The year 2020 has seen a dramatic change in the delivery of mental health services. COVID-19 has forced governments to implement rules for social distancing, resulting in rapid adoption of technologies to enable remote provision of care (Zhou et al, 2020). Faced with sudden change and little choice, few organisations have had time to think about the impact these changes have had on the quality of care, and as the adjustment unfolds, we must consider what these changes mean for the ‘new normal’ (Torous et al, 2020).
Telehealth has been the main technology adopted in clinical services as a result of COVID-19 (Zhou et al, 2020). This constitutes the use of technologies such as the telephone, videoconferencing or smartphones as a medium for clinical care. Videoconferencing and telephone support have been the primary medium adopted. Whilst technologies have much more to offer than these relatively archaic options (Torous et al, 2020), their readiness for use and familiarity amongst users made them an obvious choice for efficient adaptation of services.
Research has shown that clinicians share concerns about telehealth (Lattie et al, 2020; Turner et al, 2018). Many fear that the quality of care may be negatively impacted, and questions have been raised about whether the therapeutic relationship could be established without face-to-face contact. Such concerns must be respected and explored, ensuring that new technologies are supported by strong research evidence. In addressing these important questions, the authors of this article conducted a systematic review to determine “what is known, empirically, about differences in interactional features of psychotherapeutic encounters conducted face-to-face versus by telephone”.
Specifically, their objectives were to:
- Identify the range of comparative empirical research on interactional differences between telephone and face-to-face psychological therapy, and
- Explore the implications of this evidence base for psychological therapy practice, professional training and further research.
Following the PRISMA statement (Moher et al, 2015), one of the reviewers conducted an article search in April-May 2018, using terms related to telephone and psychological therapy, across a number of scientific databases. Using search alerts, they also identified new articles published after this date.
Study inclusion and exclusion criteria
Studies were included in the review if they:
- Empirically compared telephone and face-to-face therapy modes
- Focused on interactional features of the therapeutic encounter
- Included mental health problems as the focus of the psychological therapy
Studies were excluded in the review if they:
- Included only a single group without comparison to face-to-face therapy
- Were a retrospective interview or survey-based study
- Were not primary research (e.g. practitioner reflections, topic overviews, practice manuals/guides)
- Reported only non-interactional features (e.g. clinical outcomes, cost effectiveness, attrition)
- Focused on something other than mental health as the primary focus of the therapy (e.g. cancer, HIV/AIDS, infertility, smoking cessation)
The authors were interested in understanding differences in the processes involved in therapeutic interaction between face-to-face and telephone therapy, not the clinical outcomes. A single author identified studies for inclusion and extracted the relevant information, and a second author checked a proportion of these.
Study quality assessment
The quality of studies was evaluated by a set of criteria designed by the authors to accommodate variability in the types of studies included. The domains evaluated were:
- Strength of experimental design
- Validity and reliability of outcome assessment
- Representativeness of the sample.
One of the authors then extracted the information from the studies using a spreadsheet and this was checked subsequently by another author. Meta-analysis, a method of combining and analysing results across multiple studies with similar methodology, was used were possible.
The final results and interpretation were presented to a Lived Experience Advisory Panel, and the authors state that their reflections were incorporated into the article.
The authors identified 15 studies that met the inclusion criteria, including 8 experimental studies, and 7 observational studies of which 5 compared face-to-face and telephone therapy within the one sample and 2 compared different groups. Seven of the studies involved cognitive behavioural therapy, 7 focused on generic counselling and 1 on solution focused therapy.
Six studies were conducted in a clinical setting with individuals with a mental disorder diagnosis and 11 outside of a clinical setting with individuals with mental health difficulties but no confirmed diagnosis.
Comparison between telephone and face-to-face therapy
The authors examined the comparisons between studies in terms of several variables centring on the nature of the interaction between therapist and client: duration, alliance, disclosure, empathy, attentiveness and participation.
The findings are examined in detail within text and also summarised clearly within a table, included below.
Based on the evidence from the fifteen studies included in the review, the authors concluded that there was minimal to no difference between telephone and face-to-face therapy in terms of the nature of the interaction between the therapist and client.
Strengths and limitations
This is an interesting and timely review that provides important insights about how technology-delivered therapy compares to standard face-to-face therapy.
There were a good number of studies identified in this review and they were restricted to mainly high quality, experimental studies that can give us confidence that the findings are accurate. The search approach was well designed, covering a range of relevant databases to find relevant studies and having clearly operationalised criteria to decide what studies to include. The presentation of the results is clear and thoughtfully summarised, particularly given the nature of the review is somewhat different to regular systematic reviews that compare clinical outcomes, making it more challenging to synthesise the findings. It is great that the authors incorporated lived experience perspectives, though it is a bit unclear how this was achieved.
The review does have some limitations, as they all do. Firstly, the review is somewhat old, with the primary search conducted in 2018. Whilst search alerts were set since this time (a strength), these are not the same as re-running the search prior to submission, as is common practice. Whilst no fault of the authors, the variability in outcomes reported by the studies made synthesis challenging. Also, many of these were not validated scales, questioning reliability and validity. This meant that some of the domains of interaction only had one study, highlighting a need for further replication.
Implications for practice
Those working in clinical settings should be assured by the findings of this review and have some confidence that telephone-delivered psychological therapy does not appear to reduce therapeutic rapport. It is curious that the telephone sessions were overall shorter, whilst appearing similarly effective at enabling positive therapeutic interactions, questioning the standard length of the one-hour consult.
However, there are still many questions yet to be answered, both in relation to telephone therapy and other telehealth approaches, as highlighted by the authors. Specifically:
- Who are the people that telehealth is more or less suitable for?
- Do different therapeutic approaches, or clinical interventions, differ in terms of their impact on the therapeutic interaction via telehealth?
- How does the therapeutic interaction differ across different types of telehealth platforms?
- Does telephone therapy provide any advantages over and above face-to-face? For example, is it really cheaper?
- What barriers remain for the implementation of telehealth within clinical services and how can we overcome these?
Statement of interests
None to disclose.
Irvine, A., Drew, P., Bower, P., Brooks, H., Gellatly, J., Armitage, C. J., … & Bee, P. (2020). Are there interactional differences between telephone and face-to-face psychological therapy? A systematic review of comparative studies. Journal of Affective Disorders.
 Zhou, X., Snoswell, C. L., Harding, L. E., Bambling, M., Edirippulige, S., Bai, X., & Smith, A. C. (2020). The role of telehealth in reducing the mental health burden from COVID-19. Telemedicine and e-Health, 26(4), 377-379.
 Torous, J., Myrick, K. J., Rauseo-Ricupero, N., & Firth, J. (2020). Digital Mental Health and COVID-19: Using Technology Today to Accelerate the Curve on Access and Quality Tomorrow. JMIR mental health, 7(3), e18848.
 Lattie, E. G., Nicholas, J., Knapp, A. A., Skerl, J. J., Kaiser, S. M., & Mohr, D. C. (2020). Opportunities for and Tensions Surrounding the Use of Technology-Enabled Mental Health Services in Community Mental Health Care. Administration and Policy in Mental Health and Mental Health Services Research, 47(1), 138-149.
 Turner, J., Brown, J. C., & Carpenter, D. T. (2018). Telephone‐based CBT and the therapeutic relationship: The views and experiences of IAPT practitioners in a low‐intensity service. Journal of psychiatric and mental health nursing, 25(5-6), 285-296.
 Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., … & Stewart, L. A. (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic reviews, 4(1), 1.