The University of Nottingham
School of Education
MA Counselling
An Exploration of the Concept of Telephone Counselling/Psychotherapy
According to Recent Literature
Tutor: Max Biddulph
1
Module XXD043
Contents
Part A
Introduction………………………………………………………………………………………..3
Literature Review
1.1 Is the literature which discusses ‘telephone counselling, therapy or
psychotherapy’ offering that, or is it really offering something else
altogether?………………………………………………………………………4
1.2 Do some modalities lend themselves more readily to telephone work?..……8
1.3 Discussion………………………………………………………………………………………15
Part B
Research Design
2.0 Research questions………………………………………………………………….………17
2.1 Methodology…………………………………………………………………………….…….17
2.2 Method……………………………………………………………………………………….…18
2.3 Ethical considerations……………………………………...………………………………19
2.4 Data recording………………………………………………………………………………..20
2.5 Research instrument………………………………………………………………………..21
2.6 Data analysis and data interpretation………………………………………………….21
2.7 Findings-limitations and strengths………………………………………………………22
2.8 Dissemination and future considerations………………………………………………23
2.9 References……………………………………………………………………………………..24
3.0 Appendix………………………………………………………………………………………..28
2
1.0 Introduction
The aim of this work is to evaluate recent findings in the literature regarding telephone
counselling and telephone psychotherapy. For instance, Cooper (2009) states “ For many
forms of psychological distress, telephone…interventions appear to be as effective as face-toface interventions” (p. 155). So the focus of this piece is to identify within the literature what
is being offered in studies that claim to be delivering counselling/psychotherapy over the
telephone. In addition, I consider which forms of therapy are reported as efficacious in
telephone work. My personal positioning as a humanistic counsellor causes me to question
whether a sufficient level of therapeutic alliance can be achieved without, for example, nonverbal communication to bring about personality change. The BACP (British Association of
Counsellors and Psychotherapists) (2009) states “Counselling does not involve giving advice
or directing a client to take a particular course of action .” However, I also recognise that
there are instances when the concept of telephone counselling/psychotherapy, if possible,
could be very beneficial. For example, practical issues such as travelling costs and childcare
or a disability, which makes travelling to a clinic difficult.
A search of the literature from 1999–2010 was conducted via databases Psych
Articles APA, Psych Info Ovid, Cochrane and Pubmed. Some keywords included
telephone counselling, telephone psychotherapy and tele-therapy.
3
Literature Review
1.1 Is the literature which discusses ‘telephone counselling, therapy or
psychotherapy’ offering that, or is it really offering something else altogether?
Eakin et al. (2009) used a twelve-month telephone counselling intervention to ascertain
whether physical activity and diet in primary care patients could be improved as a direct
result. This randomised controlled trial compared telephone counselling interventions versus
usual care. It studied 434 adult patients with type-2 diabetes or hypertension from a
disadvantaged community. Patients were recruited from ten primary care practices. Physical
activity and dietary intake were assessed by self-report at baseline, four and 12 months.
According to the authors,
The study demonstrated modest improvements in diet and in physical
activity…significant intervention effects include for telephone counselling minus
usual care were reported as: calories from total fat (decrease of 1.17%;
p<0.007), energy from saturated fat (decrease of 0.97%; p< 0.007),
vegetable intake (increase of 0.71 servings; p<0.039), fruit intake (increase of
0.30% servings; p< 0.001), and grams of fiber (increase of 2.23 g; p<0.001).
(Eakin et al., 2009: 142).
The authors are therefore demonstrating a significant probability-value that a telephone
intervention can encourage patients to comply with an improved diet. However, the authors
report that the telephone counselling intervention was delivered by ‘master’s level graduates
with a background in nutrition’, which would therefore emphasise their nutritional expertise.
The graduates were “given additional training in physical activity promotion, motivational
interviewing techniques and social-cognitive theory” (Eakin et al., 2009: 143). This would
suggest that the authors viewed the ‘counselling’ aspect of the trial as secondary to the
4
expertise on nutrition. However, the ‘therapeutic interventions’ may well have been covered
by ‘additional training’, as the goal of the intervention was ultimately to measure
improvement in physical activity and diet, as opposed to affecting personality change. In this
instance, motivational interviewing, promotion and grounding in social-cognitive theory was
sufficient in achieving compliance using a telephone intervention. However counselling or
psychotherapy did not achieve its goals.
In their research article, Bee et al. (2008) offer a meta-analytic systematic review of
randomised trials of one-to-one remote psychotherapy. Thirteen studies were highlighted in
total, ten of which took place over the telephone. However, the authors highlight that, in
several studies, telephone support is given as an adjunct. The authors outline each of the
interventions in the review. The first of these is Hunkeler et al. (2000), in which usual care
plus telephone support and peer care are given to depressed primary care patients. According
to this study, nurses encouraged medication compliance, education about side effects and
behavioural activation plans comprising of a mean of 10.1 x 5.6-minute sessions spread over
a sixteen-week period. The outcome of this study had a good indication with a CCDAN-CTR
score of 25. However, I would suggest that the trial is more an indication of successful
medication compliance than telephone counselling or psychotherapy. With each telephone
session lasting and average of 5.6 minutes, it seems unlikely that a therapeutic relationship
will be established. However, the study was aimed at improving depression by increasing
compliance with medication. Its success is an indication that telehealth is a useful adjunct to
usual care.
Bee et al. also cite Lovell et al. (2006) as an intervention in the review. Lovell et al.
state in this research that
The clinical outcome of cognitive behaviour therapy delivered by telephone
was equivalent to treatment delivered face-to-face and similar levels of
satisfaction were reported.
5
(Lovell et al., 2006: 883)
So this is a report based on 72 patients with obsessive-compulsive disorder who felt
comfortable enough with telephone counselling to take part. The treatment times were
shorter for telephone counselling, comprising of 8 x 30-minute sessions, versus ten one-hour
sessions face-to-face. Both treatments were delivered by each cognitive behavioural therapist
and consistency was maintained by manuals, regular supervision and training. Of the 36
allocated to each form of therapy, fewer patients completed the face-to-face intervention
(n=33) and the six-month follow-up (n=30). All of the patients allocated to the telephone
intervention completed intervention and follow up (n=35). There is an important point here
that assertive outreach is much easier to achieve for telephone work than face-to face. One
exception to this was a patient who “was withdrawn from the telephone arm owing to
increased depression and suicidal ideation deemed by the therapist to warrant a face-to-face
appointment” (Lovell et al., 2006: 885). It would seem that the therapist felt that suicidal
ideation was not appropriate for the telephone, but face-to-face work was. Clinical outcome
was equivalent to treatment delivered face-to-face (p. 886), “The effect size of treatment was
2.5 which is as large or larger than other studies of face-to-face cognitive behavioural therapy
in obsessive compulsive disorder.” Lovell and colleagues highlight that the telephone session
duration was 50 per cent less than face-to-face, which, according to Lovell et al., has
“important economic implications” (p. 886). The authors highlight the potential cost savings,
but do not consider the impact on the therapist of a significantly higher caseload over the
telephone.
Bee et al. (2008) next consider Lynch, Tamburrino and Nagel (1997) as a
psychotherapeutic intervention of telephone counselling versus comparison group.
Results showed that the telephone group had significantly lower post
intervention scores on the HDRS compared with their pre-intervention scores.
Scores did not differ significantly over time in the comparison group. Post
6
intervention, the telephone group also had lower BDI scores, and more positive
scores for social health, mental health, and self-esteem on the DHP, than did
the comparison group.
(Lynch et al., 1997: 293)
According to Lynch and colleagues, outcomes measured against the comparison group
showed improvement. However, as Bee et al. point out, no further details were provided for
the comparison group, suggesting that these patients were offered nothing more than usual
care. However, without further details no further comparison can be drawn. The intervention
comprised of 6 x 20-minute problem-solving sessions for depression plus homework
comprising of “…the connection between depressed mood and problems, expressing
problems in a form that facilitates solutions, evaluating and modifying these solutions ” (2008:
293). The description of this intervention makes me question the term ‘psychotherapy’ when
used in this context. I will return to this point in the discussion.
Bee et al. (2008) also include another study by Lynch et al. (2004) in which
telephone problem solving and telephone stress management were each compared with
usual care. In a randomised controlled trial, 54 patients with mild depression were allocated
to either usual treatment, telephone problem solving or telephone stress management.
However, of the 36 who were allocated to a telephone treatment, half declined further input
early in the study. Of the remaining subjects, the author reported a significant drop in
depression. Outcome measures were BDI, HAMD and DHP (see Appendix). The CCDAN score
was 17, although this was based on a small sample and a low number of completed
participants. The authors concluded that
…since all subjects tended to improve, regardless of treatment received, mild
levels of depression may generally remit even without focal intervention, and
watchful waiting may be a reasonable alternative…
(Lynch et al., 2004: 790)
7
The author suggests that watchful waiting may have the same efficacy as the telephone
interventions used in the project. This was a finding in Asay and Lambert (1999), where only
15 per cent of client variance in the process of therapeutic change was attributable to specific
therapeutic intervention, whereas 40 per cent was apportioned to client variables and extratherapeutic events. However, the level of therapeutic input is still minimal in Lynch’s study,
with few patient outcomes with which to draw a parallel.
1.2 Do some modalities lend themselves more readily to telephone work?
Ludman et al. describe the
…long-term effects of a randomised trial evaluating telephone-based cognitive
behavioural therapy (CBT) plus care management for primary care patients
beginning anti-depressant treatment versus usual care.
(Ludman et al., 2007: 257)
The authors report that using a short, structured program of CBT can significantly improve
clinical outcomes for the majority of patients beginning pharmacotherapy in the setting of
primary care (p< 0.001). According to Chilvers et al. (2001), between 50 and 60 per cent of
primary care patients with depressive disorders prefer psychotherapy as the initial or primary
treatment. The authors cite this as an indication of the amount of people who would choose
psychotherapy, given the option. They then cite Unutzer et al. (2003) to demonstrate that,
despite evidence of an initial preference, few primary care patients received counselling. The
authors suggest that limitations such as time and travel can present difficulties for access, or
potential mental health stigma confrontation. In the author’s opinion, pharmacotherapy then
becomes the norm due to lack of resources, both on behalf of the client and primary care.
8
Ludman et al. hypothesised that the adjunct of telephone psychotherapy and care
management would improve long-term outcomes for those with depressive symptoms and
using antidepressants.
Psychotherapy
and
telephone
care
management
to
primary
care
antidepressant treatment for nonpsychotherapy seekers would lead to
improved long-term outcomes.
(Ludman et al., 2007: 260)
Here the authors state that the patients involved in the study were not wishing to engage in
psychotherapy at this time, so ‘traditional’ CBT methods were simplified for this trial. The CBT
program offered underwent adaptations in order to make it more palatable. It was delivered
by telephone, and CBT content was modified to focus simply on behavioural activation and
identifying and working with negative thoughts. The timing and length of sessions was
flexible, in order to accommodate patient preference. Yet despite this “ vigorous and
persistent outreach…following the model of assertive outreach strategies” was required in
order to facilitate “treatment engagement and adherence’ ”. This would suggest time was
spent in trying to get the client to answer the phone. It is reported that on average, three
outreach call attempts were needed to complete one telephone session, suggesting that a
significant amount of clinical time was spent in failed attempts to access patients. This is
despite the fact that the “phone counsellors were master’s level psychotherapists with at least
one year of experience in outpatient psychotherapy of depression ”. A comparison of ‘failures
to engage’ is not offered for the same therapists working face-to-face. Obviously, this level of
assertive outreach would impact the cost-effectiveness of the program.
The authors hypothesised that the addition of ‘psychotherapy’ would improve longterm efficacy, however they seem to equate psychotherapy as ‘simplified CBT’. However,
according to the Royal College of Psychiatrists (2010),
“… psychotherapy usually involves
regular meetings at the same time and same place every week…you meet a therapist on your
9
own to talk together in a quiet room, usually for fifty minutes ”. The Royal College of
Psychiatrists state that psychotherapy is face-to-face, in a quiet room and at a regular time
for a fifty-minute period. The intensity of this commitment appears different to that of
Ludman et al. However, a client who has never experienced therapy before would have no
comparison to draw upon. So a telephone call with a mean session length of 31.44 minutes
may seem acceptable, particularly if the client is unable to access in-person therapy. The
authors conclude that the efficacy of a brief telephone CBT program improves clinical
outcome for patients beginning anti-depressant pharmacotherapy although they do also
concede that they “cannot determine what specific elements of the phone therapy program
account for its effectiveness”. However, increased compliance with medication was achieved
and HSCL (Derogatis et al., 1974) depression scores improved, albeit with a modest effect
size of 0.25–0.3.
In a study of alliance in two telephone-administered treatments and their subsequent
relationship with depression and health outcomes, Beckner et al. (2007) compared the
efficacy of telephone-administered cognitive behavioural therapy (T-CBT) and telephoneadministered supportive emotion focused therapy (T-SEFT). The 16-week treatments of 97
patients with multiple sclerosis (MS) found that alliance scores were significantly higher in TCBT compared with T-SEFT. According to the authors,
The findings suggest that the therapist-client relationship is important to
improvement in telephone therapy and that the role of alliance in outcome
may vary by treatment approach.
(Beckner et al., 2007)
Once again, the authors employ the term ‘psychotherapy’ when discussing the efficacy of
telephone contact as a therapeutic endeavour. When making a comparison between face-toface and telephone therapy, the authors cite that regarding in-person therapy, a recent metaanalysis of 79 different studies gives an evidence base of the link between therapeutic
10
alliance and outcome (Martin, Garske and Davis, 2000). Beckner et al. then acknowledge that
only limited research suggests that a parallel link can be made about telephone therapy
(Reese, Conoley and Brossart, 2002).
The authors of this study hypothesized that
A therapeutic approach which emphasises the development of an emotionally
close client–therapist relationship as a vehicle for therapeutic change may
show a stronger alliance–outcome relationship compared with a more
structured , skill-based modality such as CBT.
(Reese, Conoley and Brossart, 2002)
In discussion the authors state that this study demonstrates that there is a positive
correlation between therapeutic alliance and outcome for participants receiving T-CBT. Betas
for treatment analyses suggest that alliance may have impacted on disability solely in T-CBT.
(T-CBT =–0.25; T-SEFT =0.01). Beckner et al. (2007) hypothesise that the reason T-CBT
enhances therapeutic alliance over the telephone is its transparency as a therapeutic model
with reference to clear rationale, education and collaboration in goals. Perhaps CBT’s efficacy
over the telephone in this research is, therefore, about clients feeling that they have
something tangible to hold on to. However, according to Greenberg, T-SEFT differs from CBT.
Whereas cognitive-focused therapies operate from a top-down model by
challenging irrational beliefs to produce different affective responses, EFT works
from the bottom up, replacing maladaptive amygdala-based reactions with more
adaptive, functional, emotional responses.
(Greenberg, 2004)
It seems that this would be far more difficult to achieve over the telephone. The relative
simplicity of T-CBT and its shared workbooks at each location is not as achievable with an
11
experiential therapy, where clients benefit from the same physical location to explore nonverbal communication, for example.
The therapeutic relationship remains an essential feature of EFT in providing
emotional and social support critical in regulating emotions and promoting
change.
The second principle in EFT is emotion regulation. Primary emotions such as
shame…are often powerful enough to overwhelm. As the person touches on
these feelings, the supportive, validating and empathic therapeutic relationship
can help bring stability and comfort to assist in emotionally regulating.
Greenberg (2004)
Greenberg (2004) describes a number of strategies, which are designed to help the
client to experience change in affect. One of these strategies is shift attention. Greenberg
describes this as a way of diverting attention to areas of non-verbal information such as body
language or expressive manner. Another technique described by Greenberg (2004) is
expressive enactment in which clients are frequently asked to engage in open-chair dialogues
with either unaccepted parts of themselves or significant others for whom they experience
negative affect. These particular strategies appear difficult to achieve over the telephone;
first, because physically we would not be in the same room so would not be able to work with
the client regarding body language and expression. Secondly, open-chair dialogue requires a
therapist to ‘be on-hand’ to intervene and hold the client, should the experience become
unmanageable.
As graduate faculty in counselling psychology, I would not recommend that
entry-level counsellors use these techniques without proper clinical supervision
and a comprehensive understanding of the theoretical underpinnings…
(Sunich, 2007)
12
In this statement, Sunich is, of course, referring to face-to-face counselling, although his
guidance would surely be no less stringent for work over the telephone. In reference to the
training of the T-SEFT therapists in Beckner et al.’s research, it simply states that they were
“trained by a psychologist who was herself trained by the manual’s author …” though whether
this
constitutes
a
comprehensive
understanding
of
the
theoretical
underpinnings
recommended by the APA, remains unclear.
Bee et al. (2008) then consider Simon et al. (2004) who compare telephone
psychotherapy, telephone care management and usual care for depressed patients in primary
care. This study had a high admission and retention rate with participation between 93 and
97 per cent for the telephone arms of the trial.
Compared with usual care, the telephone psychotherapy intervention led to
lower mean Hopkins Symptom Checklist Depression Scale depression scores
( P = .02), a higher proportion of patients reporting that depression was "much
improved" (80% vs 55%, P<.001), and a higher proportion of patients "very
satisfied" with depression treatment (59% vs 29%, P<.001). The telephone
care management program had smaller effects on patient-rated improvement
(66% vs 55%, P = .04) and satisfaction (47% vs 29%, P = .001); effects on
mean depression scores were not statistically significant.
(Simon et al., 2004: 938)
The success of this trial could be connected with several factors. First, the vigorous outreach
employed to reach the patients could be significant. Secondly, the participants were cognitive
behavioural psychotherapists with master's degrees and at least one year of experience in
outpatient psychotherapy of depression, who received weekly supervision and additional
training. In addition, the sessions were 30 to 40 minutes in duration. Another measure of the
success of this trial is the report of patient satisfaction. It would seem that patient
13
perspective is lacking in several of the studies within this literature review. I will address this
further in the discussion.
Although this does not cover all of the telephone reviews in Bee et al. (2008), it
covers those within the last ten years that use the telephone as oppsed to other forms of
technological media. In their discussion of the findings, Bee et al. discuss patient satisfaction
and, based on their review findings, state that all patients either preferred or had an equal
satisfaction with technology as a medium of care, versus face-to-face. They conclude that the
therapeutic alliance may not hinge on co-location. From the articles discussed, I would
suggest that the level of therapeutic alliance required for therapeutic change differs
depending on the issue being addressed. For further details, see discussion.
In the final study included in this literature review, Kilfedder et al. (2010) compare
the effectiveness of humanistic, non-directional, face-to-face counselling versus telephone
counselling versus bibliotherapy. In this comparison, employing a randomised trial,
“participants expressed a preference for face-to-face counsellling over the other two
modalities” (p. 223). However, the treatment results indicate a significant stress reduction
for all intervention groups and a lack of superiority for any particular intervention, although,
in terms of clinical significance, a higher percentage had improved from the telephone
counselling arm. That is balanced against client satisfaction, however, where
…a significantly higher number of participants in the face-to-face group
reported that they would still choose the service provided if they were offered
telephone counselling or bibliotherapy, as alternatives…these results indicate
that participants would prefer to receive face-to-face counselling if they were
offered
the
possibility
to
choose
among
the
three
interventions .
(Kilfedder et al., 2010: 234)
It is interesting to note that, although both counselling arms were non-directional, patients
expresssed a preference for face-to-face work when given the choice. It may be that certain
forms of therapy have more efficacy when offered face-to-face, whereas other more
14
directional interventions do not require as much therapeutic alliance, as the intended
outcomes differ. However, it is also significant that there was a lack of superiority for no one
arm and as such, perhaps a ‘least intervention first’ approach could have important economic
implications.
1.3 Discussion
This literature review has considered two separate issues in relation to telephone counselling.
The first consideration is whether counselling or psychotherapy is being offered in the studies
included. The second is whether any modality lends itself better to work over the telephone
than any other. To address the first point, I would quote the BACP (2009), who state
“Counselling does not involve giving advice or directing a client to take a particular course of
action.” It would, however, seem that several of the papers in this review claim to be offering
counselling or psychotherapy despite the fact that they clearly state that they are directing a
client to take a particular course of action. Surely this comes down to the level of change for
which we are looking. If, for example, we are identifying physical activity and diet in primary
care patients (Eakin et al., 2009), then I would suggest that a lesser therapeutic alliance
would be required with patients requiring personality change. In this instance, clients may
feel that telephone work is sufficient.
I wish to highlight Lovell et al. (2006) in which it is stated that, during a successful
study of cognitive behavioural therapy over the telephone versus face-to-face for clients
suffering from obsessive compulsive disorder, a client was withdrawn from the telephone arm
due to “increased depression and suicidal ideation deemed by the therapist to warrant a face-
to-face appointment” (p. 885). I think that this is a perfect example of the telephone being
efficacious for some clients but not others. The therapist clearly realised that telephone work
was not sufficient to hold this client ethically in their current position and they were
subsequently offered a face-to-face appointment instead. In this instance, it was important
for the therapist and the client to have the choice to work face-to-face.
15
In some of the studies, patients are offered telephone counselling and appear to do
well. However, if they had been offered face-to-face, how many would have chosen that?
According to Kilfedder et al. (2010), a significant proportion would have opted for face-toface counselling above other choices such as telephone work or bibliotherapy, when
presented with the option of doing so. This brings me to an important point about client
expectation discussed by Cooper (2009). Research suggests that ‘outcome expectancy’
(Glass, Arnkoff and Shapiro, 2001) relates to therapeutic outcome (Snyder et al., 1999). This
suggests that a client’s belief in a particular intervention will affect the outcome. So,
expressing a need for a particular form of intervention, whether that is face-to-face, over the
telephone or other, may be an important ‘predilection’ (Elkin et al., 1999), which we could
choose to ignore at our economic peril. Elkin et al. highlighted which depressed patients
identified with which belief system prior to treatment, either that of medication or
psychotherapy. The authors found that those clients who believed in the treatment they were
subsequently given not only had an improved dropout rate but also had a superior
therapeutic alliance.
The evidence suggests that many clients who choose to engage with telephone work
improve, either as an adjunct to pharmacotherapy, or as a standalone option. As much of the
literature has pointed out, there are important economic factors here. Simon et al. (2004)
discuss the concept of least intervention first and, on this basis, it would seem there are
appropriate opportunities for both face-to face counselling and telephone work, although it is
important to recognise and celebrate the significant differences between them.
16
Research Design
2.0 Research Questions
In the first part of this piece of work, I reviewed the recent literature available regarding
telephone counselling / psychotherapy. Within this review, I highlighted certain themes,
which became apparent regarding the importance of patient education and choice,
predilection and expectancy from chosen therapies, and the impact that this can have on
outcome. I also highlighted the importance of clarity when offering clients a particular form of
intervention.
2.1 Methodology
The identified methodology for this research design is qualitative. Research objectives would
be to further understand how people approach the concept of receiving counselling over the
telephone and to what extent they feel they could engage with the process. Given the link
between predilection and expectancy to therapy outcome, and the increasing use of
telephone interactions as a form of therapy, it is important that we establish that a sample
population feels that telephone therapy would be an acceptable and accessible medium. If
not, there will be an increasing risk that those suffering from psychological distress will not
feel able to access therapy, or remain engaged, due to their expectation that therapy should
be a face-to-face experience, or their predilection toward a relational experience. Focus
groups seem an appropriate method for doing this as they are “ used as a means of testing
concepts.” (Edmunds, 1999: p 2) Focus groups also provide something I feel is missing from
much of the data in the literature reviews, the client’s voice. Without this, there is a risk that
we could be swept along by the ‘encouraging economic indications’ of telephone counselling,
without seeing the wider picture. That is, adopting a phenomenological stance to those that
would receive the service, ie.the client. A service that seems to offer value for money in the
short term, may not necessarily offer long-term savings.
17
2.2 Method
In order to access participants a screener questionnaire would be conducted following
receipt of ethical approval. The screener questionnaire would be introduced by means
of a letter explaining the purpose of the research and expected participant
involvement. The letter would also outline the fact that a researcher will contact the
potential participants by telephone to discuss whether or not they wish to take part.
This would provide the participant with an opportunity to ask further questions about
participating. If participants agree to take part at this stage, the written information
about the focus groups would be sent. Signing the written consent would enable the
participant to take part in the focus group, although it would be stressed that
participants can withdraw at any stage. Following written consent, the screener
questionnaire would be delivered by telephone. This should include a demographic to
ensure an even spread of participants within each of the focus groups. Having said
that, care must be taken at this stage that no single person in a group is much older or
younger than the rest. For instance, according to Greenbaum (1998 p 46) “The more
homogeneous the group, the better the patients will relate to each other in the
discussion.” Letter would then send the time, date and location of the focus group
identified as appropriate for each member. Concurrently, the moderator will develop a
discussion guide (Greenbaum, 1998 p 46) for utilisation in the focus groups based on
the concept of telephone counselling. Each group will be designed to last between
ninety and a hundred and twenty minutes, inclusive of introduction and rounding up.
During the introduction the moderator will introduce the focus group topic. Before
starting the focus group discussion it is imperative that the moderator confirms that
the focus group will be recorded, and that each participant has understood and
consented to this.
18
The recruiting profile identified will be four groups of between 6 and 8 people. Each
focus group will have a different perspective to telephone counselling as set out
below. Group one will only have received prior telephone counselling, group two will
only have received prior face-to-face counselling, group three will have received both
telephone and face-to-face counselling, and group four will have received no prior
counselling. The group size seems appropriate to building purposeful discussions on
the given topic with sufficient depth. Regarding the practicality of the group room, it
is important that each member can see the others. It is also important that the comoderators who are observing the focus group, are able to see the participants faces.
2.3 Ethical Considerations
According to Smith (1995 p478) “The major issue to consider as a researcher using this
technique, is the potential of over-disclosure by the participants…” This seems a very
pertinent point with focus groups comprised of a majority of people who have received
counselling of various forms in the past. It is essential that the moderator is able to keep the
participants focussed on the concept of counselling over the telephone. Otherwise, there may
be a tendency toward over-disclosure, with the participants disclosing the issues which
brought them to counselling primarily. This needs to be considered and addressed from
several angles. Initially, the focus group participants should discuss boundaries with the
moderator at the beginning of the session. This will ensure that group members are aware
that they are talking about the concept of telephone counselling and not personal issues. It
should be made clear by the moderator at this point hat this is a safety strategy to protect
clients from over-disclosure. During the focus groups, the moderator needs to remain vigilant
to the possibility of participants over-disclosing by careful monitoring and use of the
discussion guide to keep people on track. Following the discussion, it is moderator’s
responsibility to ensure, during a cool down period, that each participant feels secure in their
level of disclosure during the focus group.
19
According to the World Health Organisation (WHO) it is important to “ Explain in lay terms
why the research is being done and what is expected from the results . Explain why you need
to conduct the research.” This is to ensure that potential participants have a genuinely
informed choice as to whether or not they wish to take part. Reassurance must be given at
the beginning that participation is voluntary; otherwise some people may become concerned
or confused about whether or not they have a choice to participate. The informative consent
form should also explain that the focus group session would be recorded. An explanation
should be given within this section as to where the information will be stored and for how
long. It should be highlighted that the records, whether that be audio-recordings or film
footage will be destroyed after a certain amount of time. It is also important to ensure that
the potential participants understand that confidentiality will be adhered to. Information
sharing should also be addressed. It is important that potential participants understand that,
although individual confidentiality will be respected, the overall findings of the research will
be shared. These data will be fed back to the focus groups, the community at large and that
the aim would be to publish the research within the academic community. At the end of the
informed consent form, it should be highlighted that participants may withdraw from the
research at any time. Prior to sending out any information or consent, the information would
be sent to the relevant primary care trust ethics committee for approval. Procedurally, no
contact would be made with potential participants until ethics approval had been given. Also
at the end, a contact should be given in order for people to communicate any further
questions or concerns.
2.4 Data Recording
One of the benefits of a focus group is the variety of data potentially available. This
would not only be an audio recording. It would include film footage, notes taken by
moderator and co-moderator. There is also the opportunity for further observational
note taking by further co-observers outside the room if the informed consent and the
layout of the facility allow. Following the focus group a detailed debrief interview
20
would also take place in which the research moderator, co-moderators and any
additional observers would discuss initial findings and ideas based on the focus group.
It would be helpful if this were also recorded.
2.5 Research Instrument
The moderator assumes a crucial role within the focus group. It is important from the
outset that the moderator explains that they are not the expert. This in itself is parallel
to the value of walking alongside a client in person centred counselling, which
underpins its’ efficacy for me.
“ …with a moderator who is not an expert in the area under discussion, the
participants normally work harder to explain their views on the topic, rather than
trying to impress the moderator…” (Greenbaum, 1998: p30)
I have already stated that I have a personal bias toward face-to-face counselling. This
brings me to an important point about objectivity. According to Greenbaum (1998,
p30)
“Since the outside researcher has no investment in a group’s outcome, most
participants note that the researcher is much more objective during the session and
therefore will not try to lead them in any particular direction.”
With this in mind, it would be my recommendation that a co-moderator delivered the
discussion guide within each focus group. I would co-moderate by assuming
responsibility for the technical recording of the groups.
2.6 Data Analysis and Data Interpretation
Robson (1993) suggests that the aim of data analysis is to reduce the data. Although
data are the key to any research, it would be difficult to see the wood for the trees
with a full transcription of a two-hour focus group. With this in mind the key
21
questions of the research, ie. how do people feel about the concept of telephone
counselling, must remain figure when applying a coding frame to the data. Following
the completion of the focus groups, the data should begin to be organised. Audio data
should be listened to repeatedly, film footage should be watched to begin to interpret
non-verbal data and transcripts should be read repeatedly in order for coding to begin.
Rabieeh (2004) suggests that data analysis begins with data collection. By
“facilitating the discussion and generating rich data from the interview,
complementing them with observational notes, and typing the recorded information.”
(p 657) Following familiarity by repeated immersion with the data, At this point a
thematic framework can begin to emerge by note taking in margins so that categories
begin to emerge. Rabieeh (2004) suggests that the next part of this systematic process
is to index and highlight particular quotes generated from the data, followed by
indexing and charting in order to reduce down the data to a manageable and
comprehensible form. Finally the data will be mapped and interpreted.
2.7 Findings-Limitations and Strengths
One of the strengths of focus group research is in the interaction of the group. When
moderated well and using the facilitation of the discussion guide, the participants have
the ability to build on their own phenomenological experiences through the group.
Although the discussion guide will offer a loose framework, one of the strengths of
the focus group is that stronger or weaker themes will emerge, offering data on the
importance of particular concepts, values or predilections about telephone
counselling. Also, the moderator has the opportunity to build on noted themes of
interest. This sets focus groups apart from surveys or individual interviews.
22
Inevitably there are also limitations to this research through the medium of a process
group. The group will only be a small representation of the population. The
moderator, although attempts would be made to reduce the impact of bias or personal
positioning, may be consciously or unconsciously leading the group in a particular
direction. Similarly, data analysis could be coloured by moderator bias or personal
positioning. Krueger and Casey (2000) recommend that in order to reduce any
potential bias in analysing and reading data that the analysis should be done in a
systematic way.
2.8 Dissemination and Future Considerations
As the research is aimed at those considering the utilisation of telephone work as a
form of therapy, and where the medium should sit within psychological settings, the
data would be best disseminated to the research department of the British Association
of Counsellors and Psychotherapists, and relevant psychotherapeutic journals.
Following the outcome of the study, further research would be required regarding
where the phenomenon of telephone work should sit therapeutically, from the
perspective of least intervention first.
23
2.9 References
Asay, T.P. and Lambert, M.J. (1999) The empirical case for the common factors in therapy:
Quantitative findings. In: M. Hubble, B.L. Duncan and S.D. Miller (eds), The Heart and Soul of
Change: What Works in Therapy. Washington DC: American Psychological Association, pp
33–55.
British Association of Counselling and Psychotherapy (2009) What is Counselling? Retrieved
from http://www.bacp.co.uk/education/what is counselling.html
Beckner, V., Vella, L., Howard, I. and Mohr, D.C. (2007)
Alliance in two telephone-
administered treatments: Relationship with depression and health outcomes. Journal of
Consulting and Clinical Psychology, doi: 10.1037/0022-006x.75.3.508.
Bee, P., Bower, P., Lovell, K., Gilbody, S., Richards, D., Gask, L. and Roach, P. (2008)
Psychotherapy mediated by remote communication technologies: A meta-analytic review.
BMC Psychiatry, 8:60.
Chilvers, C., Dewey, M., Fielding, K., Gretton, V., Miller, P., Palmer, B. et al. (2001)
Antidepressant drugs and generic counselling for treatment of major depression in primary
care: Randomised trial with patient preference arms. British Medical Journal, 322, 772-775
Cooper, M. (2009) Essential Research Findings in Counselling and Psychotherapy . London:
Sage.
Derogatis, L., Rickels, K., Uhlenhuth, E. and Covi, L. (1974) The Hopkins Symptom Checklist:
A measure of primary symptom dimensions. In: P. Pichot (ed.), Psychological Measurements
24
in Psychopharmacology: Problems in Psychopharmacology. Basel, Switzerland: Kargerman,
pp 79–110.
Eakin, E., Reeves, M., Lawler, S., Graves, N., Oldenburg, B., Del Mar, C., Wilke, K., Winkler,
E., Barnett, A. (2009) Telephone counseling for physical activity and diet in primary care
patients. American Journal of Preventative Medicine, 36 (2): 142–9.
Edmunds, H, (1999) The Focus Group Research Handbook, NTC Contemporary Publishing
Group
Elkin, I., Yamaguchi, J.L., Arnkoff, D.B., Glass, C.R., Sotsky, S.M. and Krupnick, J.L. (1999)
Patient treatment fit and early engagement in therapy. Psychotherapy Research, 9 (4): 437–
51.
Glass, C.R., Arnkoff, D.B., and Shapiro, S.J.
(2001) Expectations and Preferences.
Psychotherapy, 38 (4): 455–61.
Greenbaum, T. (1998) The Handbook for Focus Group Research, Sage Publications
Greenberg, L. (2004) Emotion-Focused Therapy, Clinical Psychology and Psychotherapy, 11:
3–16.
Hunkeler, E., Meresman, J., Hargreaves, W., Fireman, B., Berman, W., Kirsch, A., Groebe, J.,
Hurt, S., Braden, P., Getzell, M., Feigenbaum, P., Peng, T., and Salzer, M. (2000) Efficacy of
nurse telehealth care and peer support in augmenting treatment of depression in primary
care. Arch Fam Med, 9: 700–8.
Kilfedder, C., Power, K., Karatzias, T., McCafferty, A., Niven, K., Chouliara, Z., Galloway, L.
and Sharp, S. (2010) A randomised trial of face-to-face counselling versus telephone
25
counselling versus bibliotherapy for occupational stress. Psychology and Psychotherapy:
Theory, Research and Practice, 83: 223–42.
Krueger, R. A. and Casey, M.A. (2000) Focus Groups: A practical guide for applied
research (3rd ed) Thousand Oaks, CA, Sage Publications
Lovell, K., Cox, D., Haddock, G., Jones, C., Raines, D., Garvey, R., Roberts, R. and Hadley, C.
(2006) Telephone administered cognitive behaviour therapy for treatment of obsessive
compulsive disorder: Randomised control non-inferiority trial. BMJ, 333: 883–7.
Ludman, E., Simon, G.E., Tutty, S. and Von Korff, M. (2007) A randomized trial of telephone
psychotherapy and pharmacotherapy for depression: Continuation of durability of effects.
Journal of Consulting and Clinical Psychology, doi 10.1037/0022-006x.75.2.257–66.
Lynch, D., Tamburrino, M. and Nagel, R. (1997) Telephone counselling for patients with
minor depression: Preliminary findings in a family practice setting. Journal of Family Practice,
44: 293–6
Lynch, D., Tamburrino, M., Nagel, R., Smith, M.K. (2004) Telephone based treatment for
family practice patients with mild depression Psychological Reports, 94 (3, Pt1): 785–92.
Martin, D.J., Garske, J.P. and Davis, M.K. (2000) Relation of the therapeutic alliance with
outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical
Psychology, 68 (3): 438–50.
Miller, L. and Weissman, M. (2002) Interpersonal psychotherapy delivered over the telephone
to recurrent depressives : A pilot study. Depression and Anxiety, 16 (3): 114–17.
26
Rabieeh, F. Focus-group interview and data analysis Proceedings of the Nutrition
Society (2004) 63 655-660
Reese, R., Conoley, C. and Brossart, D. (2002) Effectiveness of telephone counselling: A fieldbased investigation. Journal of Counselling Psychology, 59 (2): 233–42.
Robson, C., (1993) The Real World Research –A Resource for Social Scientists and
Practitioner-researchers, Oxford: Blackwell Publications
Royal College of Psychiatrists (2010) www.rcpsych.ac.uk (last accessed 26/3/11).
Simon, G.E., Ludman, E.J., Tutty, S., Operskalski, B., Von Korff, M. (2004) Telephone
psychotherapy and telephone care management for primary care patients starting
antidepressant treatment: A randomized controlled trial. JAMA: Journal of the American
Medical Association, 292 (8): 935–42.
Smith, M.W. Ethics in Focus Groups: A Few Concerns, Qualitative Health Research,
November 1995 vol 5 no.4 478-486
Snyder, C.R., Michael, S.T. and Cheavens, J.S. (1999) ‘Hope as a foundation of common
factors, placebos and expectancies’, in M. Hubble, B.L. Duncan and S.D. Miller (eds.), The
Heart and Soul of Change: What Works in Therapy. Washington, DC: American Psychological
Association, pp. 179-200
Sunich, M.F. (2007) A review of the video ‘Emotion Focused Therapy over Time’. APA Review
of Books, Vol. 52, Release 30, Article 17.
27
Unutzer, J., Katon, W., Callahan, C. M., Williams, J.W., Jr., Hunkeler, E.,Harpole, L., et al.
(2003). Depression treatment in a sample of 1,801 depressed older adults in primary care.
Journal of the American Geriatric Society, 51, 505-514
www.who.int/ppc-research_ethics/ICF-parentalConsent-qualitive_for_ print.pdf
3.0 Appendix
BDI Beck Depression Inventory
CCDAN-CTR The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials
Register (> July 2006)
DHP Duke Health Profile
HDRS / HAMD Hamilton Depression Rating Scale
28