TELEPHONE COGNITIVE BEHAVIOURAL THERAPY (T-CBT)
Telephone based Cognitive Behavioural Therapy’s (T-CBT) ability to overcome some of the common barriers to therapy have been consistently highlighted (Bee et al., 2016). Despite the lack of visual data during sessions T-CBT has not been found inferior to its face to face counterpart.
Remote methods of delivering psychological treatments are being increasingly utilised as a way of managing demands on service resources (Mataix-Cols & Marks, 2006). Lower intensity telephone interventions, such as guided self-help, 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 over the telephone (T-CBT), 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 T-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 T-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 T-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 T-CBT use 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 T-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).
Concerns have been expressed that sessions via telephone 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 T-CBT to be effective and not inferior to F-CBT 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, with the F-CBT results being legitimately benchmarked compared to previous studies. 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 (T-CBT: 77.8%, F-CBT: 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 T-CBT subjects showed greater retention and response rates than those attending a face-to-face group.
Burgess, Andiappan & Chalder (2012) also reported similar rates of success between T-CBT and F-CBT in treating 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 T-CBT as effective as F-CBT with HIV sufferers, but also noted that T-CBT subjects were significantly more likely to maintain adherence to antiretroviral medication.
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 T-CBT and 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 T-CBT for psychosis were comparable to previous face-to-face psychosis intervention studies.
Concerns have been expressed that T-CBT interventions would need to contain limited content compared to interventions conducted in person. T-CBT subjects in Kalapatapu, Ho, Cai, Vinogradov, Batki & Mohr’s (2014) study were not left short compared to their face to face counterparts when they too received “2 sessions weekly for the first 2 weeks, followed by 12 weekly sessions, with 2 final booster sessions the last 4 weeks. All participants received a workbook that included 8 chapters covering CBT concepts, along with 5 optional modules of common comorbidities and treatment content” (Kalapatapu et al., 2014, p. 3). 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 T-CBT and F-CBT interventions did not differ in terms of content other than the method of delivery.
Finally, it has been suggested that these perceived limitations may combine to leave T-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 T-CBT was found comparable to F-CBT in the treatment of Major Depressive Disorder amongst suffers of Traumatic Brain Injury (Fann et al., 2015).
Of the advocates of T-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 T-CBT and F-CBT, 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 better able to help smokers quit using telephone Acceptance and Commitment Therapy (T-ACT) than when using T-CBT and Heffner et al. (2014) found they were better able to reduce concomitant hazardous drinking using the same method.
Applebaum, A. J., Duhamel, K. N., Winkel, G., Rini, C., Greene, P. B., Redd, W. H. & Mosher, C. E. (2012). Therapeutic alliance in telephone-administered cognitive-behavioral therapy for hematopoietic stem cell transplant survivors.Journal of Consulting and Clinical Psychology; Oct 2012; vol. 80 (no. 5); p. 811-816.
Beckner, V., Vella, L., Howard, I. & Mohr, D. C. (2007). Alliance in two telephone-administered treatments: relationship with depression and health outcomes.Journal of Consulting and Clinical Psychology; Jun 2007; vol. 75 (no. 3); p. 508-512.
Bee, P., Lovell, K., Aimes, Z. & Pruszynska, A. (2016) Embedding telephone therapy in statutory mental health services: a qualitative, theory-driven analysis.BMC Psychiatry, Dec 2016, vol. 16, p. 56., 1471-244X.
Brenes, G. A., McCall, W. V., Miller, M. E., Williamson, J. D., Knudson, M. & Stanley, M. A. (2012). A randomized controlled trial of telephone-delivered cognitive-behavioral therapy for late-life anxiety disorders.American Journal of Geriatric Psychiatry; Aug 2012; vol. 20 (no. 8); p. 707-716.
Brenes, G. A., Danhauer, S. C., Lyles, M. F., Hogan, E. M., Michael, E. (2015). Telephone-delivered cognitive behavioral therapy and telephone- delivered nondirective supportive therapy for rural older adults with generalized anxiety disorder: A randomized clinical trial. JAMA Psychiatry; Oct 2015; vol. 72 (no. 10); p. 1012-1020.
Brenes, G. A., Danhauer, S. C., Lyles, M. F., Anderson, A. & Miller, M. E. (2016). Effects of telephone-delivered cognitive-behavioral therapy and nondirective supportive therapy on sleep, health-related quality of life, and disability.The American Journal of Geriatric Psychiatry; Oct 2016; vol. 24 (no. 10); p. 846-854.
Bricker, J. B., Bush, T., Zbikowski, S. M., Mercer, L. D. & Heffner, J. L. (2014) Randomized trial of telephone-delivered acceptance and commitment therapy versus cognitive behavioral therapy for smoking cessation: A pilot study.Nicotine and Tobacco Research, Apr 2014, vol./is. 16/11(1446-1454), 1462-2203;1469-994X.
Burgess, M., Andiappan, M. & Chlader, T. (2012). Cognitive behaviour therapy for chronic fatigue syndrome in adults: face to face versus telephone treatment: a randomized controlled trial.Behavioural and Cognitive Psychotherapy; Mar 2012; vol. 40 (no. 2); p. 175-191.
Caserta, M. T. (2016).Sleep, quality of life, and intervention.The American Journal of Geriatric Psychiatry; Oct 2016; vol. 24 (no. 10); p. 855-856.
Dèttore, D., Pozza, A. & Andersson, G. (2015). Efficacy of technology-delivered cognitive behavioural therapy for OCD versus control conditions, and in comparison with therapist-administered CBT: meta-analysis of randomized controlled trials.Cognitive Behaviour Therapy; 2015; vol. 44 (no. 3); p. 190-211.
Doyle, C., Dunt, D., Ames, D., Fearn, M., You, E. C. & Bhar, S. (2016) Study protocol for a randomized controlled trial of telephone-delivered cognitive behavior therapy compared with befriending for treating depression and anxiety in older adults with COPD.International Journal of Chronic Obstructive Pulmonary Disease, vol. 11, p. 327-334, 1178-2005.
Dwight-Johnson, M., Golinelli, D., Aisenberg, E., Hong, S., O’Brien, M. & Ludman, E. (2011). Telephone-based cognitive-behavioral therapy for Latino patients living in rural areas: A randomized pilot study.Psychiatric Services; Aug 2011; vol. 62 (no. 8); p. 936-942.
Ekman, P., Friesen, W. V., O’Sullivan, M. & Scherer, K. (1980). Relative importance of face, body and speech in judgements of personality and affect.Journal of Personality and Social Psychology, 38, 270-277. Cited in Mohr et al. (2012).
Fann, J. R., Bombardier, C. H., Vannoy, S., Dyer, J., Ludman, E., Dikmen, S., Marshall, K., … Temkin, N. (2015) Telephone and in-person cognitive behavioral therapy for major depression after traumatic brain injury: a randomized controlled trial.Journal of Neurotrauma, vol. 32, no. 1, p. 45-57, 1557-9042.
Hart, S. L. & Hart, T. A. (2010). The future of cognitive behavioral interventions within behavioral medicine.Journal of Cognitive Psychotherapy, 24.4 (2010): 344-353.
Himelhoch, S., Medoff, D., Maxfield, J., Dihmes, S., Dixon, L., Robinson, C., Potts, W. & Mohr, D. C. (2013). Telephone based cognitive behavioral therapy targeting major depression among urban dwelling, low income people living with HIV/AIDS: results of a randomized controlled trial.AIDS and Behavior; Oct 2013; vol. 17 (no. 8); p. 2756-2764.
Horvath, A. O. & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis.Journal of Counseling Psychology, 38, 139–149. doi:10.1037/0022-018.104.22.168
Kalapatapu, R. K., Ho, J., Cai, X., Vinogradov, S., Batki, S. L. & Mohr, D. C. (2014) Cognitive-behavioral therapy in depressed primary care patients with co-occurring problematic alcohol use: Effect of telephone-administered vs. Face-to-face treatment—A secondary analysis.Journal of Psychoactive Drugs, vol. 46, no. 2, p. 85-92, 0279-1072.
Ludman, E. J., Simon, G. E., Tutty, S. & Von Korff, M. (2007). A randomized trial of telephone psychotherapy and pharmacotherapy for depression: Continuation and durability of effects. Journal of Consulting and Clinical Psychology; Apr 2007; vol. 75 (no. 2); p. 257-266.
Mataix-Cols D. & Marks, I.M. (2006) Self-help with minimal therapist contact for obsessive-compulsive disorder: a review.European Psychiatry. 2006; 21:75-80. Cited in Turner et al., (2014).
Mohr, D. C., Hart, S. L. & Marmar, C. (2006). Telephone administered cognitive-behavioral therapy for the treatment of depression in a rural primary care clinic.Cognitive Therapy and Research; Feb 2006; vol. 30 (no. 1); p. 29-37.
Mohr, D..C., Vella, L., Hart, S., Heckman, T., Simon, G. (2008) The effect of telephone-administered psychotherapy on symptoms of depression and attrition: a meta-analysis.Clin Psychol (New York). 2008; 15:243-253. Cited in Turner et al. (2014).
Mohr, D. C., Ho, J., Duffecy, J., Burns, M. N., Jin, L., Siddique, J., Reifler, D. & Sokol, L. (2012). Effect of telephone-administered vs face-to-face cognitive behavioral therapy on adherence to therapy and depression outcomes among primary care patients: A randomized trial.JAMA - Journal of the American Medical Association; May 2012; vol. 307 (no. 21); p. 2278-2285.
Muller, I., & Yardley, L. (2011). Telephone-delivered cognitive behavioural therapy: A systematic review and meta-analysis.Journal of Telemedicine and Telecare; Jun 2011; vol. 17 (no. 4); p. 177-184.
Mulligan, J., Haddock, G., Hartley, S., Davies, J., Sharp, T., Kelly, J., Neil, S. T., … Barrowclough, C. (2014) An exploration of the therapeutic alliance within a telephone-based cognitive behaviour therapy for individuals with experience of psychosis.Psychology and Psychotherapy, vol. 87, no. 4, p. 393-410, 2044-8341.
Olthuis, J. V., Watt, M. C., Mackinnon, S. P. & Stewart, S. H. (2014) Telephone-delivered cognitive behavioral therapy for high anxiety sensitivity: a randomized controlled trial.Journal of Consulting and Clinical Psychology, vol. 82, no. 6, p. 1005-1022, 1939-2117.
Stiles-Shields, C., Kwasny, M. J., Cai, X. & Mohr, D.C. (2014) Therapeutic alliance in face-to-face and telephone-administered cognitive behavioral therapy.Journal of Consulting and Clinical Psychology, April 2014, vol./is. 82/2(349-354), 0022-006X;1939-2117.
Temkin, N. R., Fann, J., Bombardier, C., Vannoy, S., Dikmen, S. & Ludman, E. (2012). Telephone and in-person cognitive behavioral therapy for depression after traumatic brain injury.Journal of Neurotrauma; Jul 2012; vol. 29 (no. 10).
Turner, C. M., Mataix-Cols, D., Lovell, K., Krebs, G., Lang, K., Byford, S., Heyman, I. (2014)Telephone cognitive-behavioral therapy for adolescents with obsessive-compulsive disorder: a randomized controlled non-inferiority trial.Journal of the American Academy of Child and Adolescent Psychiatry, vol. 53, no. 12, p. 1298, 1527-5418.
Waddington, L. (2002).The therapy relationship in cognitive therapy: A review.Behavioural and Cognitive Psychotherapy, 30, 179–192. doi: 10.1017/S1352465802002059. Cited in Applebaum (2012).