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Davis, D. E., DeBlaere, C., Owen, J., Hook, J. N., Rivera, D. P., Choe, E., Van Tongeren, D. R., Worthington, E. L., Jr., & Placeres, V. (2018). The multicultural orientation framework: A narrative review. Psychotherapy, 55(1), 89–100.

Studies have shown that many therapists have better outcomes with White clients than with racial and ethnic minority (REM) clients. Also the prevalence of racial/ethnic microaggressions in therapy is high, with as many as 81% of REM clients reporting at least one experience in which a therapist said or did something that was insensitive or offensive. Microaggressions can be understood as instances of therapeutic alliance ruptures that if unrepaired could lead to poor client outcomes. In this practice review of the existing research, Davis and colleagues consider the multicultural orientation framework to help therapists to be more sensitive and effective when working with REM clients. A key feature of the multicultural orientation framework is cultural humility, which refers to a therapist’s interpersonal stance that is open in relation to aspects of cultural identity that are important to the client. Another important concept is cultural opportunities, or the events in therapy in which the client’s cultural beliefs, values, and identity can be explored. Finally, cultural comfort refers to the therapist’s thoughts and feelings that emerge as a result of conversations about the client’s cultural identity. The review found two large and well-designed studies that looked at the association between a multicultural orientation and client outcomes. Therapist cultural humility predicted better therapy outcomes, and lower therapist cultural comfort resulted in client premature termination from therapy. In separate studies, cultural humility was associated with higher therapeutic alliance and fewer microaggressions by therapists. Finally, missed opportunities to discuss cultural identity was associated with more negative therapy outcomes for clients.

Practice Implications

Repairing alliance ruptures caused by microaggressions involves therapists: identifying the event, validating the client’s perspective, discussing the microaggression with appropriate humility, taking responsibility and making amends, and asking the client to inform the therapist about the best way forward. One study showed that the therapeutic alliance improved substantially after therapists and clients discussed and repaired a microaggression. A multicultural orientation involves therapists creating a culturally inclusive setting by overtly discussing the importance of culture and what might cause ruptures.

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.