Tips for doing effective phone therapy

While many psychologists and patients have adopted videoconferencing for psychological treatment, that option is not viable for everyone because of technology and access limitations or preference concerns. Phone-only or audio-only therapy has solid evidence supporting its effectiveness and should be considered a viable option for care. However, audio-only therapy does have some unique aspects for psychologists and patients to consider.

After considering the issues outlined in the technology checklist for telepsychological services, the psychologist also needs to conduct a thorough informed consent, consider relevant ethical/legal issues for telemental health, and determine that an audio-only treatment is appropriate for this patient. The psychologist will want to conduct a risk-benefit assessment for each potential client that addresses the individual’s particular treatment needs and considerations when engaging in audio-only behavioral telehealth.

Just as with other telemental health, the psychologist will need a plan for managing emergencies as well as an idea of the kinds of issues that might indicate audio-only therapy is not working for a particular individual.

Here are some tips for providing audio-only services.

Once you’ve determined that phone/audio-only therapy makes sense for a particular patient, plan to frequently ask about and document the individual’s status and whereabouts. You can’t see the setting so it’s important to ensure that it is your patient and they are in a private location.

In the event of an emergency, confirming the patient’s location every time ensures that you can seek assistance if needed. And, even if your patient is low risk for a mental health emergency, psychologists have already reported incidents such as a (child) patient being active during a telemental health session, falling, and beginning to cry and the psychologist needing to reach the guardian.

Other mishaps could happen as well, such as a patient choking while drinking some water or something more concerning such as threatening self-harm.

Both you and the patient need to ensure privacy and confidentiality during the session as well as afterwards. Each person should be able to secure the device or otherwise prevent others from being able to identify activity on the phone.

For example, the patient or therapist can be identified in the contact list by initials only. With videoconferencing, it is often possible to see whether another person is present during the session but whether or not a person is alone may need to be verbally confirmed with audio-only therapy. 

Both psychologist and patient should avoid using public or unsecured Wi-Fi for calls on a mobile phone or other devices. A headset improves sound quality, is comfortable, and offers more confidentiality than using the speaker phone option. If possible, avoid using a personal phone but instead rely on a business or agency phone.

Many patients, and sometimes psychologists, find it helpful to have a routine before and after a treatment session. Just as in-person visits require regular transit to sessions and greeting patients in a waiting area followed by post-session transit for the patient or paperwork for the psychologist, each party may find it helpful to plan for a few minutes transition before and after sessions. Creating a transition to or from therapy can prove beneficial for ensuring greater presence during the actual session.

While a separate space for engaging in therapy is important for privacy concerns, it is also important for focus and concentration. Encourage the patient to do what it takes to find that space, whether the space is the car, the powder room, or a far off bench under a tree removed from others.

Additionally, when using a smart phone for audio-only sessions, turn off other apps, ringers, notifications, and alarms that can disrupt the time set aside specifically to address mental and behavioral health concerns. Finally, place the smart phone screen down and encourage your patient to do the same so even silenced texts or other notices that come during the session don’t distract.

The principles in APA’s Ethics Code are just as appropriate for audio-only therapy as are the numerous guidelines that APA offers. Treatment technology does not change the fundamentals of good ethical practice informed by practice guidelines and professional consensus. Noting any concerns, and the relative risk benefit ratio, is important to document good clinical decision making.

Most people are used to communicating with others face to face, even if now that is often through video conferencing. Audio-only therapy still requires good communication skills but requires that we listen for nonverbal cues rather than watch for these cues. Some psychologists might actually prefer listening for differences in pace and tempo of discourse, pauses, hesitations, changes in tone or inflection, or other differences rather than continually focusing visually on a screen for nonverbal cues and changes.

With practice, one can become more attuned to these different types of “nonverbals” but psychologists may find, especially at first, that they need to be more overt and direct in their communication of empathy and their efforts to build rapport. Saying such things as “I can’t see your face right now, tell me what you are feeling” or “You can’t see me but I am sad that you faced this difficult experience” may facilitate the emotional exchange.

Additionally, more frequent vocalizations indicating that you are listening to your patient might also be needed. Greater capacity for tolerating silence—especially since one cannot see the patient—may be needed while the patient wrestles with difficult material, challenging ideas, or powerful emotions.

With all our patients, we must pay particular attention when our patient’s culture, ethnicity, or language differs from our own. But, when we are communicating solely via phone, we will want to “check ourselves” to ensure that we are not making inaccurate assumptions on the basis of what we hear without having the added visual information.

This will simply require an added awareness and sensitivity to these differences and how they might sound different over the phone rather than in face-to-face conversation. This is usually an issue at the beginning of a treatment relationship as patient and therapist get to know one another.

When you’re unsure of what to do, consult with knowledgeable colleagues, relevant statutes, applicable ethics codes, and available professional standards. The British Association of Counselling and Psychotherapy has some relevant guidance (PDF, 105KB). With regard to legal questions, consult with an attorney experienced in these matters.

As with all care, the treatment relationship is critical, and keeping one’s focus on building and sustaining a strong relationship can help both psychologist and patient successfully navigate audio-only telemental health to meet the treatment goals.