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  • Dr. Valerie Q. Glass, PhD & Dr. Aurélia Bickler, PhD

Cultivating the Therapeutic Alliance in a Telemental Health Setting

Glass, V.Q., Bickler, A. Cultivating the Therapeutic Alliance in a Telemental Health Setting.Contemp Fam Ther (2021).


Background Telemental health services were growing prior to Covid-19 and have expanded exponentially since Severe Acute Respiratory Syndrome Coronavirus 2019 (COVID-19) stay at home restrictions. In the past 5 years, it is estimated that between 5-21% of mental health services delivered telemental health methods of engagement (Choi et al. 2019; Pierce et al. 2020). With advancements in technology and training over the last few years, some Marriage and Family Therapists (MFT) have been adding telemental health options to their own practices. Since COVID-19, almost all practicing mental health providers have had to adjust their work with clients to include telemental health options (Madigan et al. 2020). This shift, during COVID-19, may prompt many therapists to consider the impact telemental health has on clinical outcomes. Effectiveness of Telemental Health Telemental health services can be an effective option for clients and therapists for several reasons: it is cost effective, it is not limiting due to transportation issues, those in rural areas are more reachable, scheduling can be easier for those with work and family demands, technology has evolved to provide secure platforms for engaging in confidential services, and services can reach people who may not feel comfortable in a traditional setting (e.g., because of mental health challenges, ability differences, or life circumstances) (Langarizadeh et al. 2017; Springer et al. 2020). Research indicates that some clients may seek out telemental health services when issues are more sensitive. In one study, couples addressed more difficult topics (e.g., infidelity) more frequently in telemental health settings, when compared to a sample of couples in an in-person setting (Roddy et al. 2019). This suggests that telemental health services might offer a physical distance that makes is easier to process more sensitive discussions. Barriers to Telemental Health Some barriers to telemental health care have been researched. These barriers include: feeling like the service lacked a personal connection, difficulty in picking up on non-verbal cues, clinicians’ sense that they could not use body language to comfort, inability to connect via eye-contact, challenges with technology or interruptions, limited clinical training or experience with telemental health, limited ability to develop therapeutic rapport, controlling online environments, and privacy or confidentiality (Akyil et al. 2017; Cowan et al. 2019; Wrape and McGinn 2019). Research identifies therapeutic movements into different stages of therapy can be altered by telemental health therapies. Springer et al. (2020) found that spontaneity was more difficult for therapists in telemental health settings. Additionally, working with couple or family conflicts in the moment can feel limiting because of the therapists’ use of physical space in difficult situations (Springer et al. 2020). Therapeutic Alliance in Telemental Health The therapeutic alliance is a notable challenge or perceived challenge within telemental health settings (Springer et al. 2020). The therapeutic alliance is crucial to the change process (Fife et al. 2019). Prior to doing telemental health, therapists assumed alliance building would be challenging in a telemental health setting (Springer et al. 2020). Through some clinician adaptations, therapists were able to develop strong therapeutic alliance with telemental health clients. One took that therapists used to increase this strong sense of a therapeutic alliance in telemental health setting was to be more in-tune with “verbal, nonverbal, auditory, and visual cues” (Springer et al. 2020, p. 211). Other ways therapists adapted were to include specific displays of empathy or a “positive regard” for patients (Iankieva et al. 2016). This focus on the therapeutic alliance in telemental health settings is critical in part because research indicates clients tend to feel more comfortable and vulnerable in telemental health settings (Langarizadeh et al. 2017). One critical element of therapeutic alliance building is the understanding self. This location of self requires an attunement to cultural humility (Perkins et al. 2019). Locating this sense of cultural humility when using telemental health methods is crucial to meeting client needs and establishing a therapeutic alliance (Stevenson 2014; Akyil et al. 2017). Acknowledging one’s biases allows for a more authentic, critical and sensitive approach (Watson 2019). Providing space for inclusion, cultural awareness, and the understanding of self and social location creates a bridge for connection between client and therapist (D’Arrigo et al. 2017; Watson 2019). As clients continue to become more culturally and otherwise diverse (AAMFT 2014), marriage and family therapists are faced with the need to embrace cultural diversity as something they “are” instead of something they “do” (D’Aniello et al. 2016). While some believe that certain models are more innately culturally sensitive than others (Cheung and Chan 2002), some argue that it is an additional component of common factors and is reflected in models across the field as it is essential to the effectiveness of therapy (Cheung and Chan 2002; D’Aniello et al. 2016). Establishing rapport with a client for example, is heavily reliant on the therapist’s cultural sensitivity (D’Aniello et al. 2016). A client is only as comfortable to share his or her journey as the therapist allows and promotes in the therapeutic space. This places additional responsibility on all humans to embrace the multicultural and complex riches that our society offers in defining our combined identity (McGoldrick and Hardy 2019). Bringing cultural humility to telemental health settings is not widely researched (Akyıl et al. 2017; Martin et al. 2020). Technology is one way to reach underserved populations and to embrace communication using technology (Akyıl et al. 2017). There is an evolution in how people are communicating within virtual spaces and adapting to this new “virtual language” that exists within telemental health settings. Additionally, telemental health may generate a slightly different clientle, for example, there may be any number of reasons that some clients were not coming to therapy until telemental health options were available. Being competent in cultural humility and the increased intersections of identities that might occur within telemental health settings (e.g., rural, SES, ability, etc.) is crucial to providing quality care and building therapeutic alliances (Martin et al. 2020). Research Question The purpose of this qualitative research was to explore the ways in which MFTs adapted to telemental health services during the COVID-19 health crisis; specifically in relation to therapeutic alliance building. We hoped to better understand the shifts that therapists faced utilizing telemental health and how these experiences could inform future work in telemental health settings. The research question posed in this study was: How do MFTs adapt to telemental health environments, in particular, how do they build connectivity with clients?

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