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Social Science & Medicine 71 (2010) 1308e1315

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Social Science & Medicine

journal homepage: www.elsevier .com/locate/socscimed

You can’t get anything perfect: “User perspectives on the delivery of cognitivebehavioural therapy by telephone”

Penny Elizabeth Bee a,*, Karina Lovell a, Nicola Lidbetter b, Katherine Easton a, Linda Gask a

aUniversity of Manchester, School of Nursing, Midwifery & Social Work, Jean Macfarlane Building, University Place Oxford Road, Manchester M13 9PL, United KingdombAnxietyUK, United Kingdom

a r t i c l e i n f o

Article history:Available online 15 July 2010

Keywords:UKAcceptabilityTelephoneCognitive behavioural therapyTelemedicineMental health care

* Corresponding author. Tel.: þ44 0 161 306 7652.E-mail address: penny.bee@manchester.ac.uk (P.E.

0277-9536/$ e see front matter � 2010 Elsevier Ltd.doi:10.1016/j.socscimed.2010.06.031

a b s t r a c t

Remote psychotherapy services such as telephone-administered cognitive behavioural therapy (T-CBT)have the potential to provide effective psychological treatment whilst simultaneously maximising effi-ciency, lowering costs and improving access to care. However, a lack of research examining theacceptability of non face-to-face psychotherapy means that little is known about users’ perceptions ofthese delivery models. This paper reports data from two qualitative evaluations of T-CBT delivered in thevoluntary and occupational health sectors in the UK. It explores users’ acceptance of T-CBT, contrastinginitial socially-construed expectations with more positive regard derived from experiential norms. Usersatisfaction with T-CBT was mixed. However, the relative ease with which most participants adapted totelephone-based care was suggestive of a shared construct of mental health service provision that pri-oritised the accessibility and availability of services over the social, professional and medico-legalperspectives that conventionally promote the co-location of practitioner and client.

� 2010 Elsevier Ltd. All rights reserved.

Introduction

Increasingly, innovations in treatment delivery are beingproposed by healthcare providers to maximize the availability,accessibility and cost-effectiveness of mental healthcare (Maheu,Pulier, Wilhelm, McMenamin, & Brown-Connolly, 2005). Rapidadvances in communications technologies have led to their inte-gration into health systems and to the mediation of relationships inhealthcare across time and space. Telepsychiatry in particular hasattracted substantial research and political attention. Its develop-ment and evaluation have been expedited both by a need toincrease accessibility to under-resourced areas, and by the nature ofthis speciality itself. Psychiatric assessments and consultations arelargely confined to the synthesis of audiovisual information. Thepotential ease of ‘fit’ between these tasks and the capabilities of thetechnological systems through which communication can bemediated has led to the championing of telepsychiatry not only asa practical solution to geographical inequities in service provisionbut also as a political solution aimed at increasing the economicand organisational efficiency of care. A proliferation of literaturenow exists that explores the feasibility, efficacy and acceptability oftelepsychiatry particularly in relation to the remote delivery of

Bee).

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mental health services via videoconferencing systems (Antonacci,Bloch, Saeed, Yildirim, & Talley, 2008).

In lacking the visual component integral to many contemporarycommunication media, the telephone is arguably not at the fore-front of current telemedical advances. It nonetheless retains statusas a ubiquitous social technology, with the potential to mitigatemultiple barriers to care (Maheu, Whitten, & Allen, 2001). Thetelephone is a well established tool within the voluntary supportsector, it is used routinely by clinicians providing out-of-hours crisisinterventions, and is currently emerging as a core component ofcollaborative care1 (Fortney et al., 2006; Richards et al., 2006).Increasingly it is also attracting attention as an effective mediatorfor remote psychotherapy provision (Bee et al. 2008). Randomisedcontrolled trials now report evidence of the efficacy of telephone-based Cognitive Behavioural Therapy (T-CBT) for depression (Mohret al., 2005; Simon, Ludman, Tutty, Operskalski, & Von Korff, 2004);agoraphobia (Swinson, Fergus, Cox, & Wickwire, 1995) and obses-sive-compulsive disorder (Lovell et al., 2006). Yet, despite thisgrowing evidence base and the widespread familiarity of the tele-phone as a communication tool, telephone-delivered psychother-apies have been slow to penetrate the healthcare system.

1 Collaborative care is a model of care comprised of both organisational andpatient-level components. In the case of Richards et al. (2006) for example, casemanager-coordinated medication support was combined with brief psychologicaltreatment and enhanced specialist and GP communication.

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Sociological discourses highlight disparity between politicalinterest in remote services and the extent to which mental healthprofessionals may be willing to engage with them as a platform forservice delivery (May et al., 2001). Ethnographic studies in clinicalsettings report an initial enthusiasm for technology-mediatedconsultations that is rarely sustained in practice (May, Mort,Williams, Mair, & Gask, 2003; Richards et al., 2006). Such evalua-tions highlight deeply-embedded constructs of care which oftenconflict with the theoretical promise of newer, more innovativeservice delivery models.

The relationship between practitioner and patient has long beenafforded significance within biomedical literature. Sociologicalperspectives point to the clinical encounter as a contexteboundedinteraction, the locality of which acts both as an indicator of thetype of service available and as a symbolic representation of theprovider’s responsibility to care (Jacob, 1999). Synonymousmeaning can be presumed to be present in the psychotherapeuticrelationship with the professional and organisational embedded-ness of the therapeutic consulting room acting as a proxy indicatorof confidentiality and service authenticity. Yet the relationshipbetween therapist and client extends beyond its medico-legalsignificance. The elevated status of the therapisteclient relation-ship is underpinned by the fact that it remains a significantpredictor of treatment adherence, concordance and outcome acrossa range of settings, diagnoses and therapeutic modalities (Horvath& Bedi, 2002).

Humanistic psychotherapists have long affirmed the importanceof empathic listening within the therapeutic relationship (Rogers,1975), with both verbal and non-verbal cues, including bodylanguage and posture, contributing substantially to the quality ofa clinical encounter (Watson, 2002). Thus, it is argued that anycommunication media which alters the geographical distancebetween therapist and client may also impact on the psychologicaldistance between the two. The net effect, as May et al. (2001) assert,is that the drive for amore effective and efficient health care systemis often countered by a sense of mistrust of its political andcommercial origins, and of the potential risks that more innovativeservice delivery models may generate. Opponents of technology-mediated therapies contend that, in the absence of non-verbal cues,the therapeutic alliance is compromised and the possibilities forcrisis mismanagement raised (Haas, Benedict, & Kobos, 1996;Stamm, 1998).

Conversely, advocates of remote psychotherapy assert thatwhilst much cultural significance may be placed on the co-locationof a therapist and client, the practical necessities of this arrange-ment are not always clear. Within the context of telephone-medi-ated therapies, Beckner, Vella, Howard, and Mohr (2007) argue thatwhilst the practitionereclient relationship is of relevance to ther-apeutic outcome, the precise role of this alliance may vary bytherapeutic approach. Specifically, cognitive and behaviouralpsychotherapies (CBT) may be better suited to these remotedelivery models than other treatment modalities, not least becauseof their potential to rely less on the therapeutic relationship as theprincipal agent of change.

CBTexists as an umbrella term for a range of interventions basedupon the modification of disordered thoughts and behaviours, theprinciples of which are underpinned by psychological models ofhuman emotion and behaviour. Integral to the CBT model isa concept of collaborative problem solving through which therapistand client work together in a time-limited process towards specific,explicitly agreed goals. As such scientific discourses challenge thenotion that the pre-eminent concern of CBT should be the strengthof bond between clinician and client. Insteadmuch of the rise in thepopularity of this approach has paradoxically been attributed toa set of empirically-grounded techniques (Salkovis, 2002) that are

themselves regarded to confer independent success. Support forthis argument is evidenced by the contemporary growth of CBTself-help interventions and stand-alone technologies whichdemand little or no therapist resource (National Institute forClinical Excellence, 2004a, 2004b).

Evidence of the effectiveness of CBT now exists for a wide rangeof psychiatric diagnoses including depression, generalised anxietydisorder, post-traumatic stress disorder, and panic with or withoutagoraphobia (Butler, Chapman, Forman, & Beck, 2006). However,critics of the modality brand it as little more than ‘therapeuticreductionism’ and argue that the increasing political drive forefficient and cost-effective health care is responsible for much ofthe growth in the popularity of this approach (House & Loewenthal,2008). Adversaries contend that the very concept of evidence-based medicine has in itself favoured an intervention that priori-tises problem formulation and the systematic monitoring ofquantifiable treatment outcomes (Gaudiano, 2008). Within suchcommentaries, CBT is viewed largely as a mechanistic, symptom-based intervention, which denigrates the humanistic valueinherent in the dialogue of other psychotherapies.

At first glance, the recognition given to CBT appears to opposethe broader socio-cultural values afforded to the therapeuticexchange. By redirecting emphasis away from the therapeuticrelationship and towards a set of proven clinical techniques, theneed for meanings and methods that rely on presence and close-ness is contested. Yet even in the most distilled of CBT-basedinterventions, debate over the role of interpersonal factors persists(Richardson & Richards, 2006). Meta-analyses suggests improvedtreatment outcomes when self-help for depression is augmentedby therapist support (Gellatly et al., 2007), and randomised trials ofCBT for anxiety and depression report weaker effects for self-helptechnologies compared to conventional face-to-face delivery (Meadet al., 2005; Richards et al., 2003). The implication of these studiesis that contextual factors, including the interaction between theclinician and client, may ultimately be of greater significance thanpreviously assumed.

In the context of telepsychiatry, May et al. (2001) refer to theintricacies of the patientepractitioner encounter as a ‘soft tech-nology’ governed by the weight of sociological and medicalknowledge that frame and structure these interactions. The extentto which the promise of a new and potentially more efficient formof delivery may be outweighed by impacts on the therapeuticrelationship is therefore difficult to predict. Previous assessmentsof remote psychotherapies have largely adopted biomedicalresearch procedures in which knowledge production has focussedon the generation of the quantitative data demanded by evidence-based health technology assessments (Williams, May, Mair, Mort, &Gask, 2003). A recent review of remotely-delivered therapies (Beeet al., 2008) reports that although few randomised controlledtrials have measured client satisfaction, those that have reportsimilar or greater satisfaction with telephone-based services aswith usual care (Hunkeler et al., 2000; Simon et al., 2004). Equiv-alent satisfaction has also been reported with telephone therapy aswith identical treatments delivered face-to face (Lovell et al., 2006).Such quantitative assessments however have their disadvantages,not least because of their tendency to demonstrate high levels ofuser satisfaction across patient groups (Stallard, 1996).

Despite acknowledgement of professional resistance to remotepsychiatric services, qualitative evaluations examining the views ofpatients as consumers are rare. Limited research in non-mentalhealthcare settings suggests that patients may possess clear beliefsregarding the role of communication technologies in their care(Turner et al., 2003). While telemedicine is perceived as appro-priate for routine consultations, richer face-to-face exchanges maybe demanded in more complex treatments. Thus, users of health

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services are likely to hold a variety of beliefs regarding remotely-delivered interventions depending upon the context in which theirinteractions occur. An understanding of these beliefs is necessary toilluminate further the challenges facing the integration of remotepsychotherapy provision.

Study context, group and method

This paper draws on analyses of qualitative data from 30patients from two studies examining patient experiences withT-CBT. Study 1 was a qualitative service evaluation commissionedby a voluntary UK-based organisation (AnxietyUK). Participantsself-referred to Anxiety UK for a range of chronic mental healthdifficulties including agoraphobia, generalised anxiety disorder anddepression. Between May 2007 and December 2008, a total of 100participants were assessed and treated by one of 20 trained CBTtherapists who completed 12 scheduled weekly or bi-weeklytelephone sessions of 30e60 min duration. Fifteen consented tointerview.

Study 2 (n ¼ 15) was a nested qualitative process evaluationundertaken as part of a larger RCT (n ¼ 53) (Bee, Bower, Gilbody,& Lovell, 2010). Trial inclusion criteria comprised adult employeesregistered as absent from work due to mild/moderate mentalhealth difficulties and currently on sick leave of between 8 and 90days as authorised by GP certificate. Exclusion criteria weresevere or complex mental health problems (i.e. psychosis, PTSD,co-morbid personality disorder); degenerative cognitive disor-ders, substance misuse and/or active suicidal ideation or self-harm. Eligible employees were referred to the telephone servicevia human resources. Consenting participants were assessed andtreated by one of two trained CBT therapists in 12 scheduledweekly or bi-weekly telephone sessions of 30e60 min duration.Interviews took place between June 2008 and February 2009.

Therapists in both studies were trained in face-to-face CBT witha mixed level of training and experience of T-CBT. No face-to-facecontact between therapists and participants occurred. The char-acteristics of the two study samples are described in Fig. 1. Withinthe text we refer to respondents by the study to which they wererecruited (S1 or S2). Participants (P) are assigned a code numberrather than a name or pseudonym. Gender, self-reported psycho-logical difficulties and illness duration are provided.

The aim of both studies was to explore participants’ narrativesand experiences of T-CBT. All participants were contacted post-therapy via a letter which invited them to take part in a telephoneinterview. Participation in these interviews was voluntary and wasnot a requirement of treatment in either study. Interviews wereconducted using open-ended, inductive questioning around key

n o i t p i r c s e d e t i S y d u t S e v i t a t i l a u Q : 1 S

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Fig. 1. Study & samp

themes from an interview schedule devised by the research team.Interviews were conducted by KE (Study 1) and PB (Study 2) andranged from 30 to 120 min. All interviews were audiotaped andtranscribed verbatim. Participants were sent copies of their tran-scripts for editing and correction purposes.

The resulting data were subjected to a thematic analysis.Emergent themes were independently identified and coded by PBusing the method of constant comparison (Strauss & Corbin, 1990).As themes were recorded and classified, they were compared andrefined across all interviews until no new themes emerged. Codingstrategies were initially developed within studies and then collec-tively applied across both settings. Independent verification of theemergent themes was provided by members of the research team(KL, LG). Ethical approval for the study was obtained from theUniversity of Manchester senate ethics committees.

Socio-medical constructs of remote psychotherapy provision:patient need vs. knowledge

Advocates of remote psychotherapy provision regard T-CBT notas a cheaper variant of care but as an effective intervention in itsown right. However, at the point of referral to therapy, partici-pants construed the clinical utility of the telephone as relativelyneutral in terms of anticipated success. Instead, their engagementwith this intervention was elevated in appeal by a lack of viablealternatives. Participants in both studies highlighted a range ofdeficits in conventional services that left them expressing feelingsof desperation and powerlessness in a system that appeared toundermine access to effective care. The tendency for healthprofessionals to address symptoms rather than causes led to whatmany respondents believed was an over-emphasis on a medicalmodel of care and a sole reliance on pharmacological treatments.A shared fear in the discourses of many interviewees was one ofsymptom escalation and a struggle against mental health diffi-culties of indefinable duration:

“I mean a lot of people would say the GP doesn’t want to know, Ithink the GP can only offer you so much support. He can offer youanti-depressant tablets, which I decided not to have. I suppose ifyou could have a happy pill everyday we’d all take one wouldn’twe, but it wasn’t a cure.” (S1P09, Male, Depression, 5 years)

Substantial research evidence supports the notion of inadequaterecognition and treatment of mental health difficulties within UKprimary care (Campbell, Gately, & Gask, 2007). However, despiteself-selecting a more innovative form of service delivery, studyparticipants rarely presumed this intervention to display a superioreffect. Rather, their narratives reflected from the outset an

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l a t n e m d e n i f e d - f l e S . n o i t a r u d s r y 2 n a h t , y t e i x n a d e d u l c n i s e i t l u c i f f i d h t l a e h

i b o h p a r o g a , n o i s s e r p e d % 3 7 ; c i n a p d n a a . s r y 6 6 - 2 2 d e g a , h s i t i r B - e t i h w % 6 8 e l a m e f

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s i r o h t u a s a e v a e l k c i s . e t a c i f i t r e c P G y b d e s e i t l u c i f f i d h t l a e h l a t n e m d e t r o p e r - f l e S d n a n o i s s e r p e d e t a r e d o m - d l i m d e d u l c n i

; h s i t i r B e t i h w % 7 9 , e l a m e f % 2 5 ; y t e i x n a . s r y 0 6 - 2 2 d e g a

le descriptions.

P.E. Bee et al. / Social Science & Medicine 71 (2010) 1308e1315 1311

underlying skepticism of the ability of remote communicationtechnologies to confer independent therapeutic gain:

“I didn’t know what to expect really. Somehow I thought because itwould be over the phone I thought that she wouldn’t have a clue,she wouldn’t understand if she couldn’t see me.” (S2P10, Female,Depression & Anxiety, 2 months)

Such reflections served to place T-CBT outside of the context ofan empathic patient‑practitioner exchange. Instead the scope of theinteraction that participants envisaged was one of informationdissemination and education. Several accounts emphasised thevalue that participants attributed to ‘just talking’ or ‘havingsomeone to listen’ alluding more to constructs of a passive supportintervention than an evidence-based CBT programme with proveneffect. A paucity of accounts describing the anticipated benefits ofT-CBT suggested that participants possessed, from the outset,a socially-construed notion of telephone care that remained quitedistinct from comparable constructs of psychological therapies andthe pre-requisite level of intimacy that these were believed todemand. Recognition of these culturally-embedded values and oftheir potential loss in a remote consultationmeant that participantsultimately balanced their desire for a meaningful treatment againsta more rapid pathway to care. As such, the initial decision to useT-CBT remained distinct from its acceptance as a potentially effec-tive therapeutic intervention, a concept that demanded somedenigration of normative expectation regarding the likely para-meters of a good healthcare experience:

“You can’t get anything perfect. In an ideal world to go and seea CBT specialist after two weeks of seeing your doctor, and be ableto afford it would be great. I suppose that’s what all these cliniciansare saying, it’s not an ideal world and to try to get any help formental health there has to be options and this is one. It has itsdrawbacks, I would have liked to have met the person, but on theother hand I’m grateful I got some help.”(S1P03, Female, Depres-sion, 4 years)

Cognitive restructuring: patient familiarisation with newmodels of mental healthcare

Having accessed the new treatment delivery model, it becameapparent that the neutrality with which participants viewed T-CBTwas not long standing. Many individuals appeared to sharea discourse that reflected an upward adjustment of their intrinsicexpectations and, by association, their role and behaviour withinand between their telephone-mediated exchanges. Indeed, partic-ipants who had originally expressed neutral expectations of T-CBTretrospectively held this intervention in high regard. As suchexperiential norms often displaced individuals’ initial suspicions ofthis more innovative treatment model, an effect that sometimesalso ‘snowballed’ beyond the patient themselves:

“When I first started, I knowmy son said ‘oh I wouldn’t do that. hesaid because you can’t see the person’s face and they can’t readyour body language which I suppose is true isn’t it? But I think ifanything over the phone I felt that.the words became moreimportant.there were absolutely no distractions. To get the helpquickly that was the key. I’ve been to the doctors and she said ‘nexttime you come in will you bring all the information about it?’ Myson’s also told his doctor. It’s been absolutely fantastic for him.”(S1P11, Female, Anxiety, 2 years)

As described above, participants rarely contextualized T-CBT asa therapeutic intervention, and yet once they had accessed thistreatment, they were equally rare in emphasising any disjuncturebetween its content and delivery by more remote means. The

emphasis that cognitive behavioural therapists place upon itsempirically grounded techniques has in the past neglected thecontextual factors believed to be of higher relevance in otherpsychotherapies (Richardson & Richards, 2006). Nonetheless, thisdoes not suggest that CBT practitioners and patients can disregardtheir influence completely. Indeed, as Goldfried (2004) observes,the context in which CBT is delivered remains akin to the anes-thesia under which a surgical procedure is performed.

In recounting their T-CBT experiences, interviewees describednot only their engagement in its ‘specific factors’ but also theinterpersonal gains that they were afforded. For many, the tele-phone constituted a largely pragmatic means of accessing other-wise unavailable psychotherapeutic exchange. Yet the regularityand depth of this interaction appeared to be sufficient not only togenerate trust in the methods employed but also a sense ofpsychological closeness, portrayed largely through the impetus towork towards mutually negotiated goals:

“Because it’s not the face-to-face you’re after is it? It’s the help. Andyou’re getting that over the phone and it’s a voice you recogniseand can help you, and you just welcome it, any help. And I felt as ifit was helping then as soon as the phone rang. I was ‘hiya!’ I wasthat eager to speak to her telling her how I0d got on. It’s alrighttalking to a friend but unless you’re qualified to analyse people likethat you cant’.you can listen to them and you can empathise withthem but I don’t think you can help them. Not that type of help..When she phones up I just giggle to myself because I think ohshe’s a really lovely person isn’t she. You can tell.” (S2P08, Female,Depression, 3 months)

A key observation here is not that this delivery model necessi-tated the introduction of these processes, but rather that telephonecommunication enabled participants to engage in existing, albeitunanticipated therapeutic techniques. Within such discoursetherefore, the telephone was perceived as a sufficiently adequatemedium for the delivery of conventional cognitive-behaviouraltechniques. Although patients recognised their inability to draw onthe kinds of visual information and feedback available in face-to-face consultations, many considered this advantageous in terms ofexemplifying their engagement in the skill modality of CBT. Indeed,among themore satisfied respondents it was this very lack of visualdata that became the focal point of their critiques:

“I think if anything because it was over the phone I felt that youhoned in on the words more, the words became more important,there were absolutely no distractions.”(S2P04, Male, Depression, 6weeks)

Several respondents extended this narrative by emphasisingthat face-to-face carewas not necessarily always the ‘gold standard’that professionals perceived it to be. Rather, psychological close-ness appeared possible and sometimes easier to achieve in theabsence of physical proximity:

“I suppose the advantage of talking over the phone is that some-times you know when you meet someone face-to-face for somereason or other you instantly don’t like them. I don’t think you’relikely to get that over the phone so the therapy might be given moreof a chance if you see what I mean, you’re concentrating on actuallywhat you’re doing on the therapy as opposed to whether youparticularly like this person or not.” (S1P11, Female, Anxiety, 2years)

It may be argued that in bringing appointments directly to itsclients, telephone therapy runs the risk of being perceived as anoverly intrusive model of care. However, respondents tended toview this feature positively, construing it primarily as a means of

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motivating them to take responsibility for their own recovery. Inreality, participants did not have to answer the phone, just as theywould not have to present in clinic for a face to face appointment,but for the majority, the guaranteed regularity with which thera-pists would ‘reach out’ to them was sufficient to motivate them toengage in the intervention. As such, participants’ regard for tele-phone CBT remained dynamic, improving as their knowledge andexperience of this service delivery model increased.

Moving therapy forward? Trust and respect in remote CBT

With regard to CBT, debate continues not only over the relativeimportance of the therapeutic alliance, but also as to the correcttemporal sequencing of any allianceeoutcome association(Norcross, 2002). Some suggest that the explicit rationale of CBTand the transparent process through which it effects change,including the periodic fulfilment of collaborative treatment goals,may in itself facilitate the development of a strong working alliance(Beckner et al., 2007). Others however highlight the role of moregeneric influences including therapist personability and clientsecurity within therapy. Richardson and Richards (2006) argue thatthis sense of therapeutic security demands not only that patientsare confident in the treatments they receive but also that they feelsafe in their therapeutic interactions more broadly.

Each and every participant in T-CBT described positively thepersonal attributes of their therapist. Specific qualities that wererated highly included warmth, openness and friendliness, inessence the generic skills recognised as contributing to any socialexchange. The consistency with which these qualities were high-lighted reflected the weight that participants afforded these inter-personal variables and, more pertinently, the capacity of thetelephone to convey these emotions. Whether or not such accountswere influenced by participants’ early, albeit inaccurate con-ceptualisations of T-CBT as a support-based intervention remainsunclear. What was apparent however was that the exigencies of thetherapeutic process varied substantially between individuals andfor one sub-group of participants this sense of professionalbenevolence was insufficient to guarantee the development of aneffective therapeutic alliance.

As described previously, most participants responded to thecentral premise of CBT, and in doing so assumed collectiveresponsibility for their recovery. However, a minority of the mostchronically ill participants appeared to reject this modality, strivinginstead for a therapeutic relationship based on non-reciprocalsecurity. The extent to which these participants expressed satis-faction with telephone-mediated therapy thus remained depen-dent upon their perceptions of their therapist’s ongoing availabilityand his or her engagement in their experiences:

“Well it was going really well and then I think we had one sessionwhere I said something about feeling insecure and he immediatelysaid ‘well you know we’ll have to finish these sessions at somepoint’ which is innocuous on its own but now I’m thinking, well itspoilt it because each week I’m thinking ‘is this the week he’ll finishit or will it be next week.” (S1P07, Female, Depression, 12 years)

Ultimately, the resistance of these patients to remote psycho-therapy provision appeared to be rooted in an underlying rejectionof the CBTmodality, and its manifestation as a time-limited processfocused on symptom resolution. However, where such dissatisfac-tion was evident, it also appeared to impact substantially on theacceptance of the telephone as an appropriate tool for therapeuticexchange. Some criticism originated from the technical limitationsof the system, including accent differences or interference in thetelephone lines connecting the two parties. Yet these failures wereoften subsumed within a much greater challenge of how to relate

effectively to a spatially disjointed voice. Within this context, therewere two ways in which criticisms of telephone therapy wereexpressed. Firstly, by an emphasis on its inability to detect finenuances of a client’s presentation, and secondly, by a ‘need’ forpatients to be co-located with their therapist in order to confirmprofessional acceptance of their responsibility for care. A particu-larly salient issue in this respect was the inability on the part ofparticipants to verify the credibility of the individuals and servicewith which they were interacting:

“For me it was that I don’t know who I’m talking to, I mean I don’tneed to see a photograph but its just that I don’t know what he is,he could be anybody. I’m trusting him with all this information andI must admit he’s good he’s first class in what he does but I’m stilla little.’I hope he’s qualified’ as I have no idea and it does cross mymind, so you never fully. well for me personally I’m never fullyconfident even though from the way he talks I0d be surprised if heisn’t qualified. But I don’t know.” (S1P02, Male, Depression &Anxiety 15 years)

Akin to much of the professional debate surrounding remotepsychotherapy provision therefore (May et al., 2001), theseparticipants depicted a clinical scenario in which they were affor-ded access to psychotherapy but were unable to engage in a waythat fulfilled their own socially-embedded constructs of appro-priate care. Some of the more minor communication difficultiesthat were experienced could perhaps be considered an issue ofpresentation capable of being resolved through practitioner andpatient training, yet these more deeply engrained attitudes may beharder to overcome. As May et al. (2001) observe, the mere phys-icality of face-to-face encounters convey in themselves a socialmeaning that serves to define and regulate the activities likely totake place within them. Moreover, the environments in which theyoccur serve to denote to a particular point on a trajectory of illnessand the type of clinical intervention that this may require.

Remote therapy isn’t always restricted therapy: reframingconstructs of acceptable care

Differences in the underlying treatment motivations of differentpatient groups raises the issue of whether the T-CBT debate is morea question of the suitability of patients to the treatment modality,than the capabilities of the delivery medium itself. It became clearthat as experience with the telephone service developed, manyrespondents identified features of this delivery model that liber-ated the therapeutic encounter in unique and facilitative ways. Farfrom being an inferior model of care, telephone therapy repre-sented for many an alternative yet equally satisfactory approach totreatment delivery. This was reflected by a shared discourse inwhich the adequacy of carewas judged less in terms of participants’physical proximity to a professional and more in terms of perceivedpsychological security in the therapeutic relationship. Within thiscontext, common constructs of a moral and clinical need for co-locationwere often displaced by the personal value that individualsattributed to maintaining anonymity within the mental healthsystem:

“Say [the therapist] had a distraction about them, about theirperson, you might think you’ve got to please them. Or you mightthink if they looked at you, if you see somebody face-to-face ashuman beings we see people and we want to sort of, I don’t know.It’s harder to be truthful with somebody when you look at themthan it is with a voice. Because you’ve got not feedback (with thephone) which in some instances is quite good because you can’t seethe person you’re talking to what’s the point of fooling anybody.”(S2P04, Male, Depression, 6 weeks)

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Although the establishment of a secure base fromwhich clientscan explore their mental health difficulties is recognised asa ‘common factor’ within psychotherapy provision (Barkham et al.,2003), it is often afforded much greater significance in othertreatment modalities than CBT. However, the prioritization of theseissues in the current example highlights the level of worth thatsome telephone clients may attribute to this matter. More perti-nently, it may be argued that the presence of such discourse framesa potential discrepancy in the value systems held by differentpatients and, by extension, professionals and patients. Researchsuggests that the mediation of mental health care via remotecommunications technology may meet with a level of resistanceamong mental health professionals, underpinned by deeply-embedded constructs of the therapeutic relationship and its moraland clinical role in safeguarding their accountability for care (Mayet al., 2001, 2003; Richards et al., 2006). Yet amongst participantsamples perceptions of such iatrogenic risk were often replaced bynotions of a flexible and potentially more client-centered inter-vention. As such, the propensity to engage in telephone-mediatedtherapy was governed by a very different set of values, and differentconceptualisations of the key components of acceptable care.

It should be acknowledged that the acceptance of telephone-administered therapy did not automatically negate a preference formore familiar and arguably more idealised forms of servicedelivery. Rather, what was demonstrated was the development ofa more fluid approach to mental healthcare in which the context inwhich participants were seeking therapy was afforded equal if notgreater priority than their perceptions’ of treatment adequacyderived from normative social influence. At its most pragmaticlevel, this involved acknowledging existing barriers to care, whichin themselves often provided sufficient justification for the inclu-sion of telephone-based services in future mental healthcareprovision:

“It is definitely, I think with children, it’s a lot more adaptable . itworks for my benefit. I have to keep running around and I can’talways get time for babysitters. Sometimes a phone call is so mucheasier.”(S1P08, Female, Phobia, 5 years)

As such, individual narratives echoed much of the policysurrounding remote psychotherapy provision which has for themost part, taken as its main driver the potential for increased accessto clinically and cost-effective care (Williams et al., 2003).

Conclusion: patient acceptance and resistance to telephone-based care

Increasingly, health policy is reflecting a paradigm shift in theorganisation and delivery of health services, a key feature of whichis the development and implementation of remotely-administeredcare. Yet, translating communication technologies into mentalhealth practice is not always straightforward. Studies highlight anunderlying resistance that is attributed to professional conserva-tism regarding the authenticity and morality of geographicallydispersed care (May et al., 2001). However, very little criticalattention has been paid to patient perspectives of technologically-mediated mental healthcare. Our intention therefore was toexplore the adequacy of fit between an evidence-based psycho-therapeutic intervention and its delivery bymore remotemeans. Tothis end, we drew on interview data with users of a telephone-administered CBT service recruited via two distinct pathways.

Although participants from both samples shared a relativelyhigh level of acceptance for telephone-based therapy, cross-dataanalyses revealed a polarization of patient experience amongstcertain user groups. More saliently perhaps, this heterogeneity inviews suggested that users opinions of telephone care were rarely

predicted by the technical capabilities of the media alone. Ratherthey were more readily conceptualised in terms of differing socio-medical constructs that upheld to differing degrees the status of co-location as a pre-requisite to psychological closeness and thusa therapeutically legitimate relationship. Any notion that remotecommunication technologies may be universally applicable topsychotherapeutic service provision may thus oversimplifya complex and important relationship which may exist betweena provider’s mode of communication, their clients’ characteristicsand the nature of the interaction they require.

In highlighting potential resistance toT-CBT, it is important to beclear about what is and is not being problematised. Certainly,resistance to telephone therapy was not universal across studyparticipants, and thus as we have noted, lower satisfaction isunlikely to be solely due to the technical limitations of the mediumper sec. Whether the issue lies more with the perceived ‘adequacyof fit’ between CBT and remote delivery, or between individualpatients and the treatment modality itself remains more difficult toascertain. It was noted previously that much of the current popu-larity surrounding CBT may be attributed to its downgrading of thetherapeutic relationship in favour of more empirically groundedtechniques as the main driver of change. Parallels may thus bedrawn between this intervention and a rhetoric of modern medicalpractice (Dowrick, 1997), in which emphasis is, as May et al. (2001,p.1898) observe, placed on ‘the things that doctors dowith patientsrather thanwho they are’. It is therefore possible that, among morevulnerable patients, dissatisfaction with telephone CBT may in partreflect a discrepancy between this specific treatment modality andindividual constructs of what therapy represents.

Amongst the majority of participants, the telephone wasaccepted as a delivery medium for both the spoken and unspokencomponents of CBT. The emphasis that it placed on task facilitationand client anonymity was at the forefront of many accounts, and assuch added additional weight to the professional discourse cham-pioning the independent agency of specific clinical techniques. Yet,it was not only these factors that attracted the attention of partic-ipants. Respondents also stressed interpersonal gains of the CBTapproach, including the facilitation of therapeutic security, trustand rapport. They stressed ‘knowing’ their therapist and ‘workingwith them’ and in doing so highlighted the potential value thatusers can afford these factors. The present study did not include anassessment of treatment outcome and thus the independentimpact of these variables cannot be ascertained. However inemphasising their appreciation of their therapist’s interpersonalskills, participants not only echoed a wider medical discourse thatpromotes holism in mental health nursing (Porter, 1995), but alsodemonstrated how it may be possible to mediate such factorsremotely. Indeed, whilst some participants found a lack of visualinformation to be a barrier to establishing a therapeutic relation-ship, others seemed much more capable of negotiating closeness inthe absence of physical proximity.

On one level, the potential for individuals to respond positivelyto telephone-mediated therapy may be interpreted as empiricaljustification for patient, and by extension clinician, training intechnologically-mediated communication. Certainly, it may be thatthe next generation of psychotherapeutic interventions maybenefit from delivery systems that can simultaneously maximizethe transmission of key common factors (Richardson & Richards,2006) whilst also offering increased opportunities for anonymity,autonomy and reduced stigma. On another level, the relative easewithwhichmost participants adapted to telephone-based caremaybe considered suggestive of a shared construct of mental healthservice provision that is perhaps more malleable than the profes-sionally-orientated, medico-legal perspectives reported elsewhere(May et al., 2001, 2003; Richards et al., 2006).

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Participants from both samples described an initial lack ofknowledge surrounding the nature of the telephone-based inter-vention, and in doing so intimated a level of discord between theirexpectations and more deeply engrained constructs of conven-tional therapeutic exchange. The medical, social and institutionalnorms that governed the way in which they conceptualised thepractitionerepatient encounter meant that they perceived theremoteness of telephone care as being capable of delivering littlemore than a supportive educational intervention. Yet, with theexception of the group noted earlier, this misapprehension wassoon resolved. Participants reported ‘adapting’ and ‘responding’ tothe telephone as an acceptable context for therapeutic interaction,and in doing so displayed a fluidity of views that revealed anunderlying openness to change. Thus, despite recognition of theface-to-face encounter as the conventional norm in mentalhealthcare, participants were rarely inclined to problematise thedelivery of therapy via more remote means.

It may be that the status of the telephone as a popular mediatorof social exchange contributed to a blurring of the interpersonaland clinical aspects of psychotherapy and thus to the perceivedsuitability of this tool as a mediator of care. However, as May et al.(2001) observe, the unquestionable ubiquity of communicationtechnologies has rarely been sufficient to guarantee the acceptanceand implementation of such systems in a medical context. Instead,participants’ satisfaction with telephone-based therapy may beindicative of a different set of social values that take as theirreference the inadequacies inherent in conventional serviceprovision.

Professional resistance to the remote delivery of mentalhealthcare is in part thought to reflect the stability and normality ofa form of conduct that prioritises working with patients through aninterpersonal, geographically close relationship (Good, 1994). It istherefore instructive that whilst participants viewed face-to-facecontact as the ideal, they rarely perceived such conduct to be thenorm. Rather, their social constructs of mental healthcare werebased upon a paucity of accessible expertise. Among these stake-holders therefore the social normalisation of telephone therapymay ultimately be facilitated by a lay ideation that, like its politicalcounterpart, prioritises the accessibility and availability of servicesas a key component of care. Increasingly, services that havenecessitated physical proximity between two parties are beingaccomplished with media technologies via virtual organisations.Online shopping and banking provide two examples of the growingnormalisation of remote communication in an economic and socio-legal setting. The acceptance of these systems adds weight to theargument that users of mental health services may also promoteflexible yet more remote links to care. Whether or not a bottom-upapproach to their integration into practice can ultimately overcomeprofessional opposition remains to be seen.

This novel exploration of user views of telephone-mediatedpsychotherapy provides critical insight into some of the practicesand processes of patient experiences in the socio-medical context.Concomittantly, it is subject to many limitations inherent in qual-itative research, especially with respect to generalisability. Datawere drawn from two studies which, although utilizing the sameintervention and data collection methods, recruited samples fromvery different settings. The involvement of participants from bothoccupational and voluntary health sectors serves to maximizeheterogeneity in illness trajectories. However, purposive samplingof interviewees was not possible and as such both samples includedall those consenting to interview.

It has already been acknowledged that for the most part theviews that were expressed were those of a sample who due togeographical, economic or service constraints could not accesstraditional CBT services. It is therefore possible that satisfaction

with telephone therapy was elevated by the context inwhich it wasreceived. Had patients been able to experience face-to-face as wellas telephone services the results may well have been different. Theprecise role of telephone-mediated therapy in a health systemadvocating patient choice and preference is thus difficult to inti-mate. Age did not appear to influence the views that wereexpressed. The available data were, however, unable to includecultural or socioeconomic differences and thus the implications oftelephone therapy for these groups have not been considered.Whilst T-CBT may offer a means by which to circumvent some ofthe socioeconomic barriers inherent in accessing face-to-face care,its acceptability as a service delivery model will nonetheless alwaysremain contingent upon the availability of the necessary techno-logical resources to link two geographically distinct parties. Theincreasing ubiquity of mobile phone technologies may ultimatelyaugment the clinical utility of such models. As yet however therelative impact of these systems as a platform for remote healthcaredelivery remains unclear. Additional research is required to expandour understanding of these issues.

Acknowledgements

We have drawn on work undertaken in collaboration with DrPeter Bower and Professor Simon Gilbody and thank them forcontribution to the paper in this regard. The authors also wish toacknowledge the help and cooperation of staff and users ofAnxietyUK.

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