Background

Digitised healthcare has received an enormous impulse due to the impact of the COVID-19 pandemic. Among telepsychiatry, videoconferencing is one of the most common forms of communication.1 It has been used in practice and is discussed in the scientific community for more than 60 years.1 It is expected to play an important role in the future of psychiatry2 as the physical examination of patients takes up less space than in other disciplines and communication with patients is given more weight. Given the current situation, video-based consultation seems to be a way to ensure patient care while avoiding the risk of infection.3

Empirical studies suggest that video-based consultation in psychiatry can be used in evaluation, diagnosis, treatment and education4 and without restriction for all psychiatric disorders.5 Treatment results seem to be comparable to face-to-face care, indicating positive effects, especially regarding the quality and continuity of care and coverage of rural areas with mental health services.4 6 7

Often noted, but rarely the subject of investigation, are, however, factors that elude quantifiability and measurability, such as the ethical quality of treatment or individual characteristics of the therapeutic alliance.8–10 These include impact on the roles of patients and health professionals or the significance of changes in communication patterns between both parties and the significance of in-person contact.8 9

All of the factors above are important elements in the therapeutic relationship. The influence of video-based consultation on patients and therapists’ perception and satisfaction with the therapeutic alliance has been investigated in a number of studies,6 8 11 mainly from the perspective of clinical outcomes. Surveys and standardised measures indicate hardly any difference from face-to-face care, especially from the patients’ point of view.8 11 Communicational drawbacks, such as the lack of physical proximity and nonverbal cues in videoconferencing, are frequently considered as possible hurdles.12 However, studies relating to the influence on the therapeutic relationship and analysing the ethical significance of changes are rare.6 13–15

The therapeutic relationship is of special significance from an ethical point of view. It is considered to be worthy of protection and, in addition, has shown to be a decisive factor for treatment outcome.16 The impact of video-based consultation needs to be carefully analysed.17 In this paper, we seek to answer the question whether video-based consultation can affect ethically relevant dimensions of the therapeutic relationship and, if so, how this should be addressed. Therefore, we investigate the effects of video-based consultation on the therapeutic relationship in psychiatry from an empirical and ethical perspective. First, we discuss the normative foundations of a meaningful therapeutic relationship. In particular, we elaborate on the ethically required distribution of rights and duties between professionals and patients and certain implications for behaviour in communication situations that arise directly from these demands. Second, we review and categorise the empirical effects of video-based consultations and the changes in communication between professionals and patients in psychiatry. Finally, we discuss the ethical significance of these changes by examining some exemplary points which specially consider the therapeutic relationship.

Ethical dimensions of the therapeutic relationship in psychiatry

Traditional approaches to the therapeutic relationship in medical ethics usually define a list of principles or duties to fulfil. However, modern approaches have sought to develop more fine-grained accounts which are able to theoretically ground and conceptualise rights and obligations.18 19 A common way to ethically outline therapeutic relationships in this regard is by referring to its communicative and social underpinnings. In this view, a help-seeking person and their caregiving professional enter into a relationship which can be characterised by its imbalance regarding different dimensions of power.19 20 Power, as the ability to decide and act, emerges from the unequal distribution of force, material resources and knowledge as determined by the social, cultural and institutional context of a situation.21 22 Shaping this relationship according to a moral standard, hence, requires the development of a set of different rights and obligations for both parties based on an understanding of what values ought to be protected.

While earlier models understood the imbalance between patients and professionals to be justified by the professionals’ duty to beneficence and accepted diminished patient autonomy, the last decades have brought a decisive change in social determinants (eg, increased access to information, changed exclusive status of professionals) and value considerations. Nowadays, contemporary models strongly emphasise the respect for autonomy and seek to establish a balance between professionals’ duties to beneficence and avoidance of harm, on the one hand, and patients’ self-determination, on the other. The requirement of this balance obliges patients and professionals to engage in a relationship that is grounded in respect for autonomy, lucidity, fidelity, justice and humanity towards each other.23 24

These terms loosely refer to Brody18 and Fried25 and do not depict fully formulated rights in themselves but rather present categories of meaningful relationships from an ethical perspective. Respect for autonomy, as a primary cornerstone, includes understanding individuals as being capable of self-legislation, that is, being able to decide voluntarily to act on principles that meet or flout general principles of thought and have a reason to act according to the former.26 This includes positive rights to the assistance in or fostering of autonomous decision-making and negative rights, for example, to refuse further treatment.27 Rights regarding lucidity, fidelity, justice and humanity and their respective duties are of instrumental value in creating and maintaining conditions that allow for autonomy.20 The dimension of lucidity entails rights and duties to clarity and transparency that account for a truthful and open communication. Regarding clarity, this includes refraining from knowingly communicating false information and deception.23 Second, it requires the clear, comprehensive and accurate transmission of information and communication.28 Transparency, on the other hand, obliges both parties to disclosure of all the information necessary to allow for autonomous decision making. On the side of therapists, a full disclosure of pertinent information, for example, on treatment, prognosis and alternatives, enables patients to make informed choices of their own accord which are covered by a person’s right to autonomy. On the side of the patients, honest and truthful disclosure of experiences of illness is essential for diagnosis and treatment.24

Fidelity, as the second dimension, entails rights and duties regarding stability, durability, accountability and confidentiality. Issues of fidelity are known to arise whenever individuals voluntarily enter into a relationship. By consenting to such a relationship, an ethical commitment to its boundaries is implied.29 These boundaries are set by its nature and the acknowledgement of the counterpart as an autonomous being. Professionals may, for example, rightfully expect patients to show treatment adherence and honour the agreements made.21 Patients, on the other hand, can expect accountability for the advice given and continuing service and support from their health professionals. This dimension also includes refraining from revealing confidential information to others, as it appears to be paramount for autonomous agents to be in control of not only their physical body but also information about them and where or by whom it is processed.30 This applies especially to relationships in healthcare, as intimate and private information needs to be processed as part of this relationship and, thus, must be protected.29

Justice as a term has an, at least, threefold meaning. It is used in a basic non-comparable sense and as a formal or distributive comparable term entailing different rights and obligations.31 In its first sense, to be just means treating a person according to what is due to them, that is, what this person is entitled to have.32 This leads to a second and comparative meaning, because what is owed to another is based on morally relevant properties. From a formal point of view, equality in these properties requires equal treatment. However, what is owed to a person often depends on what is owed to others. In this third meaning, for example, under scarce resources, justice in this comparative sense is concerned with questions of fair distribution. Consequently, justice in the first sense is concerned with the overall quality of a therapeutic relationship, while the second and third sense are concerned with the quality of relationships compared with each other.

Humanity finally entails rights and duties to ensure that respect for individuality and being a person as integral part of the therapeutic relationship is ensured. Autonomy in the sense discussed above can only be expressed and exercised by the ability to shape one’s own life according to one’s own values and preferences. Exercising and acknowledging individuality as a result of this shaping and as a kind of uniqueness is, hence, deeply connected to the idea of autonomy. The dimension of humanity, thus, requires considering each other’s uniqueness and individuality and treating each other with compassion.23 24

As a result, this moral framework allows both parties to be sure that their fundamental interests are protected.26 Both parties are able to show trustworthiness and to place trust in their counterpart, thus, laying out the foundations of a healing relationship.23 24 An overview of this framework can be seen in figure 1.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

Social and normative dimensions of the therapeutic relationship in psychiatry.

The special importance of trust and healing aspects in psychiatry has been stressed on different occasions. First, patient populations in psychiatric settings are particularly vulnerable, which results in different ethical problems compared with somatic settings.33 34 Patients’ vulnerability is fed by disease patterns that can directly influence their ability to make autonomous choices and by external factors (eg, the dangers of stigmatisation associated with these diseases).34 This results in particular ethical problems that challenge the therapeutic relationship, for example, when decisions have to be made about the treatment of patients who are not fully capable of giving consent, or when therapist and patient happen to meet in a public space. Second, therapeutic relationships in psychiatry can be particularly private, personal and highly emotional.33 However, the most important difference compared with other settings is that the therapeutic relationship plays a more prominent role in therapeutic effectiveness. Depending on the type of therapy, the relationship is not a means to an end to protect important values but a treatment tool in itself.33 A strong and stable relationship can significantly improve the adherence to therapy and health outcomes.35 This requires particularly high standards between professionals and patients.36 The American Psychiatric Association, therefore, has noted in its comments on the ethical principles, as published by the American Medical Association, that a functioning relationship between professionals and patients is of paramount importance in psychiatry and awareness of the ethical problems connected is needed.36

It is important to stress that, as with every conceptual model, our approach is not able to capture a complete representation of all aspects of the therapeutic relationship, nor is it the only model that could be employed. However, it seems to be able to capture some very important assumptions which are required to investigate our initial concerns. First, it allows one to understand the therapeutic relationship against the background of social determinants . Starting from a two-sided encounter characterised by certain imbalances regarding power, it connects the social situation of the therapeutic relationship to the idea of moral requirements as a counterbalance. Second, it captures the plausible assumption that therapeutic relationships are not only relevant from an ethical perspective but also build the foundation for a healing relationship. Most of the obligations defined here can become signs of trustworthiness once they are exercised. The framework, thus, illustrates how both parties can be enabled to put trust in their counterpart, while their fundamental interests are protected. Third, by connecting the different layers, this model shows that changes in one of these layers would almost certainly have an effect on the others.

Against this background it is important to consider whether the therapeutic relationship can be changed by the use of video-based consultation. In order to shed more light on this, we elaborate below on empirical particularities in the communication between interlocutors in videoconferences and their influence on the therapeutic relationship in psychiatry.

Technological mediation of the therapeutic relationship in video-based consultations

We understand video-based consultation to be a technically mediated bidirectional communication over an undefined distance which combines optical and acoustic information. This is to adopt a (post)phenomenologically oriented perspective on the technology of video-based consultation. This view is defined by the attempt to analyse technology not based mainly on its intended functionality but in terms of the role it plays between humans and their world.37 Understanding video-based consultations as mediating is to focus on the question as to how technology interferes with the human perception of and experience with their reality. Mediating technologies in this understanding do not only transmit but transform what can be perceived, for example, by amplifying or reducing sensory information.

According to this, it has been suggested that the disruption of spatial coherence and mutual gaze and their ‘reconnection’ by technical means are unavoidable features of the experience of video-based mediation.38 39 Following this thought, the transformation through technical reconnection may have an impact on many aspects of verbal and nonverbal communication between professionals and patients.13 To take a simple example, nonverbal communication especially might be particularly limited in video-based consultations and, at the same time, is often key to diagnosis and treatment.40 41 Initial evidence for this hypothesis can be found in early works, such as O’Conaill et al,42 who showed that the communication in videoconferences differs from the face-to-face situation independent of the transmission quality. Speakers give fewer backchannels and speaker-switching is more often initiated explicitly. The result is a generally more formal way of conducting a conversation.42 Furthermore, communication behaviour in groups has been shown to differ significantly in video-based settings.43 However, the analysis and investigation of therapeutic relationships in different psychiatric settings has been neglected and is mainly based on case studies yielding heterogeneous results.44 Notwithstanding this fact, studies outside the therapeutic area suggest that relationship factors are influenced by the videoconferencing setting. It has been shown, for example, that trust between participants in a videoconference can be quickly established, but is then more unstable than in a face-to-face setting.45 On the other hand, this effect can be mitigated if the conversation partners have met face-to-face previously or have time to discuss informal topics.46 Hence, it seems likely that such effects also have an impact on the therapeutic relationship in psychiatry in video-based consultations. In addition to affecting the communication, spatial disruption in technological mediation changes the social determinants between therapists and patients. As a result, it influences the asymmetry between both parties in the therapeutic relationship15 47 and, consequently, requires one to consider the adaptation of rights and duties.

We review the effects of technological mediation on therapeutic communication in common video-based consultations according to common-sense experience and existing empirical evidence. Based on the premise that videoconferencing creates a different lived experience of therapist–patient encounters mediated by a technical relay, we classify observable changes according to the four senses involved in communication: Vision, hearing, touch and physical proximity, and smell. In addition, we investigate aspects of spatial disruption and technical aspects of mediation as important components of this situation. An overview is given in figure 2.

• Download figure
• Open in new tab
• Download powerpoint

Figure 2

Aspects of technological mediation in video-based consultations.

Ethical dimensions of shifts towards technological mediation through video-based consultations in psychiatry

It turns out that empirical studies and common sense experience against a (post)phenomenological background reveal a number of changes in communication between interlocutors in videoconferences, some of them far-reaching, as a result of different sensory, spatial and technical aspects of technological mediation. The question arises whether these changes in communication can be of ethical relevance when psychotherapy and psychiatric care is delivered online via video-based consultations.

Although there is evidence of various changes in communicational patterns triggered by the differences of communication situations experienced in videoconferencing, numerous empirical studies could find hardly any differences in the therapeutic relationship in video-based consultations compared with face-to-face contacts. In addition to clinical outcomes, patient and therapist satisfaction, subjective evaluation of the therapeutic relationship, or acceptance or adherence of patients are frequently examined. These findings are initially encouraging, but there are reasons to question the conclusion sometimes drawn that there is no relevant difference between video-based consultation and face-to-face therapy in psychotherapy. Patient satisfaction is undoubtedly a significant factor in the assessment of treatment success, but it has to be considered that patient satisfaction can be an uncertain parameter in clinical studies, since patients in most medical studies tend to evaluate their own treatment positively.58 It is interesting that therapists generally evaluate video-based consultation more critically.59 A possible explanation might be that therapists are professionally trained to build and maintain a therapeutic relationship and are, therefore, more aware of it.17 It could be that subtle qualitative changes in the therapeutic relationship go largely unnoticed by patients, just as in other specialties, the professional quality of a medical treatment is not fully apparent to the patient and does not necessarily correlate with their stated treatment satisfaction. Acceptance and adherence can, furthermore, be positively biased by the fact that only relatively technology-oriented and technology-competent patients can be included in telepsychiatry studies.

Clinical outcomes as an index of the treatment quality of video-based consultations in psychiatry has been investigated in previous studies mostly using psychometric measures. However, even assuming that the treatment outcome of psychiatric care can be adequately measured by psychometric measurement, we think that this does not allow conclusions to be drawn regarding the overall quality of treatment. Since clinical outcomes are only one aspect of treatment quality, an overall assessment would have to consider additional factors including those related to the individual treatment process of patients according to their characteristics. Professionals and patients, for example, must interact and cooperate appropriately at all stages of treatment planning, procedure and evaluation in order to ensure that the therapy is ethically sound and oriented toward the well understood well-being of the patient.60 An impairment of the therapeutic relationship, as appears to be possible due to the changed communication in video-based consultations, is, in our understanding, of relevance regarding ethical considerations and an important factor for the quality of treatment concerning the process.

Based on a broader and ethically informed perspective, factors that affect the asymmetry between therapists and patients play a more important role and can be qualified in detail by focusing on the dimensions of the therapeutic relationship. In the following, therefore, we analyse possible influences of communication-changing aspects of technological mediation in videoconferences on ethically relevant dimensions of the therapeutic relationship, according to the normative framework we introduced above. Hereby, we focus on the ethical dimensions of respect for autonomy, lucidity, fidelity and humanity as entailing rights and obligations that are mostly addressing the counterpart of a therapeutic encounter directly.

Conclusions and outlook

Video-based consultations in psychiatry will become a frequently used tool in the future. Use of this tool is one of the most important challenges for the development of psychiatry.19 This may apply to medical questions regarding treatment, diagnoses and outcome. However, as we have shown here, it also applies to the core of medical relationships. Seen from an ethical and empirical perspective, changes in the conversation situation between the therapist and the patient are extensive in video-based consultations compared with the face-to-face setting. Past studies do not seem to have investigated this sufficiently but focus primarily on psychometric outcome parameters, acceptance, adherence or satisfaction of patients and therapists in surveys when evaluating video-based consultations. Studies on communication via videoconferencing in other contexts, however, suggest that there are ethically relevant changes in the quality of conversations which may also affect the assessment of the general treatment quality from a medical perspective. These changes lead, on the one hand, to shifts in the area of patient autonomy and, on the other hand, have a great influence on obligations regarding lucidity, fidelity and humanity within the relationship between therapist and patient, hence requiring adjustments in rights and duties on both sides. Our observations show that these changes need to be carefully considered and practitioners need to be aware of these changes and adapt their behaviour accordingly.

We concede that there are limitations of our analysis. First, there may be other models of the therapeutic relationship that could be employed as a starting point. However, we do not want to contribute to the extensive debate on justificatory aspects of different models of this relationship. The model depicted here is merely used as a descriptive starting point for our analysis. In this sense, we deem it to be sufficiently specific regarding its ethical dimensions and broad enough to capture basic intuitions about the ethical behaviour between therapists and patients. This includes the respect for freedom of others, truth-telling, promise-keeping, avoiding of disparities and preserving of individuality. In this regard, it allows for a reconstruction of the important shifts of the therapeutic relationship. A second limitation applies to our methodology. We have not and did not intend to base our work on a systematic review of the existing literature. Hence, results should not be understood as a synthesis of existing evidence. This may limit the validity of our claims because we were not able to review all the existing evidence and indicates the necessity for further systematisation of empirical evidence. A third limitation to consider applies to the dimension of justice in the therapeutic relationship. We have not elaborated on this dimension for several reasons. The aim of this paper was to investigate the effects between patients and professionals. Justice, in this regard, has a less substantial meaning commonly understood as the overall quality or ‘what we owe to each other’; we do not want to be concerned with this due to its overlap with all the other dimensions. However, we do not want to defend the claim that questions of justice in the second and third meaning outlined above are not important. We think that ethical questions regarding equal treatment and questions concerning a fair distribution of burdens need to be addressed. These include, for example, ethically problematic differences regarding access to digital technologies depending on social status or economic wealth. Doing justice to these difficult questions is, however, beyond the limits of this work.

To be able to assess these shifts more accurately, more—especially qualitative—empirical studies are needed on the communicative characteristics of the therapeutic relationship in video-based consultations. This future research has to focus on the process rather than the outcome of the treatment. Methods for structured analyses of conversations and frameworks for the qualitative analysis of video material exist and might provide a suitable methodological approach to further investigate the effects.44 In a second step, special attention needs to be paid to the (post)phenomenological considerations on which our thoughts are based. Future research needs to aim at unveiling the perceptions and experiences of users with mediating technologies to fully understand the dynamics of mediation. In this endeavour to understand how technology shapes perception and choices, Aagaard has, for example, suggested focusing on (1) in-depth exploration of typical use and (2) critical comparison of multiple versions of a technology.64 While the first is suitable to generate in-depth knowledge and explore the bandwidth of experiences in video-based consultation, the latter may provide the opportunity to generalise such knowledge by abstracting from a specific version of a technology. A challenge remains concerning integrating such approaches into a normative framework of analysis. Although healthcare technologies are rapidly evolving and a growing need for empirically informed normative frameworks is evident, only a very few approaches for such an empirically informed ethics of healthcare technologies exist. However, such frameworks can help to focus empirical research on features that concern ethically relevant aspects of the quality of the relationship, such as the compensation of incongruities in the therapeutic relationship, vagueness in communication and loss of information.

In addition, we suggest that steps towards the further implementation and provision of video systems for video-based consultation (eg, implementation in hospitals) should include considerations regarding ethical aspects. This may not only mean to be aware of such effects but also to engage in measures on the structural level to mitigate negative effects as far as possible. Measures to this end could include the provision of a stable internet connection, optimised hardware and software, and special rooms and environmental conditions for conducting online video therapy in hospitals. The development of technologies for video-based consultations should involve therapists and patients and take into account research findings on the communicative level. Fading out the miniature of one’s own image, for example, and the technical correction possibilities of the visual axis to enable eye contact should be discussed. The functionality of software should focus on optimising the quality of the conversation in psychiatric settings, taking into account medium-specific features and differences to the face-to-face setting.

We, finally, conclude that therapists and patients should be better trained in the appropriate and communication-enhancing use of video-based consultation. As far as possible, all participants should know the communicative characteristics, chances and risks of this form of therapy and be informed about possibilities to improve the therapeutic setting in video-based consultation. Corresponding training offers have so far been rare and insufficiently supported by employers and health insurance companies. In the course of the pandemic, many clinics and therapists, out of sheer necessity, simply took the next available software and hardware, set it up in their office and started video-based consultation for patients right away. This has worked surprisingly well and is now to be continued in the long term.65 However, the experience gained in the meantime does not replace the critical reflection and ethical aspects of the use of this technology in therapy. Procedures which have already been established should, therefore, be revised.

As long as it has not been clarified how the use of video-based consultation in psychiatry is to be evaluated ethically and as long as the shortcomings in its application mentioned here remain, we advocate a carefully limited and cautious use of this form of therapy. In our opinion, for ethical reasons, it should currently only be used where and when face-to-face therapy is not possible and risks of treatment delay clearly outweigh the risk of the digitised setting. As far as possible, video-based consultation should be considered as a supplement to face-to-face contacts, avoiding settings in which therapists and patients have not met each other in person before. In all cases, application of video-based consultations in psychiatry require the awareness of possible downsides and knowledge of empirical research results on effects on communication to avoid those pitfalls described above. We understand this awareness to be a duty of medical ethicists in research and therapists in clinical work emerging from the idea of ethical relationships in medicine itself, which requires practitioners to take a position of caution and put the relationship between patients and professionals at the centre of care.