RECENT STUDIES ON GROUP THERAPY VIA TELEHEALTH

Gentry, M., Lapid, M., Clark, M., & Rummans, T. (2019). Evidence for telehealth group-based treatment: A systematic review. Journal of Telemedicine and Telecare, 25(6), 327-342.

Tele-mental health has received increased attention and use in the context of the COVID pandemic. Coincidingly, practitioners may be questioning the effectiveness of this delivery format and how it may be optimized to meet the needs of their clients. In this 2019 systematic review article, Gentry, Lapid, Clark, and Rummans synthesized results of studies investigating the effectiveness of group tele-mental health interventions. They sought to examine three questions in particular: (a) whether a group-based psychotherapy or a support group intervention conducted via live, interactive teleconference (VTC; video based, not telephone or text-based) is as effective as similar in-person treatments, (b) whether specific group processes (e.g., therapeutic alliance) differ between face-to-face and VTC formats, and (c) whether group participants and providers are satisfied with VTC technology.  

The authors identified six randomized controlled trials studies (RCT) and five open-label trials (non-randomized with a control group) where VTC was compared to an equivalent face-to-face intervention. They otherwise reviewed and included 23 studies that were pilot, feasibility, or qualitative studies in which no control group was used and one study where VTC was compared to a text-based group intervention. The populations of focus for these studies varied and included veterans with PTSD, opioid dependent patients, patients with various medical conditions, caregivers, and patients with mood, anxiety, or adjustment disorders, among others. Treatment interventions were usually short-term (six to 14 sessions) and the theoretical orientations used varied across studies. All groups seemed fairly structured in nature as opposed to process focused and examples included CBT, relapse control therapy, psychoeducational groups, cognitive processing therapy, and mindfulness-based therapy.

Findings and Practice Implications:

1. Effectiveness of VTC: The authors concluded all studies in the review reported generally positive outcomes with the utilization of the VTC format. Among the RTC and non-randomized studies in particular, no differences were found between VTC and face-to-face groups in terms of treatment outcomes (e.g., decreased PTSD symptoms). Clinicians can therefore have more confidence that VTC group formats are useful to patients. Importantly, however, the authors’ conclusions were limited due to the lack of randomization and/or appropriate control groups across the included studies. There were also substantial differences in how effectiveness was measured across studies. Clinicians might refer to individual studies listed in the systematic review to gain guidance that is most relevant to their practice (e.g., the patient population with whom they work).
2. Group process factors in VTC: Several studies examined how group processes were impacted by a VTC delivery method. Results were overall positive, including that participants identified having a positive group experience with the VTC format, wanted sessions to continue, and expressed feelings of value by other group members. There were some exceptions, where some studies indicated patients felt their group experience would have been improved through face-to-face interactions. The three studies that measured and directly compared group process outcomes showed some mild differences between the face-to-face and VTC formats, in which there were small decreases in therapeutic alliance and group cohesion in the VTC group. The authors note this difference did not appear to result in different treatment outcomes between the groups. Group process in VTC is undoubtedly an intriguing area for innovative ideas and additional research; specific methods to enhance group cohesion and therapeutic alliance in a VTC format may be particularly valuable to investigate.
3. Patient satisfaction with VTC: Participants generally reported positive perceptions of the telehealth experience though some patients reported technological interference (e.g., trouble with lighting, background noise). One study with opioid dependent patients indicated multiple drop-outs occurred due to technology concerns. Otherwise, the authors did not discuss differences in drop-outs/acceptability depending on format. It seems creating a user-friendly interface and reducing technological distractions is important in boosting the treatment experience.

Zhou, E., Patridge, A., Blackmon, J., Morgan, E., & Recklitis, C. (2016). A pilot videoconference group stress management program in cancer survivors: Lessons learned. Rural and Remote Health (16).

The current study is one of multiple pilot, small scale studies that have been published on patients’ experiences of group therapy interventions delivered via telehealth. The conclusions of such studies provide guidance on how group telehealth can be implemented effectively in clinical settings, which will hopefully be further examined in future, larger scale research.

The participants in this study were 14 adult patients with a cancer diagnosis who completed four, 60-minute group therapy sessions delivered weekly via video conference. The sessions focused on cognitive factors that impact stress and the practice of relaxation exercises and were supplemented by an eBook that included practice exercises for homework. All participants had expressed interest in learning how to better manage stress.

Study participants attended the first group session in person at a cancer treatment center. They were provided with an iPad and staff oriented them to videoconferencing software. All subsequent sessions took place via videoconference. A study staff member contacted every participant the day before each session and conducted a “connection trial” to ensure they were able to login to the conference.

Two forms of data collection took place in this study. Participants were interviewed before and after the study about their interest in the study and their likes and dislikes about the group therapy program. Second, they completed a quantitative measure of stress (the Perceived Stress Scale, a 14-item measure assessing levels of perceived stress) before and after the study to measure the effectiveness of the intervention.

Results and Practice Implications:

-Ten of the 14 participants stated that they developed interest in the program in part because they did not have to attend in person. Thirteen out of 14 participants had a 30- or more-minute commute to the center. These findings suggest the video conferencing aspect of the intervention helped circumvent barriers to treatment access.

-Ten out of 14 participants reported finding the program helpful overall and eight reported the content was well-suited to improve psychosocial distress. This suggests the program was feasible and acceptable for most participants. Barriers to treatment were reported by six of the participants and included: difficulties developing a social connection to other group participants, difficulties focusing on the session content, and technical difficulties (e.g., audio interference with other devices, connectivity issues). To address technological concerns raised in the study, the authors suggested an additional staff member be available throughout the group to help patients navigate any technical issues that develop over the course of the session. They also suggested providing patients with headphones with a microphone built in to minimize disruptive noises. The authors wondered if patients would have felt more engaged with sessions and other group members if they utilized the chat function to send occasional messages to patients. They also discussed the idea of group-based communication between sessions through email or a web-forum.

-The Perceived Stress Scale indicated modest improvements in perceived stress that did not reach statistical significance. The authors noted the intervention may need to be longer to reach a sufficient dose of treatment. The small sample size may have also influenced the strength of the findings.

In sum, the results of this study are overall positive and support use of a telehealth format in group treatment, particularly in terms of its convenience and reception by patients. There are findings that need to be explored in future studies, such as the lack of significant change in patients’ perceived stress before and after the intervention. It would also be helpful to evaluate whether, all other conditions being equal, certain patients benefit more from a telehealth vs. face to face format and what factors distinguish these groups. It is understandable that a telehealth format would be preferable for patients with limited transportation or inflexible schedules, or possibly those that initially feel overwhelmed by direct social encounters. The influence of group process factors on telehealth effectiveness is another intriguing area for additional study and may differ from prior group research. For instance, the patient’s ability to focus on the session content may have a significantly greater influence on outcome in telehealth compared to face to face groups (given the higher potential for distraction). It would also be of interest to determine whether interventions specific to building group cohesion in a telehealth format need to be developed and what influence their inclusion may have on treatment outcome. For example, it may be easier for certain patients to avoid asserting themselves in a telehealth format, and leaders may coincidingly need to be more direct in collecting feedback and balancing participation between group members.