An argument in favour of face-to-face therapy over telephone treatment
As the ongoing political and economic uncertainty shows little sign of letting up, and services continue to experience cutbacks in resources with no reduction in terms of demand, telephone counselling services – as well as services such as e-therapy and even text therapy – become ever more widespread. Of course this comes as no surprise to those of us working within the field. Many of these services operate under the auspices that telephone counselling (which remains the focus of this article; I won’t be discussing other forms of distance counselling in this piece) is as effective as face-to-face counselling, while of course also being more convenient (NHS leaflet, 2019). This continues to be a great cause of concern for many of us within the Psychotherapeutic and Counselling professions who understand and practice relationally. Such practitioners value the intricacies and nuances of such a way of working in order to ensure efficacy and safety, and progress towards real and lasting change, which has at its centre the face-to-face contact with clients. In this article I explore the limitations of research that claims equivalency of telephone and face-to-face counselling, and argue for the value of continuing to fight for a place for the very fundamentals of our profession.
Limitations of research around efficacy of telephone counselling
There is limited evidence to support what most psychotherapists know from their training and experience regarding the efficacy of face-to-face counselling, and the importance of developing an ongoing relationship between therapist and client. Such data is not measurable with quantitative research methods, while most of the research into the efficacy of telephone counselling relates purely to CBT. Indeed a 2012 CBT telephone paper (Mohr et al., 2013) has shown that telephone counselling has less retention of gains for clients. This increases the very real likelihood of services developing a ‘revolving door’ way of working, whereby clients may experience a reduction of symptoms through accessing support but fail to deal with underlying issues, so that under times of stress, psychological difficulties resurge and clients re-enter the service, thus developing a dependency on the service, rather than healing and affecting change at a deeper level. More qualitative and anecdotal approaches have, time and again, demonstrated the value and benefits of face-to-face counselling and the physical, embodied presence of a therapist in the room with a client. As Rothschild states: ‘Phone counselling is just not the same as in person when it comes to developing relationship and giving/taking support’, (personal correspondence, 2017). Elsewhere, a Forbes study (2009) questioned 760 executives, with 84% of business executives demonstrating preference for face-to-face contact. The study found that ‘business executives overwhelmingly agree that face-to-face meetings are not just preferable but necessary for building deeper, more profitable bonds with clients and business partners and maintaining productive relationships with co-workers’ (Forbes, 2009). In undertaking reviews of the DWP Health Benefits Assessments in recent years the UK government conducted 98% of the interviews in person, despite the fact the this overall process involved a drive for saving money. In this case example, if telephone assessments would have been deemed sufficient, why were they not carried out in the vast majority of cases?
The role of face-to-face counselling in reducing levels of cortisol, the ‘stress hormone’, and raising dopamine
Hart (2008) writes that contact with others can reduce the levels of cortisol (commonly known as the ‘stress hormone’) in an individual’s nervous system, stating that almost half of all depressed adults have raised cortisol levels. Indeed low levels of face-to-face contact can double levels of depression. Such lack of face-to-face contact for people who are already markedly depressed can increase isolation, and thus the duration of the illness and the subsequent risks of suicide.
Human presence and contact also contributes to healthy levels of the neurotransmitter dopamine in an individual’s system. This can contribute to increased motivation and energy, as well as coordinating functions within many higher brain regions, and can decrease chronic anxiety states through activation of the attachment system.
The importance and value of non-verbal communication in ongoing clinical assessment and psychological formulation
The majority of communication is non-verbal, with Albert Mehrabian, Professor Emeritus of Psychology at UCLA, documenting research that 55% of communication pertaining to feelings and attitude is conveyed through facial expressions (with 7% conveyed vocally, and 38% by how things are said) (Hart 2008, p.241). Indeed the right brain hemisphere ‘grasps facial expressions in less than thirty milliseconds’ (Hart 2008, p.241). Therefore much of what is communicated by a client, both in assessment and within ongoing treatment, will be lost in telephone counselling, as key data and information from the client is picked up by clinicians not through words but through gestures, eye contact and bodily movements. Without such data the quality of treatment decreases, which in turn impacts on recovery rates and ultimately increases the risk of suicide within a client base, and at an organisational level the economic costs to both the individual and the company due to ongoing ill mental health.
Therapeutic presence, i.e. face-to-face contact, allows for an attachment relationship to develop, as ‘therapeutic presence involves therapists being fully in the moment on a multitude of levels, [including] physically [and] relationally’ (Gellar and Greenberg 2002, pp.71 – 86). The physical presence of the therapist is also key in Emeritus Professor Colwyn Trevarthen’s Theory of Intersubjectivity (2001), which emphasises the integral role of co-ordinated, reciprocal rhythmic patterns of movement, vocalisation and gesture through this face-to-face contact, as ‘being fully present then allows therapists to access an attuned responsiveness that is based on a kinesthetic and emotional sensing of the other’s affect and experience as well as one’s own intuition and skill and the relationship between’ (Geller and Greenberg, 2002, pp.71 – 86).
Through this activation of the attachment system the therapeutic relationship has been shown, by a number of researchers, to enable a client to develop means of self-regulation of the autonomic nervous system (see below) through the integration of both the right and the left brain hemispheres, which is essential for the continued development of a reflective capacity, or the capacity to mentalise (Dallos and Vetere, 2009; Fonagy, 2004; Wallin, 2007). An increased capacity for mentalisation can also contribute to healthier social skills. Research continuously stresses the added value of therapeutic presence and the human relationship being placed at the heart of the therapeutic process to enable the therapist to work with both the right – the creative, and the left – more analytic – hemispheres of the brain. The hemispheres ‘require mutual functional integration to function in everyday life [and] for the nervous system to act as one entity’ (Hart, 2008); one hemisphere cannot exist without the other’s functions (Hart, 2008).
Peter Fonagy, Professor of Psychoanalysis and Developmental Science/Head of the Division of Psychology and Language Studies at UCL, who also holds visiting professorships at Yale and Harvard Medical Schools has, along with colleagues, developed Mentalization Based Treatment (MBT), based on the link between human attachment and social cognition. MBT is one of two evidence-based psychological treatments used for personality disorders, as well as further presentations including depression, trauma, and suicidal thoughts and behaviours. MBT also helps build social skills in people who have lacked this development, due to early neglect and trauma in their lives. MBT is widely practiced in the UK, Europe and the USA, as recommended by the NICE guidelines. Research cited by UCL demonstrates that use of MBT ‘reduces hospitalisation, suicide and self-harm by 55% compared with control groups, with long lasting-benefits including reductions in depressive symptoms and suicidal and self-mutilatory acts’ (UCL, 2014).
From a trauma perspective
As therapeutic awareness has developed to understand that trauma presentations are commonly embedded within ‘generic’ presentations, ‘it is becoming a necessary clinical skill to recognize the activation of a trauma response and the potential for dissociation in the client, detectable via autonomic changes’ (Rothschild 2005, p.15). The importance of being physically with a client in order to ‘tune into’ such micro-indicators and thus minimise the risk of re-traumatisation becomes fundamental: ‘Body psychotherapists are equipped to engage in the regulation of body states through a whole variety of responses: playing non-verbally through movement, contact, making faces and voices … [thus] supporting the client to self-regulate through rest or interaction’ (Carroll 2005, p.20). For this, the therapist needs both sensitivity to micro-changes or ‘energetic’ shifts in the client … [through] the therapist’s very rapid processing of global and micro bodily information in themselves and the client’ (Carroll 2005, p.29). ‘Careful visual attention, on the part of the therapist, can often detect … chronic muscular tension as revealed in very small spontaneous motions’ (Levine et al. 2015, p.423).
Furthermore, within the context of long term traumatisation, such a history of trauma becomes evident through very careful and close observation of facial expressions, eye contact, muscular tension and micro movements such as a client’s slight shifts in their chair, a squeezing of their fists or a crossing of their legs (this list is not exhaustive). Good psychotherapy overall ‘is a process of exchange, involving a high level of co-ordination and contact, occurring spontaneously through the holding quality of the therapist’s face-to-face empathy. The client, ‘makes sounds, words and gestures to the therapist who receives them and accepts their full impact’ (Carroll 2005, p.28). Such data is collated during the client’s initial assessment but also, of at least equal importance, through the ongoing assessment and reformulation of treatment plans as client and therapist move through the work. Such ongoing assessment should be a key characteristic of any good – and safe – piece of psychotherapeutic work; a clinical assessment should never be viewed as a summative piece of work that is ‘complete’ at the end of an initial session as this would fail to take into account the essential formative nature of clinical assessment as new data about the client and their subjective experience becomes available to the therapist.
Indeed as therapy progresses ‘[a] therapist’s presence can invite the client into a safer and more open state of being, which allows the therapist into the clients’ inner world’ (Geller 2013, pp.209-222), as ‘our social engagement system coordinates cues of safety through voice and facial expressions to down regulate defence in ourselves and others’ (Porges, 2015, p.119). Such phenomena simply cannot be tracked, measured or worked with on the phone. It is only when a therapist is in front of a client that they can observe and attune to such responses. As this process unfolds and the attachment relationship develops, clients frequently feel more comfortable to reveal more about themselves – both verbally and non-verbally, consciously and less consciously – to the therapist, and the working treatment plan can thus turn out to be completely different to that which was originally developed following assessment. Without these opportunities to read a client’s cues through careful observation of their non-verbal communication, masses of important data that should be informing the ongoing client work gets missed and subsequently lost.
From a neuroscience perspective
A growing body of evidence from the field of neuroscience and affective neuroscience, towards which the psychotherapeutic field has been moving in recent decades, constantly highlights the integral role that face-to-face human contact plays in psychotherapy and counselling.
Neuroscientifically speaking, the autonomic nervous system (ANS) and social engagement system play a major role in psychotherapy: ‘The autonomic nervous system (ANS) is a core structure involved in the management of basic body states including the regulation of affect, and the survival and health of the organism. ‘There has been a spectacular increase in interest in the ANS linked with the emergence of the newly designated area of “affective neuroscience” … [with] increasing number[s] of therapists turning to neuroscience to refine and develop the theory and practice of psychotherapy especially in the realm of trauma, attachment, and psychopathology’ (Damasio 1994; De Zulueta 1993; Gerhardt 2014; Panksepp 1998; Schore 1994, 2003b). Through his work, Allan Schore, an American psychologist and researcher in the field of neuropsychology, found that ‘one of the critical discoveries is that the ANS is not simply autonomous but regulated through interaction with others, and that these interactions are laid down as internalisations at every level of the microstructure of brain and body’ (Schore, 1994); a theory seconded by many more researchers, including Susan Hart, who writes on neuroaffective development and attachment. Her research demonstrates that ‘affective attunement lets the partners communicate internal states’ (2008, p.94). Stephen Porges, author of the polyvagal theory and Emeritus Professor of Psychiatry at the University of Illinois, has found that ‘both eye contact and physical proximity are required to make optimal use of the client’s social engagement system to help them self-regulate better’, as ‘for the social engagement system to function, the cues of interaction that are processed by both the visual (facial expressions, gestures) and auditory (prosodic vocalisations) systems are critical’ (Porges 2015, p.120).
Porges’ polyvagal theory proposes that throughout evolution, ‘social connectedness evolved as [a] primary biological imperative for mammals in their quest for survival’ (Porges 2015, p.114). The theory states that the social engagement system can only come into play once defences have been worked with (Porges 2015, p.114). This, in turn, can only be achieved once clients can start to experience a sense of safety that develops within the therapeutic relationship: ‘without caring face-to-face interactions … the patient … shifts rapidly into a bodily state that supports defences and limits the ability to understand the information words convey’ (Porges 2015, p.115). In psychotherapy, this kind of relationship is achieved through careful and skilful clinical interventions that attune to the client’s experience in the room, and respond appropriately to their levels of emotional arousal.
Body psychotherapist, trainer and author Roz Carroll explains that, when working with the ANS, psychotherapeutic intervention ‘focuses on breathing, sensation, imagery or movement [of the client] [which] enhances the feedback loop from the peripheral nervous system back to the ANS’ (Carroll 2005, p.17). ‘Familiarity with the bodily phenomenology – changes in skin colour, muscle tension, pupil size, temperature, pace and feel of movement, conversation, etc – informs [such] body psychotherapy even when the therapist is not consciously formulating the process in such terms,’ writes Carroll (2005, p. 17), a position supported by Levine et al. (2015) and Porges (2015). Rothschild (2017) also writes extensively about the regulation of both the client’s and clinician’s ANS during a therapy session. She explains that this is achieved through the clinician’s close observation of the client’s non-verbal communication, indicative of the arousal levels of their ANS at various moments. It is imperative that a clinician is in tune with the client’s ANS in this way, in order to modulate the client’s arousal levels and thus avoid hyper- or hypo-arousal, neither of which are conducive to safe therapeutic work. Paying careful attention to visual cues that indicate the client’s level of arousal also allows the clinician to modulate their own emotional arousal, and thus tend to their own self care, in turn being better placed to minimise the risks of vicarious traumatisation to themselves.
I take no pains to conceal my bias throughout the course of this article. As a clinician with significant experience of working both face to face and over the telephone I hold firm to my believe that, aside from specific circumstances such as working with clients who are housebound or who lack transport connections, distance counselling cannot, and should not, be offered as a replacement for face-to-face counselling. Indeed, where economic constraints dictate such ways of working I have little doubt that the overwhelming majority of clinicians make the best of bad circumstances, and work to the best possible practice under the real constraints of their respective services. However, in order to do justice both to our clients and to our profession, we need to ensure that we don’t fall victim to what risks becoming our own propaganda, in claiming equivalency of face-to-face and telephone approaches to counselling. I hope I have gone at least some way in this article to raising questions and discomfort over the accuracy of what the current available evidence claims. So let’s do what we need to do, adapt where we need to adapt, and continue to do the utmost within trying times and circumstances to do the best for our clients, including resorting to telephone contact as and when economics dictate. But let’s not kid ourselves that clients continue to receive an equivalent service over the phone, and let’s not stop fighting for the bedrock upon which the basics of our profession rest.
Beth Glanville is one of the co-Editors and the Review Editor of Contemporary Psychotherapy. Beth is a UKCP reg. Psychotherapist / Counsellor and EMDR practitioner, specialising in psychological trauma. She currently works as a Psychotherapist at Transport for London’s Occupational Health Department, and also has a private practice in NW London.
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