British Journal of Guidance & Counselling,

Vol. 37, No. 3, August 2009, 271
286

Psychotherapy via videoconferencing: a review

Susan Simpson*

Eating Disorder Service, Royal Cornhill Hospital, Aberdeen, Scotland

(Received 12 September 2008; final version received 24 February 2009)

Research into the use of videoconferencing for clinical purposes, in particular

psychotherapy, is gradually expanding. A number of case studies and case series
have suggested that videoconferencing can be clinically effective and acceptable to
patients. Nevertheless, there is a lack of methodologically rigorous studies with
adequate sample sizes from which we can draw any generalisable conclusions and
a dearth of randomised controlled studies. Many of the preliminary projects in
this area have been feasibility studies with minimal focus on outcome and even
less on process issues in psychotherapy. Few studies have explored the cost-
effectiveness of this compared with other modes of therapy delivery. This paper
aims to review the work that has been done to date within this field, and to explore
the issues which need to be addressed if videoconferencing is to be taken seriously
in the future as a legitimate and reliable means of delivering psychotherapy
services.
Keywords: video; counselling; psychotherapy; systematic review

Method
To clarify the current status of psychotherapy via videoconferencing a systematic
review of the literature was carried out. Studies which focused on the use of
psychological therapies and counselling via videoconferencing were identified. The
identified areas of focus were psychological assessment and outcome studies,
therapeutic alliance and satisfaction, cost-effectiveness and legal and ethical issues.
In particular, the emphasis was on identifying controlled studies of video therapy
where these exist.
A systematic electronic search for articles published from 1950 to early 2006
was carried out using the MEDLINE (1950
2006), EMBASE (1996
2006) and
PsycINFO (1985
2006) databases. In addition, the Cochrane Controlled Trials
Register was searched. Several of the identified studies assessed at least some clinical
outcomes, but most were of low quality. Only three randomised controlled studies
were found.

Why video therapy?

A number of barriers exist within our society that prevent equitable access to
psychotherapy and counselling services, including geographical distances between
major cities and remote and rural communities, and a lack of adequate or affordable

*Email: Susan.Simpson@gpct.grampian.scot.nhs.uk

ISSN 0306-9885 print/ISSN 1469-3534 online

# 2009 Taylor & Francis
DOI: 10.1080/03069880902957007
http://www.informaworld.com
272 S. Simpson

transport between them. Travelling to these centres on a regular basis for treatment
often presents difficulties for potential clients in terms of costs associated with
travelling, lost working hours and time away from family and work commitments.
Livingstone (1999) described the difficulties of recruiting psychologists and other
mental health professionals to remote areas and the trend for most of the posts that
do exist to be filled by new graduates who have a greater need for supervision and
support. In these areas, professional isolation and opportunities for ongoing training
and development are extremely limited and often non-existent.
Over a number of years, clinicians have attempted to overcome these geographical
impediments through utilising the technology that has been available, including letter
writing (e.g. Davidson & Birmingham, 2001), telephone counselling (e.g. Lester,
1995; Rosenfield, 1997), email (e.g. Robinson & Serfaty, 2001), and ‘online’
communications (e.g. Castelnuovo, Gaggioli, & Riva, 2001; Lange et al., 2000).
Many of those living in urban areas also experience difficulties trying to access
mental health services, as do those in prisons, along with those who are elderly and/
or have mobility difficulties that make travel problematic. Technologies such as these
are increasingly being utilised with these populations in an attempt to provide a more
equitable service to all.
Since 1961 when videoconferencing was first trialled for group psychotherapy
(Wittson, Affleck, & Johnson, 1961), there has been a gradual growth in the use of
videoconferencing for therapeutic purposes. Much of this development has taken
place in countries such as Scotland (and the UK in general), Australia, the USA and
Norway due to the predominance of outlying remote rural and island communities
who struggle to access health services that are mostly based in large cities. Although
most government health departments endeavour to provide equitable health services,
such factors often conspire to make this difficult to achieve without the use of
technology.

Outcome studies: what is the evidence base?

Psychotherapy studies
The majority of video therapy studies described to date have used cognitive-
behavioural therapy (CBT) as their central therapeutic model. A few descriptive
studies quoting other approaches have also been published including psychoanalysis
(Kaplan, 1997), family therapy (Freir et al., 1999), behavioural weight-control group
programmes (Harvey-Berino, 1998) and video-hypnosis (Simpson, Morrow, Jones,
Ferguson, & Brebner, 2002).
Results from a number of case studies have suggested that video therapy can be
an effective means of treatment delivery. Some of those reported most recently
include the following. Manchanda and McLaren (1998) successfully used video-CBT
with a man with mixed anxiety and depressive disorder over 12 weekly sessions.
Improvement was shown by a reduction of psychopathology on a range of validated
outcome measures and independent psychiatric assessment pre- and post-treatment.
Cowain (2001) reported on the CBT treatment of a patient who presented with panic
disorder with agoraphobia and major depression. After a course of 12 sessions the
patient reported a significant reduction in symptoms of depression and anxiety and
an improvement in general functioning. Positive outcomes were also found for single-
session CBT via videoconferencing for combat-related PTSD (Deitsch, Frueh, &
 British Journal of Guidance & Counselling 273

Santos, 2000). A recent study used a multiple-baseline across individuals study to

evaluate CBT via videoconferencing for three clients with Obsessive Compulsive
Disorder (Himle et al., 2006). A standardised manualised treatment was used and
treatment fidelity was measured across sessions. A clear description of videoconfer-
encing facilities was provided and sessions were conducted at a bandwidth of 384
kbits/sec. Improvement scores on the main measure (Y-BOCS) ranged from 44
55%,
making it comparable with findings from face-to-face studies. Simpson, Deans, &
Brebner (2001) described a pilot study of 10 adult patients with a range of problems
(including depression, anxiety and relationship difficulties) over an average of 12
sessions. They compared pre- and post-treatment scores from two questionnaires
measuring clinical improvement (the General Health Questionnaire (Goldberg, 1972)
and the CORE (Core System Group, 1998)). Results suggested that all clients but one
improved over the course of therapy, demonstrating an increase in well-being and a
decrease in overall symptomatology. These are mostly descriptive reports of pilot
studies without control groups. The only controlled study of this type was conducted
by Bouchard et al. (2004), who treated 21 patients with panic disorder with
agoraphobia either with face-to-face or video-CBT. They found an equivalent
improvement in functioning and reduction in anxiety for both groups. The positive
findings suggested by these preliminary studies suggest that there is a demand for
further larger-scale studies to investigate the clinical efficacy of video therapy.
Perhaps the most comprehensive and methodologically sound study to date was
conducted by Day and Schneider (2002) who evaluated the delivery of brief CBT via
videoconferencing. A sample of 80 clients (treatment completers) with concerns
ranging from weight concerns to personality disorders were randomly assigned to
one of three treatment groups (face-to-face, two-way audio, or two-way video) or
a waiting list control group. Therapists had master’s level degrees in clinical
or counselling psychology, and were supervised by a doctoral level psychologist.
A closed circuit television system was used with two 20’’ television sets to simulate a
high quality two-way video delivery. The same system was used without a picture to
simulate a two-way audio system. A range of outcome measures were used to assess
general personality characteristics and satisfaction levels, as well as more specific
problem inventories. No significant differences were found between treatment groups
across outcome measures, although all three groups were significantly superior to the
no-treatment group. Both the audio and video groups had higher drop-out rates than
the face-to-face group. As the sample was drawn from a local population, results may
have been influenced by the fact that those living in remote areas (who potentially
stand to gain most by this technology) were not involved. It was speculated that this
may be due to the short treatment length and it was suggested that further studies
should investigate this using a longer treatment period. In addition, while involving a
wide range of presenting patient problems may improve generalisability of findings,
this does not contribute to our knowledge about which problems are best treated via
which modalities or the relevance of problem severity to preferred treatment modes.
In recent years the eating disorders field has embraced the use of a range of
technologies for the delivery of treatment and once again this has largely focused on
the use of CBT due to the substantial evidence base for this model in face-to-face
interventions. Bakke, Mitchell, Wonderlich, and Erickson (2001) described a case
study wherein two women with bulimia nervosa were treated using manual-based
CBT via videoconferencing. Both subjects had abstained from binge eating and
purging for the last four weeks of treatment, and at one-month follow-up, but
274 S. Simpson

outcome measures were not specified. More recently, in a randomised controlled trial
of manual-based CBT for bulimia nervosa, both videoconferencing and face-to-face
interventions were found to be effective. However, face-to-face treatment was
statistically superior on measures of depression and self-reported eating behaviours
(Mitchell, Myers, Swan-Kremeier, & Wonderlich, 2003; Mitchell et al., 2004).
Simpson et al. (2006) used a single case series design to study examining the
effectiveness of CBT delivered via videoconferencing for people with bulimic
disorders. The outcome was equivalent to that of trials of CBT delivered face-
to-face. Six participants with bulimic disorders attended between 11 and 26 sessions
of video therapy. Self-monitoring data were recorded over a baseline period, during
treatment and one-month follow-up. Data were analysed using an interrupted time-
series programme, with each participant acting as their own control. Post-treatment,
three participants were completely abstinent. One participant reduced bingeing by
89% and purging by 100% and two showed no improvement. Change in bulimic
symptoms was statistically significant for three of the six participants. Five
participants showed a clinically significant improvement on the Beck Depression
Inventory-II (Beck, Steer, & Brown, 1996), three on the Bulimic Investigatory Test
(Henderson & Freeman, 1987) and four on the Borderline Syndrome Index (Conte,
Plutchik, Karasu, & Jerrett, 1980) at post-treatment. Results suggest that video
therapy is of value as an intervention to clients in remote and rural areas and may be
particularly useful for those who are highly self-conscious.

Satisfaction studies
An important aspect in the evaluation of videoconferencing services is that they are
acceptable to both patients and clinicians. In order to engage in treatment it seems
reasonable to expect that some level of satisfaction with the mode of delivery is
necessary. Only a small proportion of satisfaction-based studies have in fact
measured preferences for either face-to-face or videoconferencing modes of delivery
(Williams, May, & Esmail, 2001). Nevertheless, it is important to keep in mind that
even in those studies that did include such measures, many patients did not in reality
have the opportunity to access face-to-face treatment and therefore any statement of
preference for one mode over the other may not necessarily reflect a real choice. In
addition, satisfaction is not necessarily a good indication of what is best for a given
patient. For example, a patient with dependency issues may state that they would
prefer face-to-face treatment due to their desire for proximity to the therapist,
whereas they may in fact benefit more from the space and independence generated by
a videolink. Similarly, a patient who fears intimacy may prefer video therapy, but may
in fact benefit more from exposure to the physical closeness of face-to-face treatment.
As such, preferences may to a large degree reflect idiosyncratic differences between
individuals associated with personality traits, need for personal space or control and
the nature of presenting problems.
There is some agreement that many patients find video therapy preferable to face-
to-face treatment due to feeling less intimidated and more in control of their sessions.
This may be partly associated with the fact that they have their own space and room
with their own videoconferencing remote-control handset (Allen, Roman, Cox, &
Cardwell, 1996). This may increase the sense of control and satisfaction for some but
for those who are unfamiliar with technology it may lead to increased anxiety and
confusion (Omodei & McLennan, 1998). In a face-to-face setting there is some
 British Journal of Guidance & Counselling 275

imbalance of power associated with sessions taking place on the therapist’s

‘territory’. For some patients this may offer a sense of safety, while for others it
may impede openness and trust.
The aforementioned study by Ruskin et al. (2004) reported no differences in
patient satisfaction by patients treated either face-to-face or via videoconferencing.
Kopel, Nunn, and Dossetor (2001) reported similar results whereby the majority of
children and adolescent patients rated telepsychology as ‘almost as good’ or ‘as good’
as face-to-face treatment. Bose, McLaren, Riley, and Mohammedali (2001) reported
high levels of satisfaction by 13 non-psychotic patients who were treated using brief
counselling, with 93% of this group indicating that they would be happy to use
videoconferencing again. Simpson, Doze, Urness, Hailey, and Jacobs (2001) reported
that 9 out of 10 patients rated that they were satisfied with video therapy, with a
proportion preferring it to face-to-face contact. A number of patients indicated that
they experienced video therapy as less embarrassing and confrontational than face-
to-face contact, and that they were more easily able to express difficult feelings as the
extra distance made them feel safer. A case series by Bakke et al. (2001) echoed these
findings, suggesting that patients value the privacy and anonymity of video therapy,
not to mention the huge advantages associated with the convenience of being able to
access treatment locally.
Similarly, in a pilot study of 11 clients who attended a single session of hypnosis
via videoconferencing (Simpson et al., 2002), one third expressed a preference for
videoconferencing (vs. face-to-face), and one third had no preference. The main
reasons cited by those who preferred video-hypnosis were ‘a greater sense of control’,
feeling ‘less scrutinised’ and ‘less self-conscious’. Even those who expressed a
preference for face-to-face work indicated that they would be keen to have further
video-hypnosis sessions. However, there were some concerns by those who indicated
a preference for face-to-face treatment that videoconferencing can lead to a reduced
social presence and sense of connection with the therapist. Simpson, Doze, Urness,
Hailey, and Jacobs (2001) also quoted the experience of videoconferencing of one
patient with anxious and paranoid personality traits as ‘dehumanising’ and
‘unsettling’. There is some suggestion that those with more complex problems may
find video therapy less satisfactory than those with shorter-term or simpler
difficulties, although this may reflect a general interpersonal awkwardness and
discomfort associated with being in therapy, regardless of mode of delivery (Ghosh,
McLaren, & Watson, 1997; Simpson, 2001). There is also some suggestion that
females may be more likely to prefer the videoconferencing mode to face-to-face
(Manning, Goetz, & Street, 2000) and that younger participants may be more likely
to ‘give it a go’ (Rohland, Saleh, Rohrer, & Romitti, 2000).
In a randomised study of psychiatric assessments of neurology patients, both
modes of delivery were found to be equally acceptable, but those in the videoconfer-
encing group expressed more anxiety and reservations about confidentiality (Chua,
Craig, Wootton, & Patterson, 2001). It seems plausible that these fears are more
prevalent in the initial stages of setting up videoconferencing sessions, but that these
tend to be allayed with experience. Schneider (1999) found that patients tend to adapt
to the mode of therapy delivery (i.e. face-to-face, audio-only, videoconferencing) that
they are offered within a short period of time, making use of the cues available to
them. In fact, in this study patient participation was noticeably higher in technology-
facilitated sessions (Day & Schneider, 2002). It may be that just as a sight-impaired
person may adapt to their circumstances through developing more acute or
276 S. Simpson

heightened awareness in other sensory modalities (e.g. Gougoux, Zatorre, Lassonde,

Voss, & Lepore, 2005), so a video therapy participant may utilise the information
available to them (e.g. verbal information) to a greater degree than might otherwise
have been the case in a face-to-face setting.
The same may also hold true for clinicians who partake in video therapy.
According to Omodei and McLennan (1998), after only a few minor adjustments
(e.g. learning ‘turn-taking’ conversational etiquette), most clinicians find that the
experience of video therapy is not dramatically different to that of face-to-face
therapy. This is consistent with the findings of McLaren, Blunder, Lipsedge, and
Summerfield (1996) who reported that although some therapists claimed to
experience higher levels of fatigue following video therapy sessions, others noted
feeling more relaxed and were even able to take off their shoes and put their feet on a
stool out of the view of the camera.
Ruskin et al. (2004) found that psychiatrists in their study were satisfied with
conducting sessions via both video and face-to-face modes, but satisfaction was
greater for the face-to-face sessions. There is some indication that a number of
clinicians are anxious about the prospect of offering clinical services via videoconfer-
encing due to anxieties about being unable to communicate effectively or to form a
therapeutic rapport (e.g. Jones, Johnston, Reboussin, & McCall, 2001; May et al.,
2001). A recent survey carried out in Scotland (Mitchell, Simpson et al., 2003)
indicated that clinician confidence in the use of videoconferencing was directly
related to previous ‘hands-on’ training in the use of the equipment, followed by
opportunities to use it regularly thereafter, with the availability of ‘top-up training’
when required. This highlights the need to incorporate videoconferencing training
programmes into existing counselling and therapy courses to ensure that future users
will have the skills and confidence to offer these services and that standards of care
are upheld. The authors also speculated that personality factors such as risk-taking
behaviour and openness to new experience may be positively correlated with
willingness to use videoconferencing for clinical purposes.

Therapeutic alliance and therapy process issues in video therapy

Therapeutic alliance is well documented as an essential factor which facilitates
change and insight in psychotherapy. But how does changing the mode of therapy to
videoconferencing influence elements of rapport building such as social presence,
empathy and physical and emotional intimacy or connection? A study by Fussell and
Benimoff (1995) emphasises the importance of non-verbal cues such as eye gaze and
gestures in facilitating conversational rhythms, conveying meaning and verbal
fluency. One might expect that a low quality videolink might compromise these
factors through introducing sound delays, lack of lip
voice synchronisation and
image pixilation and there is some evidence that this can delay initial rapport
building (Kirkwood, 1998). Indeed, a study by Rees and Stone (2005) found that
psychologists who watched an identical (simulated) therapy session conducted face-
to-face and via videoconferencing rated therapeutic alliance as significantly lower in
the videoconference condition. It was suggested that these ratings were most likely to
have been the result of pre-existing negative expectations that the technology would
have a detrimental effect on therapeutic alliance and would make it more difficult for
clients to detect warmth and empathy from their therapist. Holtom (2005) has
highlighted the lack of studies which specifically evaluate the processes and relational
 British Journal of Guidance & Counselling 277

dynamics that take place during counselling and the way in which these are
influenced by videoconferencing technology.
Despite the lack of methodologically rigorous studies in this area, there is some
initial evidence that in video therapy therapeutic rapport is not compromised and, in
some cases, may even be enhanced. In a pilot study by the author (Simpson, 2001) 10
patients were asked to rate therapeutic alliance using the Penn Helping Alliance
Questionnaire (Alexander & Luborsky, 1984) over an average of 12 video therapy
sessions. When compared with a similar group studied in a face-to-face setting,
patients’ ratings of therapeutic alliance were found to be equivalent. In this study
there was a trend for patients to become more comfortable with video therapy over
the course of treatment. Patients rated feeling very comfortable in 84% of sessions,
and there was a trend for this to increase over the course of video therapy. Patients
reported that they found communication via videoconferencing very easy for the
majority (81%) of sessions. Participants consistently found video therapy to be less
‘threatening’ or ‘intimidating’, which was particularly important when dealing with
shame-related issues (e.g. sexual abuse, body-image disorders) (Simpson, Deans, &
Brebner, 2001, Simpson et al., 2002). The authors suggested that alternative ways of
conveying empathy and warmth can be used such as through voice tone and being
more explicit verbally. Similar results were found by Ghosh, McLaren, and Watson
(1997) using a psycho-educational/eclectic model of therapy. In both studies, the
development of a positive therapeutic rapport was not hindered at a lower bandwidth
despite the loss of some non-verbal cues and body language and a slight sound delay.
In a case series of six bulimic patients (Simpson, Bell, Knox, & Mitchell, 2005)
treated solely via high bandwidth videolink, all rated therapeutic alliance highly
throughout treatment and scores were comparable with previous findings on studies
with depressed patients who were seen face-to-face. Participants adjusted to video
therapy at varying rates. They indicated that as they adjusted to video therapy, their
relationship with the therapist was ‘different’, but not necessarily any better or worse
than a face-to-face relationship would be. Even those patients with poor treatment
outcomes indicated that they valued their video therapeutic relationship. It was
suggested that for those who are most reluctant or anxious about video therapy, an
initial face-to-face session aimed at establishing rapport and demonstrating use of
equipment may be enough to encourage them to trial it for a period. Holtom (2005)
reiterates this by suggesting that therapists prepare patients for video therapy and be
empathic about anxieties experienced as they undergo a period of adaptation to the
videoconferencing environment.
Holtom (2005) interviewed 10 patients with a range of clinical presentations who
had experienced person-centred therapy both face-to-face and via a videolink. She
reported that most participants found it possible to develop a positive therapeutic
rapport over the videolink, but that those who had experienced several face-to-face
sessions were more resistant to this. She found that a therapeutic ‘safe space’ for
discussing difficult or painful issues can be created via videoconferencing and that
this is a factor that facilitates rapport, alongside other issues such as the ability to
establish relational depth and connection with patients. Although some authors have
expressed concerns about social presence (developing awareness of and a sense of
connection to another through non-verbal cues) (e.g. Allen & Hayes, 1994), evidence
suggests that most patients are satisfied with the level of presence, sometimes even
after just one session (Capner, 2000; Simpson, Doze, Urness, Hailey, & Jacobs, 2001).
278 S. Simpson

It seems likely that the environment at the remote site also plays a part in
determining how relaxed and ‘safe’ patients can feel when discussing difficult and
personal issues. For example, an open office in a noisy Accident and Emergency
department may be more likely to raise anxieties associated with confidentiality and
being overheard than a sound-proofed room in a designated videoconferencing clinic
with such facilities as tissues, a telephone, a comfortable chair and so on to hand.
The availability of other technological aids (e.g. document camera, email (especially
for diaries, homework etc.) and fax) may also facilitate collaboration and
communication.

Telepsychiatry
A high proportion of telehealth studies have evaluated psychiatric interventions,
largely consisting of the management of patients with acute and severe mental health
problems through medical monitoring, with supportive counselling. These mostly
comprise ‘novel clinical demonstrations’ of the use of videoconferencing within
psychiatry (Monnier, Knapp, & Freuh, 2003). For example, Alessi (2002) reported
that he successfully treated an adolescent with major depressive disorder, opposi-
tional defiant disorder and attention deficit disorder by using videoconferencing for
medical monitoring, family therapy and supportive counselling. Outcome measures
were not specified. A recent expansion in this area has been to provide psychiatric
care in prison settings (e.g. Zaylor, Nelson, & Cook, 2001; Nelson, Zaylor, & Cook,
2004).
One of the most important recent studies by Ruskin et al. (2004) involved a
randomised controlled trial with 119 depressed veterans who were randomly assigned
to psychiatric treatment (psychotropic medication, psychoeducation and brief
supportive counselling) either face-to-face or via videolink. Results of this study
showed that both groups of patients improved as shown by scores on validated rating
scales and semi-structured interview, with no significant differences between groups.
Drop-out rates were also equivalent for both groups. For a more detailed account of
telepsychiatry studies, refer to Wootton, Yellowlees, and McLaren (2003).

Psychiatric and psychological assessments

A number of studies have supported the reliability of assessment methods by
videoconferencing. However, due to small numbers and non-random sampling
procedures, the generalisability of results cannot be assumed.
Baer et al. (1995) found high levels of reliability for scores obtained through self-
report scales and interviews for both depression and obsessive compulsive disorder
via videoconferencing. Ruskin et al. (1998) also found comparable results for the
assessment of depression conducted via videoconferencing and face-to-face. Zarate
et al. (1997) reported that patients with schizophrenia could be reliably assessed via
both low and high bandwidth videoconferencing settings but that negative (non-
verbal) symptoms were less reliably detected in the low bandwidth condition.
Yoshino et al. (2001) also reported on the difficulties associated with observing
behaviour via low bandwidth videoconferencing, finding self-report to be more
accurate. Jones et al. (2001) found video assessments for those with a history of
alcohol abuse to be equivalent to face-to-face, although testing took longer via
videoconferencing.
 British Journal of Guidance & Counselling 279

A range of studies have also found high levels of reliability for psychometric
testing via videoconferencing, including a screening measure for cognitive impair-
ment and a structured interview schedule designed to identify early cognitive
impairment (Ball & Puffett, 1998), although reliability levels in the latter study
varied widely between subtests. Montani et al. (1997, 1998) found high reliability
levels for cognitive and visuospatial testing of elderly inpatients but suggested that
the quality of videoconferencing sound and picture may substantially affect reliability
levels, as well as patient factors such as anxiety levels or inconsistencies between
raters. Assessments for depression and cognitive status of both elderly veterans
(Menon et al., 2001) and children (Elford et al., 2000) were also found to be
satisfactory via videoconferencing.
Neuropsychological testing has also been trialled via low bandwidth videocon-
ferencing (e.g. Kirkwood, 1998) with some success. A number of modifications were
necessary in order to carry out testing in the videoconferencing mode, including
providing materials for each test in separate envelopes, making adjustments in light
and brightness and minimising movement in order to ensure clear presentation of
visual material. It was noted that testing via videoconferencing may produce less
performance anxiety in participants due to the absence of the assessor in the same
room. However, inconsistencies in results obtained between presentation modes for
certain tests may have been caused by difficulty in hearing the correct pronunciation
of words and of transmitting clear pictures over the (low bandwidth) videolink.
Schopp, Johnstone, and Merrell (2000) reported that patients found no differences
between neuropsychological assessments conducted face-to-face or via a videolink,
but that psychologists preferred face-to-face. Troster, Paolo, Glatt, Hubble, and
Koller (1995) and Biggins (1998) conducted neuropsychological assessments with the
aid of a psychometrician/health worker at the remote site, although the actual testing
was administered by the neuropsychologist. The latter author also made a number of
adaptations in the way in which material was presented via videoconferencing by
utilising a slide projector, video-recorder and document camera, and for the majority
of tests no significant differences were found between scores presented face-to-face or
via videoconferencing. It was suggested that in order to ensure precise results, test
instructions should be kept clear and brief.

Cost-effectiveness
Very few clinical studies to date have made cost-effectiveness calculations. The
evaluation of costs encountered or saved through the use of videoconferencing must
take into account such factors as family and work commitments, costs incurred
through time and expense of travel (and delayed flights or ferries due to adverse
weather) and accessibility of public transport. Werner (2001) highlights the
importance of considering the benefits of social contact when calculating cost-
effectiveness. Costs of videoconferencing facilities include installation and main-
tenance of equipment, ongoing technical support, documentation requirements,
accommodation and staff training. There is no doubt that if videoconferencing
facilities are placed in a centrally accessible area and are made available to a range of
clinical services, then their cost-effectiveness will increase significantly. Sadly, this is
often not the case, with pressure on accommodation within the NHS often leading to
videoconferencing systems being sited in unsuitable rooms which are overbooked for
other purposes. Lack of ongoing training and technical support can reinforce this
280 S. Simpson

problem by discouraging professionals from a range of clinical services from utilising

the facilities available. If patients are recruited from just one or two sites and demand
is low, then it can be more difficult for telehealth services to ‘break even’ (e.g.
Mielonen, Ohinmaa, Moring, & Isohanni, 2000; Simpson, Doze, Urness, Hailey, &
Jacobs, 2001).
However, initial studies in this area suggest that when managed and organised
well, services provided by videoconferencing may lead to cost savings for both
patients and health services (e.g. Bose et al., 2001; Jones et al., 2001). On the basis of
their randomised controlled trial, Ruskin et al. (2004) reported that psychiatric
treatment conducted via videoconferencing was more expensive per session than face-
to-face. However, these differences were no longer apparent once the cost of
psychiatrists travelling a distance of greater than 22 miles away from their base was
taken into account. Dunn, Choi, Almagro, Recla, and Davis (2000) reported that a
telehealth network that was made available to a range of clinical services led to
savings in monthly telecommunication costs of approximately 67%. Similarly, a
service conducting psychiatric assessments with elderly residents living in rural areas
found that these were most cost-effective when conducted via videoconferencing
(Tang, Chiu, Woo, Hjelm, & Hui, 2001).

Other clinical uses of videoconferencing technology

Clinical supervision
Supervision and consultancy both within and across professions is becoming
increasingly common, and is often a more cost-effective way of delivering
psychological services.
Relatively few studies have examined the feasibility of providing clinical super-
vision at a distance, but those that have show promising results. Gammon, Sorlie,
Bergvik, and Hoifodt (1998) examined the use of psychotherapy supervision via
videoconferencing for psychiatric trainees in Norway. Six trainees met individually
with one of two supervisors for 10 supervision sessions, alternating between
videoconferencing and face-to-face modes from week to week. All trainees and
supervisors found videoconferencing a suitable mode of supervision delivery, but
satisfaction levels varied. Some found it difficult to adjust to the reduced visibility of
non-verbal cues and eye contact, although most participants adjusted over time and
became more comfortable once they became familiar with the relationship and
developed more awareness of other forms of communication open to them. Some
preferred video-supervision because it tended to be more structured and direct than
face-to-face sessions. One interesting observation was that by observing the
limitations placed on communication via videoconferencing, participants actually
developed more awareness of supervisory process factors, which in turn enhanced the
overall quality of supervision. It was recommended that by being actively aware of
the influence of videoconferencing throughout the supervision process and by openly
reflecting on these issues, this can become fuel to the overall learning process of
supervision. Opinions also varied in relation to the level of social presence in video-
supervision sessions. Whereas one supervisee felt that these were less personal and
more distant than face-to-face sessions, another commented that supervisees were
more able to listen and concentrate, thus enhancing their ‘presence’ during video
sessions.
 British Journal of Guidance & Counselling 281

A similar study by Sorlie, Gammon, Bergvik, and Sexton (1999) using the same
methodology showed that supervisor ratings of alliance and communication did not
differ between the two conditions (video vs. face-to-face supervision), but supervisees
preferred the face-to-face condition, particularly when discussing unpleasant or
difficult issues. Analysis of sessions revealed that there were no differences between
conditions in relation to gesturing, turn-taking, listener-response or note-taking.
Authors recommended that individual differences should be taken into account and
that the option of providing initial face-to-face sessions may facilitate the process for
less experienced supervisees. These findings suggest that there is wide variation in
individuals’ experiences of working via videoconferencing and therefore, in super-
vision as in therapy, finding ways of matching individuals with modalities is likely to
be of importance for future studies.

Legal and ethical issues

As the provision of psychotherapeutic services via videoconferencing becomes more
accessible, it will be essential to establish the legal and ethical implications of offering
these across different states and countries, which have differing regulations for
registration. Capner (2000) suggests that therapists make explicit to patients that all
services are considered to take place at the psychologist’s place of work regardless of
the location of the remote site in order to provide some protection against litigation,
which may confuse this issue. In addition, she cautions that if therapists collaborate
with other health professionals at remote sites, it is essential that the boundaries are
clarified as to who is responsible and qualified to carry out which tasks, in order to
avoid the risk of professional litigation. It is particularly important whilst we are in
this early stage of developing videoconferencing psychotherapy services, that
clinicians retain their professional standards and be conscious of upholding their
duty of care to patients, as in a face-to-face setting.
It will be important for psychologists and psychotherapists to be involved in the
development of guidelines and protocols which direct the expansion of mental health
services through the use of videoconferencing. This will allow us to work more
flexibly across a range of settings, whilst putting procedures in place will ensure that
patients are aware of their rights and are protected within this technological
arrangement (Koocher, 2007). Much can be learned from the guidelines which
have already been written on the use of text-based technology (Anthony & Jamieson,
2005; Goss, Anthony, Jamieson, & Palmer, 2001).
While some services may wish to wait until larger scale trials are forthcoming
before introducing video therapy services, it is important to take into account the
promising evidence that already exists. On this basis it may be considered unethical to
withhold services from those who are willing to use videoconferencing facilities and
who are otherwise unable to access help for mental health problems (Simpson, 2003).
Clinicians may consider seeking informed patient consent in order to provide some
protection for both patients and clinicians in the meantime.

Recommendations for future research

In order to ensure more rigorous and standardised research within this field in future,
it will be essential for papers to clearly describe such factors as study design,
assessment methods, professional background of treatment providers, outcome
282 S. Simpson

measures (including baseline and post-treatment ratings) and population sample

demographics. In addition, it is important to describe details such as bandwidth,
type of videoconferencing system, positioning of monitor and camera in relation
to participants and quality of sound and picture, as these variables are likely to lead
to considerably different outcomes (Schneider, 2001). Further research is needed to
explore the suitability of videoconferencing as a mode of treatment delivery for
various models of psychotherapy. In addition, it will be important to consider the
influence of personality and interpersonal style (of patient and therapist), diagnostic
category and individual preferences associated with personal control and space.
Current evidence suggests that therapist skill and experience in the use of techno-
logy may affect performance and confidence and it follows, therefore, that novice
clinicians may benefit from specific training and supervision in the use of
videoconferencing for psychological therapy.
One of the reasons for the present dearth of larger scale studies is the difficulties
encountered in recruiting adequate numbers of patients with a given diagnosis from
individual sites. Randomisation to treatment modes is often difficult to arrange, as
those living in the most remote areas are generally unable to access face-to-face
therapy due to the costs and disruption associated with travel. It would therefore be
advisable to carry out any larger scale future studies on a multi-site basis. This area of
research may be particularly suited to preference-based trial methodology (Brewin &
Bradley, 1989) which would provide data on the type of person who is willing to opt
for one mode of treatment delivery over another. This hybrid design aims to
maximise the internal validity of traditional experimental designs whilst maximising
external validity associated with clinical effectiveness studies. This would allow for
access to a greater number of participants, whilst providing a ‘natural’ control group
made up of those who do not opt to partake in video therapy.

Notes on contributor
Susan Simpson is a clinical psychologist based in the Eating Disorder Service in Aberdeen,
Scotland, where she has worked for the past 12 years. She did most of her training in Australia
(where she is originally from), and completed a clinical doctorate in psychology at the
University of Newcastle Upon Tyne, UK. She is experienced in providing psychological
treatment by videoconferencing and her doctoral dissertation was on the treatment of bulimic
disorders by video link.

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