Do Patients Prefer Face-to-Face or Internet-Based Therapy?
Authors: David Berle, Vladan Starcevic, Denise Milicevic, Anthony Hannan, Erin Dale, Vlasios Brakoulias, Kirupamani Viswasam
Journal: Psychotherapy and Psychosomatics (2014)

Delivery of psychological therapies via the Internet holds great promise: there are benefits of accessibility, reduced stigmatisation, as well as potential reductions in the cost of service provision. A large and expanding evidence base suggests that these approaches are as effective as face-to-face therapy for many disorders [1,2]. Moreover, the patients who complete online psychological therapy programmes typically perceive these as helpful [3].The aforementioned benefits of online therapies suggest that restructuring of existing face-to-face services into solely online services or some hybrid of online and face-to-face delivery may be useful. However, an additional variable to consider is patient preferences. Given sufficient resourcing of services, where any individual has access to the therapy format of his or her choice, would most patients prefer face-to-face (individual or group) psychological therapy or psychological therapy delivered in an online format, accessible at home or on their mobile phone? The purpose of this report is to shed light on this issue.We administered an anonymous 1-page survey to 55 consecutive patients attending their first appointment at the Nepean Anxiety Disorders Clinic in Penrith, N.S.W., Australia. The survey asked respondents to rate their preferences for 5 forms of therapy delivery: individual face-to-face therapy, group face-to-face therapy, bibliotherapy (where therapy is exclusively provided by means of books and reading materials that are posted to patients), online therapy without therapist contact and online therapy with weekly therapist phone contact. To ensure that respondents were well informed about what each option involved, we provided descriptions of all forms of therapy delivery. Patients completing the survey had a primary anxiety disorder (i.e. panic disorder, generalised anxiety disorder, social anxiety disorder, health anxiety, specific phobia or obsessive-compulsive disorder). The survey was administered to patients before their first appointment to ensure that they had not yet had an opportunity to form an alliance with a therapist at the Clinic as this may have influenced their therapy delivery preferences.Approval to conduct the study was obtained from the Nepean Blue Mountains Local Health District Human Research Ethics Committee (study 13/17).Forty-two (76.4%) of the sample reported that they had previously received either individual or group face-to-face therapy, and only 1 individual (1.8%) reported having received a course of online therapy previously. The majority of participants (n = 48; 87.3%) had ‘reliable access to the Internet at home', indicating that they would be able to avail themselves of online therapy if this was available.The proportions of the sample favouring various forms of therapy delivery over each other are summarised in table 1.The results of our survey suggest that patients overwhelmingly preferred individual face-to-face therapy to all other delivery options. Importantly, this does not appear to be a consequence of a lack of basic and affirmative information about the alternative therapy modalities, given that such information was provided by the survey.It is noteworthy that online therapy with weekly therapist phone contact was preferred over face-to-face group therapy and bibliotherapy. This finding suggests that appropriately resourced online therapy - where clinicians retain regular involvement with each patient - may be a favourable ‘next best' option for clients when routine individual face-to-face therapy is not available. Also, it seems that therapeutic contact - whether through individual face-to-face therapy or online therapy with weekly therapist phone contact - was considered important by our survey participants. Our findings are broadly consistent with those from studies of non-treatment-seeking populations, where 79.4 [4] and 77.1% [5] of the participants preferred face-to-face mental health support. Also, a survey of primary health care patients showed that 92% were interested in face-to-face interventions, but only 48% in Internet treatment [6]. However, two surveys reported contrasting results [7,8]. For instance, Wootton et al. [7] found that only 10% of individuals with high levels of obsessive-compulsive symptoms would prefer face-to-face treatment to online therapy. These surveys involved self-selected samples in that they comprised individuals not necessarily seeking treatment who were accessing an online clinic website (www.virtualclinic.org.au). Additionally, the two surveys did not apparently distinguish between individual and group face-to-face therapy, potentially biasing the results. Another possible reason for the different findings is that our participants completed the survey in the waiting room of our Clinic so that any notion that therapy appointments would be inconvenient to attend (in terms of travelling to the appointments, finding parking, etc.) may have been undermined through a favourable experience of attending their first appointment.Our survey had a number of limitations. First, the validity and reliability of the survey items was indeterminate. Also, our sample was self-selected in that each respondent had already decided to attend a Clinic for face-to-face therapy. Moreover, the majority of our sample had previously received face-to-face therapy but not online therapy. This might have contributed to favourable ratings for face-to-face therapy, but not in case of patients whose previous experience with face-to-face therapy was negative. Nonetheless, insofar as our sample is representative of patients who currently attend publicly funded face-to-face mental health services in Australia, it appears that there is a strong preference for individual face-to-face therapy.Further studies might aim to use well-validated measures with broader samples of treatment-seeking individuals (before they have chosen face-to-face or online therapy). Still, the present results should be considered in light of the increasing imperative to provide consumer-focused care. In this respect, our finding that the overwhelming majority of patients favour individual face-to-face therapy over other forms of therapy delivery underscores the importance of clinics continuing to offer individual face-to-face therapies.D.B. has performed contractual consultation work for ProPhase LLC. V.S. has been receiving royalties from the books he published on anxiety disorders and hypochondriasis/health anxiety. No other author has any conflict of interest to declare with regard to this paper.