REMOTE COGNITIVE BEHAVIOURAL THERAPY
Remote based Cognitive Behavioural Therapy’s ability to overcome some of the common barriers to therapy have been consistently highlighted (Bee et al., 2016).
Remote methods of delivering psychological treatments are being increasingly utilised as a way of managing demands on service resources (Mataix-Cols & Marks, 2006). Remote interventions form a key component of the Increasing Access to Psychological Therapies (IAPT) ‘stepped care’ model (Bee et al., 2016). In a meta-analysis that included a range of technology-based Cognitive Behavioural Therapy (CBT) delivery methods, including telephone, automated voice response systems and bibliotherapy, Dèttore, Pozza & Andersson (2015) found no significant difference in treatment effectiveness for Obsessive Compulsive Disorder (OCD) symptoms compared to face-to-face CBT (F-CBT).
The effectiveness of CBT delivered remotely, compared to treatment as usual or alternative therapeutic models delivered in the same manner, has been investigated in a number of controlled trials. The addition of a remote CBT program was associated with significant improvements in clinical outcomes with primary care patients beginning antidepressant treatment (Ludman et al., 2007). Olthias et al. (2014) found remote CBT to be associated with reductions in anxiety sensitivity, panic, social phobia and post-traumatic stress symptoms compared to a waiting list control.
To date, a key motivator for trialling remote CBT has been to find more effective ways of treating mental health problems that are co-morbid with access-limiting physical health issues, such as depression amongst sufferers of chronic lung disease (Doyle et al., 2016). Muller & Yardley’s (2011) meta-analysis found that remote therapy was significantly associated with improved physical health in people with chronic illness. Efficacy has also been demonstrated for groups with geographical limitations, such as those in rural areas (Dwight-Johnson et al., 2011) and with older adults (Brenes et al., 2012; 2015; 2016).
In a study published in December 2016, Bee, Lovell, Aimes, & Pruszynska investigated CBT psychotherapists’ views on remote CBT in order to identify factors relating to its uptake and implementation in statutory mental health services. It was found that therapists consistently advocated the method’s ability to overcome some of the common barriers to therapy. This is of value, as up to three quarters of depressed primary care patients have reported factors that would make it difficult or impossible for them to attend weekly therapy sessions (Mohr et al., 2006).
Communication
Concerns have been expressed that sessions held remotely might hamper communication between the therapist and the client, which may limit effective administration of treatment protocols. Turner, Mataix-Cols, Lovell, Krebs, Lang, Byford & Heyman (2014) found remote CBT to be effective and not inferior to face to face work in treating adolescents with obsessive compulsive disorder (OCD). Intent-to-treat analyses found no differences in efficacy at post-treatment, and three and six month follow ups. While 94.4% of participants reported satisfaction with the help they received, a significant difference existed in the proportion reported being very happy with their group allocation (Remote: 77.8%, F2F: 40.7%, p = .031). Perhaps most importantly, both participants and their parents in each condition reported equivalent levels credibility in the treatment and of alliance/engagement with their therapist. Temkin et al. (2012) found that their remote patients showed greater retention and response rates than those attending a face-to-face group.
Treatment Adherence
Burgess, Andiappan & Chalder (2012) also reported similar rates of success between remote and in person treatment for Chronic Fatigue Syndrome and found comparable levels of dropout, while reduced levels of discontinuation was seen by Caserta (2016) as the distinguishing feature of the modality. Hart & Hart (2010) point to a meta-analysis of telephone based psychotherapy (Mohr et al., 2008) which yielded a mean attrition rate of 7.56%, and compared this to an analysis of in person psychotherapy studies showing a mean rate of 46.9%. Himelhoch et al. (2013) found remote CBT as effective as F2F CBT with HIV sufferers, but also noted that remote subjects were significantly more likely to maintain adherence to antiretroviral medication.
Collaboration
Therapeutic Alliance (TA) has been identified as a key indicator of successful therapeutic outcome (Horvath & Symonds, 1991), and is considered key to CBT (Waddington, 2012). Stiles-Shields, Kwasny, Cai & Mohr (2014) conducted a secondary analysis of the 325 randomised participants in the Mohr et al. (2012) study. Assessments of therapeutic alliance were found to relate to outcomes and no differences were found between groups. Applebaum et al. (2012) examined the association between TA in remote methods ad treatment success among cancer survivors and found the factor related to decreased depressive symptomatology, in accord with Beckner et al.’s (2007) findings using the same mode of therapy. Mulligan et al. (2014) also found therapeutic alliance levels following remote therapy for psychosis were comparable to previous face-to-face psychosis intervention studies.
Content
Concerns have been expressed that remote interventions would need to contain limited content compared to interventions conducted in person. Subjects in Kalapatapu, Ho, Cai, Vinogradov, Batki & Mohr’s (2014) study were not left short compared to their face to face counterparts. This study of the treatment of depression with co-occurring problematic alcohol use found parity in adherence and outcomes at end point and three and six months follow up. This result was achieved despite the authors noting that both the remote and in-person interventions did not differ in terms of content other than the method of delivery.
Case Complexity
Finally, it has been suggested that these perceived limitations may combine to leave remote CBT as only suitable in less complex cases. However, a number of the previous studies have involved subjects with complex presentations, e.g., depression with co-occurring alcohol abuse (Kalapatapu et al., 2014), and remote therapy was found comparable to F2F CBT in the treatment of Major Depressive Disorder amongst sufferers of Traumatic Brain Injury (Fann et al., 2015).
Of the advocates of telephone CBT, perhaps the most prominent among them is David Mohr, who accepts that T-CBT eliminates visual cues, but reminds us that non-verbal cues are preserved (e.g., prosody). He points to Ekman et al.’s (1980) contention that voice quality is critical in the conveyance of emotion, and goes as far as to suggest that the parity found between T-CBT and F-CBT implies that visual cues provide little additional utility, at least in the development of therapeutic alliance (Mohr et al., 2012).
Bee et al. (2008), looking at the evidence at the time, felt that few researchers took stock of client satisfaction. When they did, levels tended to be similar between remote and in person therapy, or if not, favoured the former. Finally, there have also been indications that third wave CBT interventions can also be effective when administered over the telephone. For example, Bricker et al. (2014) were able to help smokers quit using telephone Acceptance and Commitment Therapy (ACT) and Heffner et al. (2014) found they were better able to reduce concomitant hazardous drinking using the same method.
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