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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.

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.

Cuijpers, P. (2020) Measuring success in the treatment of depression: What is most important to patients? Expert Review of Neurotherapeutics, 20, 123-125.

There is lots of evidence now that psychotherapies of various types are efficacious for the treatment of depression. Psychotherapy trials focus largely on depressive symptoms, and define major depression according to psychiatric diagnostic manuals. However, the diagnosis of major depression, for example, is not a unitary construct. That is, it is simply a collection of symptoms and signs that are purported to make up a category of disorder. In fact, people with major depression are quite varied on a whole range of things, like severity, coping style, motivation, attachment style, personality, and extent of comorbidity with other diagnoses. This means that many psychotherapy studies may be focusing on patient outcomes (i.e., reduction of depressive symptoms) that may or may not be important to patients. In this paper, Cuijpers reviews the literature on what patients want from psychotherapy. He found that while symptom reduction was important to patients with depressive disorders, it was not the only outcome they wanted from psychotherapy. Patients also want to have a more fulfilling lives, to return to productive work, to solve conflicts with close loved ones, to learn to live with a chronic disability or disease, to learn to handle the effects of trauma, and other quality of life issues. Fortunately, some studies do report the effects of psychotherapy on quality of life, social functioning, anxiety, hopelessness, and interpersonal problems. However, even these studies treat such outcomes as if they were uniformly important to all patients in the study. Very few studies take a personalized approach to patient outcomes, in which the outcomes of interest are those determined by each patient specific to their own circumstances and wishes.

Practice Implications

Psychotherapists who practice from an evidence-informed perspective often try to measure outcomes in their own practices using reliable measurements. However, many of these measurements may be too general for any specific patient, or they may represent outcomes that do not align with what the individual patient wants. Practicing clinicians who assess outcomes in their own practices, may want to consider supplementing standard symptom outcome measures with more personalized assessments for patients.

Coming to a Consensus About Psychotherapy

Goldfried, M. R. (2019). Obtaining consensus in psychotherapy: What holds us back? American Psychologist, 74(4), 484-496.

In this thoughtful piece, Marvin Goldfried, one of the pioneers of psychotherapy research, discussed the lack of consensus that holds back progress in the science and practice of psychotherapy. He argued that there are three main blocks to moving the field forward. First, disagreement across theoretical orientations results in different language systems that prevents the field from learning of similarities or points of connection. At last count, there are over 500 schools of psychotherapy resulting in an absence of a common language. A lack of consensus and disparate languages means that identifying the key factors that may underlie the effectiveness of psychotherapy is difficult if not impossible. The second block to progress in psychotherapy practice and research has to do with the practice-research divide. Despite the large body of research on psychotherapy systems, many clinicians rely more on their own experience rather than the research evidence. Therapists also complain that research tends to be conducted by individuals who know little of the reality of providing clinical services, and so some of what is researched (e.g., short-term treatment packages of one theoretical orientation) may not be relevant to everyday practice. For their part, researchers have tended not to consult with or include clinicians in their research endeavors, thus resulting in research that is disconnected from practice. The third block is related to the disconnection between the past and current contributions. That is, psychotherapy schools and orientations tend to emphasize and reward what is new without acknowledging the historical, intellectual, and practical theories that preceded. As a result, there is a constant reinventing of the wheel and a tendency not to learn from past advances and failures. This creates a stagnation in advancing both research and practice. As one example of this phenomenon, Goldfried quoted the psychoanalyst Otto Fenichel in 1941 who described the effects of what we now call behavioral extinction. Yet Fenichel and his work is never cited by behavior therapy research, and so there is no opportunity to examine common underlying processes of change or the evolution of the concept over time.

Practice Implications

Goldfried ended this paper by suggesting how to move the field of psychotherapy forward. He suggested that rather than focusing on new approaches to treatment, the field should reward new knowledge grounded in research and that belongs to the field in general and not to a particular school, orientation, or person. The emphasis of research in psychotherapy should not be on who is right but on what is right. In other words, research questions should emphasize “What did a therapist do to make an impact?” For example, psychotherapy process research on the therapeutic alliance, stages of change, therapist interpersonal skills, empathy, and client factors focus on transtheoretical constructs that inform therapists on how best to work with particular clients. This PPRNet blog often summarizes psychotherapy research for its readers.

Sakaluk, J. K., Williams, A. J., Kilshaw, R. E., & Rhyner, K. T. (2019). Evaluating the evidential value of empirically supported psychological treatments (ESTs): A meta-scientific review. Journal of Abnormal Psychology, 128(6), 500-509.

In the 1990s the Clinical Division of the American Psychological Association commissioned a Task Force to identify “Empirically Supported Treatments” (EST). The Task Force decided that psychotherapies that repeatedly showed statistically significant improvements over no treatment, placebos, or another treatment would be designated as “Strongly” supported. They also designated some treatments as “Modestly” supported or with “Controversial” support. The EST movement continues to have a great impact on the practice, research, and funding of psychotherapy. Time-limited, diagnosis-focused therapies, tested in randomized controlled trials became the “gold standard”. Clinicians are expected to practice these ESTs, research agencies focus funding on these models, and some governments and insurance companies provide reimbursements only for these types of therapy. The Empirically Supported Treatments (EST) movement redefined the practice of psychotherapy as short-term, symptom-focused, technically-oriented, and mostly cognitive-behavioral. In this meta-scientific review Sakaluk and colleagues asked: how good is the evidence for the ESTs? The authors were particularly concerned with the quality of the studies from a methodological and statistical point of view: how likely was it that these findings could be replicated, or how reliable were the findings? The good news is that there were few instances (about 10%) of research supporting ESTs in which researchers mis-reported the statistics (i.e., error in the reporting of statistical findings). This is quite a bit lower than previously identified mis-reporting rates (about 50%) in psychological research in general. However, only about 19% of ESTs were supported consistently by high quality studies. Over half of ESTs were supported consistently by poor quality studies. Most of the studies supporting ESTs were not sufficiently powered to detect differences between treatments or conditions. That is, often the sample sizes of patients in the studies were too small, and so the significant results were not likely reliable or perhaps not plausible. Also, those therapies that the EST list defined as having “Strong” support were not backed by more higher quality research compared to therapies considered to have “Moderate” support. In other words, the decision to designate treatments as “Strongly” or “Moderately” supported appears to have almost no relationship with the quality of the research.

Practice Implications

Embedded in this dense methodological paper are some troubling findings and important practice implications. The authors suggested that there are a number treatments on the EST list that have dubious research support because the studies of those treatments may not stand up to replication (a critical test in scientific research). It is not clear that ESTs are any more effective than other bona-fide psychotherapies that are not on the list. (Bona-fide psychotherapies are those that are based on a psychological theory, delivered by trained therapists, and in which the patient and therapist develop a relationship). The findings question whether dissemination of and training in ESTs to the exclusion of other psychotherapies can be justified given the quality of the evidence. In other words, it is possible that other bona-fide psychotherapies that are not on the EST list may be just as effective. This does not imply that psychotherapy is not effective or that anything goes when it comes to the practice of psychotherapy. Evidence-based practice in psychotherapy should guide psychotherapists’ clinical choices. However, the EST list is not the final word on what constitutes “evidence-based” practice in psychotherapy, or on what treatments should be researched and funded.

Nehrig, N., Prout, T.A., & Aafjes-van Doorn, K. (2019). Whose anxiety are we treating, anyway? Journal of Clinical Psychology. Online first publication.

Evidence-based practice (EBP) in psychotherapy is defined by the American Psychological Association as the deliberate integration of: (1) the research evidence, (2) clinician expertise in making treatment decisions, and (3) client characteristics, preferences, and culture. The EBP statement was meant to supplant an older model of prescriptive psychotherapy practice that resulted in the creation of lists of empirically-supported treatments (EST). The ESTs were defined as: (1) manualized therapies, (2) shown to be efficacious in randomized controlled trials, (3) for patients with a specific diagnosed mental disorder. However, manualized therapies are not necessarily more effective than non-manualized treatments, and patients in randomized controlled trials may not represent those typically seen by therapists in everyday practice. Although EBPs are the current standard by which psychotherapists should practice, many therapists and organizations focus almost exclusively on the first of the EBP criteria (the research evidence of ESTs) to the exclusion of the second and third criteria (clinician expertise, and patient characteristics, preferences, and culture). In this review article, Nehrig and colleagues speculated about why this is the case by asking: “whose anxiety are we treating?” They argued that manualized therapies identified as ESTs reduce therapists’ anxiety caused by: uncertainty about treatment outcomes, the emotional toll of providing psychotherapy to people who are suffering, and the negative emotions (anxiety, despair, cynicism) that sometimes arises in therapists from the work. Nehrig and colleagues argued that ESTs provide therapists with a sense of control and certainty, while limiting therapists’ attention on relational challenges in the work of therapy. However, this emphasis on ESTs comes at a cost for therapists and patients. Therapists may not focus on developing skills to manage the relational challenges inherent in providing psychotherapy, greater certainty may reduce therapists’ engagement in sufficient self-reflection, and therapists may attend only to patients’ symptoms and not to the patient as a whole person. Nehrig and colleagues also discuss the preference for ESTs among institutions, insurance companies, and government funders of psychotherapy. ESTs reduce anxiety in these contexts because ESTs are seen by managers as methods to enhance accountability and standardization of treatment, to uphold standards of care, and to reduce potential liability. The short-term nature of most ESTs also assuages economic concerns for institutions and funders who wish to manage costs. However, this emphasis on short term manualized treatment also reduces psychotherapy from a complex interpersonal process with inherent uncertainty to one that resembles a clear-cut medical procedure that encourages top-down decision-making about clinical practice.

Practice Implications

Anxiety about the complexity of psychotherapy can cause therapists, institutional managers, and government funders to place greater value on ESTs rather than on clinical expertise of the therapist and patient characteristics. Patient characteristics, preferences, and culture are related to developing the therapeutic alliance and to patient outcomes. Astute therapists can learn to adjust their interventions to these patient characteristics, which may mean using clinical judgement to alter or deviate from a prescriptive manual. An EBP approach that integrates research, clinical expertise, and patient characteristics allows therapists to take into account transtheoretical factors known to affect outcomes like the therapeutic alliance, repairing alliance ruptures, empathy, and to use their clinical expertise to adjust their interpersonal stances to relevant patient characteristics, preferences, and culture.