It is critical to fully disclose potential limits of confidentiality with clients for therapies that involve use of wireless telephones, telephones with wireless extensions, and cell phones Koocher, Psychotherapists should consider using land lines to ensure greater client privacy and confidentiality.

Therapeutic alliance is important to the success of psychotherapy. It has been conceptualized as the bond between the psychotherapist and client as they work on the mutually agreed-upon tasks and goals of psychotherapy Bordin, Some have argued that therapeutic alliance may be difficult to develop in a telephone-based relationship. Haas noted a number of limitations with telephone-delivered psychotherapy Haas et al.

First, therapeutic alliance may be compromised because the psychotherapist may have difficulty understanding the client's experiences without access to nonauditory cues. Second, it may be difficult for the psychotherapist to convey empathy without being seen. Clients may be nonattentive and feel less in control because they cannot see their psychotherapist, or they may perceive telephone psychotherapy as less important and thus become less invested than in face-to-face psychotherapy Mozer et al.

Recent evidence, however, suggests that an effective therapeutic alliance can be established in telephone-delivered psychotherapy. As stated earlier, attrition rates for telephone psychotherapy are low Brenes et al. Both of these findings suggest the presence of therapeutic alliance. A few studies have examined therapeutic alliance in telephone-delivered psychotherapy. In the Brenes et al. In a qualitative study of telephone-delivered CBT, clients reported developing a sense of psychological closeness with their psychotherapist Bee et al.

Although differences in therapeutic alliance between face-to-face and telephone-delivered psychotherapy have not been examined fully, evidence suggests that a good therapeutic alliance can, in fact, be established in telephone-based psychotherapy. The American Psychological Association APA does not yet have ethical guidelines for the practice of telepsychology, resulting in great variability in its implementation Koocher, The APA does encourage psychologists who practice telepsychology to do so within the scope of the APA Code of Ethics and has indicated that concerns will be addressed on a case-by-case basis APA, The Ohio Psychological Association is the first state association to provide specific telepsychology guidelines Dielman et al.

The APA conducted a recent review of state telehealth laws. Of the 22 states with telehealth laws, only three have telehealth laws that apply to psychologists California, Kentucky, and Vermont , and California actually excludes telephone contact from these laws. A potential legal issue for psychologists practicing telephone-delivered psychotherapy is the location of both the psychotherapist and the client.

Most states consider the provision of psychotherapy to occur in the location of both the psychotherapist and the client. Thus, if the psychotherapist is in one state and the client is in another state, the service occurs in two states.

As a result, the psychotherapist unknowingly may be practicing without a license. Some states offer a temporary license that allows limited practice in a secondary state. An alternative is to obtain a license in another state if the psychotherapist plans to do a substantial amount of interstate work.

Another legal issue is obtaining informed consent for treatment. Just as in face-to-face psychotherapy, the traditional components of informed consent, such as disclosure of how personal health information will be used, exceptions to confidentiality, and the right to withdraw from treatment, must be explained to the client. Additionally, risks specific to telephone-delivered psychotherapy must be discussed.

Some crises that a psychotherapist may face when conducting telephone psychotherapy are suicidal intent, homicidal intent, and worsening symptoms.

Although these crises are not unique to telephone psychotherapy, they must be handled differently than in a typical face-to-face therapeutic relationship.

For example, a client in crisis may hang up during a session, preventing the psychotherapist from thoroughly assessing risk. Thus, the development of a safety plan from the start to reduce risk of crises, prevent adverse events, and respond appropriately to adverse events is of the utmost importance in telephone psychotherapy. Perhaps the largest issue in telephone psychotherapy is the psychotherapist's openness to working in a manner that seems so untraditional Bee et al.

Some reasons that psychotherapists may perceive telephone psychotherapy as more difficult include: 1 lack of nonauditory cues that can limit the psychotherapist's ability to interpret client experiences, responses, and ambivalence Haas et al. Interestingly, one study found that although psychotherapists employing telephone psychotherapy were initially skeptical, they were quickly able to develop strong, therapeutic relationships with clients and were generally satisfied with conducting psychotherapy in this manner Mohr et al.

Bee et al. In short, the limited research to date suggests that some issues of concern to psychotherapists about conducting psychotherapy by telephone are not as critical as initially believed. Telephone-delivered psychotherapy may not be appropriate for all clients. Clients whose primary problems are relationship-based in nature may benefit more from face-to-face psychotherapy, including clients who present with discordant relationships or difficulty with maintaining high functioning relationships.

Other clients may benefit from a combination of face-to-face and telephone psychotherapy. For example, individuals with problems with avoidance may use the telephone as a way to avoid fully confronting situations that provoke strong emotions and resultant avoidance. These clients may benefit from a mixed approach where telephone sessions can help the client develop coping skills and transition to face-to-face psychotherapy.

Similarly, telephone-delivered psychotherapy sessions may provide psychotherapists with an opportunity to be present in in vivo exposure exercises that otherwise would be impossible to complete in a traditional psychotherapy session. Clients for whom motivation for psychotherapy is low such as, clients undergoing court-mandated treatment, clients seeking treatment upon pressure from family or friends may receive minimal benefit from telephone-delivered psychotherapy.

More research is needed to determine who might benefit the most from telephone-delivered psychotherapy. 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.

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.

Much more work is needed to fully understand potential differential effects for psychotherapy delivery methods i. Another important issue is the dearth of research on telephone-delivered psychotherapy other than CBT.

This notion is partially supported by Beckner et al. 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. 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.

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.

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. 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.

Publisher's Disclaimer: The following manuscript is the final accepted manuscript. It has not been subjected to the final copyediting, fact-checking, and proofreading required for formal publication. It is not the definitive, publisher-authenticated version.

The American Psychological Association and its Council of Editors disclaim any responsibility or liabilities for errors or omissions of this manuscript version, any version derived from this manuscript by NIH, or other third parties. The published version is available at www. Her areas of research and practice include late-life anxiety, telephone-delivered psychotherapy, access to mental health services for rural populations, and the effects of anxiety on physical functioning and disability.

COBI W. Her areas of professional interest include assessment and treatment of anxiety, therapeutic outcomes, program evaluation, and professional development and training. Latin virtus et qualitas. English virtue and quality. Latin virtus et veritas. English virtue and truth? Latin virtus et labor. English power and labor. Latin virtus et scientia.

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