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Stoll, J., Muller, J.A., Trachsel, M. (2020). Ethical issues in online psychotherapy: A narrative review. Frontiers in Psychiatry, 10, 993. doi: 10.3389/fpsyt.2019.00993

There is emerging evidence that videoconference delivered psychotherapy is as effective as face to face therapy. Providing psychotherapy by telecommunication technologies might be synchronous (real time) or asynchronous (email, chat, internet-based) in nature. During the current COVID-19 pandemic, many psychotherapists have moved to telehealth methods due to necessity rather than by choice. Based on previous survey findings, psychotherapists’ attitudes, and legal-ethical barriers have hampered a wider use of video conferencing methods for delivering psychological interventions. In this narrative review, Stoll and colleagues conduct a broad-based summary of 249 studies touching on the main ethical arguments for and against the provision of online psychotherapy. The top five ethical arguments in favor of online psychotherapy include the following. (1) Increased access and availability: online psychotherapy can improve access to health care services for those living in rural and remote areas. (2) Enhanced communication: online therapy is as effective as face to face therapy and allows for creative approaches to delivering therapy including integrating online materials, websites, and videos into therapy sessions. (3) Client characteristics: some clients who have problems with agoraphobia and severe anxiety may find online therapy a useful first step in treatment. (4) Convenience: research indicates that both patients and therapists judge online therapy to be convenient and comfortable. (5) Economic advantages: online therapy might be more cost-efficient due to reduced overhead and travel costs for therapists and clients. The top five ethical arguments against online psychotherapy include the following. (1) Privacy and confidentiality: related to the use of unsecured websites or unencrypted communication tools. (2) Therapist competence: some therapists may not have technology related competencies including specific ethical and legal requirements. (3) Communication issues: the absence of non-verbal cues may reduce the information that therapists have to work with in a session. (4) Research gaps: there is insufficient research to support online therapy, including no knowledge about which clients can benefit, and the impact on therapeutic processes. (5) Emergency issues: ethical issues may arise as to how to manage emergencies or crises of patients who are in different locations.

Practice Implications

The practice of videoconference delivered psychotherapy is here to stay and will be more widespread even after the pandemic. Therapists can take comfort in the many ethical reasons to provide such services, including reaching patients who might not otherwise have access to therapy or who might not be comfortable seeking out face to face therapy. Nevertheless, there are a number of ethical concenrs about the use of online therapy, not the least of which includes questions about privacy and confidentiality and therapist competence. Psychotherapists should follow practice guidelines of their regulatory colleges when considering online therapy.

Dickeson, E., Roberts, R., & Smout, M.F. (2020). Predicting boundary violation propensity among mental health professionals. Clinical Psychology and Psychotherapy, Online First Publication: https://doi.org/10.1002/cpp.2465.

Boundaries of the therapeutic relationship define the role and limits of therapist behaviors, and the limits of their relationship with clients. Violations of therapy boundaries might include sexual contact, which by some estimates occurs in 0.5% to 8.6% of therapists. Other boundary violations might include a broader range of behaviors such as therapists initiating hugs, forming a social relationship with a client, flirting, and consuming alcohol with a client. A number of years ago, Gabbard developed a typology of practitioners who committed boundary violations that included: the predatory therapist, the masochistic therapist, and the lovesick therapist. Despite the widespread use of this typology, there was little research on its validity or utility. Dickeson and colleagues conducted a survey of 275 Australian practitioners (psychologists, psychiatrists, psychotherapists, and social workers, 73% women) about their behaviors related to professional boundaries and also personality traits. The goal was to evaluate if therapist variables suggested by Gabbard were related to the likelihood of crossing a professional boundary. Over 30% of the therapists in their sample reported some kind of boundary violation with clients, with 0.7% indicating they had sex with a client. Male gender (r = .147–.255), experiential avoidance (r = .144–.230), narcissistic grandiosity (r = .334–.402), narcissistic vulnerability (r = .258–.331), and impulsivity (r = .196–.262) were the most consistent predictors of some propensity to commit a boundary violation among therapists. There was no evidence that age or working in a solo practice setting were related to propensity to professional boundary violations.

Practice Implications

Gabbard’s typology for therapists who engage in boundary violations were supported to some extent. The predatory therapist type was supported by findings related to narcissistic grandiosity and impulsivity. Such therapists may seek personal gratification by exploiting clients. There was also some evidence for the masochistic therapist type as seen by significant correlations with narcissistic vulnerability and experiential avoidance. Such practitioners might extend themselves beyond the limits of professional conduct in a misguided belief that only they can help the client. There is a general consensus in the profession that boundary violations are detrimental to clients. This research suggests that therapists with narcissistic issues might be more likely to transgress professional boundaries. Personal therapy, close supervision, and ongoing professional consultation may be helpful for therapists who feel that they at risk of a professional boundary transgression.

Effectiveness and Adherence of Telephone-Administered Psychotherapy

Castro, A., Gili, M., Ricci-Cagello, I., Roca, M., Gilbody, S., Perez-Ara, A., Segui, A., & McMillan, D. (2020). Effectiveness and adherence of telephone-administered psychotherapy for depression: A systematic review and meta-analysis. Journal of Affective Disorders, 260, 514-526.

The COVID-19 pandemic has resulted in psychotherapy providers moving to online and telephone-delivered interventions. But questions remain about the efficacy of delivering psychotherapy in these formats to patients with depression. Depression is highly prevalent as it affects about 320 million people around the world and causes serious disability and lowered quality of life. Psychotherapy is effective in treating depression, however there are significant barriers to people accessing face-to-face psychotherapy including cost, stigma, distance, and disability. Telephone-delivered psychotherapy may minimize these barriers. One potential question that may arise is whether patients will adhere to telephone-delivered psychotherapy. That is, will patients find telephone sessions acceptable as indicted by the rate of starting therapy and of attending sessions? In this systematic review and meta-analysis, Castro and colleagues evaluated whether telephone-delivered psychotherapy for depression is as effective as other active treatments and more effective than no-treatment. The authors also examined the level of adherence/acceptability to telephone administered treatment, determined by the percent of scheduled sessions actually attended by a patient. The sample of studies was small such the authors only found a total of 11 direct comparison randomized controlled trials. These trials represented almost 1400 patients. The only treatment tested in these trials were CBT-oriented. Four studies found that telephone-delivered therapy produced significantly larger reductions in depressive symptoms when compared to no treatment controls (mean SMD = -0.48; 95% CI: -0.82 to -0.14). In four other studies telephone-administered therapy was just as effective as an active control (e.g., medication or self-help). The weighted average percentage of scheduled telephone sessions that patients attended was 73%, and the percent of patients who started telephone therapy after the initial referral was about 90%. These percentages indicating adherence and acceptability are similar to findings reported from individual psychotherapy studies.

Practice Implications

There are few randomized controlled trials that assess the efficacy of telephone-administered psychotherapy, and these studies were limited to only one type of intervention. However, the findings from this meta-analysis suggested that telephone-delivered psychotherapy may be efficacious and as effective as some other active treatments. Further, telephone therapy may be acceptable to patients in that they start and attend sessions at a rate similar to face-to-face therapy. These preliminary findings provide clinicians who provide telephone psychotherapy during this period of physical distancing due to COVID-19 with some evidence for the utility of telephone delivered treatment.

Predicting Which Psychotherapists Will Adopt Telepsychology

Pierce, B. S., Perrin, P. B., & McDonald, S. D. (2020). Demographic, organizational, and clinical practice predictors of U.S. psychologists’ use of telepsychology. Professional Psychology: Research and Practice, 51(2), 184–193.

Even prior to COVID-19, psychologists and psychotherapists were examining the use of telepsychology (telephone delivered psychotherapy and assessment). The interest arose from efforts to increase accessibility to psychological services for clients in rural and remote areas, and also for those for whom travelling to an urban centre was a significant barrier due to disability. However, there are barriers to psychotherapists’ use of telepsychology caused by: differing state and provincial laws and requirements, limits to working across state and provincial jurisdictions, issues related to insurance reimbursement, and concern that telepsychology and video conferencing platforms may not meet Health Insurance Portability and Accountability Act (HIPAA) or Personal Health Information Privacy and Access (PHIPA) requirements for confidentiality and privacy. In a previous study, close to 80% of psychologists felt that telepsychology could be effective, but 42% viewed telepsychology as less effective than face-to-face therapy, and 75% indicated that they would not likely refer to someone for telepsychology services. In this large survey of almost 1800 psychologists who practiced psychotherapy, Pierce and colleagues were interested in demographic, organizational, and clinical factors that predicted telepsychology-use by clinicians. The participants were 8.74 times more likely to use telepsychology if they worked in organizations that had policies supporting telepsychology-use compared to those who worked in organizations without such policies (p < .001). Nevertheless, psychologists in private practices were 2.86 times more likely to use telepsychology than those who worked in institutions. Also, psychologists who received training in telepsychology were 2.25 times more likely to use telepsychology than those who did not receive any training (p = .002). In terms of clinical practice areas, those who worked in sports performance, coaching, addictions, and parenting were more likely to use telepsychology. On the other hand, those who provided testing and evaluations were less likely to use telepsychology, likely because of practical limitations to psychometric testing online. Age and gender were not related to telepsychology use.

Practice Implications

Psychologists and psychotherapists who want to increase their comfort and satisfaction in working with telepsychology should consider getting professional development training and continuing education. In one study, over two thirds or psychologists perceived that they did not have sufficient training to use telepsychology. Organizations who want to encourage telepsychology should invest in training and provide clear policy guidelines to support professionals. The notion that older clinicians would be less likely to use telepsychology was not born out by these findings.

The Effectiveness of Telepsychology Interventions

Varker, T., Brand, R. M., Ward, J., Terhaag, S., & Phelps, A. (2019). Efficacy of synchronous telepsychology interventions for people with anxiety, depression, posttraumatic stress disorder, and adjustment disorder: A rapid evidence assessment. Psychological Services, 16(4), 621–635.

The arrival of COVID-19 as a global pandemic has led to public health authorities encouraging physical distancing, including in the context of psychotherapy. Many professional organizations and regulatory colleges have made similar calls, so that psychotherapists and mental health providers have had to come up with creative ways of continuing to provide care to their clients. Many therapists have turned to telepsychology – the provision of psychotherapy through telephone, video conferencing technologies, or internet based chat rooms. But what is the evidence for these modalities of care, is there adequate research to support their use, are they as effective as care as usual? In this rapid evidence assessment, Varker and colleagues review the existing empirical research on the efficacy of telepsychology programs. They only looked at synchronous telepsychology interventions (i.e., those interventions during which therapist and client are interacting in real time), and not asynchronous use of technology (smartphone apps and chat technologies in which therapist and client are not interacting in real time or are not interacting at all). Synchronous telepsychology is most similar to face to face psychotherapy, and likely the option adopted by most therapists during these times. Health care providers initially adopted telepsychology and telehealth to overcome barriers to access to health care and psychotherapy like distance, stigma, and transportation needs. With the global pandemic related to COVID-19, psychotherapists are increasingly using telepsychology to manage physical distancing requirements while providing services. Varker and colleagues focused their review on randomized controlled trials and meta-analyses, which researchers consider to be the highest level of evidence for an intervention. The authors found 24 studies that evaluated telepsychology interventions with clinical populations of adults who had depression, anxiety, or PTSD. They found good quality evidence for telephone-delivered therapy (11 studies) and video teleconference-delivered interventions (12 studies). That means that the studies of these modalities were high quality and so results were likely reliable. The evidence indicated that both of these modes of delivering psychotherapy were as effective as face-to-face or treatment as usual. The evidence for internet delivered text-based treatments was not of high quality (3 studies). There were too few studies of this modality, and their quality was low. And so, the authors determined that the evidence for text-based therapy was unknown.

Practice Implications

Research on telepsychology interventions is still quite new with a limited number of quality studies attesting to their efficacy. Nevertheless, the findings were promising for telephone delivered psychotherapy and videoconferencing telepsychology, such that psychotherapists can be reasonably confident in using these methods with clients. Text-based delivery of interventions had limited and poor-quality evidence. Psychotherapists should: first and foremost follow their regulatory college requirements for using telepsychology, check with their liability insurance providers, assess if their telepsychology platform is HIPPA compliant, assess if their clients are suitable for this modality, and follow best practices when using telepsychology.

Torous, J., Lipschitz, J., Ng, M., & Firth, J. (2020). Dropout rates in clinical trials of smartphone apps for depressive symptoms: A systematic review and meta-analysis. Journal of Affective Disorders, 263, 413-419.

Depression is a leading cause of disability worldwide, and yet more than 50% of people do not have access to adequate therapy. One solution might be to provide individuals with smartphone apps to help screen, monitor, or provide treatment. Smart phones are ubiquitous, and depression apps are one of the most downloaded categories of apps by the public. Research seems to suggest that smartphone apps provide some positive results for members of the public, but these findings are compromised by the high drop-out rates reported in the primary studies. Further, one study found that although many people download the apps, only about 4% actually use them. Whereas smartphone apps appear attractive to the consumer, very few actually make use of and therefore benefit from them. In this systematic review, Torous and colleagues conduct a meta-analysis of drop-out rates from studies that test the use of smart phone apps. They found 18 independent studies representing data from 3,336 participants who received a psychological intervention for depression via a cell phone app, or who were in a placebo control condition. A total of 22 different apps were tested in the studies. Initially, the pooled drop-out rate from the depression app treatment arms appeared to be about 26.2% (95% C.I.=11.34% to 46.75%), which would be in line with average drop-out rates from randomized controlled trials of face to face psychotherapy. But, the authors noted two things. First, the drop-out rate from the placebo control conditions (14.2%; 95% C.I. = 8.236 to 23.406) was almost half as high as that found for the apps. Second, through some sophisticated statistical analyses, they found evidence of “publication bias” in this research area. This means that a number of studies testing these apps likely were completed but never published (i.e., these might be studies funded by an app manufacturer that demonstrated negative findings or high drop-out rates). When the authors statistically adjusted for publication bias, they found that the actual drop-out rate from the apps was about 47.8%. That is, almost half of users did not complete or dropped out of the studies. There were no differences in drop-out between types of interventions (CBT, mindfulness, or others), and studies with larger sample sizes (i.e., better quality studies) had higher drop-out rates.

Practice Implications

Although smartphone apps appear really attractive and may be potentially useful as an adjunct to face to face psychotherapy for depression, their utility is plagued by extremely low usage rates (4%) and high drop-out rates from studies (almost 50%). Leading writers and researchers define psychotherapy as primarily a healing relationship that also includes specific interventions. The key ingredient is the human relationship. Depressed or otherwise troubled individuals cannot (because of feeling demoralized) or will not interact with a machine for healing. One way or another, when it comes to smartphone apps, depressed individuals are voting with their feet. Given these findings, health care providers should consider the ethics of giving a depressed individual only e-therapy as the primary mode of treatment.