Hybrid delivery of psychotherapy – pros and cons

The enforced distancing during the pandemic saw options for delivering psychotherapy necessarily expanded, affecting both service users and therapists. This often resulted in a change to using telephone / video calls rather than engaging in-person. Subsequently, a hybrid system has developed, often using a mix of methods to delivery therapy. The positives and negatives of the emergent hybrid approach are discussed here.

Remote flexibility

The difference of in-person versus remote psychotherapy can impact a therapist's burnout levels, for example the option of remote working and delivering online therapy can reduce travel time and costs for both therapist and service-user. Personally, I find delivering psychotherapy in-person more draining than remotely. Therefore, I find I am more productive with the hybrid way of working which has evolved for me since the pandemic.

At the same time this flexibility has also helped some service users too. Such as when they are unable to attend in person for various reasons such as feeling unwell or the cost burden but can still get support by turning the appointment into a virtual one. 

Limitations of remote appointments

However, when in-person appointments are not an option and it's solely virtual then that can deter people from engaging too. This may include them not being able to talk openly within their surroundings due to feeling restricted in what they can discuss. Some service users will prefer to see the therapist they are engaging with and sometimes a video call alone isn't sufficient.

Safeguarding and risk related concerns can be easier to discuss if the client is able to attend in person as the therapist can use their appointment location as the safe space, including contacting other professionals if needed. This can be easier with the client already present, whereas virtually the therapist has less control over the situation. A disability, such as being hard of hearing, can also make it harder to utilise a virtual appointment too.

Other factors to be considered are service users having access to the internet and smart phones and being confident in using such technology, especially if it's a video call. Another frustrating factor can be when technology doesn't work due to internet quality, as well as technical issues occurring with the platform being used. A further challenge can be when clients are using remote therapy, especially phone calls, and they are either at home or out and can view it as a casual call, like speaking to a friend. Additionally, they can become distracted by other people, including their children and or pets, which can make it difficult for them to fully engage. Naturally this can be frustrating from a therapist's perspective too.

Recent studies

There are plenty of studies that promote both ways of working as being effective. For example, Nguyen et al. (2022) found by looking at the effectiveness of remote therapy in 2 London IAPT services that those able to access therapy provided by telephone and video is clinically an effective option for IAPT services. They also stated there may be economic benefits, with several studies suggesting tele mental health is no more expensive than face to face delivery and tends to be more cost effective (Hubley et al., 2016). 

Salmoiraghi & Hussain (2015) described this approach as a viable and inexpensive treatment option where access to emergency services is limited and associations have been found with reduced psychiatric admissions. However, Appleton et al. (2021) reported technological barriers to the wider adoption of tele mental-health include: (1) the risk of digital exclusion of some service users, such as those facing significant social disadvantage or with limited technological access and expertise, and (2) the lack of technological infrastructure and clear protocols within services, impeding the integration of tele mental-health with face to face care (Sheridan Rains et al, 2021; Vera San Juan et al, 2021; Stoll et al, 2019).

Some of the main barriers in terms of actual quality of therapy can include difficulty in establishing and maintaining therapeutic relationships and in conducting high-quality assessments; service users who lack private space or find participating in intimate and distressing discussions from home intrusive (Sheridan Rains et al, 2021; Hilty et al, 2013; Hubley et al, 2016; Santesteban-Echarri et al, 2020; Vera San Juan et al, 2021; Tullio et al, 2020). A range of other ethical, regulatory, technological, cultural, and organisational barriers have also been identified pre and post pandemic too (Hubley et al , 2016; Europe economics. Regulatory Approaches to Telemedicine, 2018; Vis et al, 2018) .

Appleton et al. (2021) concluded that a combined approach of face to face and tele mental-health care maybe the most desirable service model for future care. 

Some conclusions

In conclusion individual service users will have their preferences of how they would like to receive psychotherapy and therapists will equally have their preferences of how they would like to deliver it. The hybrid-approach to psychotherapy evidently seems to be proving to be beneficial though with the caveat that there is no one size that fits all approach.

Further research looking at the clinical effectiveness of tele mental-health in different situations, how uptake can be improved for groups at risk of digital exclusion and ultimately how to create a mixed approach that can customise the most effective hybrid blend for a service-user could prove to be extremely useful in providing the best experience for both service users and therapists.

Dr Sindeep Lehl is a Principal Counselling Psychologist, working within the NHS. She specialises in physical health, especially obesity, and is a member of the BPS, BABCP, SIGOPAC, and the EMDR academy.