Assessment of the Therapeutic Alliance in Face-to-Face or Videoconference Treatment for Posttraumatic Stress Disorder

Introduction

Anumber of empirical studies show that the therapeutic relationship constitutes one of the key ingredients in any form of therapy.^1–3 In general, therapeutic alliance is defined as the cooperation demonstrated by both client and therapist in their therapeutic work. ⁴ Although numerous specific elements can be associated with this concept, the tripartite model developed by Bordin allows many of them to be integrated into a coherent whole. ⁵ He considers the alliance to be the result of three interdependent components: (a) agreement on the tasks to be accomplished during therapy, (b) agreement on the aims and goals, and (c) the quality of the affective bond between the therapist and the client. This last concept refers to the possibility of developing a positive interpersonal attachment, in particular through mutual acceptance and trust.

In a setting in which access to mental health care for the whole population remains a concern, telepsychotherapy offered by videoconference constitutes an interesting option for providing and supporting certain services remotely.^6,7 However, some clinicians believe that the therapeutic alliance is at risk due to the rather unconventional nature of this kind of intervention, and thus they remain hesitant to use psychotherapy remotely. In fact, psychologists seem to spontaneously adopt a negative attitude toward this kind of service because, in their view, videoconferencing is likely to compromise the therapist's warmth, sensitivity, empathy, and understanding. ⁸

Nevertheless, one of the advantages of videoconferencing is that it constitutes a technology that enables individuals to see and hear each other in real time on a computer monitor or video screen. As a result, this technology is the one that most closely resembles a traditional face-to-face consultation. ⁷ Despite this advantage, it is important to consider the impact of this medium on the therapeutic relationship. Currently, the literature shows that the therapeutic alliance does not appear to be compromised by videoconferencing. Indeed, the few studies that evaluated this concern with several different psychopathologies show that there is no significant difference in the quality of the therapeutic alliance between traditional and videoconferencing therapies.^9–12 Moreover, videoconferencing does not appear to compromise the scope or depth of the topics discussed in therapy or the emotions that clients feel. ¹¹

Despite these results, the number of studies on the topic remains limited, and consequently the generalizability of the results is doubtful. Further, specific variables involved in videoconferencing that could have an impact on the therapeutic relationship have yet to be explored. For example, the level of comfort with remote communication or the initial perception of telepsychotherapy could harm the therapeutic relationship. More importantly, it is essential to consider the sense of presence felt when new technologies are used to provide therapy. ¹³ The sense of presence refers to the subjective experience of being in a specific place, whereas in reality, the individual is physically somewhere else. ¹³ It is therefore plausible to hypothesize that the absence of one of these conditions in a videoconference could potentially interfere with the development of a high-quality therapeutic alliance.

Psychotherapy provided by videoconference could benefit a great number of individuals with mental health problems, including the victims of traumatic events. To date, cognitive behavior therapy remains the therapeutic approach of choice in the case of acute or chronic posttraumatic stress disorder (PTSD).^14,15 Because the therapeutic alliance seems to constitute a significant element in the process of change, ¹ it is an important aspect to consider when psychotherapy is provided by videoconference, and especially to victims of trauma. Indeed, victims of trauma may sometimes adopt a defensive interpersonal style, characterized by mistrust. The creation of a therapeutic atmosphere that allows trauma victims to feel safe is therefore important in order to foster nonthreatening contact, which in turn promotes the healing of relational problems triggered by a traumatic experience. ¹⁶

The objective of this study is to assess the impact of cognitive behavior therapy for PTSD, administered by videoconference or face to face, on the development of a quality therapeutic alliance. In addition, an exploratory assessment of the relationship between certain variables specific to the context of videoconferencing is undertaken. The variables being assessed include the individual's comfort with remote communication, the sense of presence felt during a videoconference, the individual's initial perception of the videoconference, and the quality of the therapeutic alliance.

Methodology

Results

Discussion

The results show that telepsychotherapy does not negatively affect the development of a therapeutic alliance in individuals with PTSD. These results substantiate the data from earlier studies on this subject.^10–12 In fact, therapeutic alliances developed similarly, and markedly, in both the videoconference and face-to-face treatment conditions. Interestingly, the avoided situations treated during in vivo exposure did not appear to alter the quality of the therapeutic alliance in either treatment condition.

Another important point is that the alliance clearly does not appear to be negatively affected by certain variables associated with videoconferencing. For example, participants' initial comfort level with remote communication had no effect on the development of a therapeutic alliance during treatment. Similarly, participants' initial perception of telepsychotherapy meetings was not related to the development of an alliance. Thus, people who are not accustomed to this type of technology could successfully receive videoconferencing therapy despite their initial discomfort or prejudices concerning this type of communication. Interestingly, certain client variables, (e.g., a defensive attitude toward therapy and a lack of psychological preparation)^27,28 that have been found to be associated with the development of an unsatisfactory therapeutic alliance in traditional therapy do not seem to have this negative impact on videoconferencing. It would have been interesting to examine the therapists' attitudes toward videoconferencing and find out whether an initial negative attitude on their part can affect the development of the therapeutic relationship. In fact, studies of therapists' characteristics that can have a negative impact on the therapeutic alliance show that therapists who are uncertain, critical, or tense are likely to undermine the development of the therapeutic relationship. ²⁹ Thus, therapists who show this kind of attitude because videoconferencing is being used could harm the therapeutic alliance.

It was also found that the sense of presence felt during the videoconference and the perception of the session (complete immediately after the session) may be related to the therapeutic alliance. Measuring the differential impact of these two variables reveals that perception of the most recent session is a more powerful predictor of alliance than is the sense of presence felt. However, the sense of presence has more impact on the therapeutic alliance after the treatment is completed. According to Bouchard et al., ⁹ the feeling of a strong sense of presence could greatly facilitate the creation of a therapeutic bond.

One of the major strengths of this research is the use of a control group in the face-to-face condition, which allowed for the comparison of the results. In terms of limitations, technical problems occurred with the videoconferencing sessions. These problems were essentially the result of intermittent line breaks due to power outages, tests on the line by the technology center, or power surges on the transmission line when several systems were connected at the same time. For all these reasons, the sessions were sometimes abruptly interrupted or, in some cases, unable to even start. Although these problems occurred only occasionally, such sudden, unforeseen interruptions could potentially result in ruptures in the therapeutic alliance. ³⁰ In general, these technical problems lasted only a few minutes, and the sessions were completed appropriately. If this was not the case, the therapists were also able to complete the sessions with their clients by telephone. It should also be noted that a resource person was always available on site if needed for technical support.

It is also important to mention that there is a slight time lapse in dialogue during videoconferencing, which may make communications less fluid. Further, certain subtle nonverbal signals might not be detected during a videoconference, either because one cannot always see an individual's entire body or because of slight interference in the image quality. Finally, during particularly difficult moments, the therapist may feel limited in his or her tangible ability to assist the client (e.g., by handing a tissue to a client who is crying). All of these characteristics could have damaged the development of a therapeutic alliance. However, it appears that these factors were not important enough to have a significant impact on the establishment of a quality relationship.

The results of this study are very promising for the health care system, especially for its beneficiaries. Despite the apprehension that distance could affect the therapeutic alliance and the presence of certain limitations associated with the videoconferencing system, it was found that the therapeutic relationship did not appear to be damaged and that it remained completely comparable to the kind of alliance that can develop during more conventional face-to-face treatments. Thus, it must be acknowledged that videoconferencing is a completely viable, attractive method of administering specialized health care services to individuals who would not otherwise have access to them. In light of the potential advantages of videoconferencing, various technical obstacles can be overlooked in order to improve access to health care and specialized services. Although the advances in technology allow videoconference systems to become increasingly more effective and reliable, it would be unrealistic and undesirable to substitute traditional services with this medium. Above all, the goal of videoconferencing is to ensure that services are made readily and quickly available. Of course, more studies are required in order to further evaluate the impact and effectiveness of videoconferencing.