Clinical practice considerations
Developing the therapeutic relationship
The therapeutic relationship underpins all psychological services and consideration must be given to establishing this alliance in the context of electronic communication. In most cases, developing the therapeutic relationship in a telehealth service is comparable to face-to-face delivery, particularly when the provider is aware of what adjustments they can make to facilitate the therapeutic alliance with the client.
Providers of psychological services can improve the capacity for a healthy and strong therapeutic alliance by considering the following adjustments to their practice when delivering a service via videoconference:
a. Be aware of the effectiveness of teleconferencing services.
Research has shown that the quality of the therapeutic alliance using telehealth is comparable to face-to-face. However, there is also some evidence to suggest that providers may hold the belief that therapy conducted via telehealth will be less effective than face-to-face therapy and such beliefs can impact upon the therapeutic relationship. Providers can actively increase their awareness about the effectiveness of telehealth as a mode of delivering psychological services by engaging in professional development opportunities.
b. Make adjustments to the expression of empathy.
A key determinant of a therapeutic relationship is the level of empathy displayed by the provider.
Empathy can predict outcomes regardless of the modality, delivery mode, treatment format and severity of the clients presenting problem. Making adjustments to the way empathy is conveyed may compensate for factors such as delayed sound, reduced eye contact (i.e., looking at the screen instead of the camera), and the ability to respond in a physical manner (e.g., handing the client a box of tissues). Adjustments can include:
Emphasising verbal and non-verbal gestures. Research suggests that developing rapport with a client when delivering psychological services via teleconferencing requires providers to alter their communication style. Teleconferencing generally limits the amount of non-verbal information exchanged between the provider and the client. As a result, providers will need to emphasise both verbal (e.g., expressions of unconditional positive regard, acceptance and caring) and non-verbal gestures to facilitate rapport building. Skills that may need to be used more often include active listening, taking turns, paraphrasing, using shorter sentences, as well as slowing down the interaction and paying more attention to social cues and emotional expressions. Providers will also need to be more overt and deliberate with their non-verbal communications (e.g., inflection, tone, gestures and mannerisms) compared with what is typical during face-to-face sessions.
More frequently clarifying the meaning of clients’ facial expressions and body language.
c. Approaching the session with friendliness and warmth.
Compared with clients of face-to-face services, clients in a telehealth session are generally more sensitive to the level of friendliness and warmth expressed by the provider. Providers who adjust their communication style to convey a friendly and warm approach will assist their clients to feel comfortable and at ease with the videoconference environment.
Checking with the client about their experience of the therapeutic alliance.
It can be helpful to check in with the client about their experience of the therapeutic alliance/bond and/or use validated measures to gauge the quality of the alliance.
d. Be clear about the purpose, goals and limitations of treatment.
The therapeutic alliance is enhanced when, in addition to developing a therapeutic bond/attachment, the client and therapist are clear about the goals for treatment. Providers can enhance the therapeutic relationship by clarifying the purpose of therapy, the goals for treatment and agreeing on the tasks required to achieve the desired outcomes. Such discussions are standard practice at the beginning of any psychological intervention, but in a telehealth service is it important that the discussion also focuses on the client’s expectations for treatment delivered via videoconference. Providers should also be open with clients about the benefits and limitations of telehealth and work with the client to overcome any limitations. Providers are encouraged to regularly check-in with the client to review how the telehealth modality is working for them.
e. Optimising both client and provider visual and audio experience.
There are a number of considerations (e.g., camera position) when setting up videoconferencing technology that impact on the experience for both the client and the provider. These considerations can impact on the amount of information communicated and received by both parties to the session. For example, positioning the camera only on the client’s face limits the capacity of the provider to gather non-verbal cues. It is important that providers consider these factors when setting up the teleconference session so they can advise the client to make appropriate adjustments. Some aspects found to enhance the videoconferencing experience include:
- Adequate eye-contact with the client established by:
- Ensuring the provider and client are seated squarely in front of the camera lens.
- The provider adjusting their view of the client and assisting the client to adjust their view of the provider so that you can both see each other’s face clearly.
- The provider regularly alternating their gaze between the monitor and the lens of the camera when speaking and/or listening.
- Limiting the taking of written notes as thisaverts the provider’s gaze
- Removing any accessories or obstacles that obscure visibility of facial expressions
- Good lighting at both the client and the provider end.
- Privacy (no interruptions) at both the client and the provider end.
- Maintaining a video link throughout the session even if during times of discomfort, some clients wish to switch the camera off or engage in more subtle behaviours such as moving out of the view of the camera.
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