9th Nov 2015 Mayke Mol

cCBT and the change in the relationship between therapist and patient

The relationship between therapist and patient is generally considered to be a key factor for effective treatment. In blended cognitive behavioural therapy (cCBT), the number of face-to face-sessions is reduced, and replaced by online sessions. To date we don’t know to what extent this affects the therapeutic relationship. Do therapists experience a change in their communication with the patients?

To get a first idea we interviewed two therapists, Els Dozeman and Jenneke Wiersma, who both work with cCBT and were happy to share their experiences with us.

Offline and online therapist

We asked Els and Jenneke to what extent they experience a difference in their role as an offline therapist (during face-to-face sessions) and an online therapist (asynchronous/store-and-forward and synchronous/real-time) in the relationship with their patients.


Els: “I like both roles, but I experience a difference. In face-to-face sessions it is easier to assess the patient directly; how the patient is really doing and how the patient responses to the treatment. The tone, facial expressions and physical presentation are important aspects in this. In addition, it is easier to assess if someone really understands me. In online asynchronous contact I like the fact that I can think more carefully about my feedback.”

Jenneke: “For me there is no real difference between the roles, except maybe for giving feedback. In face-to-face you can react quickly if you think, for example, that the patient didn’t understand you completely. That isn’t an option in asynchronous online contact. In online contact I am therefore more careful. I sometimes hear from patients that they feel a bit nervous about receiving feedback. In written feedback you have to be more cautious and avoid suggestive comments. However, you have more time to think about your feedback. In face-to-face it is easier to correct yourself. You can of course discuss the written feedback in face-to-face sessions as well. I don’t think there is a difference, also with videoconferencing, in your role as a therapist. You are always a therapist, only the medium is different.”

Els: “As for synchronous contact I have no experience with online chatting, but I do have experience with videoconferencing. The latter I find challenging because of technical problems. It seems similar to face-to-face, it also has the same advantages of face-to-face contact, but it demands that all the equipment works and that the participants use the webcam in the right way as well (making eye-contact, proper light, correct posture and so on).”

Online skills 

As a therapist you practice different skills: observational skills, communication and listening skills. Do Els and Jenneke think that there are other therapeutic skills required a in the online setting?

Els: “In an online relationship you can develop and maintain good personal contact (through written feedback and messages) as in an offline relationship. The skills you need are verbal and written language skills, motivational writing and feedback skills (e.g. using open questions and summarizing). These skills are also needed in the offline relationship, but they refer more to the interview skills. ICT skills are relevant in the sense that you dare to use the computer and try new methods. That you don’t always succeed in the beginning is logical, more important I think is that you show this in an open manner with your patient and show your insecurity in this respect. This is of course the same in offline contact, where you also try to be honest about the things you can or cannot do. Thus I think there is more similarity than difference in skills.”

Jenneke: “I think that written language skills and ICT skills are essential. And, that you are capable and comfortable handing a computer. Also, you must like the structure of the online environment. The patient knows what to expect and what the course of treatment will be. This entails that the therapist is more easily inclined to follow the protocol. Working according to the protocol is something that you must like as a therapist. I can imagine that other therapists more like to improvise.”


Online functions

The online platform provides therapist tools for sending messages, giving feedback and videoconferencing. How can the online function help in developing and maintain a therapeutic relationship?

Els: “The online functions are in my opinion not necessarily important for the development of the therapeutic relationship. This is established because the patient feels understood and heard. Only sending messages (on the platform) plays a part in this: you are able to show that you didn’t forget the patient by sending a reminder, asking for clarification and sending extra information. I think this helps building the relationship. In addition, providing feedback on the assignments may be important in this.”

Jenneke: “I think the fact that all the relevant treatment information is online accessible, is for me as a therapist very convenient (no more paper and pencil) and for the patient as well. Very often not all information you give face-to-face patients sticks. In addition, I think that it is the future that the patient has control and access to an online patient file, treatment course and treatment content. Moreover, that we don’t see the online environment as something exclusive but as an integrated part of mental health care.

 Els: “With videoconferencing the camera function is an essential part, nonetheless I think you can also develop a good therapeutic relationship if you only hear each other. My experience is that this even is true for written communication and without knowing each other. However, this depends on the severity and symptoms of the patient.”

eHealth in the therapeutic relationship

In routine practice generally the uptake of eHealth is slow. To speed the process of implementing eHealth there is more knowledge needed about the barriers and facilitators. What are according to Els and Jenneke factors that facilitate or hinder the uptake?barriers

Els: “e-Health provides accessible contact. The patient has easy and direct access to me as a therapist. For the therapist is it also easier to ask questions between sessions. I think that written compliments are interpreted differently than spoken positive reinforcements. Potentially, written reinforcements are more explicit and someone can read it again at another time. But therapists should be careful not to exaggerate, because then, motivational comments can lose their power, but the same holds for compliments in face to face contact.”

Jenneke: “The advantage of eHealth is that you’re clearer as a therapist about the treatment course and some patients prefer that. In that sense, online treatment may be facilitating for the relationship. However, most of my patients had a preference for face-to-face contact with me. The online environment was for them more hindering than facilitating for the relationship. The homework assignments were disliked by some, because it felt like a dime in a dozen.”

Els: “Technical glitches especially can disrupt the relationship. This can be frustrating for both sides. For example, when the patient has difficulty understanding the material or has difficulties with reading of writing (not only because of the language level but also because of the depression) on the online platform, I believe it could be important to switch to face-to-face contact (or videoconferencing).”

It depends on the patient

Jenneke: “I believe that it depends on the patient how you offer cCBT as a therapist. Because most of my patients had severe problems and suicidal thoughts, the protocol gave me something to hold on to. Working according to the protocol and taking the preference of the patient into account can be complicated. Sometimes you are inclined to follow the wishes of the patient, but I am not sure if that is good for the quality of the therapy. When patients perceive that the treatment is effective, they will evaluate the therapeutic relationship as good. I sometimes wonder if specialized care is the right place for the blended treatment we currently offer. It can fit really well in a stepped care approach. We often see that the patients with complex problems need additional treatment. Likewise, the preference of the patient is important: if they want a blended treatment, just do it. Personally, I am not sure if I would want either, because it can be very comforting to just talk to someone. The online environment demands more effort and using the computer and I want less. Especially if you have a depression, having to create a password can be a burden. In contrast, there are also patients who don’t want to a therapist and want to do more on their own.”

In sum, therapists Els and Jenneke experience more similarities than differences in their roles as online and offline therapists in the relationship with their patients. One difference is that they both are more careful in giving online feedback in order to avoid misinterpretations. As for online skills, written language skills and ICT skills are considered important for the role as an online therapist. Two other important factors that are pointed out are 1) taking the preference of the patients for eHealth into account and 2) to minimize technical glitches as much as possible. Advantages of e-Health are accessible contact to the therapist (and patient) and more structure to the course of the treatment.

Els and Jenneke have given more insight in how cCBT can affect the therapeutic relationship and hopefully we will learn more on this topic within the MasterMind project. Do the therapists from the other partners experience a change in their communication with the patients?

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