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Статия с участието на и института по Психология към БАН, публикуванa в "Journal of eHealth Technology and Application"

Telepsychology: Lessons Learned from Years of Experience

M. Jordanova 1, L. Vasileva 2, A. Vladimirova3, A. Gencheva 3, S. Shtereva-Katsarova3, B. Krendeva3, M. Rasheva 2, R. Bojinova 2

1 Solar-Terrestrial Influences Institute, Bulgarian Academy of Sciences, Bulgaria
2 Institute of Psychology, Bulgarian Academy of Sciences, Bulgaria
3, Sofia, Bulgaria

Abstract— This paper presents in brief our experience in telepsychology. Data from two surveys studying clients’ attitude towards telepsychology consulting as well as results from years of virtual consultations are offered. Authors believe that results will be useful for those that are planning to introduce telepsychology in their practice.

Index Terms—Telepsychology, clients’ demands, personality types

Telepsychology is the provision of non-face-to-face psychological services by distance communication technology such as telephone, e-mail, chat and videoconferencing [1]. Within last decade telepsychology is gaining strength. Despite of the fact that it is still in its childhood, telepsychology is an excellent tool, offering psychological help to those who need it, no matter where they are and at what time of the day or night this happens.
Telepsychology is a detailed sharing of information between a psychologist and a client aiming at development of rapport, creating a basic therapeutic alliance in order to improve compliance. A previously determined treatment program is applied. Sessions are structured in a similar way as they are structured during face-to-face meetings. Psychologists are organizing virtual appointments. As the information relating to each psychology session is effectively saved and followed up, the continuity of care is guaranteed.
It is necessary to underline that telepsychology is not appropriate for all problems. The decision to provide professional telepsychology services varies across situation, setting and time, and decisions are made on a case-by-case basis [1]. In general, telepsychology consists of short interventions and is used when face-to-face contact with licensed psychologist is impossible due to lack of transport, long distance, extreme situations, etc. Virtual consultations are alternative, especially for people who cannot afford private consulting, or for those who are afraid to speak about their difficulties face to face to a consultant, or for those who want quick answers. To put it briefly, thanks to the development of new information and communication technologies this service is available and is an option for a rapid psychological consulting, while at the same time expands the group of potential users of psychological help.
This paper presents in brief our expertise gained after years of studying clients’ attitudes towards telepsychology. Examples of when and due to what types of problems clients are approaching telepsychology experts are also included.
As a part of an ongoing project OHN 1514/2005 funded by National Science Fund, Bulgaria and Bulgarian Academy of Sciences two surveys, assessing clients’ position towards virtual psychology consultations, were performed in 2006 and in 2009. The objective was to follow the changes of attitudes toward tele-psychology and to adapt our understanding and offerings according to clients’ demands.
Total of 603 subjects, aged 18-65 yrs old, divided in 6 age groups, took part in the studies performed via Internet. Results revealed that 76% of participants are ready to use various types of virtual psychological support (Internet) as a media to receive psychological help and/or advice, if and when it is available.
A. Communication Channel
While in 2006 clients’ preferences were to communicate with experts via e-mails, within two years the preference for e-mails as main communication source has dropped with 20.2%
At the same time, both Skype and video programs gained strength. The explanation is: Skype, as user-friendly, free of charge program, gets more popular. It also combines the possibilities to use written and /or voice messages and video and has the benefit of providing storage of written communication for further analyzes. Clients feel reluctant to use it. This result reveals that if psychologists would like new communication technologies to be accepted as unavoidable part of psychology services, more attention has to be dedicated on the advertisement and making ICT technologies user friendly and acceptable in citizens’ everyday life. This may ensure the wide acceptance of tele-psychology services.
B. Age and Gender Differences
There is a different age and gender pattern when tele-psychology is concerned. Till late 20’s both sexes need and look for psychological help, while after that age the interest of women gradually declines. The decline is very sharp in men in the 4th decade of life. Around the age of 50 men again start looking for psychological support, which probably is related to the crises of the middle age.
Data revealed also that some personality characteristics as locus of control and level of anxiety shape clients’ attitudes towards telepsychology.
C. Locus of Control
Locus of Control is an important characteristic of personality and refers to an individual's perception about the underlying main causes of events in life. It may significantly influence decisions. Locus of control is a continuum, ranging from external to internal. The concept was developed originally by Julian Rotter in the 1950s. Individuals with an internal locus of control (ILC) believe that they can control events related to their life, whereas those with an external locus of control (ELC) tend to believe that real power resides in forces outside themselves and determines their life.
Within years, it was revealed that locus of control shapes individual health decisions and choices [2-3].
Recently, researchers begin to examine the relationship between locus of control in/and the technology domain, studying its relationship to computer experience, and perceived interactivity of the Web. It is supposed that the locus of control shapes individuals’ Internet behaviour, too, because Internet offers users relatively more control over the communication and exchange process than has been the case traditionally in media environments as broadcast and print [4-8].
Locus of control was evaluated via questionnaire. Subjects were distributed in two groups - individuals with external locus of control (ELC, N=22) and subjects with internal locus of control (ILC, N=36). Participants with a mixed locus of control were excluded from the analyses. When the attitude of ELC and ILC groups towards telepsychology were studies, data revealed that:
- 50% of participants with ILC and 81.8% of those with ELC are ready to use telepsychology consulting (χ2=0.00194, p<0.05).
- Although 38.88% of clients with ILC and 13.68% of those with ELC will not run the risk of searching virtual psychology consultations, the difference is not significant.
There are also differences in the preferred communication channel for contact with licensed psychologist. E-mails are preferred as main communication source from clients with ILC (52.72%). Both Skype program and video programs also gained strength. But e-mails are leading the statistics. There are many possible explanations – the fact that e-mails resemble so much ordinary mails; that they give the opportunity to create a text talk; many people feel that they can express themselves better in written words, etc. Let’s not forget that e-mails usually do not occur in real time. This is essential for clients as it gives time to think, evaluate and compose messages in a most appropriate way. Last but not least, e-mail exchange enables the record of interactions by saving the text messages
Clients with ELC are keener in applying Skype and Chat programs as the latter gives possibility to more direct and vivid, even online interaction. Unfortunately, perhaps due to the relatively small groups, the only significant difference (χ2=0.00078, p<0.001) is with the Chat program.
D. Anxiety
Anxiety is a behavioral condition, a normal reaction to stress. It helps to deal with tense situations and to keep focused on important tasks. In general, it helps coping. But when anxiety becomes an excessive, irrational dread of everyday situations, it becomes a disabling disorder. The latter may affect the way a person thinks (for example unrealistic view of problems), but it also can lead to symptoms such as restlessness, irritability, muscle tension, headaches, difficulty in concentrating etc. In case of anxiety anyone needs a psychological support. The biggest problem is accessibility. Anxiety sufferers are needy and require psychological support, advice and reassurance during various stages of anxiety and not just when the expert is available. That’s why telepsychology is just what anxiety sufferer needed.
Anxiety level was evaluated in 153 subjects and they were distributed in 3 groups - with low, moderate and high level of anxiety.
Figure 3 shows that anxiety influences the attitude towards virtual psychology. Clear linear trend is revealed. As anxiety increases, the acceptance towards virtual psychology support is also linearly increasing. There is a statistical significant difference in the attitudes of subjects with moderate and high level of anxiety (χ2=0.01065, p<0.05).
As the level of anxiety increases, clients are also changing their preference towards the way to communicate with experts. Low anxiety users prefer Skype program, e-mails and video communications are less preferable. As the level of anxiety increases, the preference changes towards e-mail. Perhaps this is due to the fact that e-mails are still considered a reflection of ordinary paper letters and are accepted as more structured source of communication. The Skype loses its dominating position but remains as a second choice while chat and video are far behind. Let’s not forget that Skype allows saving a back-up of the contact’s content with psychologist for further analyses, training and revision. Statistically significant (satisfying p<0.05), are the differences between low and high anxiety groups for the application of all communications: e-mail/ Skype (χ2= 0.02969); chat and video (χ2=0.00415); as well as between groups with low and moderate level of anxiety for the communications via chat and video (χ2=0.00025, p<0.05).
As anxiety increases clients also become more fixed on details. They start looking for additional information about the consulting psychologist such as sex, age, marital status, professional information. Statistically significant is the difference with the low – high anxiety group (χ2=0.01065, p<0.05).
E. Problems
In the survey performed in 2006, an “open” question gives subjects possibility to list the problems for which solving they would definitely look for telepsychology support. Results are presented on fig. 4. But what is the reality?
E-Therapy ( is an online telepsychology support service active for 6 years. The experience of over 10000 hour of consultations revealed that usually clients are desperately looking for telepsychology support when having more than one problem. Perhaps these are people that will never make the first step towards face-to-face contacts with an expert, so they start looking for help as the situation becames uncontrollable. Five are the main groups of problems:
- Communication problems – they prevail. Almost 80% of clients have some communication problems. Most often these are difficulties in communication in couple, difficult communication with children, problems with communication in the office, etc.;
- Sexual problems are on the second place. They include reproductive problems almost in 50% of the clients/cases, problems of individuals with homosexual orientation; sexual abuse, etc.
- Problems connected with personality are at third place. Age crises, low self-esteem, lack of self-confidence, stress disorders, copying with incidents of violence are few;
- Addictions: 45% of clients suffer from addictions - Internet, alcohol, gambling …
- Anxiety, fear and phobias are presented in 25% of the cases.
Аealing with most of the cases is rather difficult and time consuming task as a combination of several problems is very common.
It is also important to underline that 22% of all clients are young – age up to 20 yrs old, 62% are between 20 and 40 yrs old and only 16% are above 40 yrs. Women and girls prevail – 65% of all clients are females.
The age and gender differences force considering changing the strategy of offering and advertising telepsychology if we aim at reaching as much potential clients as possible.
When clients are contacting experts? The answer is presented at fig. 5. Data are based on consultations performed from end 2003 – June 2009. The results are speaking for themselves and the conclusion is obvious – clients are looking for telepsychology support almost 16 hours a day, predominantly during the working days. The results are not surprising as most of the clients prefer not to demonstrate the need of additional psychological help. Most of them are organizing their telepsychology session not from home. That’s why the maximum of consultations also reflects the maximum of Internet use.
At the end, it is worth mentioning the personality characteristics of telepsychology clients (Fig. 6). As presented at Fig. 6 extraverts (52.4%) dominated. The group consists of 30% sanguine and 22.4% choleric clients. The introvert clients are considerably smaller group composed of 18.6% melancholics and 12.1% phlegmatics.
Telepsychology is a fantastic opportunity for those who need psychological help no matter where the user is and at what time of the day or night he/she needs psychological support. It musters up strength but lots of advertisement is needed in order to reach potential clients.
Age, gender, personality or level of anxiety may shape clients’ attitudes towards virtual psychology. They have to be taken into consideration when virtual psychology consulting is performed in order to avoid misunderstanding and conflicts. The knowledge or preliminary evaluation of clients’ personality will give valuable clues to psychologists responsible for telepsychology support.
The authors Jordanova, Vasileva, Rasheva and Bojinova would like to thank the NSF, Bulgaria for their funding of project OHN1514/2005.
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