration, counsellor concreteness, and affective self-reference), empathy, attentiveness (operationalized both as how closely therapists listened and how much therapists cared/listened), and participation.

What they found - or really, what they didn’t - may come as a surprise.

Telephone sessions were consistently shorter than ones held in person, which is not surprising given therapist perceptions of time management during phone sessions. More specifically, therapists reported that phone sessions were more structured and on task, and found it easier to stick to time boundaries when conducting sessions over the phone. This experience resulted in overall shorter sessions when conducted via telephone compared to face-to-face.

More importantly, the review found no additional support of differences in any other areas of provider-patient interaction. All other interactional factors - alliance, disclosure, empathy, attentiveness, and participation - had no evidence of differences between phone and in-person sessions. This result is particularly interesting when considering how common concern over relationship factors being affected by telehealth services is among practicing clinicians. These results provide hope and validation that a strong therapeutic alliance can indeed persist despite the remote nature of telehealth services. Nevertheless, many therapists remain ambivalent about conducting sessions over the phone.

Why might this be?

The review notes that provider belief regarding the importance of visual cues may be over-inflated. Incorporation of video into telehealth may be sufficient to address any noteworthy visual cues that come up during session. At the same time, this report offers some reassurance for providers worried about connecting with patients as effectively as before. Therapeutic relationships, it seems, are not limited by distance or channel. In fact, providers may even find that remote sessions feel more focused! While telehealth doesn’t limit connection, it may be the case that new tools for communication open up new possibilities. For example, advances in remote patient monitoring and related asynchronous communication tools may enable a new form of patient-provider communication that had not been accessible to date. Both providers and patients can benefit from efforts to identify and capitalize on these technological advances, especially during this newfound telehealth era.

In this way, perhaps the most significant issue raised by the review is the contradiction between evidence and experience - i.e. therapists’ ambivalence about telehealth. While these findings can help to assuage fears that something may be lost in the shift to remote therapy, mental healthcare providers will need to address their role in mediating patient openness these new modes of communication. Education and enthusiasm on the part of the provider will support effective implementation of these changes. It will be important that patients and providers alike are supported in the shift to telehealth. Luckily, as the field of mental healthcare technology develops, there are more options than ever that can support remote communication. Much has been said about the efficacy of measurement-based care - in-person or remote - and integrating mental health technologies into practice can support both providers and patients.

The conditions that have led to the current expansion of telehealth are less than ideal, but just as these challenges push (or force) individuals and society to adopt behaviors that support public health, they give the field of mental health greater impetus to adopt practices in ways that support mental wellness for all. The therapeutic relationship is vital to treatment, and even if the use of telehealth is temporary, each provider has an opportunity to redefine and refine their practice during these trying times.