Examining the Satisfaction of Women Residing in Rural Utah who Received
Therapy for Depression through Teletherapy
D. Kim Openshaw, Ph.D., LCSW, LMFT
Family, Consumer, and Human Development
and Marriage and Family Therapy
Utah State University
Logan, Utah 84322-2700
d.k.openshaw@usu.edu
Jenny A. Morrow, M.S., LMFT
Private Practice
11075 South State Street
Sandy, Utah 84070
morrow.jenny@gmail.com
Roxanne Pfister, M.S.
Center for Epidemiologic Studies
Utah State University
Logan, Utah 84322-2700
roxane.pfister@usu.edu
Dan Moen, Ph.D. (ABD), LMFT
Family, Consumer, & Human Development
Utah State University
Logan, Utah 84322-2700
daniel.moen@aggiemail.usu.edu
1|Page
Abstract
This pilot study examined client satisfaction with teletherapy for treatment of mild to
moderately severe depression. Four indicators of satisfaction were assessed, satisfaction with the
process of therapy, ability to form a therapeutic relationship, teletherapy medium, and
willingness to refer. Seventeen women residing in rural Utah communities received therapy
through a unique delivery medium referred to as Technologically Assisted Psychotherapeutic
Intervention (TAPI). Mean scores, z-scores, and two-tailed tests of significance were used to
determine level of reported satisfaction across the various indicators. Data suggest that
participants were very satisfied with the process of therapy, were able to form an empathic bond
with their therapist, and indicated willingness to refer others for teletherapy (TAPI). A moderate
degree of satisfaction was noted for the delivery medium (TAPI).
2|Page
Introduction
Rural residents experience emotional and relational distress much the same as do those
residing in urban communities; the primary difference is that mental health services are often
unavailable or inaccessible to rural residents (Mohatt, Bradley, Adams, & Morris, 2005).
Teletherapy, Technologically Assisted Psychotherapeutic Intervention (TAPI), emerges as a
medium with the potential to transcend the barriers of availability and accessibility (Openshaw,
Pfister, Silverblatt, & Moen, 2010). TAPI is a unique teletherapy delivery method that offers
multiple interventions (e.g., power points, online measures of progress, and online modules) to
engage clients learning processes and enhance the overall course of therapy, in a “face to face”
therapeutic context delivered via real time videoconferencing.
Mohatt et al., (2005) found that, even if services are available and accessible, if they are
not acceptable to the community residents they will most likely not use them. It is suggested that
one correlate of acceptability has to do with satisfaction with the services—specifically
satisfaction with the therapy experience, therapeutic relationship, and technology used to deliver
the services. The issue of acceptability is brought to the forefront in this study as it looks at
multiple factors of satisfaction for the use of TAPI as a medium in delivering mental health
services.
Conceptualizing Satisfaction
Satisfaction has been operationalized as a subjective sense of pleasure experienced when
a need or desire has been fulfilled (Murphy, Faulkner, & Behrens, 2004; Roe, Dekel, Harel, &
Fennig, 2006), and is important in nearly every aspect of life where services and/or products are
offered (Lin, 2007; Schwab, DiNitto, Aureala, Simmons, & Smith, 1999; Tang, Lu, & Chan,
2003). Hubble, Duncan, and Miller (1999) report that client satisfaction with their therapy
experience is positively correlated with completing therapy, and a successful therapeutic
3|Page
outcome is positively related to their overall quality of life (Heuft, Senf, Wagener, & Pintelon,
1996; Silverberg, 1982). Understanding that there are a variety of common factors correlated
with the successful completion of therapy it is posited that successful completion of therapy
increases the likelihood of acceptance of individual, couple, and family services, thus increasing
the probability of community recognition and approval.
Satisfaction with the therapy experience. The therapy experience encompasses all that
goes on in the hour of therapy and how that affects what occurs during the other 167 hours in the
week post-therapy (Openshaw, 1998a; 1998b). For purposes of this study, three factors measure
satisfaction of the therapy experience: clinician competence, privacy and confidentiality, and
outcome. Clinician competency refers to the client’s perception of the clinician’s ability to
identify relevant clinical needs, some of which may be covert; to diagnostically articulate these
needs or issues of importance; and to collaboratively organize them into an agreed-upon
treatment plan. Privacy and confidentiality are essential to fostering an environment that feels
safe to clients. When privacy and confidentiality are melded with perceived care and concern,
and demonstrated through active listening and nonjudgmentality, the safe holding environment
emerges, opening the avenue for client managed vulnerability. Managed vulnerability, in the
context of a “safe holding environment,” creates a therapeutic atmosphere where clients are more
apt to risk and provide the clinician with relevant clinical data necessary to facilitate therapeutic
outcome. Finally, clients enter therapy with an attitude of hope, desiring a specific outcome to
be achieved. Initially they may not understand the role of the clinician, the process of therapy, or
how change will occur; however, they anticipate the clinician orchestrating therapy towards
achieving their desired goal (Norcross & Wampold, 2011).
Therapeutic relationship as an indicator of satisfaction. Empathy, a measure of the
client-therapist relationship, is cited in the literature as the single most significant determinant of
therapeutic change (Elizur, 1985; Hubble, et al., 1999; Keefe, 1976; Thwaites & Bennett-Levy,
4|Page
2007) and satisfaction (Campbell, 2004; Lovell et al., 2006). Empathy is a reciprocal process
that encourages client managed vulnerability and suggestibility. Managed vulnerability opens
the way for the client to be honest and accurate in their past and present depiction of distress.
Suggestibility enhances the likelihood that clients will examine critical change options, opting to
incorporate suggestions and resources into their daily life. Having a positive therapeutic
relationship with the clinician not only enhances therapeutic outcome, but also augments overall
satisfaction with the therapy experience (Mitchell, 1998; Searcy, 1990).
Satisfaction with the teletherapy delivery medium. The traditional method of
providing therapy has been face-to-face; however, with technological advances, therapy can be
delivered effectively via the Internet and Interactive Video Conferencing (Openshaw, et. al.,
2011). Satisfaction with the delivery medium is characterized by four attributes; quality of
teletherapy audiovisual, equipment performance, client and clinician competence with
equipment, and client’s perception of privacy. Audiovisual acuity is necessary to provide a
“face-to-face” context that simulates that of an office setting. Quality audiovisual allows the
clinician to respond to the subtle nonverbal nuances of the client. The clinician’s ability to be
attentive to such subtlety gives clients a sense that they are understood, which in turn boosts the
perception (Anker, Sparks, Duncan, Owen, & Stapnes, 2011) of empathy (Watson, 2002). The
reliability of the equipment is especially important. Equipment failure, though not dissimilar to
experiences in an office setting (e.g., electrical or heating failure), can be disruptive to the
therapy process if unreasonably frequent. In that TAPI is a new form of technologically-based
mental health delivery, it is critical that both clinician and client be adequately trained in how to
use the equipment. Clients will most likely approach TAPI with some degree of angst.
Competence with the equipment will decrease this sense of anxiety and encourage clients to ask
questions of the clinician when concerns arise. Finally, a sense of privacy is recognized as a
necessary condition for a client to be sufficiently at peace to reveal all that is needed for the
5|Page
formulation of a collaboratively developed treatment plan. This privacy includes being able to
go to the site where the equipment is located without being easily identified as a “client” and to
engage in the process of therapy without interruption or being overheard (Midkiff & Wyatt,
2008).
Willingness to refer as a measure of satisfaction and indicator of acceptance.
Willingness to refer is a dimension of satisfaction that does not present unless the other basic
elements of therapy are satisfactorily experienced (Stegeman, 2008). Referral sources become
one of several key dimension of feasibility and form the foundation for increasing acceptance.
Satisfaction with teletherapy, as evidenced by a positive therapeutic outcome, increases the
likelihood that those participating will return for services should the need exist, refer family and
friends to such services, and share their experience with primary care physicians and clergy.
While this is not the only way that acceptance may be fostered in rural communities, where
stigma may interfere with seeking out such services, it does serve as a significant grassroots
methodology for promoting knowledge of teletherapy and how such maybe acquired in a
confidential manner.
Satisfaction across time. As therapy progresses it is common for the therapeutic
relationship to be strengthened. In addition, positive outcomes are correlated with a strong
therapeutic relationship (Macneil, Hasty, Evans, Redlich, & Berk, 2009). In these intense
therapeutic relationships clients tend to focus on the positive aspects of therapy and if asked,
report satisfaction with their therapy experience and the therapist. It is suggested that if their
report is sincere, it will sustain itself across time. This research posits that measuring satisfaction
across time will allow for clients to put distance between their therapy experience and their
relationship with the therapist. This measure can then become a more valid indicator of
satisfaction than if merely examined at the time therapy is completed.
Central Hypothesis
6|Page
Central to this study is the hypothesis that women who have reported depressive
symptoms and are provided Cognitive Behavioral Therapy (CBT) using Technologically
Assisted Psychotherapeutic Intervention will report satisfaction with their therapy experience,
their relationship with their therapist, and with the technology at the conclusion of therapy and
post therapy.
Methods
Design
A purposive-convenience sample consisted of 17 adult women responding to an
announcement in their local newspaper. Criteria for acceptance included residence in a rural
Utah community and documented symptoms of depression. All participants were married and
Caucasian with a mean age of 39.9. Nine reported that they were employed in “white collar”
occupations, one “blue collar,” two were students, and five were not employed. Ten were using
psychotropic medications and two had been previously hospitalized.
The basic research design relevant to this pilot study was:
S
X
T1
T2
T3
where S represents screening, X represents ten weekly, one hour sessions of Cognitive
Behavioral Therapy (CBT) using TAPI as the delivery medium, and T represents assessment for
satisfaction, where T1 is immediate after therapy, T2 and T3 are 3 and 6 months post-therapy,
respectively.
Procedures
Women who participated in CBT for depression using TAPI were invited to take part in
the satisfaction survey. Of the 17 women in treatment, 16 agreed to participate and provided
completed data at the conclusion of therapy, then again 3 and 6 months post-therapy.
TAPI Satisfaction Instrument (TAPI-SI)
7|Page
A review of the literature indicated there were no instruments, outside of the Burns
Empathy Scale (Burns, 1989), created that would allow an examination of satisfaction with the
delivery medium (TAPI) or other forms of teletherapy in any comprehensive manner. The TAPI
Satisfaction Instrument (TAPI-SI) was developed to accommodate these dimensions and
included a fourth suggestive of acceptance, a barrier to rural mental health service. Face validity
was determined by having a variety of colleagues examine the items of the TAPI-SI to ascertain
whether the items addressed the phenomenon under investigation.
Satisfaction with the Therapy Experience Scale (STES). The Satisfaction with the
Therapy Experience Scale explored client satisfaction with the process of therapy and assessed
how well their expectations for therapy outcomes were met. The STES was comprised of 12
Likert items on a 5-point scale from strongly disagree (1) to strongly agree (5), and one general
question, “Overall, how would you rate the quality of services you received” scaled from poor to
excellent that ranged from (1) to (5).
Burns Empathy Scale (BES). The Burns Empathy Scale (BES), a measure of the clientclinician relationship, consists of a 10 item, 5-point Likert scale ranging from strongly disagree
(1) to strongly agree (5), and is a well-tested measure of perceived empathy (Burns, personal
communication, August 26, 2009) (Burns, 1989; Sekirnjak, 1998; Sekirnjak & Beal, 1999; Burns
& Auerbach, 1996; Burns & Nolen-Hoeksema, 1992; Castonguay et al., 2004; Persons & Burns,
1985).
Satisfaction with Technology Scale (STS). The Satisfaction with Technology Scale
(STS) consists of 6 Likert items on a 5-point scale ranging from poor (1) to excellent (5). Items
examined satisfaction with teletherapy images and sound, equipment performance, client
understanding of the equipment, and privacy. One general question was also asked: “Overall,
8|Page
how satisfied were you with teletherapy?” This 5 point Likert question ranged from Very
Dissatisfied (1) to Very Satisfied (5).
Willingness to Refer Scale (WRS). One general Likert item, “How willing would you
be to recommend teletherapy to a friend?” addressed this focus with answers ranging on a 5point scale from definitely unwilling (1) to definitely willing (5).
Analyses
Examination of Satisfaction
The research question of relevance was whether women residing in a rural Utah
community, when provided therapy through the medium of TAPI would report satisfaction with
their therapy, relationship with their therapist, and the technology (TAPI) and if these women
would be willing to refer friends.
Analytic method. Initial analyses of the data were based on the calculation of a total
mean score, which was then compared against the possible total score to provide a preliminary
understanding of satisfaction. Next, z-scores, permitting examination for clinically significant
change, were calculated for each participant based on the small n methodology recommended by
Jacobson and Truax (1991). Third, repeated measures ANOVA was used to determine whether
there was a significant difference between perceived satisfaction post-therapy, and 3- and 6month post-therapy. Because participants were grouped into one grouping regardless of when
they began the therapy, within-subject effects was the point of focus. Finally, an item analysis
was completed on multi-item scales to make certain that the intricacies of each question were
considered.
Results
Satisfaction with the Therapy Experience
Descriptive data for the general satisfaction question, reported in Table 1, dovetails nicely
with data from the Satisfaction with the Process of Therapy Scale (Table 2); meaning that both
9|Page
suggest participants had a positive therapeutic experience. Mean score on the global item was
similar to those from the STE (Table 2). These two data sets suggest, in a preliminary manner,
that women involved in the treatment of their depression were satisfied with the therapy
experience.
Table 1
Overall Levels of Satisfaction Immediately After Therapy, 3-Months Post-Therapy, and 6-Months
Post-Therapy; STES, General Satisfaction, BES, STS, & WRS
Variable
Satisfaction with the Therapy
Experience Scale STES)
Post-therapy
3-months post-therapy
6-months post-therapy
General Satisfaction
Post-therapy
3-months post-therapy
6-months post-therapy
Burns Empathy Scale (BES)
Post-therapy
3-months post-therapy
6-months post-therapy
Satisfaction with the Technology
Scale (STS)
Post-therapy
3-months post-therapy
6-months post-therapy
Willingness to Refer to TAPI (WRS)
Post-therapy
3-months post-therapy
6-months post-therapy
10 | P a g e
N
Total Possible
Mean
SD
16
16
16
5.00
5.00
5.00
4.69
4.69
4.81
0.602
0.602
0.403
16
16
16
5.0
5.0
5.0
4.81
4.63
4.63
0.403
0.619
0.500
16
16
16
5.0
5.0
5.0
4.68
4.72
4.66
.893
.458
.465
15
16
16
5.0
5.0
5.0
4.08
3.77
3.82
.672
.498
.622
16
16
16
5.0
5.0
5.0
4.63
4.69
4.81
0.619
0.602
0.403
Table 2
Z-Scores for Satisfaction Variables
Satisfaction with the
Therapy Experience
Satisfaction with
TAPI equipment
Empathy
Willingness to
refer
3 months 6 months 3 months 6 months 3 months 6 months 3 months 6 months
Case postpostpostpostpostpostpostpostNo. therapy
therapy
therapy therapy therapy therapy therapy therapy
Case 1
-1.90*
-1.400
-1.40
-.94
-1.4
-.86
-2.308
-1.30
Case 2
0.00
-2.80*
3.99*
2.94*
-.60
.11
0.00
1.31
Case 3
0.00
2.80*
-.80
-1.40
-.60
-.43
2.31*
0.00
Case 4
-.64
.35
0.00
0.00
.80
.22
0.00
0.00
Case 5
3.19*
0.00
0.00
-.35
-.80
-.22
0.00
0.00
Case 6
0.00
-.70
-.80
-0.47
-.20
-.22
0.00
0.00
Case 7
0.00
1.75*
-.20
-.35
-.80
-.86
0.00
0.00
Case 8
0.00
0.00
0.00
0.00
-.40
-.32
0.00
0.00
Case 9
0.00
0.00
0.00
0.00
-.20
.11
0.00
0.00
Case 10
0.00
0.00
.40
.24
**
**
2.31*
1.31
Case 11
0.00
0.00
0.00
0.00
-.60
-.11
0.00
0.00
Case 12
0.00
0.00
0.00
0.00
-1.2
-.65
0.00
0.00
Case 13
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Case 14
0.00
0.00
-.20
0.00
-.60
.22
0.00
0.00
Case 15
0.00
-1.10
0.00
0.00
0.00
-.32
0.00
0.00
Case 16
0.00
0.00
0.00
0.00
0.00
.22
0.00
2.61*
11 | P a g e
Z scores (Table 3) provide a more thorough examination of satisfaction with the therapy
experience on a case by case basis. Of the 16 viable cases, at three months post therapy, one
demonstrated increased (Case 5, z = 3.19; p≤ .05)) and the other decreased satisfaction with their
experience with therapy (Case 1, z = -1.90; p≤ .05) At 6 months post therapy, clinically
significant change was noted for three cases, two of which were in the direction of increased
satisfaction (Case 3; z = 2.80; p≤ .05 and Case 7; z = 1.75; p≤ .05), and one in the opposite
direction (Case 2; z = -2.80; p≤ .05). At 6 months there was a decrease in their reported
dissatisfaction, at least sufficient so that the level was no longer clinically significant. At 6
months case 2 reported dissatisfaction at a clinically significant level. Thus, of the 16
participants 2 were dissatisfied (12.5%).
Table 3
Item Analysis of the Satisfaction with the Therapy Experience: Descriptive Statistics
To what extent did your therapist:
1. help you achieve the purpose
for which you sought
therapy?
2. help you obtain skills that
will help you handle future
problems?
3. demonstrate competence as a
therapist?
4. understand your needs?
5. help you define your needs?
6. involve you in the treatment
planning (such as treatment
goals and frequency of
appointments.)?
7. respond to your requests?
8. respect your privacy and
confidentiality?
9. address issues important to
you?
10. show care and concern for
you?
11. listen and understand what
12 | P a g e
N
Postmean
SD
3-month
mean
SD
6-month
mean
SD
16
4.63
.500
4.69
.479
4.81
.403
16
4.69
.479
4.63
.500
4.75
.447
16
16
16
5.00
4.81
4.69
.000
.403
.602
4.94
4.81
4.88
.250
.403
.342
4.81
4.75
4.81
.403
.447
.403
16
16
4.88
4.94
.342
.250
4.94
4.88
.250
.342
4.81
4.81
.403
.403
16
5.00
.000
4.94
.250
4.88
.342
16
4.94
.250
4.94
.250
4.94
.250
16
5.00
.000
5.00
.000
4.94
.250
you were saying?
12. demonstrate an
understanding of your
diagnosis?
16
4.81
.403
4.88
.342
4.88
.342
16
4.75
.477
4.75
.447
4.75
.577
To examine further where those involved in TAPI may have been dissatisfied, focus was
turned to an item analysis (see Table 3). Data suggest that all items were suggestive of a high
level of satisfaction. Thus, corroborating the mean and z score findings. A further indication of
satisfaction with the therapy experience was found in the ANOVA results for the Satisfaction
with Therapy Experience items. Noted was the fact that there were no within group, across time,
differences (f(1,15) = 3.462, p = 0.083).
Empathy
Mean scores indicate high levels of perceived empathy immediately after, and at 3- and
6- months post-therapy (Table 1). Z-scores (Table 2) support these findings, indicating that there
were no clinically significant changes in participants’ reported experience of empathy across
time with one exception, Case 2 (z = 3.99 & 2.94; p≤ .05 at 3 and 6 months respectively), in
which there was a statistically significant increase in perceived empathy; though this must be
viewed in the context of the high mean score and small standard deviations.
The item analysis (Table 4) showed consistently high mean scores across all items
ranging from 4.50 out of 5.0 on item 9, post-test to a high of 4.88 on several items. Examination
of the Burns Empathy Scale items indicate that, when comparing baseline (post-therapy) and 6months post-therapy mean scores, some of the items were modestly lower than at post-therapy;
however, the change was not statistically significant. These findings support the hypothesis that
participants were able to form an empathic relationship with their therapist in a face-to-face
while using Interactive Video Conferencing.
ANOVA data suggest that from baseline through 6-months post-therapy there were no
statistically significant within-group findings f(1.15) = 0.004, p = 0.949). Thus, statistically, the
13 | P a g e
ANOVA data indicate that from post-therapy to 6 months post-therapy there was no change in
the perception of empathy held by the women.
Table 4
Item Analysis of the Empathy Scale
Item
N
1. I feel that I can trust my
therapist.
2. Sometimes my therapist does
not seem to be completely
genuine.*
3. My therapist thinks I’m
worthwhile.
4. My therapist pretends to like
me more than he or she really
does.*
5. My therapist is friendly and
warm toward me.
6. My therapist does not seem to
care what happens to me.*
7. My therapist usually
understands what I say to him
or her.
8. My therapist does not
understand the way I feel
inside.*
9. My therapist is sympathetic and
concerned about me.
10. My therapist sometimes acts
condescending and talks down
to me.*
*Items Reverse Scored
Post
mean
SD
3month
mean
SD
6month
mean
SD
16
4.88
.500
4.69
.602
4.75
.447
16
4.69
1.25
4.81
.403
4.63
.719
16
4.80
.561
4.63
.500
4.63
.500
16
4.56
1.26
4.63
.806
4.50
.730
16
4.75
.683
4.88
.342
4.81
.403
16
4.69
1.25
4.88
.342
4.63
.619
16
4.75
.775
4.75
.447
4.69
.602
16
4.50
1.27
4.44
.814
4.56
.512
16
4.75
.577
4.75
.447
4.56
.629
16
4.69
1.25
4.75
.775
4.88
.500
Satisfaction with TAPI Equipment
Average mean score on the Satisfaction with TAPI Equipment Scale (STES) is relatively
consistent across time. These scores indicate that while satisfied with the technology, the mean
scores were in the moderate range (Table 1) and maintained this level of satisfaction across time
according to z-scores (Table 2). Examination of the mean score for each item of the STES
suggests areas for future attention to make the experience more pleasing (Table 5). Participants
reported that visual images on the computer and performance of the equipment were their two
14 | P a g e
main concerns across time; however, 3 and 6 months post-therapy they also reported that their
understanding of the equipment was not as satisfying as they would have desired. Within-group
ANOVA data suggest that satisfaction with the equipment was stable across time ( f(1,6) = 4.5,
p = 0.078). It is important to note that while the mean scores for satisfaction with the technology
were lower than in other areas, this must not be misconstrued to mean that participants were
dissatisfied with the technology. When taken together with other findings, it appears to be more
a function of the limitations to Macromedia Breeze than to having their therapy provided via
TAPI.
Table 5
Item analysis of the TAPI Equipment Satisfaction Scale
How satisfied were you with
the:
1. Teletherapy images
(visual images on computer)
2. With the teletherapy
sound
3. Adequacy of privacy
4. Performance of the
equipment
5. Therapists understanding
of the equipment
6. Your understanding of
how to use the
equipment
N
Post
mean
SD
3-month
mean
SD
6-month
mean
SD
16
16
3.73
4.13
1.10
.990
3.56
3.81
.964
.834
3.44
4.06
1.20
1.06
16
4.13
1.125
3.94
1.237
4.06
1.12
16
3.87
.915
3.38
.500
3.44
.629
16
4.53
.640
4.31
.602
4.31
.602
16
4.07
1.163
3.63
.885
3.63
.885
Willingness to Refer Others for TAPI
Mean scores suggest that those who participated in therapy provided via TAPI were
willing to refer; in fact, the scores increased slightly from baseline to 6-months post-therapy
(Table 1). Z-scores (Table 2) supported the conclusion drawn from mean scores with the
exception of Cases 1 who reported a modest, though clinically significant decrease in willingness
to refer. When examining this case across the other satisfaction indicators, it appears that this
individual was not satisfied with their experience in any of the categories. ANOVA data
15 | P a g e
indicated that there were no statistically significant differences within the group from post-test
through 6-months post-test ( f(1,15) = 1.311, p≤ 0.270).
Discussion
Data suggest that TAPI is a viable method of mental health service delivery to rural
residents (Openshaw, et al., 2011). Satisfaction is a critical aspect of making this delivery
service modality credible and acceptable. Using specific mean item scores, this discussion will
examine ways in which TAPI might be improved in each of the specific areas: satisfaction with
the therapeutic experience, therapeutic relationship, technology, and willingness to refer.
Satisfaction with Therapy
An examination of the mean scores suggest three foci for consideration, namely,
“understanding the needs of the client ( X = 4.81 to 4.75),” “responding to the client’s request
( X = 4.94 to 4.81),” and “respecting the client’s privacy and confidentiality ( X = 5.00 to
4.88).” The first two items address the therapist’s demonstrated ability to understand the needs
of the client1 and respond to their requests; that is, it is essential that the clinician be perceived as
one who listens to understand. With teletherapy, this may be more critical than when sitting in
the office with a clinician, though the skills are not different, for example, reflective listening,
joining, and empathy. Reflective listening, demonstrated by frequent summations of the client’s
expressions of needs, expectations and concerns, enhance the client’s perception of being heard.
Joining and empathy establish an emotional connection with the client while maintaining
objectivity.
To remedy potential issues, a variety of interventions could be suggested; however, four
are provided. First, in that physical distance is present, it especially behooves clinicians to
1
At this juncture, the word client will be substituted for participant.
16 | P a g e
understand the relevance of interpersonal strategies associated with relationship formation and
maintenance. Next, teaching clinicians how to effectively use assimilative and accommodative
joining skills is essential in the context of a manualized treatment program that can quickly
dehumanize the clinical process. Assimilative skills are those that the clinician uses to become a
part of the clinical system (e.g., Moving in closer to the client.); whereas accommodative skills
(e.g., Sitting back and asking the client to, for example, write out possible solutions ) permit the
clinician to adjust herself to the situation, punctuating aspects of the clinical process pertinent to
foster a therapeutic relationship while challenging the rules of the system. Third, clinicians must
use the camera effectively so that it appears that the clinician is looking at the client. Eye contact
is an important part of the overall process of therapy and foundational to interpersonal
communication. Finally, when using a manualized treatment program it is crucial that the
clinician be able to follow the manualized intervention strategy while simultaneously
personalizing the interventions.
The issue of privacy/confidentiality was not associated with clinicians violating ethical
protocol, but rather with the office location and setting. This difficult problem is faced by those
who have a physical location where clients come to meet with their therapist. Expecting privacy,
they arrive only to see other clients who they may or may not know sitting in the waiting room.
Locations were selected where clients would not be easily distinguished from students attending
the regional campus. Therapy rooms were not discernible from faculty offices, and participants
were invited to “lock the door” once inside and turn the “sound screen” on. Some clients
reported that they could hear people outside and did not understand that the sound screen
prevented those outside of the room from overhearing the essence of the therapy sessions. In
future studies it would be advisable to take more time to explain how client
privacy/confidentiality is being addressed at their location.
Therapeutic Relationship: Mutuality with the Clinician
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Seven of 10 items in the Burns Empathy Scale indicated a modest decline in client
perception of clinician empathy over time (Table 5). Items 1, 2, and 4 address two important
qualities of empathy: trust and genuineness (Rogers, 1957; Truax, 1971). In that the mean scores
were lower 6 months post therapy, though not significantly, and choosing to error on the
conservative side, suggestions are provided to transcend a potential difficulty in this area. Due to
physical distance, therapists need to be particularly attentive to these qualities, displaying
behaviors consistent with trust and genuineness more rigorously than perhaps they may need to
in person. It is possible for teletherapy practitioners to focus so much of their attention on the
screen or the manualized process, that the client does not perceive them to be as connected with
them. Of concern was the fact that some therapists were engaged in other activities (e.g., writing
clinical notes) during TAPI sessions. Most likely this was because it would have been difficult
for the client to observe their behavior. It seemed to the author that these clinicians were
unaware of the relevance of body language and how even subtle nonverbal messages may be
observed or subconsciously experienced.
A modest decrease in perceived worth (items 3 and 9), a function of having needs and
expectations recognized and validated by the clinician, and demonstration of care (items 4 and 6)
was reported. For the client to experience a sense of worth and validation, the clinician must not
only be able to perceive their needs/expectations, but they must also have the skills to selectively
choose when and how to confirm that they have accurately heard. Validation strategies (e.g.,
frequent summations, benevolent reframes, and unconditional positive regard) are important in
any clinical setting; however, because of the unique manner of delivering teletherapy services it
is essential that this form of contact be consistent. Perceived demonstrations of care are
suggested when clinicians use email to provide reminders of appointments, delivering messages
of hope and inspiration, and asking how the week is going. These strategies are critical to
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fostering a sense of acceptance for therapy services among rural residents where favorable
reception of therapy is lower than for those residing in urban communities. The overarching goal
is to enhance the perception that the therapist is “thinking about them” and considers them as
“persons of value.”
Responses to item 7 demonstrated a modest decrease in the report that clients felt
understood. It may be that the initial scores were inflated to “please the clinician;” however as
time proceeded post-therapy, a more objective evaluation emerged. On the other hand, the small
decrease may have no meaning at all. Regardless, being understood is central to the client and as
such the clinician must be aware of and comprehend not only each client’s specific needs, but
expectations as well. Attributes suggested by Carl Rogers (1957) such as unconditional positive
regard, genuineness, and nonjudgmentality become the basis for therapeutic joining and the
essence of empathy (Hubble, Duncan & Miller, 1999). These attributes makeup the “critical
skill” to therapeutic outcome (Keefe, 1976). When demonstrated in the context of a collaborative
therapeutic relationship, clients perceive the clinical environment as safe, and the clinician as
empathetic (Openshaw, 1998a & 1998b). When these conditions are present clients allow
themselves to be vulnerable and suggestible to the process of therapy, synergistically and
isomorphically facilitating therapeutic outcome.
Satisfaction with the Technology
Satisfaction with TAPI technology declined over time, though not significantly. Having
worked with Macromedia Breeze, while admirable for what could be done, it has serious
limitations (e.g., bust size rather than full body images are visible thus limiting attentiveness to
nonverbal messages, and it works best with one client and clinician). By contrast, technology
used in distance learning (Interactive Video Conferencing) has much to offer the field of
teletherapy and could be effective across various client populations, offering excellent
audiovisual for real time communication. It is suggested that improved equipment will increase
19 | P a g e
satisfaction. In addition, more effective training for clients and clinicians in the use of the
technology, especially with a focus on potential “quirks” that are common would increase client
confidence with the technology. Finally, in that many of the difficulties can be identified in
advance, it is important that these “quirks” have solutions readily available to the client and
clinician.
Adequacy of privacy as it relates to the equipment is different from that which was
previously discussed. In this context clients do not always have a good understanding of how the
TAPI technology offers privacy, particularly in a world of hackers. The solution to this would be
to provide clients with sufficient information about TAPI technology so as to decrease any fears
they may have. This necessitates that those involved in providing therapy via TAPI have more
than adequate knowledge of the technology to project a peace of mind as it relates to
technological privacy. This privacy is not afforded in all forms of technology such as email,
instant chat, chat rooms, and cell phones, thus raising the question of their use for transmitting
confidential information.
Willingness to Refer
One would anticipate that any dissatisfaction with TAPI-delivered therapy would affect
willingness to refer others to this form of therapy. Findings suggest, however, that those who
have participated were well impressed with TAPI and reported willingness to refer. While not
statistically significant, this enthusiasm appears to have increased slightly over time (from 4.63
at baseline to 4.81, six months post-therapy).
Conclusion
If therapy, provided through TAPI, results in positive clinical outcomes (Openshaw, et
al., 2011), can be feasibly implemented in rural communities without significant cost (Roper,
2009), and satisfaction with the services are reported (Morrow, 2008), it may be concluded that
TAPI is a viable medium for reaching out and serving rural mental health needs. As satisfaction
20 | P a g e
with TAPI and willingness to refer increases in rural communities, key referral sources (i.e.,
primary care physicians, clergy, school counselors, and community members) will become
increasingly likely to learn about these services and utilize them. It is posited that as key
referral sources are educated in the existence and benefits of TAPI, and as TAPI is viewed by
these referral sources as a viable therapeutic resource for their patients, it is projected that an
increasingly large referral base will be established and community acceptance enhanced.
Finally, as participants provide family, friends, and neighbors information regarding teletherapy
rural residents move beyond the fear and stigma associated with mental health services, and
become advocates for TAPI.
All in all, with the ever increasing presence of stressors, particularly the economy as it
affects individuals, marriages/couples, and families, this art of therapy could be a “Godsend” to
those unable to receive necessary mental health services due to the barriers of availability,
accessibility, and acceptability.
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