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Australia is a world leader in the integration of digital technologies into psychological care and practice. These technologies have the capacity to enhance existing face-to-face therapies and to increase access to services and reduce the unmet need for mental health interventions, particularly in rural and remote regions. The use of videoconferencing technologies to deliver psychotherapy (VCP) via telehealth services is one such example.

Videoconferencing technologies allow a therapist and client based in different locations to use synchronous sound and vision to engage in psychological services. These services enable delivery of treatment to individuals who may otherwise be unable to access psychological services due to a lack of available providers, transportation or other logistical difficulties, or because of difficulties arising from their mental or physical health conditions. In early applications clients typically accessed VCP through shared devices at specialised clinics within their community. However, more recent technological advances mean VCP can be delivered direct to the client’s home via their personal devices. For example, within the Queensland public health system a telehealth strategy is providing individuals with chronic back pain living outside of the Brisbane metropolitan area the opportunity to access psychological support services. Since the inclusion of rebates for VCP in the Australian Government’s Better Access to Mental Health Care (Better Access) initiative in November 2017, psychologists in private and non-government settings can also use VCP to extend the reach of their psychological services. Furthermore, the recent removal of the requirement for a portion of sessions to be face-to-face will no doubt further increase access and use of VCP.

Efficacy of VCP

VCP is well supported in terms of efficacy (Mohr, Burns, Schueller, Clarke, & Klinkman, 2013). A systematic review (Backhaus et al., 2012) of 42 empirical studies found that VCP interventions had similar outcomes to traditional face-to-face psychotherapy. Across these studies, VCP was delivered in a range of formats (individual, group and family therapy), utilising a range of therapeutic approaches (e.g., cognitive behavioural, family systems, eclectic), to a variety of client populations (e.g., child/adult, gender, ethnic background), and for diverse client difficulties (e.g., trauma, mood, anxiety). In a recent non-inferiority meta-analysis, 12 VCP studies met inclusion criteria, with VCP demonstrating non-inferiority to traditional face-to-face psychotherapy services (Norwood, Moghaddam, Malins, & Sabin-Farrell, 2018).

All 42 studies reviewed by Backhaus et al. (2012) found VCP to be a feasible delivery method that was associated with successful expression and interpretation of emotions via the technology. Clients reported high satisfaction with the services, and for those studies that compared VCP to face-to-face services, similar satisfaction levels were observed between conditions. When dissatisfaction was reported by clients, this primarily related to technical difficulties associated with the technologies, although these difficulties did not impact overall levels of satisfaction with treatment. These findings support VCP as a valuable tool for psychologists in the delivery of efficacious and evidence-based treatments that increase client choice and access to healthcare.

“These findings support VCP as a valuable tool for psychologists in the delivery of efficacious and evidence-based treatments that increase client choice and access to healthcare”

What about the working alliance?

A review of 23 studies indicated that a working alliance can be developed effectively within the remote modality (Simpson & Reid, 2014). In particular, client ratings of bond and presence were at least as high in VCP as in face-to-face settings. Therapist ratings of the working alliance, however, were lower for VCP than for face-to-face. This would suggest that therapists may perceive or have concerns regarding the impact of technology that are not shared by clients.

VCP may also offer advantages for some specific client groups (Simpson & Reid, 2014). In particular, clients may feel safer and more able to communicate via the remote technologies, with reports of reduced shame and self-consciousness in discussing difficulties. Some studies have also found that VCP may enhance communication, by slowing interactions and placing greater focus on techniques such as turn-taking, social cues and signs of emotionality. As such, the evidence suggests that VCP offers a suitable medium to enable therapists to give the therapeutic alliance the same amount of attention and focus as in traditional psychotherapy.

Exploring the practicalities

Better Access telehealth services can now be delivered to eligible clients living in regional and remote locations (Modified Monash Model [MMM] regions four to seven). Clients meeting eligibility requirements can now receive up to 10 mental health treatment sessions (individual or group) via VCP. Detailed information about the Better Access telehealth items, including eligibility and approved services can be found on the Australian Psychological Society (APS) website (bit.ly/2HTiAsF).

To engage in VCP, the practitioner and client (or community facility where the client will be engaging in VCP) will need appropriate technological equipment including:

• an internet enabled computer, device (e.g., tablet or smartphone); or
• videoconferencing machine
• audio input (microphone)
• audio output (speakers or headphones)
• webcam or camera
• a reliable internet connection; and
• videoconferencing software (e.g., Zoom, which provides end-to-end encryption for data security and is promoted as facilitating practitioner compliance with the Health Insurance Portability and Accountability Act in the United States).

Tips and tricks

Providing effective VCP may require some subtle shifts away from the psychologist’s face-to-face psychotherapy comfort zone. Psychologists entering this area need to prioritise self-awareness of how their usual therapeutic skills translate across technology. Developing a library of online resources and electronic versions of worksheets that can be exchanged with clients is helpful. VCP can also be augmented by the use of digital programs, some of which allow psychologists to access client progress (see “Head to Health” over the page). Other adjustments involve more fundamental changes, such as the use of empathic micro-counselling skills, which need to be accentuated so that nonverbal gestures and verbal encouragers are rendered easily noticeable by clients even on low quality connections. Even so, poor connections can lead to misaligned audio and video resulting in periods of silence where an encourager would normally be heard in face-to-face therapy, presenting potential for small empathic failures. Deliberate use of more selective responses that are simpler (uh-huh, yes vs brief paraphrase) and more explicit (nodding vs reliance on facial expression) can assist.

Overall, psychologists need to maintain awareness of the current flow of communication by checking in with the client and monitoring their own reactions (e.g., frustration). Engaging the client in meta-communication about VCP and judicious self-disclosure about the clinician’s experience of technology issues can be brought into the therapy as an alliance building strategy. Setting up early contingency plans for technology interruptions will make this in-session response easier. In addition, developing a handout for the client to receive prior to commencing VCP is beneficial, especially sending out a hard copy in case of a complete technology failure. Awareness and planning around the use of VCP in this way is not only of benefit for client-centred and ethical practice, but also to improve the practitioner’s acceptance and confidence in providing VCP.

A note on ethics

A number of ethical issues need to be considered when implementing digital technologies in psychological practice. Concerns have been raised that for asynchronous technologies in particular (e.g., email), difficulties may arise in managing client crises and risk. However, there is no evidence that risk increases when using synchronous technologies such as videoconferencing or telephone counselling. Indeed, risk management strategies may be somewhat similar to those in face-to-face psychotherapy, as outside of the therapy session, management is likely to occur at a distance even for traditional services (Mohr et al., 2013).

Issues of privacy and data security also need to be considered when engaging in VCP. In particular, psychologists must ensure they practice in accordance with the privacy and legal requirements (e.g., mandatory reporting) for the jurisdictions in which services are both provided and received. For example, if a Queensland-based practitioner delivers services to a client residing in the Northern Territory, the practitioner must practice in accordance with both state’s laws and requirements. In addition, it is the responsibility of the psychologist to demonstrate that reasonable steps have been taken to ensure that VCP technologies meet privacy obligations. As part of informed consent procedures, the possibility of potential electronic security breaches should be discussed with VCP clients, as well as strategies clients may employ to secure their own devices and connection. Psychologists should also take reasonable steps to secure data, such as using separate devices for business and personal use, keeping security software up-to-date and encrypting personal data.

Where can I access more information or support?

The APS provides useful information regarding VCP at the link provided earlier, including tips for ensuring security of devices and data, determining whether a client is appropriate for VCP, establishing a working alliance via VCP, establishing risk management protocols, and organisational considerations. The MMM regional locator can help you to determine whether a client resides in MMM regions 4 to 7 (bit.ly/2QptgPf).

Psychologists can access training and support through the government funded e-mental health in practice initiative, which provides online and in person training on a variety of technologies in mental health practice, including VCP (www.emhprac.org.au). The Australian Government’s digital mental health gateway, Head to Health, provides resources for clients and practitioners on using digital technologies in practice (https://headtohealth.gov.au).

Finally, if you would like to be connected with a group of practitioners who are interested in the use of technologies in practice, you can also join the APS’s ePsychology Interest Group (https://groups.psychology.org.au/eIG). The group aims to provide members with updates on advances in the field, as well as a space for discussion of the practical application of technologies.

The first author can be contacted at [email protected]