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During the COVID-19 pandemic, people have been encouraged to maintain social distance. Technology helps people schedule meetings as remote videoconferencing sessions rather than face-to-face interactions. Psychologists are in high demand because of an increase in stress as a result of COVID-19, and videoconferencing provides an opportunity for mental health clinicians to treat current and new referrals. However, shifting treatment from face-to-face to videoconferencing is not simple: both psychologists and clients miss in-person information cues, including body language.
This review proposes a new theoretical framework to guide the design of future studies examining the impact of a computer as a mediator of psychologist-client relationships and the influence of videoconferencing on the relationship process.
We conducted a literature review including studies focused on communication and key concepts of the therapeutic relationship and therapeutic alliance.
Studies have reported that clients are generally satisfied with videoconference therapy in terms of the relationship with their therapists and the establishment of the therapeutic alliance. Conversely, studies indicate that psychologists continue to highlight difficulties in establishing the same quality of therapeutic relationship and therapeutic alliance. The contrasting experiences might underlie the differences in the type of emotional and cognitive work required by both actors in any therapy session; furthermore, the computer seems to take part in their interaction not only as a vehicle to transmit messages but also as an active part of the communication. A new model of interaction and relationship is proposed, taking into account the presence of the computer, along with further hypotheses.
It is important to consider the computer as having an active role in the client-psychologist relationship; thus, it is a third party to the communication that either assists or interferes with the interaction between psychologists and clients.
Since the beginning of 2020, the COVID-19 health pandemic has induced people to avoid face-to-face interactions. The phenomenon is impacting several professions, and features of videoconference (VC) platform have been currently adapted for business meetings. In the case of psychologists, professional association boards across the world have encouraged professionals to keep treating clients using videoconference technologies (VCTs). The assumption is that VCTs might also help clients who live in rural and remote areas, extending access to mental health services [
Psychotherapy sessions are traditionally delivered face-to-face in the psychologist’s consultation room. In this physical space, the therapist and the client start to build their relationship and create strong mutual trust. The uninterrupted sharing of a physical space enables the therapist to identify clients’ reactions and vice versa. Moreover, presence enables therapists to be at once
According to Rogers [
However, an effective TR is also associated with the formation of a good cooperation between psychologists and clients defined as
Thus, effective cooperation between psychologists and clients is crucial to the therapeutic processes involved in the therapeutic context and to establish a beneficial TR. A lack of either of these two factors, of TA and TR, prevents psychologists and clients from laying the foundation for clients’ future changes.
The strict correlation between the therapist and client relationship and treatment outcomes has also been recognized in the literature [
Hence, the ability of any medium to support the development of effective TR and TA is therefore critical. Videoconference therapy has been growing, but the COVID-19 pandemic has accelerated the demand for it. There are foreseeable, potential risks in moving therapy to the web by using videoconferencing psychotherapy (VCP). Therapists are not trained to conduct clinical treatments by videoconferencing (VC) as they normally rely on face-to-face interactions; thus, the establishment of a concept termed
Omodei and McClennan [
In this paper, we focused on the interactions between TA and VC experiences to develop propositions for future research. Through this investigation, we addressed the following question: “How do psychologists and clients experience the TR and TA in videoconference psychotherapy?”
Nonetheless, before going through the VCP studies, we describe a pivotal theoretical framework that has impacted research and practice in psychology. This framework, the General System Theory (GST) [
In the following sections, we will look at face-to-face psychotherapy, highlighting the impact of presence on the TR. The rest of the paper will propose an overview of the studies related to communication and conducted on computer-mediated communication (CMC). We aim to underline studies relating to cooperative environments where the collaboration and the development of trust among users is crucial for reaching the final goal. Cooperation and trust are essential, key elements for the development of the TA and TR in the clinical context. We will then present the research methodology applied by explaining how the screened, selected articles have been processed. Afterward, we present the literature on both clients’ and psychologists’ experiences of TA and VCP. The last section will be dedicated to the discussion of the results and the presentation of some propositions, followed by the conclusion and suggestions for future research.
This section introduces face-to-face psychotherapy and the role of presence in developing effective TR and TA. We also expanded on the important role of cognitive and emotional factors in TR.
Research has shown the improvement of clients participating in psychotherapy compared with people who had not received any psychological treatment [
As for therapeutic rapport, some studies [
Another study noted that psychotherapy is ineffective when therapists struggle to create a relationship based on warm communication and empathy [
In human beings, the interaction processes include 2 aspects: cognition and emotion. According to emerging neuroscience studies, cognition and emotion are 2 separate mental functions that communicate through the mediation of interrelated, separate brain schemes [
Face-to-face psychotherapy relationship.
To conclude, the effectiveness of traditional psychotherapy is based on face-to-face interactions that trigger therapeutic and relational processes. An effective sense of presence leads psychologists and clients to interact more successfully: improving communication and the chance to verify the accuracy of the therapists’ diagnosis. By building effective TR and TA, both actors can better achieve the final goal: the client’s wellness. Hence, how do therapists and clients deal with the
To address these questions, a proper understanding of the concept of trust in CMC is crucial because trust is related to the formation of an effective TR and TA in a therapeutic environment. Hence, analyzing the establishment of trust between people interacting in CMC, it will be possible to gain data regarding the development of trust in computing environments. The presence of trust in face-to-face relationships is necessary for establishing a cooperative rapport aimed toward the achievement of common goals. Trust can then be defined as “a willingness to be vulnerable, based on positive expectations about the actions of others” [
In the next section, we present an extended study related to trust in CMC; we aim to gain a proper understanding of trust establishment in the case of relationships mediated by computers.
Research findings related to trust in CMC are inconsistent. Although studies show that cooperative trust can be easily achieved with a software system [
Some authors [
Bos et al [
In summation (
Trust in computer-mediated communication.
Study | Title | Study design | Study participants | Task | Methodology | Outcome |
Bickmore et al [ |
Establishing the computer–client working alliance in automated health behavior change interventions | 3 treatment groups: Control Nonrelational Relational |
Healthy participants interested in increasing their physical activity |
Interaction with a software | Mixed methods | Trust is reachable even with a software |
Bos et al [ |
Effects of four computer-mediated communications channels on trust development |
66 groups (3 persons per group) interacting face-to-face and through video, audio, and text chat |
People related to the university (mostly students) |
Interacting during a social dilemma game: Daytrader | Quantitative | Trust emerges with delay and is fragile |
Nguyen and Canny [ |
Multiview: spatially faithful group video conferencing | 3 experiments (7 groups of 3 individuals and 1 group of 2 individuals): Partial and full spatial awareness with respect to gaze Same as A with higher attention to gesture Mutual spatial awareness with respect to gaze |
Sample from the University of California, Berkeley (undergraduate and graduate students) |
The sample was asked to judge the pupils’ direction | Qualitative | Presentation of the multiview design |
Nguyen and Canny [ |
Multiview: improving trust in group video conferencing through spatial faithfulness | 29 groups of 2 individuals and 37 groups of 3 divided in the following groups: face-to-face groups Directional VCa Nondirectional VC |
169 participants (from the Social Science Laboratory, University of California, Berkley) |
Modified version of the social dilemma game developed by Bos et al [ |
Mixed methods | Spatial distortion in group meeting by video negatively impacts the development of trust, while trust is established when a spatially faithful VC system is provided |
Drolet and Morris [ |
Rapport in conflict resolution: Accounting for how face-to-face contact fosters mutual cooperation in mixed-motive conflicts |
2 experiments. Solving conflict in side by side or face-to-face–phone or face-to-face |
Experiment 1: 134 master’s students from Stanford University (Department of Business Administration) Experiment 2: 42 persons (master’s and bachelor’s students) from Stanford University |
People needed to negotiate having access to nonverbal behavior and cultivating relationships that enable reciprocal collaboration | Quantitative | People were more collaborative in face-to-face interactions rather than by phone |
aVC: videoconferencing.
Nonetheless, research conducted on CMC provided inconsistent outcomes related to whether the psychotherapy sessions could be face-to-face or CMC. In our previous study [
To conclude, all these studies highlighted the difficulty of establishing a strong trust between users in CMC. Moreover, with regard to the possibility of having psychotherapy sessions face-to-face or through CMC, the literature mentions 2 different points of view; in particular, due to the fragility of trust in CMC, the building of an effective TR is more likely to be compromised.
Before presenting the results of the literature review on the clients and psychologists’ experiences of VCP, we will provide our article selection criteria.
This literature review follows the design approach described by Webster and Watson [
We started our search on PsycINFO, launching several inquiries. Our strings included keywords selected through the analysis of the works identified in the two prior steps:
Consequently, we started our
Flowchart. Selection of studies.
This section focuses on the previous literature reviews that explore the cooperation between clients and psychologists, namely the TA, and processes such as trust and empathy building between both actors of the TR. This section considers the following important studies that have provided significant data, especially considering the needs to deeply comprehend the formation of the TR.
Sucala et al [
By focusing on these reviews and according to Sucala et al [
By reporting previous studies providing useful insights on clients’ and psychologists’ videoconference experiences, this research will offer a new perspective aimed at understanding the relational dynamics buried in the foundation of the TR by VC. The following investigations suggest positive clients’ experiences, but the literature also reports that psychologists struggle to deliver VC treatments. For this reason, it is essential to understand the different experiences in terms of the psychologist-client relationship.
Before presenting the following studies, it is important to mention that some research replaced the term TA with WA. The latter, according to Bordin [
In this section, we introduce the previous literature on clients’ experiences of VCP: while there are some doubts about the opportunities to generate interactive VCP features similar to those of face-to-face treatment [
Schopp et al [
In another study, we noticed that some clients might be influenced by the lack of face-to-face communication, which limits trust establishment. Haberstroh et al [
Nevertheless, with regard to the WA, Day and Schneider [
The same result was confirmed by Glueckauf et al [
Studies conducted with participants affected by PTSD showed great results. A study conducted by Germain et al [
Carpenter et al [
From the analyzed studies, although some inconsistencies emerge, it appears that clients could easily establish the TA and a proper relationship with their psychologists, as technology would support them in enhancing interaction, attention, and intimacy.
In this section, we present the psychologists’ VCP experiences, which strongly differ from the clients’ VCP experiences. Indeed, psychologists had concerns about the establishment of a relationship with their clients.
Wray and Rees [
However, while Cohen and Kerr [
Rees and Stone [
A more recent study [
According to Fletcher-Tomenius and Vossler [
Summing up these studies, psychologists’ difficulties in establishing relationships with their clients emerge. These are summarized in
In this study, clients and psychologists’ experiences of VCP were presented. The analyzed investigations reported inconsistent results. Some research claims VCP efficiency and its correlation to clients’ beneficial changes [
By examining clients’ VCP experiences, it seems that they take advantage of the VCP in terms of developing TA without experiencing discernible differences with face-to-face psychotherapy [
It appears that the lack of presence might impact the general picture of the relationship and, consequently, the effectiveness of the treatment. Although there are inconsistent data regarding TA establishment, clients are gratified and obtain beneficial results by VCP.
Conversely, considering psychologists’ VCP experience, we observed more consistently negative responses. They feel
Considering all of the aforementioned studies, the incongruence, and the inconsistency of both clients’ and psychologists’ VCP experiences, we developed a theory aimed at providing a new framework for understanding the relationship connecting both the actors of the VCP interaction. Thus, in the next section, we introduce the model of the invisible third party.
Furthermore, according to the aforementioned studies, we explored the following propositions:
Proposition 1: VCP might help clients to rapidly reach a strong TA by using digital technologies that enhance communication and intimacy with the psychologist.
Proposition 2: VCP might require clients to put more emotional than cognitive effort in the relationship with their psychologists.
Proposition 3: VCP impacts the psychologists’ ability to establish a strong TA because of the lack of information and control over the relationship.
Proposition 4: VCP might help psychologists establish a strong relationship with their clients by increasing the quantity and quality of information.
Proposition 5: VCP might impact the confidence of psychologists, as they have to build a mental picture of their clients without proving it.
The contribution of this paper draws attention to the role of the computer not only as a vehicle of communication but mostly as a
Videoconference psychotherapy relationship model of the invisible third party.
According to Haley [
In our model, we introduce the computer as the third invisible party (
This new member of the interaction continuously gives new rules to the concept of relationship building. The computer-mediated application of meta-communication might result in high complexity, along with psychologists’ required emotional efforts. Consequently, psychologists might prefer face-to-face psychotherapy to VCP due to the lower cognitive effort required by face-to-face psychotherapy.
According to our model, the following propositions should be explored:
Proposition 6: VCP might require psychologists a specific cognitive effort, rather than an emotional one, in meta-communication with their clients.
Proposition 7: VCP might challenge psychologists in dealing with the cognitive overload effort to mentalize and solve the unpredictable presence of the computer, which might control the relationship.
Studies based on CMC highlighted that communication can be impacted by audio-video quality [
Of course, if all these aspects challenge the communication mediated by the technology, they can also have a severe impact on the effectiveness of psychological treatment. Psychologists are trying to provide their support to their clients, even in large organizations [
Our review of the literature on the experiences of clients and psychologists in the VCP highlighted that they have opposite perceptions of TA and TR established by VC. The role of the VCP in supporting psychologists and clients appears particularly crucial, especially in the current pandemic period. The current situation has also required an incremented use of smartphones for VCP, and according to Kim et al [
Based on the results of this investigation, the model of the invisible third party has been presented; this includes the computer as one of the actors of the psychotherapy relationship. This actor’s role has not been considered so far in studies conducted on VCP. Nonetheless, we argue that its presence in the relationship impacts the development of the elements required for the emergence of empathy, trust, and emotional bonds. These processes are in fact necessary to establish a successful TA and determine VCP positive outcomes. With COVID-19 giving rise to global growth in the adoption of VC platforms, it is more likely that therapists are going to be increasingly relying on VCTs [
Overview of the studies examined in our analysis.
computer-mediated communication
computer-mediated system
General System Theory
information system
therapeutic alliance
therapeutic relationship
videoconferencing
videoconferencing psychotherapy
videoconference technology
working alliance
None declared.