Disclaimer The material in this report, including selection of articles, summaries, and interpretations is the responsibility of Swinburne University of Technology, and does not necessarily reflect the views of the Australian Government. Swinburne University of Technology does not endorse any particular approach presented here. Evidence predating the year 2000 was not considered in this review. Readers are advised to consider new evidence arising post publication of this review. It is recommended the reader source not only the papers described here, but other sources of information if they are interested in this area. Other sources of information were not included in this review including non-peer reviewed literature or information on websites. © Commonwealth of Australia 2017 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth. Requests and inquiries concerning reproduction and rights should be addressed to the publications section, Department of Veterans’ Affairs or emailed to . Please address any comments or queries about this report to
The REA methodology prioritises the use of systematic reviews, meta-analyses, and guidelines in order to utilise pre-existing high-quality rigorous research, to limit unnecessary duplication, and increase the rapidness of the review (Varker et al., 2014). A search was conducted in July, 2016 to identify the most recent systematic review relevant to the research questions. The search identified two high quality, recent systematic reviews. The first of these systematic reviews was conducted by Backhaus et al. (2012). This paper reviewed studies published between 1997 and 2010 which investigated therapy delivered via videoconferencing technology and covered areas such as: the type of psychological disorders investigated and clinical outcomes, as well as the populations studied, satisfaction ratings, therapeutic alliance, and attrition rates of OVC. An additional systematic review by Simpson and Reid (2014a) was also identified. This paper reviewed studies published between 1990 and 2013 which focussed on the therapeutic alliance in OVC. The REA also considered studies published after the cut off dates of these respective reviews up to July 2016. Search terms As discussed, a problem in this area of research is that multiple terms are often used interchangeably (e.g., telehealth, videoconferencing, e-therapy, etc.). Thus, given this issue and the scope of the current study, a large number of different search terms and combinations were used to identify papers relevant to the research questions. Terms such as “telehealth”, “online counselling”, “videoconferencing”, “therapeutic alliance”, “working alliance”, “satisfaction”, “mental health”, “veterans”, “depression”, “anxiety”, “posttraumatic stress”, and “quality of life” were all used in different combinations. An example of the search strategy conducted using the PsycINFO database is shown in Appendix 2. Paper selection The following inclusion and exclusion criteria were used to determine which papers were eligible to be included in the review: Inclusion Criteria:
mental health problems and that these improvements are not significantly different to those achieved by clients receiving treatment in-person. Furthermore, client perceptions of the TA and satisfaction have also been found to be similar to those of in-person treatment. The evidence base relevant to clinical outcomes for depression and anxiety, as well as overall functioning, the TA, and satisfaction, was ranked as “Promising”. Although results from preliminary studies examining these outcomes are encouraging, few studies have used large samples, randomisation and/or a control group. In addition, considering the limited amount of research conducted on OVC to treat adults with PTSD one-on-one, and the smaller effect sizes that have been reported using this modality when compared to in-person treatment, the evidence base for OVC to treat PTSD was ranked as “Unknown.” Hence, there is a need for further, more methodologically sound research, to validate previous findings and establish whether OVC is equivalent to traditional in-person treatment for PTSD. A similar conclusion has been reached for therapist perceptions of TA. Although several studies have reported that therapist perceptions of TA are lower for OVC than for counselling, the limited number of rigorous current studies investigating this issue and the novelty of the OVC modality for many therapists makes an ‘Unknown’ ranking most appropriate for the equivalence of OVC and in-person counselling in this context. Implications Despite the ability of mental health professionals to adopt OVC as an approach to enhance access to treatment, utilisation has remained low (Simpson & Reid, 2014b). Several factors have likely hindered the implementation of OVC in Australia including a lack of methodologically rigorous research as well as an enduring, unfounded scepticism regarding the development of the therapeutic relationship in OVC (Richardson & Simpson, 2015). It appears as though clinicians either continue to doubt the evidence base for OVC and need further, more methodologically rigorous research or are simply unaware of the evidence base altogether. Hence, an increased awareness of the benefits of OVC is needed among mental health professionals before OVC can be utilised more frequently. It is thought that improving knowledge of and attitudes toward OVC may increase the frequency with which
Treatment response was measured with the Hamilton depression scale, BDI, Spielberger Trait Anxiety Inventory Scale, the Spielberger State Anxiety Scale, the GAF, CGI, and Medical Outcomes Study Short-Form Health Survey - Satisfaction (custom scale) - Attrition (% of drop outs) - The Quality of Life Enjoyment and Satisfaction (QLES) was used to measure changes in quality of life. - The Working Alliance Inventory Short Form was used to measure the therapeutic alliance. - Satisfaction was measured the shortened Client Satisfaction Questionnaire (CSQ) Setting and sample characteristics Depressed American veterans N=119 (88% male, mean age of 49.7) Adults diagnosed with Axis-I disorder and referred for treatment. N=26 (42% male, mean age of 30) Depressed elderly veterans (aged ≥58 years) N=241 (98% male, mean age of 63.9) Participants: I N=59 N=14 N=120 Participants: C N=60 No significant differences between the groups at baseline were reported. N=12 No significant differences between the groups at baseline were reported. N=121 No significant differences between the groups at baseline were reported. Summary of the results A significant overall effect of time was observed, suggesting a decline in the frequency and severity of PTSD symptoms for both groups. The interaction term was not significant, suggesting that there was no difference between the two treatment conditions. A significant overall effect of time was observed, suggesting a decline in the frequency and severity of PTSD symptoms for both groups. The interaction term was not significant, suggesting that there was no difference between the two treatment conditions. A significant overall effect of time was observed, suggesting a decline in the frequency and severity of PTSD symptoms for both groups. The interaction term was not significant, suggesting that there was no difference between the two treatment conditions.
Evidence Profile – posttraumatic stress disorder Study 1 Study 2 Study 3 4 Authors and year Strachan, Gros, Ruggiero, Lejuez & Acierno (2012) Germain, Marchand, Bouchard, Drouin & Guay (2009) Yoder, Ruggiero, Gros & Acierno (2010) Gros, Yoder, Tuerk, Lozano & Acierno (2011) Design RCT Non-randomised controlled Non-randomised controlled trial Non-randomised controlled Intervention (I) and Comparison (C) (I): OVC (C): In-person treatment (I): OVC (C): In-person treatment (I): OVC (C): In-person treatment (I): OVC (C): In-person treatment Focus of Intervention Treatment (using Behaviour Activation therapy) Treatment (using CBT) Treatment (using exposure therapy) Treatment (using exposure therapy) Participant inclusion criteria Participants were included in the study if they met criteria for PTSD or subthreshold PTSD, defined as fulfilment of Criteria A (traumatic event) and B and either C (avoidance) or D (hyperarousal) Participants were included in the study if they had a primary diagnosis of PTSD from the SCID-IV Participants were included in the study if they had been diagnosed with combat-related PTSD from the SCID-IV Participants were included in the study if they had been referred to receive exposure therapy for PTSD Primary outcome domain (measures) The time-by-treatment group interaction; to determine whether the change in PTSD symptoms over time was influenced by the treatment condition. - PCL-M, BDI-II, and BAI The time-by-treatment group interaction; to determine whether the change in PTSD symptoms over time was influenced by the treatment condition. Reduction in symptomology from pre- to post-treatment - PCL-M - BDI The time-by-treatment group interaction; to determine whether the change in PTSD symptoms over time was influenced by the treatment condition. - PCL-M - BDI - DASS - IIRS
Secondary outcome domain (measures) Change in symptomology over time: - Modified PTSD Symptom Scale (MPSS) - BAI - BDI - Assessment of Current Functioning (ACF) Comfort with technology: - Distance Communication Comfort Scale (DCCS) - Videoconferencing Telepresence Scale (VTS) - Videoconference Therapy Questionnaires (VT-Q) Change in symptomology over time: - PCL-M - BDI - DASS - IIRS Setting and sample characteristics American veterans with PTSD or subthreshold PTSD. N=31 (92.5% male, mean age of 30.4) Adults with PTSD. N=48 (39.6% male, mean age of 42.5) American veterans with combat-related PTSD. N=47 (94% male, mean age of 39). American veterans with PTSD. N=89 (~90% male, mean age of 45) Participants (I) N=18 N=16 N=12 N=62 Participants (C) N=13 No significant differences between the groups at baseline were reported. N=32 No significant differences between the groups at baseline were reported. N=35 No significant differences between the groups at baseline were reported. N=27 No significant differences between the groups at baseline were reported. Summary of the results A significant overall effect of time was observed, suggesting a decline in the frequency and A significant overall effect of time was observed, suggesting a decline in the frequency and Participants in both groups were found to experience significant clinical improvements over time. However, the effect size for the A significant overall effect of time was observed, suggesting a decline in the frequency and
severity of PTSD symptoms for both groups. The interaction term was not significant, suggesting that there was no difference between the two treatment conditions. severity of PTSD symptoms for both groups. The interaction term was not significant, suggesting that there was no difference between the two treatment conditions. group (d=4.2) was larger than that of the OVC group (d=2.9) severity of PTSD symptoms for both groups. However, the interaction term was significant, suggesting that clients receiving in-person treatment experienced a greater reduction in symptoms than those receiving OVC. Evidence Profile – therapeutic alliance Study 1 Study 2 Study 3 4 Authors and year Day & Schneider (2002) Germain, Marchand, Bouchard, Guay & Drouin & (2010) Simpson, Guerrini & Rochford (2015) Richardson, Reid & Dziurawiec (2015) Design RCT Non-randomised controlled Non-randomised controlled trial Uncontrolled Intervention (I) and Comparison (C) (I): Three treatment groups: OVC, telephone, and in-person (C): Wait list (I): OVC (C): In-person treatment (I): OVC (C): In-person (I): OVC (C): none Focus of Intervention Treatment Treatment Treatment Treatment Participant inclusion criteria Clients in need of counselling Participants were included in the study if they had a primary diagnosis of PTSD from the SCID-IV Clients in need of counselling Clients receiving OVC
Primary outcome domain (measures) To determine whether ratings of the working alliance were influenced by the treatment condition. - Vanderbilt Psychotherapy Process Scale (VPPS) - CSS - TSS The time-by-treatment interaction; to determine whether there was any change in alliance scores over time and whether this was influenced by the treatment condition. - WAI - SEQ - DCCS -VTS -VT-Q Reduction in symptomology from pre- to post-treatment - CORE-10 To evaluate the client experience of OVC - ARM Secondary outcome domain (measures) To determine whether clinical outcomes were influenced by the treatment condition. - BSI (GSI) - GAF - CSS - TSS To determine whether ratings of the working alliance were influenced by the treatment condition -CORE-ARM Setting and sample characteristics Clients receiving counselling for a variety of problems N=80 (35% male, mean age of 39.4) Adults with PTSD. N=46 (41.3% male, mean age of 42) Clients receiving counselling for a variety of problems N=23 Clients receiving counselling for a variety of problems Participants (I) OVC N=26; Telephone N=27; In-person N=27 N=17 N=6 (50% male, mean age=34) N=8 (25% male, ages ranged from 27 to 52 years) Participants (C) N=27 N=29 No significant differences between the groups at baseline were reported. N=17 (41% male, mean age=31.8) N/A Summary of the results There was a significant difference between the A significant overall effect of time was observed, Reductions in distress and high alliance scores Ratings of alliance were high from baseline and
groups indicating that participants engaging in OVC had higher alliance scores than those in the in-person condition. suggesting an improvement in alliance scores over time for both groups. The interaction term was not significant, suggesting that there was no difference between in alliance scores between the two treatment conditions. were found for each group. No significant differences were found between the two groups. improved over the duration of treatment.