Psychologists in the 21st century must address a number of issues regarding the provision of mental health care, including barriers to care, greater emphasis on providing care to the underserved, and lowering health care costs. In this paper, we have focused on one method of doing so - providing psychotherapy by telephone. We have reviewed the evidence base for how and why telephone-delivered psychotherapy can be effective and provided practical suggestions for dealing with some of the difficulties that occur with delivering psychotherapy by telephone.
Although more studies are clearly needed, a growing number of methodologically strong studies demonstrate positive outcomes for telephone-delivered psychotherapy. Much of this research was conducted by Mohr, who concluded that “enough positive trials exist for telephone CBT to be considered an empirically supported treatment” (Mohr et al., 2011
, p. 264). Nonetheless, we still lack comparisons of telephone-delivered psychotherapy versus face-to-face psychotherapy and evidence-based determinations of which clients might derive the most benefit from telephone-delivered psychotherapy. Furthermore, most published RCTs compared telephone-delivered psychotherapy with information only, treatment as usual, and wait-list comparison groups rather than more active comparison groups. Moreover, the one study compared face-to-face and telephone deliveries of the same treatment found no significant differences in outcomes (Lovell et al., 2006
). Much more work is needed to fully understand potential differential effects for psychotherapy delivery methods (i.e., face-to-face versus telephone).
Another important issue is the dearth of research on telephone-delivered psychotherapy other than CBT. One potential explanation is that CBT may be easier to deliver by telephone because it relies more on the development of specific skills and less on the therapeutic relationship as the “principal agent of change” as in more emotion-focused types of therapies (Beckner, Vella, Howard, & Mohr, 2007
; Bee et al., 2010
). This notion is partially supported by Beckner et al. (2007)
, who found greater therapeutic alliance for telephone CBT than telephone emotion-focused supportive therapy. They suggest that in emotion-focused therapy, the lack of physical proximity and nonverbal communication may hamper development of trust needed to explore and understand one's emotional experience.
Because little research has compared various types of psychotherapy conducted by telephone, little can be said about the relative effectiveness of various methods. There are two notable exceptions. One study compared telephone-delivered CBT with telephone-delivered emotion focused therapy. While both types of psychotherapy produced significant declines in depressive symptoms, CBT recipients experienced significantly greater benefits (Mohr et al., 2005
). Another study demonstrated that brief telephone-delivered interpersonal therapy was superior to usual care in reducing depressive symptoms in HIV-AIDS patients (Ransom et al., 2008
). Thus, some evidence suggests that non-CBT approaches can be efficacious when delivered by telephone. However, more work is needed to explore this area, to determine how much these approaches may need to be adapted for telephone delivery, and the effect of telephone delivery on therapeutic processes central to the psychotherapy being studied.
Another potential reason for the extensive focus on CBT is that it requires relatively minimal adaptations for telephone delivery. In CBT, most techniques traditionally taught face-to-face can be extended to the telephone (except deep breathing and progressive muscle relaxation techniques where visual observation is helpful). However, use of written materials, DVDs, or online videos to demonstrate the exercises may minimize this concern. Conversely, other techniques may be more feasible to conduct via the telephone. For example, a psychotherapist can be fully present during an in vivo exposure experience without being physically present.
Telephone-delivered psychotherapy is one component of telehealth. In addition to psychotherapy delivered by telephone, video, internet, e-mail, and smart phone technology have been incorporated into mental health treatment. Some applications are self-guided, in which clients may have minimal contact with a psychotherapist. However, increased psychotherapist presence has been associated with significantly better outcomes (Spek et al., 2007
), suggesting that psychotherapy delivered by telephone or in person may be preferable. Then again, use of technology with minimal psychotherapist contact may be adequate for very highly motivated clients or those with subthreshold symptoms, whereas increased psychotherapist contact (whether by telephone or videoconference) may be preferred for clients with more serious disorders (Newman et al. 2011
). Studies of new modalities for delivering telehealth and the degree of psychotherapist contact will help to develop the most efficacious telehealth treatments.
Overall, research suggests that telephone-delivered psychotherapy has the potential to deliver promising results. Psychotherapists must be aware of the challenges of conducting telephone psychotherapy and develop a plan for dealing with these challenges in advance. With the ever-growing reliance on technology, specific training in alternate methods of delivering psychotherapy (e.g. the telephone) should be integrated into clinical training programs to prepare trainees to be competent providers within the rapidly changing landscape of available mental health services.