A qualitative study of clinicians’ experiences and attitudes towards telephone triage mental health assessments

Telephone delivery of psychological interventions: Balancing protocol with patient-centred care

Common mental health problems of anxiety and depression affect significant proportions of the global population. Within the UK, and increasingly across western countries, a key policy response has been the introduction of high volume, low intensity psychological assessment and treatment services, such as the NHS's Improving Access to Psychological Therapies (IAPT) service, the largest service delivery model yet to be implemented at a national level (England). IAPT may be delivered in face-to-face meetings or over the telephone, as well as through other media. In order to increase access and achieve wide reach with efficient use of resources, IAPT's service models utilise relatively structured and standardised protocols, whilst aiming simultaneously to deliver a tailored and personalised experience for patients. Previous research has revealed that this can be a challenging balance for front-line practitioners to strike. Here we report research into the telephone delivery of guided self-help, low intensity interventions within IAPT, examining the challenges faced in remote delivery when combining structure with personalisation during assessment and treatment sessions. We show the ways in which the lack of flexibility in adhering to a system-driven structure can displace, defer or disrupt the emergence of the patient's story, thereby compromising the personalisation and responsiveness of the service. Our study contributes new insights to our understanding of the association between personalisation, engagement and patient experience within high volume, low-intensity psychological treatment services. Our research on the telephone delivery of IAPT is particularly timely in view of the current global Covid-19 health crisis, as a result of which face-to-face delivery of IAPT has had to be (temporarily) suspended.

Psychotherapy by Telephone or Internet in Austria and Germany Which CBT Psychotherapists Rate It more Comparable to Face-to-Face Psychotherapy in Personal Contact and Have more Positive Actual Experiences Compared to Previous Expectations?

Objectives: COVID-19 has led to changes in the provision in mental health services. The current study investigated influencing factors on: (i) the comparability of psychotherapy via internet/telephone with psychotherapy in face-to-face contact as well as (ii) the actual experience with psychotherapy via internet/telephone compared to respective prior expectations in CBT therapists. Methods: A quantitative cross-sectional study was conducted in the form of an online survey. The research samples, registered cognitive-behavioral therapy (CBT) psychotherapists in Austria and Germany, were contacted by e-mail. Results: One hundred and ninety CBT therapists were analyzed in this study. The total number of patients treated via telephone/internet is a decisive factor for the subjective evaluation of the comparability of psychotherapy via telephone/internet and psychotherapy in personal contact. This factor also influences the extent (positive/negative) of the assessment of the actual experience with psychotherapy via internet/telephone compared to previous expectations. Neither age nor gender were associated with comparability of psychotherapy via internet/telephone with psychotherapy in face-to-face contact or the actual experience with psychotherapy via internet/telephone compared to respective prior expectations. Conclusions: Implications of the results are that attitudes towards remote psychotherapy might be increased in CBT therapists when they treat more patients remotely and experiences with remote psychotherapies should be included in psychotherapy training.

What influences practitioners' readiness to deliver psychological interventions by telephone? A qualitative study of behaviour change using the Theoretical Domains Framework

BACKGROUND

Contemporary health policy is shifting towards remotely delivered care. A growing need to provide effective and accessible services, with maximal population reach has stimulated demand for flexible and efficient service models. The implementation of evidence-based practice has been slow, leaving many services ill equipped to respond to requests for non-face-to-face delivery. To address this translation gap, and provide empirically derived evidence to support large-scale practice change, our study aimed to explore practitioners' perspectives of the factors that enhance the delivery of a NICE-recommended psychological intervention, i.e. guided self-help by telephone (GSH-T), in routine care. We used the Theoretical Domains Framework (TDF) to analyse our data, identify essential behaviour change processes and encourage the successful implementation of remote working in clinical practice.

METHOD

Thirty-four psychological wellbeing practitioners (PWPs) from the UK NHS Improving Access to Psychological Therapies (IAPT) services were interviewed. Data were first analysed inductively, with codes cross-matched deductively to the TDF.

RESULTS

Analysis identified barriers to the delivery, engagement and implementation of GSH-T, within eight domains from the TDF: (i) Deficits in practitioner knowledge, (ii) Sub-optimal practitioner telephone skills, (iii) Practitioners' lack of beliefs in telephone capabilities and self-confidence, (iv) Practitioners' negative beliefs about consequences, (v) Negative emotions, (vi) Professional role expectations (vii) Negative social influences, and (viii) Challenges in the environmental context and resources. A degree of interdependence was observed between the TDF domains, such that improvements in one domain were often reported to confer secondary advantages in another.

CONCLUSIONS

Multiple TDF domains emerge as relevant to improve delivery of GSH-T; and these domains are theoretically and practically interlinked. A multicomponent approach is recommended to facilitate the shift from in-person to telephone-based service delivery models, and prompt behaviour change at practitioner, patient and service levels. At a minimum, the development of practitioners' telephone skills, an increase in clients' awareness of telephone-based treatment, dilution of negative preconceptions about telephone treatment, and robust service level guidance and standards for implementation are required. This is the first study that provides clear direction on how to improve telephone delivery and optimise implementation, aligning with current mental health policy and service improvement.

Are there interactional differences between telephone and face-to-face psychological therapy? A systematic review of comparative studies

BACKGROUND

Despite comparable clinical outcomes, therapists and patients express reservations about the delivery of psychological therapy by telephone. These concerns centre around the quality of the therapeutic relationship and the ability to exercise professional skill and judgement in the absence of visual cues. However, the empirical evidence base for such perceptions has not been clearly established.

METHODS

We conducted a systematic review to establish what is known empirically about interactional differences between psychotherapeutic encounters conducted face-to-face vs. by telephone.

RESULTS

The review identified 15 studies that used situated, comparative approaches to exploring interactional aspects of telephone and face-to-face psychological therapy. These studies revealed evidence of little difference between modes in terms of therapeutic alliance, disclosure, empathy, attentiveness or participation. However, telephone therapy sessions were significantly shorter than those conducted face-to-face.

LIMITATIONS

We identified only a small number of heterogeneous studies, many of which used non-randomised, opportunity samples and did not use validated measures to assess the constructs under investigation. Disparate therapeutic modalities were used across studies and samples included both clinically diagnosed and non-clinical populations.

CONCLUSIONS

Available evidence suggests a lack of support for the viewpoint that the telephone has a detrimental effect on interactional aspects of psychological therapy. The challenge for clinical practice is to translate this evidence into a change in practitioner and patient attitudes and behaviours. In order to do so, it is important to understand and address the breadth of factors that underpin ongoing ambivalence towards the telephone mode, which pose a barrier to wider implementation.

Physicians' experiences, attitudes and challenges in a Pediatric Telemedicine Service

BACKGROUND

Telemedicine in general, and telephone triage, in particular, is considered a high-stress clinical activity and involves decision making under conditions of uncertainty and urgency.

AIM

We wanted to explore the experiences, attitudes, and challenges of the physicians in a Pediatric Telemedicine Service operated in Israel, and to explore whether the doctors are using non-medical factors (not related to the medical problem), when making the clinical decisions in this setting.

METHODS

We used a qualitative methodology in order to obtain rich data that would reflect the participants' subjective experiences. Fifteen physicians who worked during the last 5 years in the "Pediatrician Online of Clalit" service were interviewed. Data were analyzed thematically.

FINDINGS

Seven main themes concerning the physicians' challenges during their work at this service were revealed, including difficulties diagnosing from a distance, treating unfamiliar patients, working alone, urgency and load of calls, technological obstacles, and a "moral conflict" between the desire to meet parents' expectations and maintain standards of care. The physicians stated that non-medical factors also affect their decisions.

CONCLUSIONS

In telemedicine setting, physicians face various difficulties and challenges, requiring special expertise, qualities and skills. Special measures are needed to obtain proper diagnosis and decisions.

Telephone-based CBT and the therapeutic relationship: The views and experiences of IAPT practitioners in a low-intensity service

WHAT IS KNOWN ON THE SUBJECT

There is a move towards the use of new ways of delivering mental health care, particularly via an increased use of telephone therapies. Although some studies have noted the advantages of telephone-delivered therapies (e.g., removing access barriers) and reported on equivalent therapeutic effects when compared to face-to-face, there are concerns about how telephone-based therapy adversely affects the therapeutic relationship.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

It contributes new knowledge regarding psychological practitioners' experience and views about using telephone-based therapies and how this affects the therapeutic relationship.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

This paper provides data about the new practitioner workforce (IAPT Psychological Wellbeing Practitioners) and adds to a growing area of research regarding their clinical role. It has relevance for mental health nursing, because health services internationally and across the professions are exploring how telehealth can improve health care. This paper suggests that mental health services need to focus on what type of therapeutic relationship their practice facilitates and on offering transparency to service users. It concludes that telephone work in IAPT can accommodate a working alliance, but not other types of therapeutic relationship, which practitioners and service users hoped for. Services need to focus on what facilitates and inhibits deeper therapeutic closeness and connection.

ABSTRACT

Introduction Over-the-telephone (OTT)-delivered psychological therapies as an alternative method to face-to-face (F2F) are becoming more prevalent in mental health care. Research suggests a range of benefits of OTT use in therapy, but there are growing concerns about its consequences for the therapeutic relationship. This paper presents new knowledge regarding psychological practitioners' experience and views of OTT work and its potential effects on the therapeutic relationship in the context of the UK's Increasing Access to Psychological Therapy (IAPT) programme. Aim This paper presents IAPT practitioners' experiences and views of OTT work and its potential effects on the therapeutic relationship. Methods Completed questionnaires (exploring OTT versus F2F work) which were distributed to IAPT practitioners revealed a concern about the therapeutic relationship in OTT. To explore this further, nine in-depth semi-structured interviews with PWPs were conducted and the findings from this qualitative study are reported here. Results Practitioners noted OTT use facilitated access and flexibility for service users; however, they expressed some concern over the adverse effect of OTT on the therapeutic relationship. Discussion Although a working alliance was possible OTT, this research suggests the type of therapeutic relationship formed OTT in a "low contact-high volume" service such as IAPT needs to be better defined. By addressing this, dissonance which might arise between practitioner aims and the aims of IAPT can be reduced. This research also contributes to wider debates regarding mental health care and its provision in the UK. Implications for practice This paper concludes that mental health services need to focus on what type of therapeutic relationship their practice facilitates and to offer transparency to service users. The findings suggest that telephone work in IAPT can accommodate a working alliance, but not other types of therapeutic relationship, which practitioners and service users hoped for. Services need to offer a more nuanced understanding of the concept of a therapeutic relationship and focus on what facilitates and inhibits deeper therapeutic closeness and connection.