Arts and Social Sciences, Irving K. Barber Faculty of (Okanagan)
Psychology, Department of (Okanagan)
DSpace
UBCO
Wellspring, Ian
Doctor of Philosophy - PhD
University of British Columbia
The COVID-19 pandemic has influenced an increase in Videoconferencing Psychotherapy (VCP) to deliver psychological services (Shore et al., 2020). However, there has been minimal research that has investigated whether therapists’ clinical skills in Face-to-Face (FtF) therapy transfer to VCP. There has also been ongoing consideration regarding clients’ comfort in disclosing information across communication mediums, with mixed prior research. Further, there has been minimal research considering the prevalence and reasons why clients may provide untruthful information in therapy, and therapists’ credibility assessment ability, particularly in VCP. This research aimed to consider whether, and in what potential ways, therapists’ clinical competencies are impacted by conducting therapy across different communication mediums. The perceived advantages and disadvantages of mental health applications were also considered. Study one garnered information about graduate student clinicians’ and clients’ experiences (i.e., clinical skills, comfort disclosing information) following either a FtF or VCP therapy session. Study two collected information about registered psychologists’ experiences and perceptions of their clinical competencies across communication mediums. Participants in study two were also asked to gauge the credibility of a mock VCP client. A mixed-methods survey approach was adopted. Thematic analyses revealed that psychologists perceived clients’ individual differences as being more important for disclosing information in therapy as compared to the communication medium. For example, they believed general levels of openness about one’s personal history played more of a role in disclosure, as compared to the communication medium. Across graduate student clinicians and registered psychologists, therapists reported feeling generally competent in VCP but endorsed not feeling as competent in phone therapy. Registered psychologists were found to experience significantly higher levels of boredom, inattentiveness, and drowsiness in VCP as compared to FtF therapy. Lastly, registered psychologists’ ability to detect deceit in a mock VCP session was 46.75%. This was not significantly different from chance or the deception detection accuracy of 54% found in most prior literature, which is likely reflective of a Truth Bias in most clinical settings. The present results have various implications, particularly in identifying competency areas for therapists to consider when providing mental health services across communication mediums.
THE THERAPIST’S DUAL REALITY: AN INVESTIGATION INTO THE IMPACT OF VIDEOCONFERENCING PSYCHOTHERAPY (VCP) ON THERAPISTS’ PERCEPTIONS OF THEIR CLINICAL ABILITIES by Ian Wellspring B.A. (Hons.), Mount Royal University, 2015 Master of Arts (Psychology), University of British Columbia (Okanagan), 2020 A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE COLLEGE OF GRADUATE STUDIES (Psychology) THE UNIVERSITY OF BRITISH COLUMBIA (Okanagan) August 2024 © Ian Wellspring, 2024 ii The following individuals certify that they have read, and recommend to the College of Graduate Studies for acceptance, a thesis/dissertation entitled: THE THERAPIST’S DUAL REALITY: AN INVESTIGATION INTO THE IMPACT OF VIDEOCONFERENCING PSYCHOTHERAPY (VCP) ON THERAPISTS’ PERCEPTIONS OF THEIR CLINICAL ABILITIES submitted by Ian Wellspring in partial fulfillment of the requirements of the degree of Doctor of Philosophy. Dr. Michael Woodworth, Faculty of Arts and Social Sciences Supervisor Dr. Leanne ten Brinke, Faculty of Arts and Social Sciences Supervisory Committee Member Dr. Maya Libben, Faculty of Arts and Social Sciences Supervisory Committee Member Dr. Sally Willis-Stewart, Faculty of Health and Social Development University Examiner Dr. Daniel Stubbings, Cardiff Metropolitan University External Examiner iii Abstract The COVID-19 pandemic has influenced an increase in Videoconferencing Psychotherapy (VCP) to deliver psychological services (Shore et al., 2020). However, there has been minimal research that has investigated whether therapists’ clinical skills in Face-to-Face (FtF) therapy transfer to VCP. There has also been ongoing consideration regarding clients’ comfort in disclosing information across communication mediums, with mixed prior research. Further, there has been minimal research considering the prevalence and reasons why clients may provide untruthful information in therapy, and therapists’ credibility assessment ability, particularly in VCP. This research aimed to consider whether, and in what potential ways, therapists’ clinical competencies are impacted by conducting therapy across different communication mediums. The perceived advantages and disadvantages of mental health applications were also considered. Study one garnered information about graduate student clinicians’ and clients’ experiences (i.e., clinical skills, comfort disclosing information) following either a FtF or VCP therapy session. Study two collected information about registered psychologists’ experiences and perceptions of their clinical competencies across communication mediums. Participants in study two were also asked to gauge the credibility of a mock VCP client. A mixed-methods survey approach was adopted. Thematic analyses revealed that psychologists perceived clients’ individual differences as being more important for disclosing information in therapy as compared to the communication medium. For example, they believed general levels of openness about one’s personal history played more of a role in disclosure, as compared to the communication medium. Across graduate student clinicians and registered psychologists, therapists reported feeling generally competent in VCP but endorsed not feeling as competent in phone therapy. Registered psychologists were found to experience significantly higher levels of boredom, inattentiveness, and drowsiness in iv VCP as compared to FtF therapy. Lastly, registered psychologists’ ability to detect deceit in a mock VCP session was 46.75%. This was not significantly different from chance or the deception detection accuracy of 54% found in most prior literature, which is likely reflective of a Truth Bias in most clinical settings. The present results have various implications, particularly in identifying competency areas for therapists to consider when providing mental health services across communication mediums. v Lay Summary The current project investigated whether therapists’ perceptions of their clinical skills were impacted by conducting therapy over videoconferencing as compared to in-person and phone. Clients, graduate clinicians, and registered psychologists were asked to participate in an online survey. Therapists perceived themselves as being effective in face-to-face and videoconferencing psychotherapy, but not phone therapy. Interestingly, therapists stated that they felt more inattentive, drowsy, and bored in videoconferencing psychotherapy. It was also found that client individual differences, such as general comfort disclosing, were perceived as being more important for their comfort disclosing information as compared to the communication medium. Although clients reported being more likely to lie in videoconferencing psychotherapy, therapists’ ability to detect if a client was lying to them in a mock videoconferencing session was similar to that of non-therapists. The current series of studies has important implications for how videoconferencing psychotherapy is delivered and provides avenues for future research. vi Preface For the present thesis, I was responsible for managing and coordinating a team of research assistants with data collection. Of note, Dylan Nemes and Tanis Goryniuk directly assisted with data collection and contacting various organizations. Data was collected utilizing Qualtrics survey platform. I was also responsible for the thematic analysis, generation of an Excel dataset, data analysis, and the written portion herein. This research has been approved by the UBC Okanagan Behavioral Research Ethics Board under Ethics Certificate numbers H22-02865 (Study One) and H22-02610 (Study Two). No findings of this study have been published. Generative Artificial Intelligence (AI) was not used for any aspects of this work. vii Table of Contents Abstract………………………………………………………………………………………….iii Lay Summary…………………………………………………………………………………….v Preface……………………………………………………………………………………………vi Table of Contents……………………………………………………………………………….vii List of Tables……………………………………………………………………………………xii List of Figures………………………………………………………………………………….xiii Acknowledgment……………………………………………………………………………….xiv Dedication……………………………………………………………………………………….xv Chapter 1: Introduction…………………………………………………………………………1 1.1 Videoconferencing Psychotherapy (VCP)………………………………………...1 1.2 Phone Therapy………………………………………………………………….....8 1.3 Zoom Fatigue…………………………………………………………………….,9 1.4 Disclosures in Therapy…………………………………………………………..10 1.5 Credibility and Deception……………………………………..............................11 1.6 Mental Health Applications……………………………………………………...15 1.7 Objectives and Hypotheses………………………………………………………16 Chapter 2: Study One – Methods and Results………………………………………………..18 2.1 Study One Approach……………………………………………………………..18 2.1.1 Analyses Procedure………………………………………………………19 2.1.1.1 Quantitative Analysis…………………………………………….19 2.1.1.2 Qualitative Analysis……………………………………………...20 2.2 Graduate Clinical Psychology Student Clinicians……………………………….21 viii 2.2.1 Demographics & General Therapy Experience………………………….23 2.2.1.1 Methods…………………………………………………………..23 2.2.1.2 Results……………………………………………………………24 2.2.2 Videoconferencing Psychotherapy Experiences…………………………24 2.2.2.1 Methods…………………………………………………………..24 2.2.2.2 Results……………………………………………………………25 2.2.3 Clinical Competencies…………………………………………………...30 2.2.3.1 Methods………………………………………………………….30 2.2.3.2 Results……………………………………………………………32 2.2.4 Deception Questionnaire.………………………………………………...35 2.2.4.1 Methods…………………………………………………………..35 2.2.4.2 Results……………………………………………………………36 2.2.5 Disclosures Questionnaire.……………………………………………....37 2.2.5.1 Methods…………………………………………………………..37 2.2.5.2 Results……………………………………………………………37 2.3 Clients……………………………………………………………………………38 2.3.1 Demographics…………....……………………………………………....41 2.3.1.1 Methods………………………………………………………….41 2.3.1.2 Results……………………………………………………………41 2.3.2 Disclosures Questionnaire …………....…………………………………41 2.3.2.1 Methods…………………………………………………………..42 2.3.2.2 Results……………………………………………………………42 2.3.3 Deception Questionnaire …………....…………………………………...45 ix 2.3.3.1 Methods………………………………………………………….45 2.3.3.2 Results……………………………………………………………45 Chapter 3: Study Two – Methods and Results………………………………………………..51 3.1 Recruitment………………………………………………………………………51 3.2 Analyses Procedure………………………………………………………………52 3.2.1 Quantitative Analysis…………………………………………………….53 3.2.2 Qualitative Analysis……………………………………………………...53 3.3 Participants……………………………………………………………………….54 3.4 Demographics and Therapy Experience…………………………………………55 3.4.1 Methods…………………………………………………………………..55 3.4.2 Demographic Results…………………………………………………….55 3.4.3 Therapy Experience Results……………………………………………..55 3.5 Mental Health Applications……………………………………………………...56 3.5.1 Methods…………………………………………………………………..56 3.5.2 Results……………………………………………………………………56 3.6 Videoconferencing Psychotherapy Experiences…………………………………64 3.6.1 Methods…………………………………………………………………..64 3.6.2 Results……………………………………………………………………65 3.7 Trainee Current Progress Report (TCPR)………………………………………..68 3.7.1 Methods…………………………………………………………………..68 3.7.2 Section M of the TCPR Results………………………………………….70 3.7.3 Section J of the TCPR Results…………………………………………...70 3.8 Psychologists Perceptions of their Clinical Skills ………………………………75 x 3.8.1 Methods…………………………………………………………………..75 3.8.2 Results……………………………………………………………………75 3.9 Disclosures ………………………………………………………………………79 3.8.1 Methods…………………………………………………………………..79 3.8.2 Results……………………………………………………………………79 3.10 Deception Questionnaire…………………………………………………………82 3.10.1 Methods…………………………………………………………………..82 3.8.2 Results……………………………………………………………………83 3.11 Credibility Assessment Task……………………………………………………..84 3.11.1 Methods…………………………………………………………………..84 3.11.1.1 Deception Stimuli Creation………………………………84 3.11.1.2 Credibility Assessment Task Procedure ………………...86 3.11.1.3 Design …………………………………………………...87 3.11.2 Results……………………………………………………………………88 Chapter 4: Discussion…………………………………………………………………………..93 4.1 Patterns of VCP Use……………………………………………………………..95 4.2 Mental Health Applications……………………………………………………...96 4.3 VCP Experiences………………………………………………………………...99 4.4 Clinical Competencies………………………………………………………….101 4.5 Disclosures……………………………………………………………………...106 4.6 Deception……………………………………………………………………….109 4.7 Limitations and Future Directions……………………………………………...120 4.8 Implications and Conclusion……………………………………………………128 xi References……………………………………………………………………………………..136 Appendices…………………………………………………………………………………….175 Appendix A……………………………………………………………………………..175 Appendix B……………………………………………………………………………..177 Appendix C……………………………………………………………………………..179 Appendix D……………………………………………………………………………..180 Appendix E……………………………………………………………………………..183 Appendix F……………………………………………………………………………..185 Appendix G……………………………………………………………………………..186 Appendix H……………………………………………………………………………..187 Appendix I……………………………………………………………………………..189 Appendix J……………………………………………………………………………..190 Appendix K……………………………………………………………………………193 xii List of Tables Table 1…………………………………………………………………………………………...27 Table 2…………………………………………………………………………………………...31 Table 3…………………………………………………………………………………………...33 Table 4…………………………………………………………………………………………...35 Table 5…………………………………………………………………………………………...46 Table 6…………………………………………………………………………………………...66 Table 7…………………………………………………………………………………………...71 Table 8…………………………………………………………………………………………...72 Table 9…………………………………………………………………………………………...80 Table 10……………………………………………………………………………………….....92 xiii List of Figures Figure 1………………………………………………………………………………………….28 Figure 2………………………………………………………………………………………….39 Figure 3………………………………………………………………………………………….44 Figure 4………………………………………………………………………………………….49 Figure 5………………………………………………………………………………………….58 Figure 6………………………………………………………………………………………….60 Figure 7………………………………………………………………………………………….63 Figure 8………………………………………………………………………………………….69 Figure 9………………………………………………………………………………………….76 Figure 10………………………………………………………………………………………...78 Figure 11………………………………………………………………………………………...81 Figure 12………………………………………………………………………………………...90 xiv Acknowledgements I would first like to acknowledge and thank my supervisor, Dr. Michael Woodworth, for your continued support, patience, and guidance. I am so grateful and honoured for all your help, insight, and dependability throughout this process. Your door has always been open and I have felt continuously supported, not only within the field of research, but also clinically and personally as I seek to define personal and professional identities. Words cannot express how much I appreciate all of it. Thank-you for being a fantastic and brilliant role model and teacher. Thank-you to my committee members – Dr. Woodworth, Dr. ten Brinke, and Dr. Libben – for devoting your time to this project. Your thoughtfulness, feedback, and insights were immensely appreciated throughout this process and it was a pleasure to work with you all. I would also like to acknowledge the profound role of my lab mates and peers for their support. Thank-you for the study breaks, weekly debriefs, last-minute peer reviews, related and unrelated discussions, advice, and humour throughout this process. This process would not have happened without you, and you all made it a memorable and enjoyable experience! Thank-you to my family and friends for your encouragement and support. Your patience as I work towards this goal is greatly appreciated – it means the world to me. xv Dedication Rebecca and Winston. 1 Chapter 1: Introduction In 2004, the Canadian Psychological Association (CPA) outlined the core clinical competencies that psychologists must possess to be effective practitioners (CPA, 2004). These core competencies were outlined in a Mutual Recognition Agreement (MRA) and included interpersonal relationships, assessment and evaluation, intervention and consultation, research, ethics and standards, and supervision. Research has consistently demonstrated that therapists’ competence in these skills improves therapeutic outcomes (e.g., Rodolfa et al., 2005). Specifically, creating and maintaining interpersonal relationships (i.e., rapport or the therapeutic alliance) has been integral to therapist’s core clinical competencies, as it has been shown to be particularly important for positive therapeutic outcomes (Ardito & Rabellino, 2011; Horvath et al., 2011; Wampold & Imel, 2015). However, there has been increased utilization of videoconferencing in order to provide psychological services since the COVID-19 pandemic, to which there appears to be minimal research that has considered whether psychologists’ core competencies transfer from Face-to-Face (FtF) therapy to Videoconferencing Psychotherapy (VCP; Mallen et al., 2005). 1.1 Videoconferencing Psychotherapy Videoconferencing Psychotherapy (VCP) is a form of psychotherapy that is delivered through a videoconferencing platform (Backhaus et al., 2012; Fernandez-Alvarez & Fernandez-Alvarez, 2021; Humer et al., 2020). This includes platforms such as Skype (Bell, 2013), Microsoft Teams (Miller & McDonald, 2020), and Zoom (Humer et al., 2020), amongst others. Interestingly, VCP was gaining popularity before the pandemic due to the numerous benefits associated with it (Backhaus et al., 2012; Mehrotra et al., 2017; Smith et al., 2022). These included minimizing time constraints and scheduling difficulties, reducing the stigma associated 2 with seeking mental health services (Ben-Salmon et al., 2021; Muir et al., 2020), and allowing practitioners to provide services to rural and underserved regions where there may not be mental health services readily available (Gibson et al., 2011; Gonzalez & Brossart, 2015; Møller et al., 2022a; Muir et al., 2020). Given these benefits, research on VCP has been ongoing for approximately three decades (Thomas et al., 2021), with one of the earliest studies being conducted by Wittson (1965) who used a closed-circuit television to conduct therapy. Indeed, videoconferencing technology has been significantly enhanced, with the pandemic bringing renewed focus to the utilization of videoconferencing to provide therapeutic services (Chen et al., 2020; Shore et al., 2020). Prior to the COVID-19 pandemic there was hesitation by therapists to adopt VCP (Mendes-Santos et al., 2020), primarily related to decreased confidence in their competencies in a non-FtF medium (Glueckauf et al., 2018). However, there has been increased acceptance and adoption of VCP since the pandemic due to a more positive perception of VCP (Connolly et al., 2020). Indeed, in the past few years, mediums such as Zoom have become increasingly common (Browning et al., 2023; Hall et al., 2023; Latifi & Doarn, 2020; Sammons et al., 2020; Seivert & Badowski, 2021), to the extent that trainee therapists are being trained in VCP (Schiller et al., 2024). VCP is not a particularly novel modality as previous research has investigated its effectiveness (Backhaus et al., 2012; Berryhill et al., 2019a; 2019b; Thomas et al., 2021), impact on the therapeutic alliance (Glass & Blicker, 2021; Simpson & Reid, 2014), and ethical adherence (Madigan et al., 2021; Stoll et al., 2021), amongst others. In particular, there has been various outcome-based literature (i.e., investigating whether the delivered treatment produced the intended effect) that has considered whether VCP results in a positive impact on mental health concerns, resulting in some systematic reviews (Abel et al., 2017; Berryhill et al., 2019a; 3 Langarizadeh et al., 2017) and meta-analyses (Batastini et al., 2021; Fernandez et al., 2021; Lin et al., 2022; Norwood et al., 2018; Tuerk et al., 2018). Indeed, there have been individual outcome-based studies that have considered VCP’s broad effectiveness (Davis et al., 2024), as well as for anxiety-related disorders (Bouchard et al., 2004; 2020; Morriss et al., 2019; Stubbings et al., 2013; Theberge-Lapointe et al., 2015; Watts et al., 2020), depression (Berryhill et al., 2019a), Post-traumatic Stress Disorder (Acierno et al., 2016; Franklin et al., 2017; Liu et al., 2019), Obsessive-Compulsive Disorder (Fitt & Rees, 2012; Lee et al., 2018; Stubbings et al., 2015; Vogel et al., 2014), eating disorders (Abrahamsson et al., 2018; Hamatani et al., 2019; Yu et al., 2020), as well as comorbid presentations (Matsumoto et al., 2018; 2020). A recent meta-analysis sought to consider whether outcome-based literature consistently demonstrated that VCP was equivalent to FtF therapy across a variety of mental health presentations (Batastini et al., 2021). Generally, and consistent with the aforementioned systematic reviews, VCP-based services resulted in similar treatment effects (i.e., had the desired outcome and resulted in a positive impact on mental health). Despite this finding, there were several limitations acknowledged by the researchers that impacted the generalizability of the findings, notably that only a small handful of studies directly compared VCP to FtF therapy. Batastini et al. (2021) also did not consider whether therapists’ clinical skills necessary to provide effective treatment in VCP transferred from FtF therapy. This becomes particularly relevant when considering the therapeutic alliance. There has been particular attention paid to how VCP impacts the therapeutic alliance (Aafjes-van Doorn et al., 2024; Backhaus et al., 2012; Cipolletta et al., 2018; Eichenberg et al., 2022; Leuchtenberg et al., 2023; Simpson & Reid, 2014). Research has demonstrated that the therapeutic alliance is a key component of a positive and effective therapeutic experience for 4 clients in FtF settings (Cameron et al., 2018; Fahlgren et al., 2020; Norcross & Wampold, 2011). When the therapeutic alliance is compared across communication mediums, it has been illustrated that a strong working alliance and rapport can be established in VCP (Backhaus et al., 2012; Cipolletta et al., 2018; Eichenberg et al., 2022; Leuchtenberg et al., 2023; Simpson & Reid, 2014). Systematic reviews and meta-analyses have provided further insight into the therapeutic alliance within a VCP context (Aafjes-van Doorn et al., 2024; Norwood et al., 2018; Seuling et al., 2023; Simpson & Reid, 2014). In particular, Simpson and Reid (2014) found that generally clients rated the therapeutic alliance as being comparable across communication modalities, while therapists rated it slightly lower (but still strong) in VCP as compared to FtF. Aafjes-van Doorn et al. (2024) expanded on this to consider whether the therapeutic alliance within VCP impacted therapeutic outcomes. While results demonstrated that a strong therapeutic alliance continued to have a positive effect on treatment outcomes, the effect was smaller when compared to FtF therapy. The slightly lower effect was attributed to either additional therapeutic processes occurring in VCP (that are not as readily apparent in FtF therapy), or the therapist themselves not having as much of an effect on treatment outcomes, which could be related to their therapeutic competencies within VCP. In terms of the other therapeutic process domains, there has been extant research that has considered whether the therapeutic process remains consistent across communication mediums (Békés et al., 2021; 2023a; Cataldo et al., 2023; Edelbluth et al., 2024; Leuchtenberg et al., 2023). Cataldo et al. (2023) considered the technological aspects of VCP that impact the therapeutic process by interviewing 17 psychologists about their experiences with VCP, and then conducting a thematic analysis. From the interviews, they developed an Input-Process-Output model to describe the therapeutic process in VCP. Broadly, psychologists reported being able to 5 address some of the main technological limitations (i.e., internet connection), but also described feeling as though they could not as readily manage the therapeutic process, specifically regarding developing a therapeutic alliance/relationship. This was primarily attributed to the technological aspects of VCP that increase the cognitive load required by therapists. These included distractions with VCP such as internet connectivity, environmental distractions, and/or ensuring a confidential space for both therapist and client. In addition, psychologists reported being impacted by the decreased non-verbal information that therapists can rely upon (i.e., eye contact not in line with the camera, connectivity impacting available non-verbal information, etc.). The authors proposed that addressing various technological considerations could simultaneously decrease the cognitive load experienced by therapists, while also increasing the available non-verbal information. For example, it was proposed that it would be beneficial to increase eye movement detection functionality and attempt to augment emotion recognition. These types of enhancements would potentially enable the therapist to be more therapeutically present, thereby enhancing the therapeutic alliance and related treatment processes. Edelbluth et al. (2024) similarly investigated how therapeutic processes were potentially impacted by providing therapy in videoconferencing. They surveyed both clients and therapists across two groups, the first of which transitioned from FtF therapy to VCP during the pandemic (227 client-therapist relationships) while the second group solely engaged in FtF therapy prior to the pandemic (227 client-therapist relationships). Both the clients and therapists completed various measures related to the therapeutic alliance, the emotional connection within the relationship, and the development of coping skills (i.e., “I tried to improve coping skills today”). Interestingly, they demonstrated that there was actually an increase in the therapeutic alliance for both therapists and clients after transitioning from FtF therapy to VCP (despite therapists rating 6 the relationship lower as compared to clients). Moreover, there were not any significant differences noted in terms of the therapist and client being emotionally connected, while coping skills in the solely FtF group were rated higher. However, they clarified that VCP did not negatively impact coping skills (i.e., there was not a decrease in how coping skills were rated after transitioning to VCP). In sum, the authors determined that VCP does not have a negative impact on the overall therapeutic process. Interestingly, Møller et al. (2022b) also found that there was a stronger therapeutic alliance when clients already had an established relationship with their therapist prior to transitioning VCP, despite describing it as a less personal. However, neither Edelbluth et al. (2024) nor Cataldo et al. (2023) considered how VCP impacts therapists’ clinical competencies and related therapeutic processes. Messina & Löffler-Staska (2021) sought to address the clinical competency research gap by using the Trainee Current Progress Report (TCPR; Orlinsky et al., 2015) to assess therapists’ perceptions of their clinical skills across communication modalities. The TCPR is a validated measure that includes various subsections that assesses therapists’ perceptions of their clinical skills, difficulties in practice, and experiences during therapeutic sessions. It is currently being implemented across the globe (e.g., Italy, Germany, United States, etc.) by the Interest Section on Therapist Training and Development of the Society for Psychotherapy Research (SPRISTAD; Messina et al., 2019; Messina & Löffler-Staska, 2021; Orlinsky et al., 1999; 2001; 2015). Messina & Löffler-Staska (2021) found that therapists reported perceiving themselves as being less effective in their clinical skills (i.e., effectively engaging clients in a working alliance, mastery of therapeutic techniques, etc.) for VCP as compared to FtF therapy. Results also illustrated that therapists reported higher ratings of ‘flow’ and lower ratings of boredom during FtF therapy as compared to VCP. However, Messina & Löffler-Staska (2021) collected data 7 during the early stages of the pandemic, and the increased exposure to VCP since then may have enhanced perceived clinical skills since this time. Lin et al. (2024) compared therapists’ confidence and perceived effectiveness of their therapeutic skills as therapists were garnering more experience with VCP during the COVID-19 pandemic. The authors surveyed 440 therapists practicing in the United States at the beginning (i.e., Spring 2020) of the COVID-19 pandemic, and 345 therapists partially into the pandemic (i.e., Summer 2021). They assessed their perceived effectiveness for 19 therapeutic skills (e.g., empathically engage, foster therapeutic alliance, resolve rupture in the therapeutic relationship, etc.) across communication mediums. Results demonstrated that therapists significantly rated their skills in VCP lower when compared to FtF therapy during both 2020 and 2021. However, therapists also reported a significant increase in their VCP-related skills between 2020 and 2021, more so than the increase in their FtF therapy skills. The discrepancy in therapeutic skills across communication mediums was primarily attributed to a lack of non-verbal cues that therapists can rely upon to guide their interventions (Lin & Anderson, 2024; Lin et al., 2024). In particular, Lin and Anderson (2024) documented that therapists’ self-rated non-verbal skills were negatively related to their perceived therapeutic skills in VCP. However, Lin et al. (2024), as well as Messina & Löffler-Staska (2021), did not consider therapists’ perceptions of client disclosures, nor therapists’ credibility assessment capabilities within a therapeutic setting. Moreover, despite Lin et al. (2024) collecting data over a period of time, they (as well as Messina & Löffler-Staska, 2021) collected data during the earlier stages of the pandemic. This leaves a critical gap in our understanding of the effectiveness of therapists’ clinical skills in the VCP domain. This is particularly notable in the wake of COVID-19 as research suggests that VCP may continue to be a necessary and common method of service delivery (Connolly et al., 2021; Schiller et al., 2024). 8 Despite the overall extant research considering therapists' clinical competencies in VCP, there have been various guidelines and best-practice documents published to assist practitioners in ensuring that the services they provide over videoconferencing continue to be efficacious (American Psychological Association, 2013; Alqahtani et al., 2021; Batastini et al., 2023; Batastini et al., 2021; Batastini & Vitacco, 2020; Canadian Psychological Association, 2023). Interestingly, despite the various guidelines, Lin et al. (2024) found that only 65.22% of therapists self-reported adhering to the principles outlined in them. Nonetheless, and more recently, the Canadian Psychological Association published the CPA Guidelines on Telepsychology (2023). The guidelines were developed to address four areas of VCP practice: assessment, intervention and consultation, training, and supervision. An ongoing theme throughout the guidelines related to self-assessment and seeking supervision or training related to VCP clinical competencies. Although the benefit of engaging in active self-reflection to ensure competence cannot be overstated, it is imperative to identify particular competencies (if any) that require increased attention during self-reflection and/or training. Further, minimal research has compared both VCP and FtF therapy to phone therapy, which is surprising considering its historical and still fairly common current usage to deliver psychological services. 1.2. Phone Therapy It is now hard to imagine that virtual-based mental health services actually began with providing therapy over the phone (Sampaio et al., 2021). Although FtF therapy continues to be the preferred communication modality, phone therapy is still practiced in several contexts, including when FtF therapy or VCP are not readily available options (Irvine et al., 2020; Sampaio et al., 2021). The benefits of phone therapy mirror those cited as the advantages of VCP, such as being more readily able to provide services to clients in remote and rural locations 9 (Dew et al., 2013). Moreover, phone therapy continues to be delivered for crisis intervention lines given that it is available 24/7 and can service clients in rural locations (Coman et al., 2001; Lester et al., 2012). Phone therapy has also been integrated into specific therapeutic interventions, specifically Dialectical Behavior Therapy (Ben-Porath, 2015; Oliveira & Rizvi, 2018). Efficacy based literature has demonstrated that phone therapy is effective for managing symptoms of depression (Goldin et al., 2019; Watts et al., 2013), anxiety (Ekberg et al., 2011), and PTSD (Stecker et al., 2014), amongst others. As such, although VCP is experiencing increased use since COVID-19 (e.g., Shore et al., 2020), phone therapy continues to also be an option when in-person services (and sometimes virtual services) cannot be offered. Minimal research has compared therapists’ perceptions of phone therapy to VCP, and the research that has been conducted has demonstrated that therapists perceive equal quality of the therapeutic relationship, despite feeling not as confident in their VCP abilities (Békés et al., 2023b). This was primarily attributed to increased exposure to phone therapy prior to the COVID-19 pandemic (Békés et al., 2023b). However, this highlights that phone therapy should be considered along a spectrum of communication mediums for therapists to consider when delivering psychological services, which also could be impacted by the levels of fatigue therapists experience in non-FtF communication mediums. 1.3 Zoom Fatigue Considerable research has documented the phenomenon of Zoom fatigue, which occurs when an individual experiences exhaustion following a videoconferencing meeting, or a series of videoconferencing meetings (Beyea et al., 2024; Nadler, 2020; Ratan et al., 2022; Wiederhold, 2020). For instance, Queiroz et al. (2023) illustrated that as the length and frequency of 10 videoconferencing meetings increased, individuals also experienced an increase in their levels of fatigue (both cognitive and emotional). Interestingly, participants also reported not feeling as though their social skills were as effective in videoconferencing as compared to face-to-face interactions. Further, Fauville et al. (2021) found that women reported higher levels of Zoom fatigue. Increased focus on oneself during a Zoom meeting (termed mirror anxiety) mediated this relationship (i.e., increased focus on oneself influenced higher Zoom fatigue for females). However, there has been minimal research that has considered whether therapists experience similar feelings of fatigue in a VCP, and the extant research that has been conducted has demonstrated increased fatigue in VCP (Békés & Aafjes-van Doorn, 2020). It is important to consider how levels of fatigue in various communication modalities may impact important aspects of therapy, including how therapists perceive disclosures. 1.4 Disclosures in Therapy A therapist’s ability to foster interpersonal relationships helps clients develop a sense of trust, such that they may feel comfortable disclosing information, which in turn has important implications for treatment planning (Levontin et al., 2019; Pipkin et al., 2021). There is research that has considered clients’ inclination to be completely forthright in therapy (e.g., Farber et al., 2019), as well as if the medium of communication impacts client disclosures by either hampering or enriching therapists’ skill in eliciting information (e.g., Glass & Blicker, 2021). The limited research that has been conducted has found that clients feel more comfortable disclosing in VCP as compared to FtF (Glass & Bickler, 2021; Simpson et al., 2005; Stubbings et al., 2015). More specifically, Glass and Blicker (2021) found that therapists believed their clients were more comfortable disclosing information in VCP as they were in a familiar space (i.e., at home). In 11 addition to examining the openness of clients in therapy, it is also important to consider the veracity of this information when provided within a therapeutic context. 1.3 Credibility & Deception Research has shown that clients are not always credible in their self-report (Baumann & Hill, 2018; Blanchard & Farber, 2016; 2020; Curtis & Hart, 2015; 2019; Farber & Sohn, 2007; Hill et al., 1993). For instance, Blanchard and Farber (2016; 2020) found that approximately 93% of clients reported engaging in some form of deception during therapy. Similarly, Curtis and Hart (2019) found that 76% of clients would be “somewhat to very likely” to blatantly lie to their therapist in a future therapy session. Martin (2006) surveyed a sample of psychology graduate students who were also accessing therapeutic services to query the topics that they would be more likely to lie about during therapy. The most common domains related to relationships (13%), substance use (11%), and the severity of the symptoms that they were experiencing (9%). Blanchard and Farber (2016) expanded on this and found that clients were inclined to provide untruthful information in areas such as liking comments or validation from the therapist, reasons for why they were late or cancelled a session, or how effective they were finding therapy. Interestingly and importantly, they also found that approximately 31% of clients endorsed being deceptive about suicidal ideation. Curtis and Hart (2019) also noted that clients endorsed most frequently providing untruthful information in an effort to protect the therapist (i.e., not wanting to harm the therapist’s feelings). More recently, Farber et al. (2019) investigated the lifetime incidence (i.e., one instance of deception at any point during therapy) and the prevalence of clients providing untruthful information over the course of therapy (i.e., consistently being deceptive about the same topic). They similarly found that 93% of clients endorsed either lifetime or ongoing incidence of 12 deception in therapy, 62% of which reported a lifetime incidence of minimizing their symptom severity as the most common area of deception. Farber et al. (2019)’s follow-up study found that the most ongoing topic that clients consistently did not disclose information about throughout therapy was sexual related information, while the most common area in which clients engaged in complete fabrications related to suicidal ideation. Qualitative analysis indicated that clients were deceptive in order to decrease the probability of the therapist feeling disappointed (i.e., ‘other’ orientated), or to preserve their own feelings (i.e., self-orientated). The self-orientated reason was related to clients not being as readily open to acknowledging the levels of distress that they actively experienced and would therefore minimize them. Hart et al. (2024) further considered whether clients providing untruthful information in therapy impacted both the therapeutic alliance and treatment outcomes. Of note, clients who provided untruthful information in therapy reported not as readily achieving their treatment goals, while also having a poorer therapeutic alliance with their therapist. Taken together, determining genuine interactions in therapy clearly holds substantial value both for rapport as well as the clinician’s ability to understand the breadth of the potential presenting concerns. The therapists’ ability to gauge credibility in therapeutic settings is also important given the implications for how the information is used (i.e., treatment planning, ethical responsibilities, etc.). Considering the high-stakes nature of some of the information provided, it is particularly important to also consider the impact across communication modalities. In non-therapeutic settings, there has been a demonstrated effect of communication medium on both the types of lies told (Eskritt et al., 2021; van Swol et al., 2015), as well as credibility assessment accuracy (Hancock et al., 2010; Zhou & Zhang, 2007). For instance, van Swol et al. (2015) found that more blatant lies (i.e., complete fabrication of a statement) were 13 told in videoconferencing, whereas there were more lies by omission (i.e., withholding information) told in FtF communication. In terms of credibility assessment accuracy, there is mixed literature in terms of Computer-Mediated-Communication (CMC) and deception detection accuracy (Eskritt et al., 2021; Hancock et al., 2010; Zhou & Zhang, 2007). Zhou and Zhang (2007) and Dunbar et al., (2013; 2014) have found that there was higher credibility assessment accuracy in videoconferencing, whereas Eskritt et al. (2021) did not find any differences (despite participants experiencing more anxiety when lying FtF). Moreover, Burgoon et al., (2003) found that deception detection accuracy was higher in FtF settings when compared to instant messaging and videoconferencing. However, most of the research has considered text-based CMC and there are limited studies that have considered videoconferencing deception, with extant literature illustrating mixed findings in relation to videoconferencing (e.g., Burgoon et al., 2003; Dunbar et al., 2013; 2014). Online deception research in the past two decades has provided various explanations for deception in CMC platforms, including videoconferencing (Burgoon et al., 2010; Carlson et al., 2004; Eskritt et al., 2021; Hancock et al., 2010; Hancock & Woodworth, 2013; van Swol et al., 2013; 2015; Zhou & Zhang, 2007). For instance, according to Interpersonal Deception Theory (IDT; Burgoon & Buller, 2008), deception will vary based on the contextual factors present, including the medium in which the interaction is occurring (i.e., FtF vs. CMC). Hancock et al. (2004) provided three potential explanations for their series of findings of increased frequency of deception in CMC-based communication platforms. These included the Richness Theory (i.e., increased deception in virtual communication mediums due to decreased richness in media detail; Daft & Lengel, 1986), Social Distancing hypothesis (i.e., increased probability and prevalence of lies when people are socially distanced from each other; DePaulo et al., 1996), and 14 Feature-Based Theory (i.e., specific characteristics of the communication medium such as synchronicity, recording nature, and distance of people impact deception). Markowitz (2022) replicated Hancock et al. (2004)’s results, while also illustrating that individual differences may also play an influential role in the increased frequency of deception in CMC-based communication mediums. While research on deception is abundant, there have been no studies that have applied these credibility assessment theories to the specific, and arguably unique, therapeutic context. Research shows that credibility assessment accuracy is approximately 54% in non-therapeutic settings (e.g., lies about opinions of social topics), even for mental health professionals (Bond & DePaulo, 2006; Nortje & Tredoux, 2019). There are a variety of theories regarding what may be influencing individuals’ approximately chance levels of detecting deceit. Notably, the Truth Bias and reliance on non-reliable cues to deceit have been proposed as potential factors that impact credibility assessment accuracy. The Truth Bias asserts that individuals typically want to believe others (Bond & DePaulo, 2006; Levine 2014; Levine et al., 1999; Street & Masip, 2015; Vrij, 2008; Vrij & Baxter, 1999). As such, the tendency is for individuals to assume that someone is telling the truth, even if they are not completely certain whether someone is being truthful or not (Levine, 2014; Vrij 2008). Levine’s (2014) Truth-Default-Theory (TDT) proposes that assuming honesty is the default setting for individuals, and purports that there needs to be sufficient information to suggest otherwise before someone asserts that another person is lying to them. Of note, it has been demonstrated that therapists tend to believe that their clients are being honest and similarly maintain a Truth Bias (Curtis & Hart, 2015; Kottler & Carlson, 2011), which would likely impact their credibility assessment accuracy. Moreover, while there has been a demonstrated impact of communication medium on the types 15 of lies told and credibility assessment accuracy, there is also evidence demonstrating that the Truth Bias remains present in CMC contexts (Burgoon et al., 2003; van Swol et al., 2015). Unfortunately, there appears to be no literature investigating therapists’ ability to make accurate credibility assessments in therapeutic settings, let alone across communication mediums. Although not a direct investigation of deception detection ability, Farber et al. (2019) noted that of the clients who endorsed being deceptive in therapy, only 9% recalled being ‘detected’ by their therapist as being untruthful. As discussed, it is likely that credibility assessment may impact therapists’ ability to behave in the most ethical and competent manner given the high-stakes nature of some of the information disclosed in therapy. For example, a client may not be credible about their suicidal ideation (Blanchard & Farber, 2020), which holds important treatment implications, as well as influences the therapist’s decision about breaking confidentiality. Indeed, credibility judgments are relevant to all therapeutic contexts but may become particularly relevant in forensic contexts wherein therapists are also assessing for risk of harm to others and re-offence (Dickens & Curtis, 2019). It could also be the case that therapists’ clinical competencies are not as effective in VCP as compared to FtF because their ability to make an accurate credibility assessment is impacted by the communication modality. 1.6 Mental Health Applications The COVID-19 pandemic has also increased focus on online mental health applications, such as Better Help. Martinengo et al. (2019) noted that there are approximately 69 mobile phone applications designed to provide mental health services. Despite the potential benefits of such therapeutic options (such as ease of access; Eftychiou, & Morr, 2017; Marcelle et al., 2019) there have also been several concerns raised (Martinengo et al., 2019; Palmer & Burros, 2021). For instance, Wang (2021) noted that some therapists were raising concerns (ironically also 16 online) about how mental health applications do not provide a healthy, effective therapeutic relationship for clients. Mixed research has addressed these types of concerns and even fewer studies have considered therapists’ perspectives on the effectiveness of these applications. With regard to the effectiveness of mental health applications, the majority of research has considered their efficacy in addressing symptoms of anxiety and depression (Marshall et al., 2020; Six et al., 2021; Wang et al., 2018), substance use (Boumparis et al., 2019; Satre et al., 2021), and post-traumatic stress disorder (Wickersham et al., 2019), amongst others. Generally, research suggests that mental health applications show initial efficacy and ‘promise’ in addressing mental health concerns (Satre et al., 2021; Wang et al., 2018; Wickersham et al., 2019). However, it has been documented that the majority do not have sufficient efficacy data (Wang et al., 2018) nor utilize effective approaches (Marshall et al., 2021). Moreover, there have been concerns raised with the sample sizes and brief nature of therapy delivered via mental health applications that make it difficult to determine if they are effective (Wickersham et al., 2019). It should also be noted that some researchers have highlighted that the high degree of variability in terms of the settings and features of mental health applications also makes it unclear as to how some mental health applications are effective (Wisniewski et al., 2018). Nonetheless, there is initial evidence of their effectiveness and there has been an increased reliance on them to either provide or supplement therapeutic services in an increasingly computer-mediated world. 1.7 Objectives & Hypotheses The aim of this research was to consider whether, and in what potential ways, therapists’ clinical competencies are impacted by conducting therapy across different communication mediums (i.e., FtF, phone, videoconferencing). Study one collected information about therapists’ 17 and clients’ experiences (i.e., perceptions of their clinical skills, comfort disclosing information) following either a FtF or VCP therapy session. Study two garnered information about registered psychologists’ experiences with therapy across communication mediums, specifically related to the perceptions of their clinical competencies (i.e., credibility assessments, clinical skills). It also considered potential factors that may influence therapists’ perception of their clinical skills (i.e., fatigue), and elicited their perspectives on mental health applications. Study two also considered registered psychologists’ ability to make accurate credibility assessments in a mock VCP session. While primarily exploratory, our hypotheses were in line with Messina & Löffler-Staska (2021), and it was hypothesized that there would be lower scores for VCP as compared to FtF therapy for therapists’ perceptions of their clinical competencies. Moreover, it was hypothesized that the present findings would be consistent with Messina & Löffler-Staska (2021) in that therapists would report being more bored and drowsy for VCP, and would report higher ratings of flow for FtF therapy. Regarding clients’ comfort disclosing information across communication mediums in therapy, it was hypothesized that clients would report feeling more comfortable disclosing in VCP and would believe that they are more believable in VCP as compared to FtF therapy. Consideration of the incidence and likelihood of clients providing untruthful information in therapy across communication modalities was exploratory, given the minimal literature considering lying across communication modalities within therapy. Lastly, given that most prior research has demonstrated that individuals are approximately chance (i.e., 54%) at detecting deceit (e.g., Bond & DePaulo, 2006), it was hypothesized that therapists’ credibility assessment accuracy would also not be significantly different than the consistent deception detection accuracy rate found in previous literature, as well as chance. 18 Chapter 2: Study One – Methods and Results The aim of study one was to garner both client and clinician perspectives of VCP, specifically in comparison to FtF therapy. Using an online questionnaire, study one surveyed graduate clinical psychology student clinicians and adult clients completing either FtF or VCP sessions at a university psychology clinic. The objective was to not only consider client and graduate student clinicians’ experiences with disclosures across communication modalities, but also their perspectives of deception within therapy. 2.1 Study One Approach A mixed methods approach was utilized in an effort to provide opportunities for direct quantitative comparisons, while also eliciting detailed information about therapists’ and clients’ experiences with therapy across communication modalities. Mixed-methods approaches provide various methodological advantages, including providing both breadth and depth of data and information, increased certainty in findings if similar results and patterns are documented across the methodological approaches, and providing opportunities for the results of one method (i.e., qualitative) to inform and provide information for potential interpretations of findings for the other method (i.e., quantitative; Bergman, 2008; Creswell, 2003; Dawadi et al., 2021; McKim 2017; Plano et al., 2016; Sami, 2016). For example, utilizing both Likert scale (i.e., closed-ended) and open-format questions can assist in ensuring that the research findings have increased generalizability, while also ensuring that a developed and detailed understanding of a particular phenomenon is ascertained (Dawadi et al., 2021; Plano et al., 2016). A mixed methods approach was adopted for study one (and study two) given that some areas of VCP have documented evidence and research support (e.g., rapport), while other 19 areas do not have as thorough of a research base (i.e., deception, therapeutic competencies) and as such would require a more detailed understanding of these concepts within VCP. Given that study one collected information from graduate student clinicians and clients who were actively engaged in therapy, there were efforts to garner information in a manner that did not negatively impact the therapeutic process while also maintaining the fidelity of the data. For instance, a common measure utilized in clinical settings when considering deception (or more accurately, impression management) are the Paulhus Deception Scales (PDS; Paulhus, 1998). However, the inclusion of the PDS in the current study could have negatively impacted the therapeutic process (e.g., clients changing their self-impression after completing the measure, clients being concerned that their therapist believed they were being deceptive) and was therefore not included. Another readily considered measure in broad therapeutic settings is the Working Alliance Inventory (WAI; Horvath, 1984). However, the use of the WAI in the current series of studies would have been confounded by the already established therapeutic relationship for both clients and clinicians. This is of particular consideration given that some, if not the majority, of the therapeutic relationships and treatment programs would have been ongoing for periods greater than six months (if not years). Moreover, as discussed, previous research investigating VCP has readily investigated the therapeutic alliance across communication modalities (e.g., Aafjes-van Doorn et al., 2024; Simpson & Reid, 2014). 2.1.1 Analyses Procedure 2.1.1.1 Quantitative Analysis The quantitative analysis followed a progressive approach. Given the small sample sizes for study one, only descriptive statistics were calculated. Inferential statistics were considered when the sample size was adequate to meet inferential statistic criteria, particularly study two. 20 2.1.1.2 Qualitative Analysis Qualitative analysis utilized a phenomenological approach in which participants’ descriptions of their experiences and their responses were analyzed through reflexive and inductive thematic analysis (Braun & Clarke, 2019; Braun et al., 2014). As such, themes were developed, and were reflective of, the content of the qualitative data. To begin, each participant’s response was reviewed, collated, and uploaded to NVivo12. Themes and subthemes were then identified by reviewing the data and looking for similar responses that corresponded to an overarching category. A theme was defined as either an implicit or explicit topic that catalogues similar ideas and concepts into a broader category (Ryan et al., 2003; Vaismoradi et al., 2016). Quotes that best represented the identified theme were selected and included in the results section. A count of how often each theme arose across participant responses was conducted to determine the prevalence of any identified themes. Participants were given an opportunity to provide feedback on the validity of the questions. This provided an opportunity to ensure that the participants felt comfortable and confident in responding to the questions, as well as ensuring that the questions being asked validly assessed the underlying constructs. However, no feedback was provided by participants. As noted, participant responses were reviewed utilizing an inductive approach as the themes were created based upon the data, rather than having the categories created and defined ahead of time (i.e., deductive approach; Proudfoot, 2023; Vears & Gillam, 2022). Indeed, an inductive approach allowed for both a breadth and depth of data and information (Dawadi et al., 2021; McKim 2017; Plano et al., 2016). Moreover, as mentioned, some areas of VCP have documented evidence and research support (e.g., rapport) while other areas do not have as thorough of a research base (i.e., deception, therapeutic competencies). As such, an inductive 21 approach provided increased opportunity to more thoroughly address the areas that have had minimal research focus. Further, thematic analysis was selected given that participants were responding to singular questions in a survey format (as compared to a formal interview or interaction between participants), which has reduced contextual cues (i.e., tone, phonology, enunciation, etc.) that would suggest utilizing a discourse analysis approach. Inductive thematic analysis has been utilized in prior research investigating general healthcare (Klooster et al., 2022; Novak et al. 2022) and mental healthcare providers’ perspectives of their services (Gray et al. 2017; Hammond et al., 2018; Kremer et al., 2018; Olds & Hawkins, 2014), including psychologists’ perspectives of scientist-practitioner competence (Barrett et al., 2023). 2.2 Graduate Clinical Psychology Student Clinicians Graduate clinical psychology student clinicians were Ph.D. students who provided therapeutic services through a university psychology clinic in British Columbia, Canada. Graduate students in clinical psychology were selected given that VCP will likely be a staple of psychological services in the future (Schiller et al., 2024), particularly once they have completed their training. Moreover, they began providing therapeutic services during the COVID-19 pandemic and as such had minimal prior experience providing FtF therapeutic services. The graduate clinical psychology student clinicians provided therapeutic services to both community members and university students who accessed services through a university clinic. Therapeutic services were provided under the supervision of a registered psychologist, who was in good standing with the British Columbia College of Psychologists (BCPA). While providing therapeutic services, the graduate student clinicians would have received a minimum of weekly, one-hour individual supervision and weekly two-and-a-half-hour group supervision with the aforementioned registered psychologist. Further, at minimum, graduate clinical psychology 22 students would have completed two graduate level intervention classes, a graduate level ethics course, and would have completed a comprehensive assessment practicum prior to providing therapeutic services. As such, clinicians would have had exposure to providing general client services prior to providing specific therapeutic services. It is acknowledged that the primary researcher (Ian Wellspring) maintained a dual relationship with the graduate student clinicians (i.e., research participants). Specifically, he occupied the roles of both a colleague/student trainee and researcher. As such, the confidentiality and anonymity of the graduate student clinicians as researcher participants were of utmost consideration. Indeed, this dual role was highlighted in the consent form and various efforts were made to address this ethical consideration and maintain research participant confidentiality and anonymity. Firstly, it was clearly stated and reiterated during the consent process that clinicians were freely able to not participate in the study if they decided, without any consequences or penalty. Secondly, participants were provided with additional contact information of other researchers (aside from the primary researcher and supervisor) who did not have dual role relationships with the participants. The additional researchers that were included were members of the present dissertation committee. Thirdly, a volunteer Research Assistant (RA) was involved in study one. The RA did not have any relationship with the clinic prior to their research involvement. Their primary responsibilities were to be the primary contact for participants and to also review the data prior to the primary researcher accessing the data. During their data review process, they removed any identifying information so that the primary researcher was unable to identify respondents (i.e., maintain anonymity). The outlined procedures were approved the by research ethics board of the University of British Columbia (Okanagan), the clinic director, and clinic administrative staff. Given the 23 brevity of the survey, the design and flow of the survey are illustrated through the order of the following sections. The questionnaires were not presented in a randomized order, but rather the order of the following sections reflects the order of the survey. Moreover, the methods and results for each questionnaire are presented sequentially given the nuanced differences for similar topics within questionnaires across the various survey populations (i.e., graduate student clinicians, clients, and registered psychologists). A sequential order was selected in an effort to ensure that the reader can readily recall, as well as easily reference, the adopted method for each discussed result. 2.2.1 Demographics & General Therapy Experience 2.2.1.1 Methods Participants were first prompted to provide general demographic information, including their age, gender identity, and cultural identity. The initial study was originally proposed to collect data from other university institutions, and as such aggregated data from various institutions would have provided anonymity for the research participants. However, since the data was collected from a single institution, of which the primary researcher maintained a dual role, the demographic data was removed by the RA in an effort to maintain participant anonymity. At the time of this manuscript, the demographic data could not be reported as it would disclose identifying information. In addition to being asked to provide general demographic information, participants were asked to provide information about the therapeutic training that they completed at the time of the current survey (See Appendix A). This included being asked about the number of direct therapy hours they had accumulated through their training program, as well as an estimated breakdown of the number of training hours related to VCP. They were also asked to provide information 24 about their primary therapeutic orientation (i.e., Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, etc.). The primary therapeutic orientation of the training program was Cognitive Behavioral Therapy. 2.2.1.2 Results There were five graduate clinical psychology clinicians who completed the survey. As discussed, demographic data and inferential statistics are not able to be reported given the small sample size. In general, clinicians reported on average having approximately 252 hours (SD = 72.59) of direct therapy experience. 2.2.2 Videoconferencing Psychotherapy Experiences 2.2.2.1 Methods Clinicians were asked broadly about their experiences with VCP (See Appendix B). In particular, they were asked to provide an indication of the rates of VCP that they offered before and following the COVID pandemic, the amount of training they received with regard to VCP, and their preferred communication medium. Participants were also asked about their comfort in providing VCP, various levels of fatigue, and level of effort that they felt they required in order to effectively engage in VCP when compared to FtF therapy. In line with the mixed-methods approach, questions were both quantitative (i.e., Likert scale response options) and qualitative (i.e., open-format response options) in an effort to be able to quantitatively compare the communication modalities on the identified domains, as well as garner detailed information about graduate student clinicians’ experiences across communication modalities. Lastly, participants were prompted to complete Section M of the TCPR (Orlinksy et al., 2015) in order to assess their in-session experiences across communication modalities (See Appendix C). Section M of the TCPR has been utilized in studies assessing in-session 25 experiences for both FtF and VCP (Messina & Löffler-Staska, 2021), as well as general therapy experiences (Messina et al., 2017; Orlinksy et al., 2015; Rønnestad et al., 2019; Tilkidzhieva et al., 2019). With regard to reliability, Messina & Löffler-Staska (2021) illustrated that Section M of the TCPR has excellent validity with Cronbach’s alphas ranging from .64 to .96. It should be noted that the reliability fluctuates depending on the item being queried (e.g., anxiety vs. boredom). Section M of the TCPR includes 17 items that are rated on an 11-point Likert scale from 0 (“Never”) to 10 (“Very Often”). Section M of the TCPR prompts respondents with “how often have you found yourself feeling….”, which is followed by 17 descriptors for the therapy session (i.e., anxious, challenged, drowsy, trapped, etc.). Participants were prompted to complete Section M twice as once was in reference to their FtF therapy in-session experiences, while the second iteration was considering VCP. 2.2.2.2 Results All graduate student clinicians stated that they began offering therapy during the COVID-19 pandemic, with the majority of their training being in practicum rotations that were operated virtually. Clinicians reported receiving approximately 95 hours on average of clinical training for VCP. Given that most clinicians began their training during the COVID-19 pandemic, they endorsed not providing VCP prior to the pandemic. However, they reported that on average approximately 62.5% (SD = 17.68%) of their therapeutic services were offered virtually as the restrictions related to the COVID-19 pandemic were progressively being removed such that FtF therapy could be offered. Two clinicians indicated that they expected this percentage to remain stable, or increase, while two expected it to decrease. Similarly, two clinicians advised that they had a preference for combined/hybrid services, two endorsed FtF therapy as their preference, and one stated equal preference. On a 5-point Likert scale ranging from “very uncomfortable” to 26 “very comfortable,” clinicians were modestly comfortable with providing VCP (M = 3.33, SD = 1.15). Clinicians also provided Likert ratings for the levels of fatigue and mental effort that they experienced across communication modalities when providing therapy (See Table 1). Considering general fatigue, three key themes arose from the qualitative analysis, which included that the level of fatigue is the same, there are higher levels of fatigue for VCP, and client dependency (See Figure 1). Two graduate student clinicians (n = 2) reported that the level of general fatigue is comparable across communication mediums. For example, one clinician stated that “it takes as much effort to focus and engage in the session for the same amount of time, I'm not sure a screen makes much of a difference for me.” For the increased general fatigue in VCP theme, one clinician (n = 1) noted that they experienced increased fatigue in VCP because it is “harder to pay attention on virtual sessions.” Lastly, one clinician (n = 1) highlighted that the level of fatigue is more dependent upon the client’s presentation or topic, rather than the communication modality. Themes of finding a comparable level of emotional fatigue (See Figure 1), finding FtF therapy more emotionally fatiguing, or finding VCP more emotionally fatiguing arose when clinicians were prompted to compare emotional fatigue across communication mediums. Two clinicians (n = 2) stated that they found the levels of emotional fatigue to be the “same” across communication mediums. One graduate student clinician endorsed feeling more emotionally fatigued in FtF therapy and elaborated that “I think you feel more face to face and therefore more emotional fatigue comes from in-person versus online.” One clinician (n = 1) commented that they find VCP more emotionally fatiguing because “with face-to-face clients, there is 'less filter', and as a clinician, I feel that I am better able to sense the client's vibes more, and go off those 27 Table 1 Descriptive Statistics for Levels of Fatigue and Mental Effort for Graduate Student Clinicians Across Communication Mediums Variable Face-to-Face Therapy VCP Absolute Mean Difference M SD M SD Fatigue General Fatigue 2.75 0.96 3.25 0.96 0.50 Emotional Fatigue 3.5 0.58 3.00 0.82 0.50 Mental Fatigue 3.00 1.15 3.50 1.00 0.50 Effort General Effort 5.25 1.50 4.75 1.71 0.50 28 Figure 1 Themes from the Qualitative Analysis that Graduate Student Clinicians Reported Regarding the Level of Fatigue Across Communication Mediums Note. The first level is the topic that participants were asked to discuss. The second level is the themes that were identified in relation to the topic. The third level includes select example quotes that are most representative of the theme. Levels are color-coded to indicate similar themes across the types of fatigue. General FatigueLevel of Fatigue is Equal (n = 2)"It takes as much effort to focus and engage in the session for the same amount of time, I'm not sure a screen makes much of a difference."Higher Levels of Fatigue in VCP (n = 1)"Harder to pay attention on virtual sessions."Client Dependent (n = 1)"I think it is based on the client themselves."Mental FatigueLevels of Mental Fatigue Equal (n = 2)"Same."High Levels of Mental Fatigue in VCP (n = 1)"Harder to pay attention on virtual sessions."Client Dependent (n = 1)"I see this as being more client dependent (e.g., their level of engagement or psychological-mindedness) rather than whether or not I saw my client face to face."Emotional FatigueLevels of Emotional Fatigue Equal (n = 2)"Same."Higher Levels of Emotioal Fatigue in FtF Thearpy(n = 1) "I think you feel more face to face and therefore more emotional fatigue comes from in person versus online."Higher Levels of Emotional Fatigue in VCP(n = 1)"With face-to-face clients, there is 'less filter', and as a clinician, I feel that I am better able to sense the client's vibes more, and go off those interactions more easily," 29 interactions more easily, compared to virtually, where the computer screen almost acts as a protective barrier for the client.” In sum, it appears that clinicians endorsed diverse experiences in terms of experiencing emotional fatigue across communication platforms. Regarding mental fatigue, three themes were reported: experiencing the same level of mental fatigue across communication modalities, experiencing more mental fatigue in VCP, and client dependency (See Figure 1). Similar to above, two clinicians (n = 2) endorsed experiencing similar levels of mental fatigue across communication mediums. One clinician (n = 1) reported that they experienced more mental fatigue in VCP due to it being “harder to pay attention on virtual sessions.” In terms of client dependency, it was reiterated that “I see this as being more client dependent (e.g., their level of engagement or psychological-mindedness) rather than whether or not I saw my client face to face.” In sum, qualitative analysis of the experiences of mental fatigue revealed similar themes as the other forms of fatigue. A qualitative analysis was conducted investigating clinician responses to open-format prompts comparing the levels of effort required to engage in therapy across communication modalities. Two themes were identified, which included both modalities requiring a similar amount of effort or finding FtF therapy requiring more effort. There were two clinicians (n = 2) that endorsed noticing that therapy requires similar amounts of effort across both FtF therapy and VCP, with one commenting “my effort or engagement does not vary.” Two clinicians (n = 2) stated that they found that FtF therapy required increased effort when compared to VCP. One clinician elaborated that there is increased effort “because I typically offer virtual services out of my own home, which feels like it takes less effort and time out of my day.” However, the same clinician provided a caveat that the therapy sessions themselves required a similar amount of effort. Another clinician attributed the increased effort in FtF therapy to having to maintain 30 increased awareness as “I do not feel that I have to be as self-aware about my body language when I am doing videoconferencing therapy, whereas in-person, I feel that it takes more effort to be aware of my entire body language toward the client.” Lastly, clinicians completed Section M of the TCPR (Orlinsky et al., 2015) for both FtF and VCP (See Table 2). Clinicians responded on a 10-point Likert scale ranging from 0 (“never”) to 10 (“very often”). Descriptively, clinicians endorsed feeling more creative in FtF therapy as compared to VCP. Moreover, clinicians endorsed (descriptively) feeling more bored, trapped, and drowsy in VCP as compared to FtF therapy. However, it should be reiterated that it is uncertain whether these are statistically significant differences given the sample size. 2.2.3 Clinical Competencies 2.2.3.1 Methods The TCPR (Orlinsky et al., 20115) was also utilized to assess clinicians’ perspectives of their clinical competencies (Section J) across communication modalities. In particular, it was used to query clinician’s perceptions of their clinical competencies in FtF therapy, VCP, and phone therapy (See Appendix D). Prior research has utilized Section J in order to assess clinical skills across communication modalities (Messina & Löffler-Staska, 2021), and (as discussed) it has been utilized to more broadly assess clinical competencies for therapists (Messina et al., 2017; Orlinksy et al., 2015; Rønnestad et al., 2019; Tilkidzhieva et al., 2019). Messina & Löffler-Staska (2021) also demonstrated that Section J of the TCPR maintained excellent reliability (α = 0.97). Section J includes 12 items that are rated on a 10-point Likert scale ranging from 0 (“not at all”) to 10 (“very much”). In line with the mixed-methods approach, graduate student clinicians were also provided with open-format response queries to garner their perceptions about their clinical competencies 31 Table 2 Comparison of Graduate Student Clinician Experiences Across Communication Modalities Variable Face-to-face therapy VCP Absolute Mean Difference M SD M SD Creative 7.50 2.52 3.75 2.63 3.75 Engrossed 6.75 0.96 3.75 2.06 3.00 Trapped 0.00 0.00 2.75 3.77 2.75 Focused 8.00 1.41 5.50 3.11 2.50 Inattentive 2.50 1.91 4.50 2.52 2.00 Drowsy 4.25 0.50 6.00 3.65 1.75 Enthused 6.25 1.71 4.50 2.65 1.75 Stimulated 6.50 1.91 4.00 1.83 1.50 Inspired 5.25 2.87 4.00 1.41 1.25 Bored 2.75 1.26 4.00 1.83 1.25 Pressured 3.50 1.91 3.00 1.41 0.50 Calm 6.25 2.06 5.75 2.06 0.50 Tense 4.25 1.71 3.75 3.50 0.50 Anxious 5.25 3.2 5.50 3.00 0.25 Challenged 5.50 2.52 5.75 2.63 0.25 Overwhelmed 3.00 2.16 2.75 2.22 0.25 Relaxed 5.75 3.30 5.75 2.87 0.00 Note. The variable domains are ordered from most to least absolute mean difference. 32 across communication modalities. Specifically, they were asked broadly to comment on their skills in VCP, phone therapy, and FtF therapy individually, and they were asked to directly compare their perceptions of their skills in VCP to their skills in FtF therapy and phone therapy. This provided an opportunity for graduate student clinicians to provide a detailed understanding as to how communication modalities may impact their perceived clinical competencies. 2.2.3.2 Results Similar to in-session experiences, inferential statistics could not be calculated with the data from Section J of the TCPR due to a small sample size (See Table 3). Graduate student clinicians were also prompted to qualitatively elaborate on their perceptions of their clinical competencies in VCP. All clinicians endorsed feeling competent in VCP (n = 5). For example, one clinician stated “I think my skills and competencies are effective in virtual therapy. I am able to build rapport with clients, set goals, and work on treatment targets productively.” Another clinical clarified that despite being competent in VCP “my mind tends to wander more automatically.” Clinicians were further prompted to directly compare their clinical skills in VCP to their skills in FtF therapy, which revealed that although all clinicians believed they were effective in VCP, they perceived themselves as being more effective in FtF therapy (n = 5). For example, one clinician commented that “I am more aware of bringing myself back to the present moment better for face-to-face therapy” while another stated that “I think my rapport may be slightly better with my in-person clients given the small talk we have transition between the waiting room and therapy room and such.” Furthermore, another clinician elaborated that “it is easier to build rapport and the relationship in-person, and I think this is largely due to my own awareness of relationship dynamics being stronger and perhaps more accurate.” In sum, clinicians reported 33 Table 3 Comparing Graduate Student Clinician Perceptions of Their Clinical Skills Utilizing Section J of the TCPR Across Communication Modalities Variable Face-to-face therapy VCP Absolute Mean Difference Between VCP and FtF Therapy Phone Absolute Mean Difference Between Phone and FtF Therapy M SD M SD M SD How effective are you at engaging clients in a working alliance? 8.75 1.50 7.75 1.71 1.00 5.50 0.71 3.25 How ‘natural’ (authentically personal) do you feel? 8.25 1.71 7.25 1.50 1.00 6.50 2.12 1.75 How much mastery do you have of the techniques and strategies involved in practicing therapy? 6.25 1.71 5.75 1.26 0.50 5.00 0.00 1.25 How well do you understand the moment-by-moment process in sessions? 6.50 1.73 4.75 1.71 1.75 4.00 1.41 2.50 How effectively do you communicate your understanding and concern to clients? 6.75 1.26 6.25 1.26 0.50 6.50 2.12 0.25 34 Variable Face-to-face therapy Face-to- VCP Absolute Mean Difference Between VCP and FtF Therapy Phone Absolute Mean Difference Between Phone and FtF Therapy M SD M SD M SD How well are you able to detect and deal with the emotional reactions that your clients have towards you? 6.00 2.83 5.50 1.00 0.50 4.50 0.71 1.50 How good are you at making constructive use of your own personal reactions to clients? 7.25 2.06 6.75 1.89 0.50 4.50 0.71 2.75 How much precision, subtlety, and finesse have you attained in your therapeutic work? 5.75 1.26 5.50 1.29 0.25 5.50 0.71 0.25 How effective are you in helping your clients? 6.50 1.29 6.50 1.29 0.00 5.00 0.00 1.50 Note. Two clinicians completed Section J for providing therapy over the phone. 35 continuing to be effective in VCP but considered themselves to have enhanced effectiveness in FtF as compared to VCP. In terms of phone therapy, some clinicians highlighted that they had minimal exposure (and in some cases, no exposure) to phone therapy, and it was therefore difficult to elaborate on the effectiveness of their clinical skills. Those who had some exposure with providing phone therapy described themselves as being effective and attributed this to having reduced pressure to monitor one’s own facial and physical expressions. For example, one clinician stated that “not having to self-monitor my physical presentation/actions/reactions as much frees up mental space for me to do therapy” while another commented “I feel that I can 'hide' my expressions better and focus solely on how I want to interact with the client verbally.” One clinician went on to state that “my ability to be empathic is not impacted at all, which is a really good thing.” When prompted to directly compare their clinical skills in phone therapy to their FtF therapy skills, clinicians reported that although they perceived themselves as more effective in FtF therapy, it also requires increased effort. For example, one clinician clarified that “with face-to-face therapy, there are so many nonverbal cues to be aware of with clients. And this can be especially challenging if I felt bored or anxious in session as this would impact rapport building.” Generally, clinicians perceived themselves as being more effective in FtF therapy, but highlighted nuances to phone therapy (i.e., decreased pressure to manage non-verbal cues) that may allow it to be easier to engage in. 2.2.4 Deception Questionnaire 2.2.4.1 Methods Clinicians were subsequently prompted to complete a short questionnaire assessing their perceptions as to the frequency at which clients may provide untruthful information in therapy 36 across communication modalities (See Appendix E). A portion of the questions included in the current deception questionnaire were developed from prior research considering deception in therapy more broadly (e.g., Curtis et al., 2015). In particular, Curtis et al. (2015)’s queries were mildly adjusted for the current study in order to more specifically query about deception in a specific communication modality (e.g., “How confident are you that you can detect when clients are lying to you over videoconferencing?). This included querying the participant’s prior exposure to the research literature on deception, their confidence in their ability to be able to detect deceit, their beliefs about the frequency that clients are deceptive in a therapeutic context, and the perceived importance of being able to detect deceit within therapy. Participants were not asked to consider whether their own specific clients are/were being deceptive in therapy, nor were they prompted to make any veracity judgement related to the clients to whom they provide therapeutic services. Rather, they were asked to reflect upon client deception more broadly and consider the potential frequency of, and confidence in detecting, deceit in a therapeutic setting. 2.2.4.2 Results Graduate student clinicians were queried as to their levels of exposure to research considering deception. On a 7-point Likert, with higher scores indicating higher levels of exposure, there was below average familiarity (M = 2.25, SD = 1.26). Clinicians then rated the level of importance to detect deceit in FtF therapy (M = 4.75, SD = 0.5) and VCP (M = 4.75, SD = 0.5). In terms of their perceived confidence in detecting deceit, on a 7-point Likert scale (with higher scores indicating higher levels of confidence), clinicians reported just below average confidence for FtF therapy (M = 3.00, SD = 1.41) and VCP (M = 2.25, SD = 1.26). Regarding deception frequency, clinicians indicated on a 7-point Likert scale (with higher scores indicating higher frequency) that they believed clients provided untruthful information an 37 average amount for FtF therapy (M = 3.50, SD = 0.58) and VCP (M = 3.75, SD = 0.96). Clinicians were also prompted to provide an estimated percentage of the amount of time that clients are untruthful in FtF therapy (M = 26.25%, SD = 11.09%) and VCP (M = 30.00%, SD = 13.54%). Lastly, they were also prompted to provide an estimate as to the number of lies clients might be inclined to tell in a single session during FtF therapy (M = 1.62, SD = 1.25) and VCP (M = 2.88, SD = 2.53). It should be noted that each clinician (n = 5) stated that they believed clients would provide more untruthful information in VCP as compared to FtF therapy. One graduate student clinician elaborated that “clients might lie more often virtually since it's further removed from the therapist.” Lastly, clinicians rated clients’ level of believability in FtF therapy (M = 4.50, SD = 1.91) and VCP (M = 5.00, SD = 1.15) on a 7-point Likert Scale (with higher scores indicating higher ratings of believability). 2.2.5 Disclosures Questionnaire 2.2.5.1 Methods Graduate student clinicians were also asked about their perceptions of clients’ comfort in disclosing information across communication modalities within a therapeutic setting (See Appendix F). Participants were asked both a set of Likert Scale questions and were provided with an open-ended response option in an effort to obtain both qualitative and quantitative data. The Likert Scale response format provided an opportunity to directly compare clinicians’ perceptions of client disclosure across communication modalities. Moreover, the open-format response option allowed clinicians to elaborate and provide context for any perceived differences or similarities in client disclosures across communication modalities. 2.2.5.2 Results 38 Clinicians were first asked to estimate clients’ comfort disclosing information in an everyday conversation on a 5-point Likert scale (higher scores indicating higher levels of comfort) for FtF (M = 2.75, SD = 0.96) and videoconferencing conversations (M = 3.50, SD = 1.00). Following this, graduate student clinicians provided their perceptions of clients’ comfort disclosing information in FtF therapy (M = 3.00, SD = 1.15) and VCP (M = 2.75, SD = 1.50). Qualitative analysis of graduate student clinicians’ perceptions of clients’ comfort disclosing information across communication mediums revealed three themes: increased comfort disclosing in FtF therapy, comparable comfort, and client dependency (See Figure 2). Two clinicians (n = 2) stated that client characteristics were more relevant for disclosing information as compared to the communication modality. For example, one graduate student clinician stated “I think individual differences matter more, including their approach to therapy in general and trust in the process” while another advised that “I believe much of this would depend on the individual and vary person to person depending on their level of comfort with tech, with the therapist, and with seeing themselves on zoom, or with disclosure broadly.” In terms of the theme of clients being equally comfortable, one clinician commented that “it seems to be pretty equal from my perspective.” Lastly, for the theme of increased comfort disclosing in FtF therapy, one clinician stated that “I think that rapport is harder to establish over videoconferencing platforms, therefore clients are less likely to disclose especially private information over videoconferencing.” In essence, themes were related to increased comfort in FtF therapy disclosing information, equal comfort across communication mediums, and the theme that individual differences are more relevant than the communication medium. 2.3 Clients Clients who accessed a university psychology clinic for therapeutic services were also 39 Figure 2 Themes from the Qualitative Analysis that Graduate Student Clinicians Reported About their Perceptions of Client Disclosures Across Communication Mediums. Note. The first level is the topic that participants were asked to discuss. The second level is the themes that were identified in relation to the topic. The third level includes select example quotes that are most representative of the theme. Graduate Student Clinicians' Perspectives of Clients' Comfort Disclosing Across Communication Mediums in TherapyClient Dependency (n = 2)"I believe much of this would depend on the individual and vary person to person depending on their level of comfort with tech, with the therapist, and with seeing themselves on zoom, or with disclosure broadly." Increased Comfort in FtF Therapy (n = 1)"I think that rapport is harder to establish over videoconferencing platforms, therefore clients are less likely to disclose especially private information over videoconferencing."Equal Comfort Across FtF Therapy and VCP(n = 1)"It seems to be pretty equal from my perspective." 40 provided an opportunity to engage in a survey about their perceptions of both FtF therapy and VCP. Of note, the clients were community members and university students who accessed clinic services, typically through self-referral. As described above, clients were provided long-term therapeutic services by graduate level (i.e., Ph.D.) clinical psychology graduate students under the supervision of a registered psychologist. The general diagnostic presentation for clients who tend to access the clinic varies and can include addressing symptoms of Post-Traumatic Stress Disorder (PTSD), depression, anxiety, substance use, and personality disorders (amongst others). However, it should be noted that although the diagnostic formulation(s) varies, clients can also access therapeutic services without a formal diagnosis. As such, treatment targets can include goal setting, behavioural activation, managing negative cognitions, interpersonal effectiveness and communication strategies, self-care, stress management, identity formation, in addition to managing thoughts and behaviours related to attempts to end their own life (i.e., suicidal ideation). The length and frequency of treatment similarly vary depending on the client’s goals and presenting concern. As discussed, the university psychology clinic is operated by the psychology department, and as such, clients who access services through the clinic can be community members and it is not limited to providing services to solely university students. The primary researcher also provided therapeutic services to clients through the university psychology clinic. Similar to graduate student clinicians, various procedures were implemented in an effort to maintain client confidentiality and anonymity. Firstly, clients who were being provided services by the primary researcher at the time of the survey were not contacted to participate in the research study. Secondly, the clients who were invited to participate were not asked any identifying questions directly about their therapy (i.e., diagnosis, treatment goals, etc.). Thirdly, any identifying information that would have been collected would 41 have been removed by the RA before the primary researcher accessed the data, similar to the procedures outlined for clinicians. Lastly, it was directly stated to clients in the research consent form that their participation in the research study would not in any way impact their ongoing therapy with their clinician. The outlined procedures were approved the by research ethics board of the University of British Columbia (Okanagan), the clinic director, and clinic administrative staff. Given the brevity of the survey, the design and flow of the questionnaires are illustrated through the following sections (i.e., demographics, disclosures, deception questionnaire). 2.3.1 Demographics 2.3.1.1 Methods Clients were first prompted to provide general demographic information, including their age, gender identity, and cultural identity. Similar to the graduate student clinician survey, the initial study was originally proposed to collect data from other university psychology clinics, and as such aggregated data from various institutions would have provided anonymity for the research participants. However, since the data was collected from a single clinic, this data was removed by the RA in an effort to maintain participant confidentiality and anonymity. Therefore, general demographic data for clients who accessed the clinic were not available at the time of this manuscript. 2.3.1.2 Results Seven clients completed the client survey. As noted, demographics were not analyzed in an effort to maintain client confidentiality and anonymity. Furthermore, due to the small sample size, inferential statistics could not be completed, and the data presented in the subsequent sections is solely descriptive. 2.3.2 Disclosures Questionnaire 42 2.3.2.1 Methods Clients were asked about their comfort disclosing information in VCP as compared to FtF therapy (See Appendix G). Similar to clinicians, clients were asked about their comfort disclosing information utilizing both Likert scale response options and open-format response prompts. Clients were not asked about disclosing information in a recent (or any) therapy session and were rather queried about their general comfort disclosing information in a therapeutic context across communication modalities. 2.3.2.2 Results Table 4 provides an overview of clients’ comfort disclosing information across communication mediums in both everyday conversations and therapeutic settings. Qualitative analysis of clients’ responses revealed three themes: preference for face-to-face, advantages of videoconferencing, and having similar comfort across communication mediums (See Figure 3). Three clients indicated that their comfort disclosing information was the same across communication mediums. There were two clients who advised that they felt more comfortable in FtF therapy disclosing information, both of whom attributed the increased comfort in FtF therapy to the increased non-verbal cues of the therapist that they can rely upon in order to moderate their response to the therapist’s reactions. For example, one client reported that “I feel slightly more comfortable disclosing information in a face-to-face therapy session due to physical proximity to the service provider. I feel that I can see the entirety of their person, read their body language better, see if they are gesticulating, holding tension, etc.” Lastly, one client endorsed feeling more comfortable disclosing information in VCP and stated that “in-person communication is not fun…sensory issues are huge [and] I have anxiety and panic…through video is so much easier and I have control.” 43 Table 4 Clients’ Comfort Disclosing Across Contexts and Communication Mediums Context Face-to-Face Videoconferencing M SD M SD Everyday Conversation 3.57 1.13 3.28 0.95 Therapy 3.71 1.89 3.28 0.95 Note. Client responses were on a 5-point Likert scale with higher scores indicating increased comfort in disclosing information. 44 Figure 3 Themes from the Qualitative Analysis that Clients Reported about Their Comfort Disclosing Information Across Communication Mediums in Therapy Note. The first level is the topic that participants were asked to discuss. The second level is the themes that were identified in relation to the topic. The third level includes select example quotes that are most representative of the theme. It should be noted that the total accumulates to six in the above figure as one participant did not complete the related question but completed the remaining survey. Clients' Comfort Dislcosing Information in Therapy Across Communication MediumsComparable Across Communication Mediums(n = 3)"Same."FtF Preference (n = 2)"I feel slightly more comfortable disclosing information in a face-to-face therapy session due to physical proximity to the service provider."VCP Preference (n = 1)"In person communication is not fun... through video is so much easier and I have control." 45 2.3.3 Deception Questionnaire 2.3.3.1 Methods Clients were asked to provide an estimate about how many lies they would be inclined to tell in both a VCP and FtF therapy session (See Appendix H). Subsequently, they were asked about their perceived believability when providing inaccurate information across communication modalities. Lastly, clients were given open-format prompts to provide their insights and elaborate on the potential reasons why they would provide untruthful information in a therapy session across communication mediums. Similar to above, clients were not asked to provide information about a specific instance during which they provided inaccurate information to their therapist. 2.3.3.2 Results Clients were first asked if they have ever provided untruthful information to their therapist in FtF therapy, to which three clients reported providing untruthful information, while three endorsed not lying to their therapist (one indicated that they have not had FtF therapy). Interestingly, five clients reported lying to their therapist in VCP, as compared to two who advised that they have not lied to their therapist in VCP (See Table 5). When provided an open format response, three clients advised that they would be more likely to lie in VCP as compared to FtF therapy in the future. One client went on to state that “I would be slightly more comfortable on video due to the perceived distance between myself and the therapist and the fact that I can physically hide things off camera.” Another client commented that “it would probably be easier to lie on a video call because it's harder to read people over video.” The remaining four clients stated that they were uncertain as to whether they would be inclined to tell more untruthful information in VCP or FtF therapy in future sessions. 46 Table 5 Deception Frequency Reported by Clients Across Communication Contexts and Mediums Context Face-to-Face Videoconferencing Absolute Mean Difference M SD M SD Likert Scale Frequency Everyday Conversation 2.14 0.69 2.14 0.69 0.00 Therapy 1.33 0.58 2.25 0.50 0.92 Reported Estimates Everyday Conversation 0.75 1.13 0.75 0.95 0.00 Therapy 0.00 0.00 0.00 0.00 0.00 Believability Ratings Everyday Conversation 3.43 1.99 4.57 0.98 1.14 Therapy 3.00 1.41 4.75 0.96 1.75 Note. ‘Likert Scale Frequency’ ratings were on a 7-point Likert scale with higher scores indicating increased frequency. ‘Reported Estimates’ are percentage ratings out of a possible 100%. ‘Believability Ratings’ were rated on a 5-point Likert scale with higher scores indicating increased believability. 47 In terms of believability, Table 5 highlights the perceived believability ratings clients endorsed across communication mediums and contexts. Although inferential statistics cannot be conducted, it should be noted that there is a 1.75 Likert point difference between believability ratings in FtF therapy and VCP (with VCP having the higher believability rating). Clients were also asked an open-ended question eliciting their perspectives of their believability across communication mediums, which revealed that all seven clients solely reported being more believable in VCP. Specifically, clients cited finding it easier to manage their emotional responses in VCP as compared to FtF, which would allow them to be more believable. For instance, one client stated that “having the other person in the room influences my feelings and would increase my caution to tell a lie when I feel like I am not a good liar,” while another client commented that “through video I can control my anxiety through my environment.” Another client elaborated that “I believe I would be much more believable over videoconferencing…I am a very poor liar and lying elicits feelings of guilt and shame that come out in my physical behaviour.” One client also noted that VCP allows for a decrease in the number of non-verbal cues that psychologists/clinicians can perceive, and they would therefore be more believable in VCP as compared to FtF therapy. In sum, clients reported that they perceive themselves as more believable in VCP, and mainly attributed this to finding it easier to manage their emotional responses in VCP, as well as the perceived decrease in the number of non-verbal cues that clinicians would be able to discern. The perceived believability may also be dependent upon the reasons for providing untruthful information in therapy. Clients were prompted to elaborate upon the reasons why they would be inclined to provide untruthful information in VCP and FtF therapy. Three primary themes arose for potentially being deceptive in FtF therapy: therapy logistics, therapeutic process, and would not 48 lie (See Figure 4). Two clients endorsed the therapeutic process theme for providing untruthful information in FtF therapy. For example, one client reported that they would be inclined to lie “if I felt unheard and it invalidated [me], then I would just pretend everything is okay.” Another client indicated that they would be deceitful in FtF therapy if “I am asked a question I am not ready to talk about and preferred to omit the information in the session rather than establish a boundary, explain why, and then have to experience the full weight of accountability for my choice (exhausting).” Regarding the therapy logistics theme (n = 1), one client commented that they would provide untruthful information “if it was late [I would lie about] what the reason would be.” Lastly, one client advised that they would not be inclined to lie in FtF therapy (n = 1). In sum, clients reported that they would be inclined to lie in FtF therapy due to therapy logistics (i.e., being late), therapeutic process (i.e., invalidation, not feeling comfortable), or would not lie in FtF therapy. Similar to above, three primary themes were elucidated for lying in VCP and included therapy logistics, therapeutic process, and would not lie (See Figure 2). It should be noted that these were the same themes that were endorsed for the above-mentioned analysis reviewing clients’ reasons for lying in FtF therapy. For therapy logistics (n = 2), clients continued to report wanting to lie about the reason for being late for their VCP session, while one client elaborated that “the only times I have ever lied in videoconferencing therapy are when I am late and am ashamed of the reason and instead try to make it look like it was not my fault.” Another client indicated that they would lie in VCP when they “had said I would not do [something] in my last session and I had done it. I might be inclined to hide physical evidence or else say I did not do it.” Two clients endorsed lying about themes related to the therapeutic process (n = 2), such as lying when they “felt ashamed about something” or if “[they] felt that the therapist was not a 49 Figure 4 Themes from the Qualitative Analysis that Clients Reported About the Reasons Why They Would Provide Untruthful Information in Therapy Note. The first level is the topic that participants were asked to discuss. The second level is the themes that were identified in relation to the topic. The third level includes select example quotes that are most representative of the theme. Levels are color-coded to indicate similar themes. Reasons Provided by Clients for Providing Untruthful Information in TherapyFtF TherapyTherapy Logistics (n = 1)"If it was late [I would lie about] what the reason would be."Therapeutic Process (n = 2)"If I felt unheard and it invalidated [me], than I would just pretend everything is okay."Would not Lie (n = 1)"I wouldn't lie in therapy."VCPTherapy Logistics (n = 2)"...when I am late and am ashamed of the reason and instead try to make it look like it was not my fault."Therapeutic Process (n = 2)"[I] felt that the therapist was not a good match or didn’t understand [me]."Would not Lie (n = 1)"I would not lie in therapy." 50 good match or didn’t understand [them].” One client reiterated that they would not lie in VCP. In general, the themes related to lying in FtF therapy and VCP were similar, although themes of feeling ashamed and lying about why they were late for their session were more readily highlighted in VCP as compared to FtF therapy. 51 Chapter 3: Study Two – Methods and Results The objective of study two was to garner registered psychologists’ experiences with FtF therapy, VCP, and phone therapy, specifically their perceptions of their clinical competencies across communication modalities. Similar to study one, a mixed methods approach was utilized in an effort to provide opportunities for direct quantitative comparisons, while also eliciting detailed information about registered psychologists’ experiences when providing therapy across communication modalities. As such, registered psychologists were asked a series of Likert Scale and open-format response questions about the identified domains. This included questions about the frequency of VCP before and after the COVID-19 pandemic, current proportion of VCP as compared to FtF therapy sessions, their preferred communication modality, and their comfortability with using videoconferencing for psychological services. Psychologists were also prompted to provide their perceptions of mental health applications (e.g., BetterHelp). There were also queries and prompts eliciting information about their clinical skills across communication modalities, experiences during FtF therapy and VCP, perceptions of clients’ comfort disclosing information, and perceptions of clients providing untruthful information in therapy. Lastly, an additional component of study two (as compared to study one) included asking participants to engage in a credibility assessment task in an effort to consider therapists’ ability to detect deceit in a mock VCP setting. The credibility assessment task was included within the present survey in an effort to frame it as a clinical competency, in line with the other assessed clinical competencies. It was also included in the same survey to decrease the frequency at which therapists receive requests to engage in survey-based research given the potential survey fatigue (de Koning et al., 2022) that they may have been experiencing. 3.1 Recruitment 52 Participants for study two included registered psychologists who practiced in North America (i.e., Canada, United States of America). Participants were recruited through two data collection approaches. The first recruitment approach included contacting registered psychologists indirectly by contacting psychological organizations (e.g., Canadian Psychological Association) to distribute the survey via social media, online advertisements, and email. Within this method, the primary researchers did not directly contact psychologists, but rather they contacted various organizations and governing bodies who distributed the survey to individuals on an email list, or through their social media platforms.1 Approximately 98 organizations were contacted to distribute the survey, of which 18 distributed the survey (two organizations distributed the survey on two occasions). Following the first recruitment approach, it was recognized that an increased sample size was required in order to effectively conduct the proposed analyses. An additional round of recruitment was therefore implemented using a secondary method, which was to contact psychologists directly. The primary researcher collated psychologists’ emails that were publicly available through the College of Psychologists for various jurisdictions across North America. The psychologists were then contacted from a non-identifying email address and invited to participate in the survey. All research participants during both recruitment approaches were given the opportunity to provide their email to be entered into a draw for a $100 Amazon gift card once they completed the survey. 3.2 Analyses Procedure 1 Thank-you to the organizations who distributed the survey, which included: Canadian Psychologist Association, College of Psychologist of British Columbia, Health Registrar, California Psychological Association, Canadian Counselling and Psychotherapy Association, Alberta Psychologist Association, Psychology Association of Saskatchewan, Manitoba Psychological Society, Association of Psychology of Newfoundland, College of Psychologists of New Brunswick, American Psychology and Law Society, Association of Psychologists of Nova Scotia, Association of Black Psychologists, New Hampshire Psychological Association, Oklahoma Psychological Association, Alaska Psychological Association, District of Columbia Psychological Association, Iowa Psychological Association, Wyoming Psychological Association. 53 As discussed, the present series of studies adopted a mixed-methods approach in an effort to provide opportunities for direct quantitative comparisons, while also eliciting detailed information about therapists’ and clients’ experiences with therapy across communication modalities (e.g., Dawadi et al., 2021). In particular, there was minimal prior research for some of the identified research questions/topics, to which qualitative analysis was uniquely suited to address these areas given the minimal previous research to formulate quantitative hypotheses. Therefore, separate analytical approaches were implemented for study two, which was dependent on the type of data collected (i.e., qualitative, quantitative), the specific research question, and the available sample size to conduct such analyses. On average, it took approximately 35 minutes for clients to complete the survey. 3.2.1 Quantitative Analysis The primary inferential statistics that were conducted for study two included paired-samples and one-sample t-tests, which fluctuated depending on the sampling method and research question. It should be noted that in some cases, additional Bayesian analyses were conducted in an effort to increase confidence if there were (or were not) statistically significant differences, particularly with regard to the credibility assessment task. Indeed, Bayesian analysis allows researchers to identify the level of confidence that a particular effect is within a specified interval (Wagenmakers et al., 2017). Lastly, a within-subjects Analysis of Variance (ANOVA) was utilized to compare Section J and Section M responses for registered psychologists across communication modalities given the three levels of communication (i.e., FtF therapy, VCP, phone therapy). 3.2.2 Qualitative Analysis 54 The qualitative analyses followed the same procedures as outlined in Section 2.1.3. Briefly, qualitative analysis utilized a phenomenological approach in which participants’ descriptions of their experiences and their responses were analyzed through reflexive and inductive thematic analysis (Braun & Clarke, 2019; Braun et al., 2014). As such, themes were developed, and were reflective of, the content of the qualitative data which is in line with an inductive approach. Themes and subthemes were then identified by reviewing the data and looking for similar responses that corresponded to an overarching category. A theme was defined as either an implicit or explicit topic that catalogues similar ideas and concepts into a broader idea/topic (Ryan et al., 2003; Vaismoradi et al., 2016). Quotes were selected that best represent the identified theme. A count of how often each theme arose across participant responses was conducted to determine the prevalence of the identified themes. Similar to study one, participants were given an opportunity to provide feedback on the validity of the questions in addressing their experiences with VCP. However, it should be noted that no feedback was provided by participants. Similar to study one, the methods and results for each questionnaire for study two are presented sequentially in an effort to ensure that the reader can readily recall, as well as easily reference, the adopted method for each discussed result. 3.3 Participants There were 94 participants who initially began the survey. However, the completion rates for 67 participants were below 5% and as such they were removed from data analysis. The final sample of participants included those who completed 90%-100% of the survey, resulting in 27 participants. In order to detect medium effect sizes (i.e., Cohen’s D of approximately .50) for the proposed analyses (i.e., paired and one-samples t-tests) a sample size of approximately 30-40 55 clients was required. As such, the current sample size is approaching (but not within the ideal range) of an adequate sample size. In some cases, and as discussed, additional Bayesian analyses were conducted in order to increase confidence about the effects. 3.4 Demographics & Therapy Experience 3.4.1 Methods Psychologists were first requested to provide general demographic information, including their age, gender identity, and cultural identity. Participants were also asked to provide information about their current therapeutic practice (See Appendix J). This included being asked about their therapeutic orientation, as well as their primary practice setting (i.e., private practice, health authority, etc.). 3.4.2 Demographic Results The average age of participants was 41.36 (SD = 13.74), ranging from 27 to 76 years. 17 females and 10 males were included in the study. There were 11 participants who identified the United States of America as their country of origin, while 12 identified Canada. The remaining participants indicated that their country of origin was Turkey (n = 2) and Sudan (n = 2). 3.4.3 Therapy Experience Results On average, psychologists had approximately 10.18 years (SD = 10.52) of experience providing therapeutic services, ranging from approximately 0.1 years (i.e., ~ 1 month) to 40 years. The primary therapeutic modalities that psychologists endorsed adopting included Acceptance and Commitment Therapy (n = 2), Dialectical Behavioral Therapy (n = 7), Cognitive Behavioral Therapy (n = 5), Emotion-Focused Therapy (n = 4), Humanistic/Person-Centered Therapy (n = 3), Interpersonal Therapy (n= 2), Integrative Therapy (n = 1), and Psychodynamic Therapy (n = 1). As their secondary therapeutic modality, psychologists reported utilizing 56 Cognitive Behavioral Therapy (n = 5), Acceptance and Commitment Therapy (n = 10), Dialectical Behavior Therapy (n = 2), Emotion-Focused Therapy (n = 2), Humanistic/Person-centred Therapy (n = 3), Psychodynamic Therapy (n = 2), and Integrative Therapy (n = 1). Psychologists third therapeutic orientations included Acceptance and Commitment Therapy (n = 1), Cognitive Behavioral Therapy (n = 3), Dialectical Behavior Therapy (n = 5), Emotion-Focused Therapy (n = 3), Humanistic/Person Centred Therapy (n = 6), Interpersonal Therapy (n = 4), and Integrative Therapy (n = 1). There were a handful of psychologists that indicated “Other” as a therapeutic modality, which when prompted to elaborate included Gestalt Therapy, Existential Therapy, and Eye Movement Desensitization (EMDR). In terms of therapeutic setting, private practice was the most commonly endorsed (n = 15), followed by community health authorities (n = 4), hospitals (n = 3), counselling centres (n = 2), and Veterans Affairs (n = 1). One psychologist reported providing services in “mixed” (i.e., multiple) settings. 3.5 Mental Health Applications 3.5.1 Methods Subsequent to completing the demographics and therapy experience questionnaire, psychologists were asked about their perceptions of the effectiveness of mental health applications. At the beginning of the mental health applications questionnaire, participants were provided a definition of mental health applications as well as some examples, which included both videoconferencing and text-based platforms. They were provided with open-format queries eliciting their general perceptions of these applications, in addition to their perceived effectiveness. 3.5.2 Results 57 There was a total of 16 psychologists who indicated that they were familiar with mental health applications, while 8 stated that they were not aware of mental health applications. Some psychologists stated that they had ‘heard of them’ (n = 7). For instance, one psychologist stated that “I have heard of them but have not used them” while another psychologist reported being “only minimally aware through people telling me about them or their experiences.” One psychologist advised that they refer clients to utilize these applications during their hospital discharge, while two other psychologists provided their own definition for mental health applications (i.e., “an application that offers therapeutic treatment”). Lastly, one psychologist indicated that they “worked on Better Help,” while two others stated that they had been approached by companies to provide therapeutic services through these applications/platforms. Psychologists were also prompted to provide their perceptions as to the advantages and disadvantages of mental health applications (See Figure 5). The primary advantage reported by psychologists was ‘access’ (n = 14). Indeed, various psychologists stated they increase “access for those who wouldn’t otherwise attend therapy.” The second most commonly reported advantages were ‘affordability’ (n = 3) and ‘convenience’ (n = 3; “access them when it is convenient to [the client’s] schedule and cut down on the travel”). Moreover, two psychologists indicated that mental health applications can reduce the amount of time that a client waits prior to engaging in mental health services (i.e., “it may allow patients to get appointments quicker”). Two psychologists also advised that they would utilize mental health applications to enhance therapeutic services that are already being provided as one stated mental health applications are “skills based,” while another mentioned that “I’ve used the applications above to support/supplement skills learned in therapy sessions. I have not used these as a replacement for therapy.” Interestingly, two psychologists indicated that mental health applications may provide 58 Figure 5 Themes from the Qualitative Analysis that Registered Psychologists Reported About the Advantages of Mental Health Applications Note. The first level is the topic that participants were asked to discuss. The second level is the themes that were identified in relation to the topic. The third level includes select example quotes that are most representative of the theme. Psychologist Reported Advantages of Mental Health ApplicationsAccess(n = 14)"Increaseaccess for those who wouldn’t otherwise attend therapy."Afford-ability (n = 3) "Its cheapter."Con-venience (n = 3)"Access them when it is convenient to [the client’s] schedule and cut down on the travel."Reduce Waittime (n = 2)"It may allow patients to get appoint-ments quicker."Enhance Services Already being Provided(n = 2)"I’ve used the applications above to support/supplement skills learned in therapy sessions."Crisis Interven-tion (n = 2)"It may help defuse a situation.” Destigma-tization (n = 2)"It is more reassuring and safer to help [clients] recover their mental health." Self-paced Services (n = 2)"Cients can self-pace their treatment." 59 “possible crisis intervention” or avenues to “defuse a situation.” Two psychologists stated that mental health applications may assist in destigmatizing mental health, with one specifically mentioning that “the advantage of mental health apps for potential clients is that it is more reassuring and safer to help [clients] recover their mental health step by step through a series of treatment programs.” Lastly, two psychologists noted that mental health applications allowed clients to “self-pace” their therapeutic experience and offered an opportunity for clients to direct the pace of treatment. In essence, the advantages of mental health applications included increasing accessibility, affordability, convenience, allowing clients to self-pace their treatment and decreasing the time clients are waiting for mental health services. Further, they are perceived as potentially enhancing therapeutic services that are already being accessed, allow for quicker access during crisis situations, and may aid in destigmatizing mental health. Psychologists endorsed four primary themes when asked to consider the potential disadvantages of mental health applications: ethical considerations, therapeutic process, rapport, and client considerations (See Figure 6). The most commonly reported theme was concerns about the ethics of providing therapy via mental health applications (n = 12). Psychologists broadly cited “ethical concerns,” while others highlighted more specific considerations. For instance, some psychologists endorsed being concerned about confidentiality (n = 5), stating that “I think the downside of mental health apps for potential customers is the risk of information leakage” and “[some mental health apps] recently broke laws pertaining to HIPAA and selling [personal health information].” Additional ethical concerns that psychologists reported included being concerned that mental health professionals might be practicing outside of their scope of practice and/or will not have the necessary qualifications in order to provide adequate care (n = 3). For example, some psychologists stated that they were “not sure about qualifications” and 60 Figure 6 Themes from the Qualitative Analysis that Registered Psychologists Reported About the Disadvantages of Mental Health Applications Note. The first level is the topic that participants were asked to discuss. The second level is the themes that were identified in relation to the topic. The third level includes select example quotes that are most representative of the theme. Psychologist Reported Disadvantages of Mental Health ApplicationsEthics (n = 12)"I think the downside of mental health apps for potential customers is the risk of information leakage.""There is minimal account-ability."Therapeutic Process (n = 10)"Lack of evidence based practice.""The therapeutic relationship is missing (and is pretty crucial).”Client Considerations (n = 10)"Clients’ ability to benefit from these depend on several factors (i.e., cognitive ability, motivation, account-ability).” "24/7 texting support is not helpful for all client presentations." 61 that “there is minimal accountability.” Further ethical considerations reported by psychologists also included “poor boundaries” (n = 1), specifically commenting that “risk can’t be managed” (n = 1) and stating that they believe they would not be able to address all of a client’s symptoms, such as “dissociative or manic episodes” (n = 1). The second most commonly reported disadvantage of mental health applications was concerns about the therapeutic process (n = 10). Generally, psychologists expressed concern about whether mental health applications provided evidence-based care (n = 4), commenting that there is a “lack of evidence-based practice” and that there might be instances when “clients [are] believing they're getting a full 'dose' of therapy when they may not be.” One psychologist highlighted that mental health applications “reduces therapy to a skill set to be learned,” while another participant noted that there is less opportunity to effectively track client progress. Interestingly, one psychologist also indicated that there are “possible misunderstandings over text” that would negatively impact the therapeutic process. The therapeutic process also related to the third most commonly reported theme of perceived disadvantages, which were concerns about fostering rapport through mental health applications (n = 5). In fact, one psychologist stated that “the therapeutic relationship is missing (and is pretty crucial)” while another stated “possibly less openness given the different therapeutic relationship.” Another elaborated that “I believe that the therapy relationship is the main healing agent - so these apps fly in the face of my training and experience of what heals/works.” The last concern that psychologists reported as a disadvantage for mental health applications was regarding client considerations. For instance, one psychologist stated that “24/7 texting support isn’t helpful for all presentations” while another commented that “for clients who 62 suffer from anxiety disorders, they may use the applications as a way to avoid public settings or socializing.” Moreover, another psychologist stated that “[mental health applications] are not always an adequate substitute for face-to-face therapy. Clients’ ability to benefit from these depend on several factors (i.e., cognitive ability, motivation, accountability).” Another psychologist noted that mental health applications have a “generic application of manualized interventions” that does not allow for individualized treatment. It was further mentioned that “I also think that overreliance on phones and social media has resulted in worse interpersonal skills and more symptomatology so I'm not a fan of using those same things to try to solve the problems being caused by the addiction to these devices.” In essence, the disadvantages that psychologists highlighted surrounding mental health applications included ethical concerns, mental health applications’ impact on the therapeutic process and rapport and highlighted the need to consider unique aspects of the client when reflecting on whether mental health applications would be appropriate for particular client presentations. Psychologists were asked to provide their overall opinion as to the effectiveness of mental health applications, which included themes of them being effective, considering them to not be effective, skepticism of their effectiveness, and client-centred approaches (See Figure 7). Psychologists most commonly endorsed that mental health applications are effective (n = 7), stating that “they can be very effective” and “its better than nothing and requires clients’ initiations.” In terms of addressing barriers to accessing treatment, one participant commented that mental health applications offer “at least some outlet (possibly a first step) towards using professional services.” The second reported theme was being skeptical or unsure about mental health applications’ effectiveness (n = 5) as it was occasionally stated that “I believe these can be somewhat effective but dubious pay standards and general business practices give me significant 63 Figure 7 Themes from the Qualitative Analysis that Registered Psychologists Reported About the Perceived Effectiveness of Mental Health Applications Note. The first level is the topic that participants were asked to discuss. The second level is the themes that were identified in relation to the topic. The third level includes select example quotes that are most representative of the theme. Psychologists' Perceived Effectiveness of Mental Health ApplicationsEffective(n = 7)"They can be very effective.""At least some outlet (possibly a first step) towards using professional services."Not Being Effective (n = 3)"I think they are severely limited and run a risk of being dangerous for higher risk clients."Skepticism About Effectiveness (n = 5)"I believe these can be somewhat effective but dubious pay standards and general business practices give me significant pause in recommending that anyone use them."Client Centered Approach(n = 2)“I think it depends on the person.” 64 pause in recommending that anyone use them.” Further, three psychologists commented that they did not have enough of an understanding/awareness of the evidence-based literature in order to make an informed decision. In terms of the third most common theme, there were statements indicating that some psychologists did not perceive mental health applications as being effective (n = 3). This included statements such as “I doubt the efficiency of long-term support” and “I think they are severely limited and run a risk of being dangerous for higher risk clients.” Lastly, two psychologists also reported that the effectiveness of mental health applications would likely be dependent upon client considerations (i.e., “I think it depends on the person”). In general, psychologists endorsed themes of mental health applications being effective, citing a lack of literature and familiarity with the applications, stating that they are not effective, and/or advising that client characteristics are more relevant as compared to the communication medium. 3.6 Videoconferencing Psychotherapy Experiences 3.6.1 Methods Following general demographics and their perceptions of mental health applications, psychologists were asked broadly about their experiences with VCP (See Appendix J). Within this section, psychologists were first asked to provide an indication as to the rates of VCP that they offered before and following the COVID pandemic, the amount of training they received with regard to VCP, their preferred communication medium, and their comfort with providing VCP. Participants were also asked about various levels of fatigue that they experienced following both FtF therapy and VCP, and the level of effort they felt they required to effectively engage in VCP (when compared to FtF therapy). In line with the mixed-methods approach, questions about VCP included quantitative (i.e., Likert scale response options) and qualitative (i.e., open-format response prompts) questions. 65 3.6.2 Results There were approximately 21 psychologists who did not provide VCP prior to the COVID-19 pandemic. Psychologists reported that on average 5.0% of their therapeutic services were offered virtually before the pandemic, ranging from 0% (most commonly endorsed percentage) to 50.00%. After the COVID-19 pandemic was declared by the WHO, psychologists indicated that approximately 68.00% of their therapeutic services were offered virtually (Range = 2.00% - 100.00%). Only one psychologist reported a decrease in VCP services that were offered before and after the pandemic, which reportedly decreased from 70% to 60%. The majority of psychologists (n = 25) indicated that the percentage of their therapeutic services that are offered virtually were anticipated to remain consistent, or even increase, as they continue to offer therapeutic services. Two psychologists indicated that they would likely decrease the percentage of virtual services that they provide. With regard to psychologists’ preferred communication medium, six psychologists indicated that combined/hybrid practice is their preference, seven noted that FtF is their preference, while 12 reported that VCP is their preferred medium. Psychologists on average reported feeling “very comfortable” with utilizing VCP given an average response of 4.36 (SD = 1.22) on a 5-point Likert scale ranging from 1 (“very uncomfortable”) to 5 (“very comfortable”). Psychologists reported on average receiving approximately 63.16 hours (SD = 227.39) of training on VCP, ranging from 0 hours to 1000 hours (Mdn = 5). The most common forms of training reported by psychologists were online workshops and/or webinars (n = 8), continuing education courses (n = 4), job site training (n = 3), and supervised practice (n = 1). One participant reported receiving training in their graduate school program, while another advised that they were trained in interpersonal skills for VCP. Four psychologists reported receiving no 66 Table 6 Descriptive and Inferential Results for Fatigue and Effort Across Communication Mediums Variable Face-to-Face Therapy VCP Absolute Mean Difference Wilcox Ranked Sum Degrees of Freedom p d M SD M SD Fatigue General Fatigue 2.52 1.19 2.64 1.29 0.12 W = 67.5 26 .68 .097 [-0.65, 0.46] Male 2.25 1.15 3.40 1.46 1.15 Female 2.84 0.93 2.20 1.21 0.64 Emotional Fatigue 2.60 1.22 2.40 1.00 0.20 W = 45.0 25 .66 .18 [-0.38, 0.46] Male 2.90 2.16 2.45 0.80 0.45 Female 2.72 1.07 2.40 1.03 0.32 Mental Fatigue 2.48 1.12 2.58 1.14 0.10 W = 32.0 26 .59 .00 [-0.57, 57] Male 3.00 2.21 2.65 1.80 0.35 Female 2.54 0.88 2.43 1.26 0.09 Effort General Effort 4.79 1.21 4.76 1.54 0.03 W = 36.0 26 .81 .002 [-0.54, 0.57] Male 4.70 2.57 3.90 2.81 0.80 Female 4.43 0.82 4.54 1.08 0.90 Note. Measures of general, emotional, mental fatigue, and effort were significantly different from normal utilizing the Shapiro-Wilk Test. As such, Wilcoxon Ranked Sum Tests were utilized as non-parametric alternatives. 67 formalized training for delivering VCP. Psychologists were also asked to rate and compare their levels of fatigue (general, emotional, mental) and effort across both FtF therapy and VCP. Table 6 provides the descriptive statistics for the levels of fatigue and effort across communication mediums. A review of the data utilizing the Shapiro-Wilk test indicated that ratings of fatigue (i.e., general, emotional, mental) and effort were significantly different from normal. As such, Wilcox Ranked Sum tests were utilized to compare the levels of general, emotional, and mental fatigue across the communication mediums. All pair-wise comparisons of fatigue were not significantly different. A qualitative analysis was also conducted to provide insight into the potential differences in general, emotional, and mental fatigue experienced across communication modalities (See Figure 8). For general fatigue, there were 10 participants who endorsed experiencing more fatigue in FtF therapy as compared to VCP. One psychologist went on to state that FtF therapy has increased general fatigue as psychologists “have to be ‘on’ more with face-to-face, in less comfortable clothing and shoes,” while another stated that there are “more non-verbal behaviours to be mindful of (sitting position, outfit choices, etc.).” Seven participants stated that the levels of general fatigue were “similar” across communication mediums. There were four participants who stated that they experienced increased fatigue in VCP, while one psychologist in particular noted that “although you may feel tired after using video conferencing psychotherapy, you can relieve the fatigue through activities or exercises.” Lastly, one psychologist stated that the levels of general fatigue vary depending on the session itself, with one psychologist stating that “usually my fatigue is tied to the dynamics of the session so it's hard to say.” 68 With regard to emotional fatigue, there were four primary themes that arose: more emotional fatigue in VCP, more emotional fatigue in FtF therapy, equal levels of emotional fatigue, and client/session dependency. There were 10 psychologists who stated that the levels of emotional fatigue were comparable across communication mediums. Four psychologists commented that there were increased levels of emotional fatigue in VCP, with some stating that “video therapy is more tiring than surface therapy.” There were four psychologists who endorsed experiencing elevated levels of emotional fatigue in FtF therapy, with one elaborating that “I find teletherapy easier to manage emotionally and thus less emotional fatigue. Also oddly I find not needing to make small talk when walking back to my office for in-person visits very relieving, I didn’t realize how much that took out of me emotionally.” Lastly, there were two participants who mentioned that the levels of emotional fatigue are dependent on the client/session themselves and clarified that it “depends more on nature of patient's problems than modality of services.” Four themes similarly arose for levels of mental fatigue, which included more mental fatigue in VCP, more mental fatigue in FtF therapy, equal levels of mental fatigue, and client/session dependency. There were nine psychologists who stated that they experienced the “same” level of mental fatigue across communication modalities. Four psychologists commented that they experienced higher levels of mental fatigue in VCP. One psychologist attributed the increased mental fatigue to the “technical difficulties with virtual services [that] can be frustrating.” Two psychologists endorsed having higher levels of fatigue for FtF therapy, while one elaborated that there is “more to think about (i.e. managing nonverbal behaviours).” Lastly, two psychologists reiterated that the levels of mental fatigue “depends on the client.” 3.7 Trainee Current Progress Report (TCPR) 3.7.1 Methods 1 Figure 8 Themes from the Qualitative Analysis that Psychologists Reported Regarding the Level of Fatigue Across Communication Mediums Note. The first level is the topic that participants were asked to discuss. The second level is the themes that were identified in relation to the topic. The third level includes select example quotes that are most representative of the theme. Levels are color-coded to indicate similar themes across the types of fatigue.General FatigueLevel of Fatigue is Equal (n = 7)"They are similar."Higher Levels of Fatigue in VCP (n = 4)"Although you may feel tired after using video confereing, you can relieve the fatigue through activities or exercises."Higher Levels of Fatigue in FtF therapy (n = 10)"Have to be ‘on’ more with face-to-face."Client Dependent (n = 2)"Usually my fatigue is tied to the dynamics of the session so it's hard to say."Mental FatigueLevels of Mental Fatigue Equal (n = 9)"Same."High Levels of Mental Fatigue in VCP (n = 4)"Technical difficulties with virtual services [that] can be frustrating."Higher Levels of MEntal Fatigue in FtF therapy (n = 2)“More to think about (i.e. managing non-verbals).” Client Dependent (n = 2)"Depends on the client."Emotinoal FatigueLevels of Emotional Fatigue Equal (n = 10)"Same."Higher Levels of Emotioal Fatigue in FtF Thearpy(n = 4) "I find not needing to make small talk when walking back to my office for in person visits relieving."Higher Levels of Emotional Fatigue in VCP(n = 4)"Video therapy is more tiring than surface therapy."Client Dependent (n = 2)"Depend more on nature of patient's problems than modality of services." 1 The Trainee Current Progress Report (TCPR; Orlinsky et al., 20115) was also utilized to assess psychologists’ perspectives of their clinical competencies and therapy experience across communication modalities (See Section 2.1.1.3). Specifically, Section M (See Appendix C) and Section J (See Appendix D) were similarly utilized for study two. Psychologists were asked to respond to questions from Section J and Section M regarding FtF therapy, VCP, and phone therapy. 3.7.2 Section M of the TCPR Results Section M of the TCPR was utilized to compare psychologists’ experiences of therapy across communication modalities. Section M demonstrated excellent reliability for FtF therapy (a = .95) and acceptable reliability for VCP (a = .73). Table 7 provides an overview of the descriptive statistics and comparative analyses via paired samples t-tests. As seen in Table 7, there was a significant difference in levels of boredom, drowsiness, and inattention across communication mediums. A paired samples t-test revealed that there were significantly higher levels of boredom in VCP (M = 4.00, SD =2.30) as compared to FtF therapy (M = 2.45, SD = 1.64), t (1, 26) = -2.69, p < .05, d = .71 [-1.33, -0.09]. Psychologists similarly reported significantly higher levels of feeling drowsy in VCP (M = 3.77, SD = 2.61) as compared to FtF therapy (M = 2.40, SD =1.91), t (1, 26) = -2.75, p < .05, d = .65 [1.26, 0.03]. Lastly, there was also a significantly higher rate of feeling inattentive in VCP (M = 3.30, SD = 2.50) as compared to FtF therapy (M = 2.10, SD = 1.19), t (1, 26) = -2.89, p < .01, d = .71 [-1.32, -0.09]. 3.7.3 Section J of the TCPR Results Psychologists were also asked to complete Section J of the TCPR (Orlinsky et al., 2015), which asks a series of questions focused on clinical competencies, for each communication medium. Section J demonstrates excellent reliability for FtF therapy (a = .91), VCP (a = .97), 71 Table 7 Comparison of Psychologists’ Experiences Across Communication Modalities Variable Face-to-face therapy VCP t p d Absolute Mean Difference M SD M SD Bored 2.45 1.64 4.00 2.30 -2.69 .014 -.71 [-1.33, -0.09] 1.55 Drowsy 2.40 1.91 3.78 2.61 -2.75 .012 .65 [1.26, 0.03] 1.38 Inattentive 2.10 1.19 3.30 2.50 -2.89 .0093 .71 [-1.32, -0.09] 1.20 Creative 5.15 2.56 6.21 2.28 -1.45 .16 .46 [-1.06, 0.15] 1.06 Calm 5.65 3.21 6.67 2.75 15.00 .21 .37 [0.97, 0.23] 1.02 Inspired 4.95 2.78 5.92 2.15 -1.17 .25 -.41 [-1.00, 0.19] 0.97 Pressured 2.50 1.69 3.43 1.90 -1.92 .10 -.43 [-1.03, 0.18] 0.93 Enthused 5.65 2.78 6.55 2.13 39a .67 .38 [-0.99, 0.23] 0.90 Engrossed 5.35 2.93 6.21 2.89 -0.82 .41 .30 [-0.90, 0.30] 0.86 Focused 6.55 2.85 7.17 2.23 42.5a .86 .26 [-0.85, 0.34] 0.62 Challenged 4.32 1.99 4.83 1.59 -1.29 .21 .25 [-0.85, 0.37] 0.51 Tense 2.95 1.19 3.43 1.35 -1.34 .20 -.31 [-0.91, 0.30] 0.48 Trapped 1.55 1.52 1.96 1.79 35a .77 -.22 [-0.82, 0.39[ 0.41 Relaxed 6.45 2.38 6.78 2.09 54a .57 -.15 [-0.75, 0.45] 0.33 Anxious 2.85 1.39 3.13 1.70 -0.15 .88 .17 [-0.77, 0.43] 0.28 Stimulated 5.65 3.07 5.92 2.28 47a .95 .11 [-0.70, 0.49] 0.27 Overwhelmed 2.75 1.95 3.00 1.66 55.5a .81 -.12 [-0.72, 0.48] 0.25 Note. a Indicates that the data was significantly not normal as indicated by a significant Shapiro Wilk test. The Wilcoxon Ranked Sum Test was utilized as a non-parametric alternative. * Indicates significance at the 0.05 level. The degrees of freedom (df) for each comparison were 2, 26. The variable domains are ordered from most to least absolute mean difference. 1 Table 8 Comparing Psychologists’ Perceptions of Clinical Skills Utilizing the TCPR Across Communication Modalities Variable FtF Therapy VCP Absolute Mean Difference Between VCP and FtF Therapy Phone Therapy Absolute Mean Difference Between VCP and FtF Therapy F p η2 M SD M SD M SD How effective are you at engaging clients in a working alliance? 7.97 2.05 7.79 1.74 0.18 6.13 2.44 1.84** 20.11* <.01* 0.11 [0.01, 1.00] How ‘natural’ (authentically personal) do you feel? 7.91 2.00 8.08 1.54 0.17 5.83 2.20 2.08** 18.65 <.01* 0.20 [0.07, 1.00] How much mastery do you have of the techniques and strategies involved in practicing therapy? 8.09 1.52 7.79 1.76 0.30 5.91 2.11 2.18** 12.78 <.01* 0.22 [0.08, 1.00] 73 Variable FtF Therapy VCP Absolute Mean Difference Between VCP and FtF Therapy Phone Therapy Absolute Mean Difference Between VCP and FtF Therapy F p η2 M SD M SD M SD How well do you understand the moment-by-moment process in sessions? 8.00 1.59 7.83 1.78 0.17 5.35 2.42 2.65** 16.58 <.01* 0.26 [0.11, 1.00] How effectively do you communicate your understanding and concern to clients? 8.09 1.18 7.96 1.45 0.13 6.04 2.33 2.05** 11.70 <.01* 0.21 [0.07, 1.00] How well are you able to detect and deal with the emotional reactions that your clients have towards you? 7.91 1.50 7.46 1.50 0.45 5.43 2.25** 2.25** 12.67 <.01* 0.24 [0.10, 1.00] 74 Variable FtF Therapy VCP Absolute Mean Difference Between VCP and FtF Therapy Phone Therapy Absolute Mean Difference Between VCP and FtF Therapy F p η2 M SD M SD M SD How good are you at making constructive use of your own personal reactions to clients? 7.78 1.42 7.46 1.67 0.32 5.43 2.21 2.35** 11.22 <.01* 0.22 [0.08, 1.00] How much precision, subtlety, and finesse have you attained in your therapeutic work? 7.65 1.43 7.71 1.87 0.06 5.58 2.17 2.07** 10.25 <.01* 0.23 [0.09, 1.00] How effective are you in helping your clients? 7.74 1.53 7.71 1.64 0.03 5.96 2.20 1.87** 5.80 <.01* 0.15 [0.03, 1.00] Note. a The data for these analyses violated the assumption of normality. As such, Friedman’s test was utilized as a non-parametric alternative and the Chi-Squared statistic is reported in the table. * Significant at the .01 level. ** Significant difference during follow-up analyses utilizing Tukey’s HSD. Degrees of freedom (2, 26). 1 and phone therapy (a = .98). Table 8 provides an overview of the descriptive statistics and the results from the one-way, within-subjects Analysis of Variance (ANOVA). Psychologists responded on a 10-point scale ranging from 0 (“not at all”) to 10 (“very much”), and as such higher scores indicated higher perceptions of clinical competencies. Post-hoc analyses were conducted utilizing Tukey’s HSD, which revealed that phone therapy was consistently and significantly rated lower at the p-value of .01 when compared to FtF therapy, whereas there were no significant differences between VCP and FtF therapy clinical competencies. 3.8 Psychologists’ Perceptions of Their Clinical Skills 3.8.1 Methods Psychologists were also prompted to describe their perceptions of their clinical competencies in response to open-format queries. This first included being prompted to provide an overview of their clinical competencies, broadly, in both VCP and phone therapy. Subsequently, they were asked to describe their perceptions of their clinical competencies in VCP and phone therapy when directly compared to FtF therapy. 3.8.2 Results Psychologists reported four general themes in terms of their perceptions of their clinical skills in VCP: being effective, adequate, client considerations/dependency, and not being effective in VCP (See Figure 9). 13 psychologists reported that their clinical skills were effective in VCP. For example, one psychologist stated that “based on verbal feedback from my clients they find treatment very effective” while the remainder of the psychologists reported simply “being effective.” In terms of the second theme, three psychologists stated that they felt as though their clinical skills were “adequate”, “okay,” or “passable” in VCP. For the client dependency theme, three psychologists stated that their clinical skills fluctuated depending upon the client 76 Figure 9 Themes from the Qualitative Analysis that Registered Psychologists Reported About their Perceptions of Their Clinical Skills in VCP Note. The first level is the topic that participants were asked to discuss. The second level is the themes that were identified in relation to the topic. The third level includes select example quotes that are most representative of the theme. Registered Psychologists' Perceptions of Their Clinical Skills in VCP When Compared to FtF TherapyEffective (n = 13)"Based on verbal feedback from my clients they find treatment very effective.” Clinical Skills are Adequate (n = 3)"Adequate...okay...passable."Client Dependency(n = 3)"I think I have become competent in more general work [in VCP] though I still do not prefer trauma work in this way.” Not Effective in VCP (n = 2)"I am not effective." 77 presentation with one clarifying that “I think I have become competent in more general work [in VCP] though I still do not prefer trauma work in this way.” Another psychologist elaborated that “I believe I am about 80-85% as effective using videoconferencing psychotherapy - and that drops to about 25-30% when it involves doing therapy with teenage adolescents who don't want to show their face on the camera and benefit from being in the room with me, doing art therapy, showing me things on their phone, or just sitting with me.” Lastly, two psychologists commented that their clinical skills in VCP were not effective. When qualitatively asked to compare their clinical skills directly across communication mediums, 16 psychologists stated that they were equally effective across communication mediums, while six endorsed being more effective in FtF therapy. Similar to above, two psychologists commented that the effectiveness of their clinical skills across communication mediums was dependent upon the client presentation and type of therapy being conducted. Specifically, they expressed that they found it particularly more challenging to conduct eye-movement desensitization in VCP as compared to FtF, while another reiterated that they found themselves less effective in VCP when providing therapy for adolescents. Psychologists were also asked to compare the perceived effectiveness of their clinical skills for phone therapy, which revealed three primary themes (See Figure 10). First, it was reported that they found therapy more challenging, and were not as effective, providing phone therapy due to a decrease in client non-verbal cues that could be relied upon (n = 8). For example, one psychologist stated that “you can't see the patient's expressions and body language” and another emphasized that “the visual aspects add incredibly important context.” Secondly, it was mentioned approximately 10 times that psychologists perceived their clinical skills to not be effective in phone therapy. Alternatively, three psychologists perceived their 78 Figure 10 Themes from the Qualitative Analysis that Registered Psychologists Reported About their Perceptions of Their Clinical Skills in Phone Therapy Note. The first level is the topic that participants were asked to discuss. The second level is the themes that were identified in relation to the topic. The third level includes select example quotes that are most representative of the theme. Registered Psychologists' Perceptions of Their Clinical Skills in Phone TherapyNot Effective Due to Lack of Non-verbal Cues(n = 8)"You can't see the patient's expressions and body language."Generally Not Effective(n = 10)"I'm not as effective."Effective in Phone Therapy(n = 3)"I am effective due to my training in providing services by phone." 79 clinical skills to be effective in phone therapy, and largely attributed this to “my training in providing services by phone.” Lastly, one description was provided that “I find that telephone sessions are useful in crisis management and reviewing the use of skills taught in therapy…I don't believe that I am effective in delivering EMDR or CBT on the telephone.” When psychologists were asked for their perspectives on their clinical skills in phone therapy when directly compared to FtF therapy, approximately 15 psychologists stated that they felt more competent in FtF therapy. Largely psychologists reiterated the lack of non-verbal cues as impacting their clinical skills in phone therapy, while others generally described feeling more competent in FtF therapy (i.e., “I feel more equipped to respond to client needs and challenges”). It was mentioned twice that psychologists felt more competent in both FtF and VCP therapy when compared to phone therapy, while two psychologists reported being equally effective in both phone and FtF therapy. 3.9 Disclosures 3.9.1 Methods Psychologists were asked about their perceptions of clients’ comfort in disclosing information across communication modalities within a therapeutic setting (See Appendix F). Consistently, a mixed-methods approach was utilized and as such psychologists were asked to both qualitatively and quantitatively rate their perceptions of client disclosures across communication mediums. 3.9.2 Results Table 9 provides an overview of the descriptions and associated inferential analysis (i.e., t-test, Wilcoxon Ranked Sum Test). A Wilcoxon Ranked Sum Test was utilized to compare psychologists’ perceptions of comfort in FtF therapy to VCP given that the data violated the 80 Table 9 Psychologists Perceptions of Clients’ Comfort Disclosing Information Conversation Face-to-Face Videoconferencing Absolute Mean Difference M SD M SD ‘Everyday’ Conversation 3.21 1.02 3.38 1.06 0.17 Therapy 3.48 1.12 3.71 0.98 0.23 assumption of normality. The results indicated that there were no significant differences between psychologists’ perceptions of clients’ comfort in FtF therapy (M = 3.48, SD = 1.12) and VCP (M = 3.72, SD = 0.98) for disclosing information, W (1, 24) = 41.00, p > .05, d = -0.25 [-0.81, 0.31]. The qualitative analysis considering psychologists’ perceptions of clients’ comfort disclosing information revealed four primary themes: more comfortable in FtF therapy, more comfortable in VCP, communication mediums are comparable, and client dependency (See Figure 11). There were seven psychologists who reported that clients’ comfort disclosing information across communication mediums was dependent upon client characteristics. For instance, one psychologist commented that “I think it depends on the client's personality, their readiness and openness to engage in therapy - less so for most clients about the medium” while another mentioned “this may be due to selection bias [but] the clients who do not like video conferencing do not select therapy in this way.” Another psychologist elaborated by stating that “it depends on the client…some are more revealing face-to-face, others are super revealing (maybe too revealing) on videoconferencing - like someone showing me their house or introducing all their pets or the family member walking behind them.” There were six psychologists who stated that they believed that their clients were more comfortable disclosing 81 Figure 11 Themes from the Qualitative Analysis that Registered Psychologists Reported About their Perceptions of Clients’ Comfort Disclosing Information Across Communication Mediums Note. The first level is the topic that participants were asked to discuss. The second level is the themes that were identified in relation to the topic. The third level includes select example quotes that are most representative of the theme. It should be noted that 8 psychologists endorsed confidentiality and maintaining a private space as being a primary concern for both FtF therapy and VCP across each of the aforementioned themes. Psychologists Perceptions of Clients’ Comfort Disclosing Information Across Communication Mediums in TherapyMore Comfortable in FtF Therapy(n = 6)"A client is likely to be more comfortable disclosing information in a face to face session because they have more nonverbal information regarding the therapist’s reaction than they have by video conference."More Comforatble in VCP(n = 6)"I've found this to be the greatest area of effectiveness, once a person finds a place that they are truly comfortable."Equal Comfort Across Communication Mediums (n = 5)"I think it is about the same."Client Depdency (n = 7)"I think it depends on the client's personality, their readiness and openness to engage in therapy - less so for most clients about the medium." 82 information in FtF therapy. For example, one psychologist stated “a client is likely to be more comfortable disclosing information in a fac- to-face session because they have more nonverbal information regarding the therapist’s reaction than they have by video conference. They may [also] not have the same level of privacy via video conferencing as in an office.” Five psychologists stated that they perceived clients’ comfort to be comparable across communication mediums by commenting that “I think it is about the same.” Regarding the last theme, there were indications by six psychologists who believed that their clients were more comfortable in VCP as compared to FtF. For example, one psychologist reported “I've found this to be the greatest area of effectiveness, once a person finds a place that they are truly comfortable.” Moreover, another psychologist mentioned that “if they have a secure, private place to speak where no one can hear them - I think they can be more candid.” Lastly, it should be noted that across each of the aforementioned themes, a theme of privacy was documented (n = 8) with various psychologists highlighting that FtF provides increased confidence that it is a confidential space, while also noting that clients can be more forthcoming in VCP if they feel that they are in a private and confidential space. Indeed, the context of disclosures also necessitates that the clinician potentially has to make a judgement as to the veracity of the information. 3.10 Deception Questionnaire 3.10.1 Methods Clinicians were prompted to complete a short questionnaire assessing their perceptions of clients providing untruthful information in therapy, and client believability across communication modalities (See Appendix E). Similarly, registered psychologists were not asked to consider their own client’s deceit nor make any credibility judgement related to the clients to whom they provide therapeutic services. Rather, they were asked to reflect upon client deception 83 more broadly and consider the potential frequency of, and confidence in detecting, deceit in a therapeutic setting. 3.10.2 Results In terms of familiarity with research on deception, on a 7-point Likert scale with higher scores indicating increased familiarity, psychologists indicated having average familiarity with the research on deception (M = 3.08, SD = 1.75, Range = 1 - 7). A comparison of confidence ratings (rated on a 7-point Likert scale with higher scores indicating higher confidence) in their ability to detect deceit in a therapeutic setting was not statistically significant across FtF therapy (M = 4.12, SD = 1.36) and VCP (M = 3.80, SD = 1.55), t (1, 26) = 1.06, p = .30, d = .22 [-0.34, 0.77]. In terms of the importance of detecting client deceit in therapy, on a 7-point Likert scale with higher scores indicating higher importance, there was no significant difference for FtF therapy importance (M = 3.92, SD = 1.5) as compared to VCP importance (M = 4.14, SD = 1.83), W (1, 25) = 1.50, p > .05, d = 0.11 [-0.75, 0.54]. Psychologists were also asked to rate their perceptions of the frequency to which clients might provide untruthful information in a therapeutic setting. Utilizing a 7-point Likert scale with higher scores indicating increased frequency, there were no significant differences in psychologists’ perception of deception frequency in FtF therapy (M = 3.55, SD = 0.83) and VCP (M = 3.32, SD = 0.80), W (1, 26) = 10.5, p = .59, d = 0.12. There was similar non-significance when psychologists were asked to indicate the percentage of time that they believed clients may be providing untruthful information in FtF therapy (M = 21.5%, SD = 31.46%, Range = 2% - 78%) and VCP (M = 26.16%, SD = 19.19%, Range = 2% - 50%), t (1, 26) = -0.75, p = .49, d = 0.20 [-0.36, 0.75]. It was reported that on average psychologists believed that there were 13.00 (SD = 25.72) lies told in FtF therapy, as compared to 9.94 (SD = 16.44) lies in VCP. Regarding 84 believability, which was rated on a 7-point Likert scale with higher scores indicating higher believability, psychologists did not report a significant difference between FtF therapy (M = 4.20, SD = 1.19) and VCP client believability (M = 2.44, SD = 2.17), W (1, 26) = 57.5, p = .13. 3.11 Credibility Assessment Task 3.11.1 Methods 3.11.1.1 Deception Stimuli Creation The deception stimuli were created by having undergraduate and graduate research assistants (i.e., the ‘client’) provide both truthful and deceptive responses to a set of eight questions (See Appendix I) that were selected from Aron et al. (1997). It should be noted that Aron et al. (1997)’s stimulus questions have been utilized in subsequent communication research (e.g., Sprecher, 2021). Two undergraduate and two graduate research assistants were selected given the availability of research assistants, those who were blind to the study questions and hypotheses, expressed interest in the study, and who would be convincing, as well as comfortable, playing the role of a ‘client.’ This included two male and two female ‘clients.’ The questions from Aron et al. (1997) were selected based on a) whether they would be questions potentially asked in a therapeutic setting, and b) whether an individual would be able to provide a deceptive response to the question(s). In an effort to increase ecological validity, the ‘clients’ were not provided with the questions prior to being recorded given that clients in a therapeutic setting would also not be provided with the set of questions prior to therapy. ‘Clients’ were notified during the creation of the stimuli that they did not have to respond to the question if they felt uncomfortable answering. However, all the ‘clients’ provided responses to each question. Although ‘clients’ were not provided with the questions beforehand, they were provided with a thorough explanation of the 85 procedure(s) of the study, and how the stimuli would be utilized in order to provide their informed consent for the recordings and use the recordings. In terms of veracity, ‘clients’ were asked to provide one truthful response and one complete fabrication (i.e., lie) in response to all eight of the questions. The order in which the responses to the questions were recorded was counter-balanced (i.e., ‘client’ one provided deceptive responses first, while ‘client’ two provided truthful responses first). An additional response was recorded to a ninth question (i.e., Complete this sentence “I wish I had someone with whom I could share…”), as this was utilized as the introduction task for participants to become familiar with the procedure (i.e., the outcome was not included in the analyses). As such, there was a total of 17 responses for each ‘client’ (i.e., eight truthful, eight deceptive, one control response). The undergraduate and graduate students were provided with the opportunity to debrief their responses with the primary researcher, given that they were asked to provide truthful information to some of the questions. They were also provided the opportunity to access support and mental health services through a third-party service if they so requested. However, it should be noted that all the ‘clients’ indicated that they were comfortable with the responses that were recorded and provided their verbal consent for registered psychologists to view the stimuli. The ‘client’ responses were recorded in a Zoom meeting. A neutral background (i.e., blank wall) was used during the stimuli recording, and each response ranged from approximately 45 seconds to 1 minute. The range for stimuli length was selected based on the length of stimuli used in prior deception research (e.g., McQuaid et al., 2016), as well as to minimize the survey length to maintain participant engagement. All responses were recorded in the same room with the same background. The primary researcher (who asked the stimuli questions) connected to Zoom from a separate room and utilized the same room for each of the recordings. As discussed, 86 a total of four ‘clients’ were recorded (two male, two female). It should be noted that one participant required one response to be re-recorded due to an intermittent internet connection, which impacted the quality of the recording. However, the secondary recording did not have any interruptions in the recording. All ‘clients’ utilized computers that had 720p webcam camera recording equipment, which resulted in high-quality stimuli. Each recording session to record all the responses was approximately 45 to 60 minutes, which was dependent upon the response length provided by the ‘clients.’ As discussed, ‘clients’ were asked to provide a complete fabrication as their deceptive response to the questions. A manipulation check was conducted after all the stimuli were created in which the primary investigator queried the level of deception that was provided for the deceptive responses, to which the ‘clients’ confirmed were complete fabrications (i.e., 100% untruthful). ‘Clients’ involvement in the creation of the stimuli was not compensated. 3.11.1.2 Credibility Assessment Task Procedure Registered psychologists were asked to engage in an exercise intended to best approximate clients providing responses in a VCP session in an effort to gauge their credibility assessment abilities. The deception stimuli previously described were used for the credibility assessment task. Participants were asked to imagine that they were interacting with a potential client in a VCP session, during which time they would ask questions of the ‘client.’ They were first introduced to the procedure using the ‘client’ response to “Complete this sentence ‘I wish I had someone with whom I could share…’”, which was a truthful response. This provided an opportunity for participants to become familiar with the study procedure, while also providing a baseline truthful response. Following this, participants were presented with the eight stimuli in a randomized order. After viewing a pre-recorded response from the ‘client,’ they were asked to 87 make a credibility assessment based on that recording. They were then asked a) how open they believed the client was, b) how honest they believed the client was, and c) their confidence in the honesty and openness ratings. After making their credibility assessment, the participants were presented with another stimuli clip of the same client. Notably, each participant was randomly assigned to a different stimulus of one of the four clients; however, all the stimuli recordings the participant viewed were of the same client. Of the eight responses, four were truthful and four were complete fabrications. With regard to randomization, the truthful and deceptive responses were in a semi-randomized order across all eight questions. Due to constraints inherent to the survey platform (i.e., Qualtrics), complete randomization could not be achieved. However, a survey flow was created in order to best achieve randomization. As such, for each ‘client’ there were two sets of potential recordings that were created. The first set included truthful responses for questions one through four, and deceptive responses for questions five through eight. The second set included deceptive responses for questions one through four, and truthful responses for questions five through eight (i.e., the opposite of set one). The order in which the videos were presented within each set was randomized. It should be noted that which set and which client that was presented to the psychologists was randomized. 3.11.1.3 Design After engaging in the aforementioned questionnaires (i.e., perceptions of clinical competencies, client disclosures, etc.), participants engaged in the credibility assessment task. This began with an introduction video. Registered psychologists were prompted to imagine that they were engaging in a VCP session with a ‘client’ and were asking the ‘client’ a series of questions. Participants were then randomly presented the introduction task of one of four 88 ‘clients’ (i.e., “Complete this sentence ‘I wish I had someone with whom I could share…’”), followed by the eight test items. As noted above, it was randomly determined which ‘client’ the participant viewed, but they viewed the same ‘client’ for all nine questions. Of each client, participants would have been randomly selected to view set one or set two (See “Credibility Assessment Task” section). 3.11.2 Results Psychologists were prompted to engage in a credibility assessment task, which included mock stimuli of ‘clients’ engaging in a VCP session. A one-sample t-test was conducted in order to ascertain whether their overall accuracy percentage of detecting deceit was significantly different when compared to deception detection accuracy typically found in the literature. Specifically, given the significant and consistent finding, Bond and DePaulo (2006)’s accuracy rate of 54% was utilized as a comparison. A test for the assumption of normality utilizing the Shapiro-Wilk test indicated that the data was normally distributed (W = 0.95, p = 0.34). A one-sample t-test did not reveal a statistically significant difference between psychologists’ overall percentage accuracy (M = 46.75%, SD = 17.15%) and the anticipated mean accuracy of 54%, t(1, 26) = -1.86, p = .079, d = .42 [-0.87, 0.05]. An additional one-sample t-test analysis was conducted to determine whether the current study’s 46.75% accuracy rate for psychologists was significantly different than chance (i.e., 50%), which did not reveal any significant differences, t(1, 26) = -0.82, p = 0.43, d = 0.18 [-0.62, 0.26]. Given that the current sample size (27 participants) was approaching but was not within the ideal sample size (approximately 30-40 participants), to detect moderate effect sizes, an additional Bayesian analysis was conducted to consider whether 46.75% is significantly better than chance levels at detecting deceit. Bayesian analysis is an approach to facilitate ascertaining 89 the probability of a specific outcome (Andraszewicz et al., 2015; Lee & Wagenmakers, 2013; O’Connor, 2017; Stefan et al., 2019; Wetzels et al., 2011). Within psychological statistics, this means it aids in identifying the probability that a specified value occurred either under the null or alternative hypothesis (O’Connor, 2017; Stefan et al., 2019). For this study, results indicated a Bayes Factor of 0.97 [0.95, 0.99]. Using Lee and Wagenmakers (2013) and Andraszewicz et al. (2015)’s guidelines, this indicates that there is no evidence to suggest that the current study’s 46.75% accuracy rate for psychologists occurred under either the null hypothesis or the alternative hypothesis. Simply, based on the Bayesian analysis, the 46.75% deception detection rate is similar to the deception detection rate of 54% found in previous literature. In terms of confidence ratings, psychologists maintained an average confidence rating of approximately 56.25% (SD = 31.04%). In line with Volz et al. (2022), there are various methods to analyze the relationship between confidence and deception detection accuracy, including correlation and calibration methods. A correlation analysis revealed that confidence was not significantly correlated with overall deception detection accuracy, r (1, 26) = 0.21 (p = 0.36). In terms of the calibration approach, in line with Volz et al. (2022) and Reinhard et al. (2013), participants were divided into four confidence categories that resulted in equal sample sizes across each group (n = 6). Figure 12 illustrates the accuracy scores for each confidence category. A calibration score was then calculated, to which the process for the calculations can be found in Volz et al. (2022). A calibration score can range from 0.00 (perfect calibration as in the confidence ratings are directly in line with the accuracy percentages) to 1.00. The calibration scores indicated that there was closer to “perfect” calibration for the lower confidence groups (C Low = 0.061; C Medium-Low = 0.069) as compared to the higher confidence groups (C Medium-High = 0.74; C High = 0.81). 90 Figure 12 Line Chart Displaying the Overall Deception Detection Accuracy for Each Confidence Group Note. There were six participants in each confidence category. 50.00%47.50%37.50%54.17%0.00%10.00%20.00%30.00%40.00%50.00%60.00%Low Medium-Low Medium-High HighOverall Deception Detection Accracuy Confidence Category 91 Total accuracy percentages were also calculated for the percentage of truthful clients correctly identified as being truthful, and the percentage of deceptive clients that were correctly identified as being deceptive. Truthful clients were correctly identified 70.01% (SD = 30.99, Range = 0 – 100%) of the time. Deceptive clients were correctly identified 23.75% (SD = 29.77, Range = 0 – 100%) of the time. A paired samples t-test indicated that there was a significant difference between the percentage of truthful messages correctly identified as compared to the percentage of deceptive clients correctly identified (t (1, 26) = 4.12, p < .01, d = 0.9 [0.39, 144]), with deceptive client accuracy being significantly lower. Psychologists rated the perceived overall openness of clients (M = 54.17%, SD = 26.04%) and confidence in their openness assessments (M = 67.94%, SD = 18.85%). Participants were also prompted to provide an honesty rating, which averaged 62.67% (SD = 17.86%), with average confidence in their honesty assessments being 71.22% (SD =20.88%). A further analysis was conducted considering the openness and honesty ratings of truthful and deceptive mock ‘clients’ separately (See Table 10). Tests of normality were conducted for openness ratings for the truthful (W = 0.96, p = .45) and deceptive (W = 0.93, p = .13) ‘clients,’ which indicated that the data were normally distributed. A paired samples t-test comparing the openness ratings across veracity conditions indicated that they were not significantly different, t (1, 26) = -0.118, p = .91, d = -0.01 [-0.63, 0.61]. Data for the honesty ratings for truthful (W = 0.88, p = .089) and deceptive (W = 0.96, p = .56) ‘clients’ were also normally distributed. A paired samples t-test revealed a statistically significant difference (t (1, 26) = 3.69, p = .0015, d = 0.65 [0.01, 1.28]), with higher honesty ratings in the truthful condition (See Table 10). An additional analysis was conducted in an effort to determine if the overall deception detection rate was related to psychologists’ perceptions of their clinical competencies in FtF 92 Table 10 Descriptive Statistics Openness and Honesty Ratings Across Veracity Conditions Variable M SD Range Minimum Maximum Truthful Openness 53.11 25.88 0.00 96.00 Openness Confidence 68.59 18.99 18.50 97.75 Honesty 68.85 19.17 10.25 99.75 Honesty Confidence 70.46 20.12 20.50 100.00 Deceptive Openness 53.51 28.07 26.32 92.75 Openness Confidence 67.29 22.16 16.75 97.75 Honesty 55.81 20.91 16.00 90.75 Honesty Confidence 71.97 22.68 18.50 100.00 therapy, VCP, and phone therapy. A total competency score was created by summing psychologists’ scores on Section J of the TCPR for each of the communication modalities. There was a non-significant correlation for FtF therapy (r (1, 26) = .017, p = .94) and a similar non-significant correlation for VCP (r (1, 26) = .089, p = .71). There was also a non-significant correlation of r (1, 26) = .15 (p = .53) between the clinical competencies total score for phone therapy and deception detection accuracy rate. 93 Chapter 4: Discussion The current series of studies examined various factors related to Videoconferencing Psychotherapy (VCP). Specifically, it considered the experiences and self-perceived clinical competencies of therapists across communication modalities. Further, it elicited both client and therapists’/psychologists’ perspectives of VCP, phone therapy, and Face-to-Face (FtF) therapy, making it a much needed but rare examination of both professional and patient perspectives. This research is particularly timely as a substantial number of therapists are more readily adopting videoconferencing into their practice and an increasing number are using it as their primary communication platform (e.g., Schiller et al., 2024). The mixed-methods approach that was adopted in the present series of studies aided in allowing for quantitative comparisons when appropriate and feasible, while the qualitative analyses provided further opportunities to garner a deeper understanding of therapists’ and clients’ perspectives of therapy across communication mediums. Of note, the qualitative analyses provided opportunities to (at minimum) identify areas for future consideration. Furthermore, the results from the mixed-methods approach provided clear directions for future research and suggestions for clinical practice. In terms of clinical competencies, there were a variety of interesting findings across both graduate student clinicians and psychologists. For example, both groups indicated that they believed they were equally effective across FtF therapy and VCP (i.e., no significant differences), but perceived themselves as being significantly less effective in phone therapy across all competency domains. Interestingly, despite psychologists rating themselves as being equally effective in both VCP and FtF, they paradoxically also reported experiencing significantly increased drowsiness, inattentiveness, and boredom during VCP as compared to FtF therapy. This is partially consistent with prior literature (e.g., Messina & Löffler-Staska, 2021). It 94 could be the case that less engagement in VCP could clearly have negative downstream effects on clinical skills over an extended period of time. The decreased engagement could be attributable to the phenomenon of ‘Zoom fatigue’ (Nadler, 2020; Wiederhold, 2020), or decreased engagement that is considered to be inherent in non-FtF settings (Ebardo et al., 2021; Dacillo et al., 2022). Psychologists’ perceptions about the advantages and disadvantages of mental health applications were also elicited. In particular, psychologists reported believing that mental health applications provide increased access to mental health services, while also decreasing the stigma associated with the same. However, the advantages of mental health applications were contrasted with various perceived disadvantages. Specifically, psychologists shared significant concerns regarding the ethical considerations of mental health applications (i.e., confidentiality, ensuring evidence-based care, etc.). Interestingly, the perceived advantages and disadvantages of mental health applications that psychologists reported largely reflect similar themes in efficacy-based literature. The qualitative analyses in the present series of studies demonstrated that clients reported variable levels of comfort disclosing information across communication mediums. Intriguingly, the thematic analysis also revealed that psychologists and graduate student clinicians perceived client characteristics as having a larger impact (as compared to the communication medium) in terms of clients’ comfort disclosing information. Indeed, this is evidenced by how varied clients’ self-reported comfort disclosing information in therapeutic settings fluctuated within the current study. This discrepancy highlights the need to more readily consider client factors, and how they may interact with the communication modality for therapy. 95 The qualitative analyses of disclosure credibility within therapy illustrated that clients endorsed providing more untruthful information in VCP as compared to FtF therapy. This could be related to their perceptions of believability as clients also readily reported feeling more believable in VCP as compared to FtF therapy. The increased likelihood of lying in VCP might also be partially explained by the Social Distancing Hypothesis, which asserts that increased distance may allow for increased deception (DePaulo et al., 1996). When psychologists engaged in a credibility assessment task, it was revealed that their deception detection accuracy rate (46.75%) was not significantly different when compared to the accuracy rates found in other studies (54%; Bond & DePaulo, 2006), as well as chance levels (i.e., 50%). This is likely reflective of a Truth Bias (Levine, 2014) that is maintained by therapists (Curtis, 2013; Kottler & Carlson, 2011). Indeed, the current study found additional evidence of a substantial and significant Truth Bias maintained by therapists, which can potentially have downstream effects on therapeutic outcomes. In sum, the current series of studies highlighted various perceived advantages and disadvantages of communication platforms for providing therapy. 4.1 Patterns of VCP Use Psychologists reported a substantial increase in the rate and amount of VCP offered since the COVID-19 pandemic, consistent with prior research (Latifi & Doarn, 2020; Seivert & Badowski, 2021). Specifically, psychologists reported a significant increase of utilizing videoconferencing to provide therapy from (on average) 4.4% to 70%. Furthermore, the majority of psychologists (92%) anticipated that this percentage would either remain consistent or continue to increase, while very few psychologists endorsed wanting to decrease the levels of VCP. The majority of psychologists (72%) also advised that they preferred VCP or hybrid practice, as compared to solely FtF. As discussed, there was an increased need to offer 96 therapeutic services during the COVID-19 pandemic in an effort to address the increase in mental health concerns (Fitzpatrick et al., 2020; Rossell et al., 2021), as well as to continue offering therapy to those who were already accessing services. Perhaps for those psychologists who were not providing videoconferencing services prior to the pandemic, COVID-19 provided an opportunity to adopt a ‘novel’ communication medium in order to provide therapy. This may have enhanced their knowledge and comfort level in providing therapy with a virtual medium, increasing their willingness to continue offering VCP after the pandemic. However, VCP is not the only technology platform that can be a conduit for therapeutic services as mental health applications have also experienced an increase in usage for clients. 4.2 Mental Health Applications Psychologists were provided an opportunity to provide their perspectives as to the advantages and disadvantages of mental health applications (e.g., BetterHelp). It should be reiterated that the qualitative analysis for mental health applications (and other topics through study two) included responses from 27 psychologists, which research has demonstrated is an adequate sample size for thematic analysis given that the themes in the current study were saturated (i.e., there were no additional and unique themes identified as the sample size increased; Boddy, 2016; Vasileiou et al., 2018). The qualitative analysis revealed various perceived advantages, which primarily related to increasing access to mental health care due to affordability, convenience, and decreased time spent on waiting lists for mental health services. These findings are in line with prior research that has touted the benefits of mental health applications (Eftychiou, & Morr, 2017; Marcelle et al., 2019). Specifically, increased access has continuously been highlighted as a primary reason for the creation and implementation of mental health applications (Marcelle et al., 2019). The present study also demonstrated that mental 97 health applications are perceived to provide an avenue for crisis management as having mental health services readily available 24/7 may allow clients to access appropriate and timely assistance when (or if) a crisis arises. Another perceived advantage noted in the current study was that mental health applications may assist in decreasing the stigma associated with accessing mental health care, which is also in line with prior research (Kim et al., 2022). There are mental health applications that provide transparent (i.e., the client has access to a complete treatment plan from the outset of treatment) treatment programs, to which the increased transparency may decrease the level of uncertainty that is experienced with accessing therapy. Relatedly, there may be increased anonymity when clients access services through a mental health application as compared to reaching out to a therapist to meet in-person or over videoconferencing (Kim et al., 2022). However, the advantages of mental health applications should be considered in conjunction with their perceived potential disadvantages. Psychologists primarily expressed their perceived concern for the ethics surrounding mental health applications. The most readily reported ethical concern pertained to maintaining confidentiality and anonymity. For instance, some psychologists reported that there is evidence indicating that some mental health applications have been documented as violating confidentiality and privacy acts. Prior research has similarly discussed maintaining client confidentiality as a primary concern for the developers and operators of mental health applications to consider (Jones & Moffitt, 2016; Lustgarten et al., 2020; Stiefel, 2018). Psychologists also noted that it is ethically necessary to ensure that clients are receiving the best, most appropriate, and evidence-based mental health care, which prior research has also demonstrated as a concern (Kaplan, 2020). In particular, psychologists indicated that they perceived mental health applications as potentially having decreased accountability and 98 assurance that clients are receiving evidence-based care. Further, psychologists expressed concern about clinicians’ ability to foster and maintain a positive therapeutic relationship through mental health applications, particularly when therapy is being provided via instant messaging. It should be reiterated that these themes about the perceived concerns of maintaining confidentiality, ensuring that effective care is provided, and ensuring that rapport can be established have been discussed in prior literature considering mental health applications (Martinengo et al., 2019; Palmer & Burros, 2021; Wang, 2021). Psychologists were also asked to provide their perspective as to the effectiveness of mental health applications. Overall, the majority of psychologists believed that mental health applications can be efficacious. The above-mentioned advantages of mental health applications were reiterated as the reasons for their perceived effectiveness (e.g., increased access, decreased stigma, etc.). As mentioned, there has been research that has illustrated that mental health applications are effective at increasing access to services and allow for increased monitoring of mental health symptoms (Wang et al., 2018). However, other psychologists perceived mental health applications as not being effective or indicated that the ongoing research regarding their effectiveness is not yet conclusive to provide an informed opinion. Consequently, the perceived ineffectiveness of mental health applications was linked to the perceived disadvantages, such as concerns about whether they provide evidence-based treatment and confidentiality. Interestingly, there is empirical research that has demonstrated that the majority of mental health applications do not have sufficient efficacy data (Wang et al., 2018) nor utilize effective approaches (Marshall et al., 2021). In summary, psychologists’ responses paralleled the majority of current efficacy literature, which has acknowledged the potential benefits of mental health applications, while simultaneously expressing concern about the lack of research considering their 99 effectiveness. The ongoing considerations about the efficacy of mental health applications may also be apparent when examining therapists’ and clients’ experiences with VCP. 4.3 VCP Experiences Graduate student clinicians and psychologists were asked to rate the levels of fatigue and required effort to engage in both VCP and FtF therapy. Interestingly, there were no significant differences reported by therapists in terms of the level of fatigue or mental effort required to engage in therapy across communication mediums. Indeed, this is contrary to prior literature that has illustrated that there are increased levels of fatigue for general (i.e., non-therapeutic) videoconferencing meetings (Fauville et al., 2021; Nadler, 2020; Wiederhold, 2020), as well as therapeutic settings (Békés & Aafjes-van Doorn, 2020). Therapists may have experienced Zoom fatigue earlier in the COVID-19 pandemic when VCP was experiencing a significant and abrupt increase (Békés & Aafjes-van Doorn, 2020; Latifi & Doarn, 2020; Seivert & Badowski, 2021), to which adjusting to a novel communication platform would have required greater effort and therefore influenced greater fatigue. However, as therapists became more acquainted and familiar with videoconferencing as a communication avenue to provide therapy, they may now be experiencing less fatigue. The similar levels of fatigue across communication mediums could also be explained by the therapeutic context. There is a stream of literature that has documented the high levels of compassion fatigue (Deighton et al., 2007; Figley, 2002; Ondrejková & Halamová, 2022; Sinclair et al., 2017) and burnout amongst therapists (Kaeding et al., 2017; Rummell, 2015; Sprang et al., 2007), regardless of communication medium. This would suggest that therapists experience increased levels of fatigue when they are engaged in therapy due to the amount of effort required to effectively engage with their clients (Posluns & Gall, 2020). Similar levels of fatigue across 100 communication mediums might reflect the increased fatigue associated with conducting therapy (Rummell, 2015), rather than the communication medium itself. However, there could be differing levels of fatigue (as proposed by research demonstrating the Zoom fatigue phenomenon; Nadler, 2020) for therapists if they were to engage in an everyday conversation via videoconferencing as compared to face-to-face. Prior research has documented that there are gender differences in the experience of Zoom fatigue (e.g., Fauville et al., 2021), but the current series of studies was not able to thoroughly ascertain whether the effect of gender would also be present within a therapeutic context given the small sample of males. A potential aim for future studies is to garner a larger sample in order to more thoroughly test the impact of gender on fatigue within therapy, specifically with regard to videoconferencing. In sum, the comparable levels of fatigue across communication mediums could be related to becoming more acquainted with utilizing videoconferencing to provide therapy, or it could reflect the fatigue associated with conducting therapy more generally. The current study also demonstrated that psychologists generally have similar experiences in session during VCP and FtF therapy, with a few exceptions. Specifically, psychologists endorsed significantly higher levels of drowsiness, boredom, and being inattentive in VCP. This both supports and contrasts hypotheses, given the increased levels of boredom and drowsiness for VCP (as anticipated), in addition to increased levels of inattentiveness (unanticipated). The present results are also partially consistent with Messina & Löffler-Staska (2021)’s findings who also found that clinicians endorsed significantly higher ratings of boredom and drowsiness in VCP as compared to FtF therapy. Increased boredom in VCP could certainly over the course of a session (or sessions) cause increased drowsiness, which would also likely make it more difficult to remain engaged and/or pay as close attention. This could be a cyclical 101 pattern in which the increased drowsiness might lead to even more inattentiveness, exacerbating the levels of boredom. Interestingly, the feeling of boredom is not unique to therapists as other research has demonstrated that individuals do experience increased boredom in videoconferencing (Ebardo et al., 2021; Dacillo et al., 2022; Nesher &Wehrt, 2022). In particular, Ebardo et al. (2021) attempted to explain their findings of increased boredom in videoconferencing as being related to decreased social interaction in videoconferencing. Videoconferencing may provide a less stereotypically “social” context to feel particularly engaged, influencing therapists to experience increased boredom and subsequent drowsiness in VCP. Hensel et al. (2020) also suggested that increased technical difficulties could influence higher ratings of boredom, which also may not allow for the therapist and client to as effectively engage. Perhaps more importantly, there has been research that has demonstrated that when there are increased levels of boredom within therapy, there also tends to be a decrease in the levels of overall therapeutic effectiveness (Heinonen et al., 2014; Heinonen et al., 2012). It would therefore be beneficial to consider whether the communication medium also has a significant impact on therapists’ clinical skills. 4.4 Clinical Competencies An integral consideration of the present study was therapists’ perceptions of their clinical skills across communication mediums. Notably, therapists’ (i.e., both psychologists and graduate psychology students) perceptions of their clinical skills were consistently rated lower for phone therapy as compared to VCP and FtF therapy. This was found across both qualitative enquiry as well as statistically significant results from quantitative analyses. Considering that phone therapy continues to be utilized in a number of contexts to deliver mental health services (e.g., Irvine et al., 2020), it is essential to consider how this perceived decreased competency may impact 102 therapy across all competency domains. The current study’s thematic analysis revealed that therapists primarily attributed the decreased clinical skills in phone therapy to having minimal non-verbal cues to rely upon. This is consistent with other qualitative research where therapists reported that a lack of non-verbal cues in non-FtF therapy sessions may impact therapeutic effectiveness (Ahlstrom et al., 2022). Moreover, while scarce, there is some research suggesting that decreased non-verbal cues impact therapists' clinical skills (Sherer & Rogers, 1980), specifically their ability to foster a positive therapeutic alliance (Giacco et al., 2020) and their therapeutic presence (Alvandi, 2019; Full et al., 2024; Geller, 2020). In particular, Lin and Anderson (2024) also demonstrated that a self-perceived lack of non-verbal cues is significantly related to a decreased perception of clinical competencies in VCP. For instance, an element of conducting a Mental Status Exam (which is a standardized manner in which to document objective client observations) is attending to the client’s non-verbal cues (e.g., general appearance, movements, etc.; Foley & Gentile, 2010). A substantial decrease in non-verbal cues could therefore impact therapists’ clinical abilities to conduct a Mental Status Exam and further impact their clinical competencies. This would be an integral area for future research, particularly how the communication medium may impact therapists’ ability to note and respond to non-verbal cues. Interestingly, the thematic analysis also revealed that despite a reported decrease in non-verbal cues, some therapists indicated that phone therapy is both useful and effective during crisis situations as it allows for immediate support. Although phone therapy was rated significantly lower on each item of Section J of the TCPR for psychologists, the two lowest perceived competencies were maintaining a sense of mastery of therapeutic techniques, and being able to utilize precision and subtlety when implementing clinical interventions. The reduced information (i.e., non-verbal cues as discussed 103 above) that therapists have available through phone therapy could significantly impact their ability to implement their clinical skills to their fullest extent. For example, therapists may be able to engage in a thought challenge exercise with a client, but without being able to process the non-verbal information that would be available in FtF therapy, this intervention may not be as tailored or effective for that specific client in phone therapy (i.e., decreased subtly/precision). Indeed, this is related to therapeutic presence discussed by Geller (2020) who states that the clinician has increased effectiveness if they are able to be present with the client while an intervention is being delivered and adjusted appropriately given the client’s response. Moreover, phone therapy also presents major restrictions in terms of the clinical interventions that can be utilized. For instance, a psychologist who practices eye movement desensitization therapy could obviously not effectively engage clients, let alone employ this type of treatment, over the phone. Another potential explanation for the perceived significant decreased clinical abilities in phone therapy could be due to a lack of training. Interestingly, phone consultation is a core component of a comprehensive Dialectical Behavioral Therapy (DBT) program (Chapman, 2018; Landes et al., 2021). Chapman (2018) readily identified that although phone therapy is a core component of DBT, there is minimal training provided to therapists about how to implement clinical interventions meaningfully and effectively over the phone. Given this, Chapman (2018) did release guidelines to provide phone therapy. Nonetheless, given the lack of training most therapists have likely received, they may not feel as competent in phone therapy, which may not be the case for VCP. In terms of VCP clinical competencies, there was not a statistically significant difference in perceptions of clinical competencies when comparing VCP and FtF therapy as measured by Section J of the TCPR, which is in contrast to the current study’s hypothesis. This was generally 104 consistent with the current study’s qualitative analysis indicating that the majority of psychologists (and graduate psychology students) perceived their clinical skills to remain effective in VCP. This is in contrast to some prior literature that has investigated therapists’ clinical competencies across communication mediums, specifically Messina & Löffler-Staska (2021). Messina & Löffler-Staska (2021) demonstrated that therapists reported significantly less perceived clinical competency across each of the domains from Section J of the TCPR for VCP. Interestingly, Messina & Löffler-Staska (2021)’s findings were in contrast to most literature demonstrating that VCP is effective (e.g., Fernandez et al., 2021). The timing of when the current research and Messina and Löffler-Staska (2021)’s study were conducted could provide a potential explanation for the contrasting findings. First, therapists very well could have been initially skeptical about the perceived effectiveness of their clinical skills when VCP was first beginning to be utilized during the pandemic. Messina & Löffler-Staska (2021)’s study would reflect this time period, which is in contrast to the present research conducted during the later stages of the pandemic. This is accentuated by Lin et al. (2024)’s results, which also demonstrated that therapists reported a significant increase in their self-perceived therapeutic skills as they garnered more experience with VCP during the pandemic. In the period of the current research, therapists could have become more comfortable with providing therapy within a VCP context and could have therefore rated their skills as equivalent across communication modalities. Second, the present study and Messina & Löffler-Staska (2021) only considered therapists’ perceptions of their clinical skills. However, the majority of efficacy research that documents if a therapist is effective is completed by monitoring a treatment outcome (e.g., is there a decrease in levels of depression following therapy delivered by a CBT-orientated 105 therapist). The increased use of VCP and the passing of time since the pandemic started, could have provided more of an opportunity for therapists to increase their knowledge of VCP’s efficacy through training/workshops/literature. This may have resulted in their perceptions of their clinical competencies increasing to be more in line with the VCP efficacy research. Although the majority of therapists reported perceiving themselves as being equally competent in VCP and FtF therapy, the thematic analysis indicated that there was a subset of psychologists who felt they were effective in VCP, but not as effective as they would be in FtF therapy. The qualitative analysis illustrated that therapists attributed the decreased non-verbal cues that they can rely upon in VCP as the primary factor impacting their perceived competencies. Interestingly, therapists similarly attributed the lack of non-verbal cues as the primary reason for having decreased competence in phone therapy. As discussed above, it is likely that decreased information (i.e., non-verbal cues) that can be observed across communication mediums could likely impact a therapist’s ability to provide efficacious therapy and effectively utilize their clinical skills (e.g., Geller, 2020). Based on the current research, it is proposed that the communication mediums can be conceptualized along a spectrum of information that is available to the therapist, with FtF therapy providing the most information, while phone therapy provides the least amount of information (termed ‘Information Hypothesis’). The more information that a therapist has available, the more tailored, targeted, and effective the therapist can be in implementing their interventions. Therapists may still be effective in VCP given that there is still a higher level of information available (as compared to phone therapy), but they may feel as though they are still more effective in FtF therapy given the increased amount of information that is available to guide their clinical interventions. 106 Much of the information that therapists are relying upon is dependent upon the client (i.e., individual differences) and how they present across communication mediums. The interaction between the communication medium and client characteristics could also impact a therapist’s ability to utilize their clinical skills. For example, two clients could both likely benefit from engaging in exposure and response prevention work, to which the therapist has a mastery of skill and competency. However, the first client may have a higher level of ‘openness to experience’ (personality trait) allowing them to engage in exposure activities more readily, regardless of whether it is a VCP or FtF therapy session. Whereas the second client may have lower levels of ‘openness to experience’ and would therefore require increased support that can arguably be more readily offered during an FtF therapy session as compared to a VCP session. In essence, although the communication medium does play a role in therapists’ perceptions of their clinical competencies, individual client differences may also be a factor to consider. Indeed, previous research considering VCP has raised the notion that individual difference factors, specifically diagnostic presentation, are an integral area for future research (e.g., Batastini et al., 2021). Perhaps the impact of client characteristics can most readily be observed in their comfort with disclosing information across communication mediums. 4.5 Disclosures Qualitative analyses in the current study demonstrated that psychologists and graduate student clinicians perceived that clients were equally comfortable across communication mediums disclosing information. Interestingly, this is in contrast with prior qualitative and quantitative literature (as well as the current hypotheses) that have found that clinicians perceived their clients as being more comfortable in VCP as compared to FtF therapy disclosing information (Glass & Blicker, 2021; Simpson, 2005; Stubbings et al., 2015). Prior studies 107 considering comfort disclosing information were conducted either prior to or during the COVID-19 pandemic, which was a time when both therapists and clients had to make substantial alterations in terms of their communication practices. The present study was conducted during the final stages of the COVID-19 pandemic. In fact, the World Health Organization removed the pandemic designation while data collection was ongoing (i.e., March 2023). As considered earlier, since the COVID-19 pandemic began, many clients would have become more familiar with a previously potentially unfamiliar communication medium. Once they became acquainted and likely more comfortable with the technology and medium itself, their comfort disclosing information may have become more equivalent with their comfort in FtF settings. Our qualitative analyses eliciting client and clinician/psychologist perspectives about disclosing information highlighted substantial variation given the varying nature of the reported themes, specifically for clients. One of the reported themes for both psychologists and graduate student clinicians was that client comfort disclosing information was more likely related to the client’s individual characteristics, rather than the communication medium. Characteristics that were specifically mentioned included rapport, levels of anxiety, and general comfort disclosing information (regardless of communication medium). Interestingly, the themes reported by clients within the qualitative analysis regarding their comfort disclosing information varied substantially (i.e., preference for FtF therapy, preference for VCP, equal comfort), which is likely reflective of the impact of individual differences. For instance, some clients noted that FtF therapy allows them to observe therapist’s non-verbal cues, while other clients noted that VCP provides increased “psychological distance” which thereby allows them to feel more comfortable disclosing information. However, the diverse nature of the themes highlighted in the client qualitative 108 analysis accentuates the primary theme that was reported by both graduate student clinicians and psychologists, which is that comfort disclosing information is more dependent upon client characteristics as compared to the communication medium. Although specific individual difference measures (i.e., personality, anxiety, etc.) were not considered in the present study, such measures should be investigated as moderating variables in future studies. Moreover, perhaps more refined commonalities and themes around comfort in disclosing information would also develop with an enhanced sample size. As briefly noted, the current qualitative results are in contrast to some prior research that has highlighted the impact that the communication medium has on clients’ comfort disclosing information (e.g., Glass & Blicker, 2021). The contrast is likely related to the sample including both therapists and patients as some prior studies have primarily queried therapists’ perceptions of client’s comfort disclosing information. Oftentimes, clients disclosing information can be an indicator of a positive therapeutic alliance (Gunn & Pistole, 2012; Leach, 2005; Miller et al., 2017). Interestingly, research has demonstrated that there is often a discrepancy between therapist and client perceptions of rapport, with therapists tending to rate it lower as compared to clients (Leach, 2005; Thompson & McCabe, 2012). An analogous pattern of results has been found in previous research considering rapport across communication modalities, which similarly revealed that clients rated rapport as higher in both FtF therapy and VCP as compared to therapists (Ertelt et al., 2011; Richardson et al., 2012; Simpson & Reid, 2014). Research considering the rapport discrepancy has highlighted that therapists’ confidence, own levels of stress within therapy, and aspects of their personal lives impact how they perceive rapport (Nissen-Lie et al., 2010; Orlinsky et al., 2010). There has been particular attention to the increased focus on the therapeutic alliance that therapists maintain, which likely influences lower 109 ratings (i.e., increased scrutiny and attention to detail resulting in lower ratings; Simpson & Reid, 2014; Orlinsky et al., 2010). A similar phenomenon could be occurring in the present study, with therapists being more closely attuned to client disclosures as compared to the clients themselves, particularly within a more novel communication medium. The methodology of the current study may also help explain contrasting results as prior literature has utilized primarily quantitative data, while the current study adopted a mixed methods approach that also included opportunities for qualitative analyses. Further, the sample size for clients was small (N = 7), and as such the thematic analysis should be interpreted with caution despite it providing integral directions for future research with an increased sample. Nonetheless, once a disclosure is made it also becomes important for the therapist to consider the veracity of the information. 4.6 Deception In line with prior research (e.g., Curtis & Hart, 2016), the current qualitative analyses revealed that clients in the present study endorsed providing untruthful information in therapy. Indeed, research has demonstrated that the majority of clients have been deceptive to their therapist on at least one occasion, if not multiple times (Blanchard & Farber, 2016; Curtis & Hart, 2016; Farber et al., 2019). However, the current study included an opportunity for qualitative analyses, which illustrated that clients endorsed lying in both FtF therapy and VCP. Further, there were more clients who reported historically lying in VCP as compared to FtF therapy. Clients in the present study also reported being more likely to provide untruthful information in future VCP sessions as compared to FtF. These findings are also in line with prior research that has demonstrated an increase in providing deceptive statements in synchronous and non-recording technology platforms (such as videoconferencing) as compared to FtF in non-therapeutic settings (Hancock et al., 2004; Markowitz, 2022). 110 Previous research has provided some potential explanations for the current study’s tentative indication that clients may be more likely to lie in VCP. As discussed, Hancock et al. (2004) provided three potential explanations: Richness Theory (Daft & Lengel, 1986), Social Distancing hypothesis (DePaulo et al., 1996), and Feature-Based Theory. Markowitz (2022) also demonstrated that individual differences, specifically elements of dark personality traits, impact deception across communication mediums. Interestingly, the current study may provide tentative support for the Social Distance proposition (DePaulo et al., 1996) and Markowitz’s (2022) acknowledgement of the impact of individual differences of the person who is providing untruthful information. Firstly, the thematic analysis indicated that some clients in the present study would be more likely to provide untruthful information in VCP due to a “perceived distance between myself and the therapist.” As proposed by the Social Distance Hypothesis (DePaulo et al., 1996; Hancock et al., 2004), the increased social distance may decrease the amount of shame and guilt that would be associated with lying, thereby increasing one’s comfort providing untruthful information in a virtually mediated (and therapeutic) context. Secondly, as discussed earlier, psychologists and graduate student clinicians reiterated that client individual difference factors are an integral component for client disclosures across communication mediums. Although Markowitz (2022) focused on the Dark Tetrad (i.e., psychopathy, Machiavellianism, narcissism, sadism), it raises the consideration that other individual difference factors could be relevant in terms of deception within therapy. For example, a client’s level of anxiety (i.e., individual difference factor regardless of diagnosis) could impact whether they may be more prone to provide untruthful information in therapy. It should be noted that the current findings are based on qualitative analyses, while most prior research (e.g., Hancock et al., 2004) adopted quantitative approaches and as such the 111 comparisons across studies should be considered with caution. Notwithstanding, the frequency of providing untruthful information in differing communication mediums may also be influenced by client’s perceived believability across communication mediums. The qualitative analysis indicated that clients in the present study perceived themselves as being more believable over videoconferencing as compared to FtF. If clients perceive themselves as more believable, then they may be more likely to provide untruthful information in VCP due to a belief that there is a decreased likelihood of the negative consequences associated with being caught lying. Interestingly, clients indicated that their enhanced believability in VCP was related to an increased ability to manage their own emotional experience and body language since the other person (i.e., therapist) would not be in the physical room with them. This is also in line with the Social Distance Hypothesis (DePaulo et al., 1996; Hancock et al., 2004) as increased distance may allow clients to have increased attention to oneself, and thereby feel more confident in providing untruthful information. It is also possible that the increased perceptions of believability are related to the potential decreased (or compromised) visibility of a client by the therapist in videoconferencing. Therapy in the same physical space would require a client to manage their non-verbal communication across more of their body, whereas in videoconferencing the client would only have to focus on their emotional expressions from typically the shoulders (or perhaps chest) upwards. For example, foot tapping (which may indicate anxiety) would not have to be as readily managed in videoconferencing. It should be noted that the Social Distance Hypothesis also considers that increased distance decreases the amount of non-verbal information that can be perceived by the receiver (i.e., therapist). Nonetheless, clients overall reported an increased frequency of conveying deceitful information 112 and perceiving themselves as more believable in VCP as compared to FtF therapy. This propensity to lie may also be dependent upon the reasons for providing untruthful information. The qualitative analysis highlighted various reasons that clients endorsed for giving untruthful information in a therapeutic context, which were similar across FtF therapy and VCP. One of the primary themes related to the therapeutic process, such as lying when they felt invalidated or when prompted to discuss a topic they did not want to discuss. Within both of these situations, the untruthful information would almost certainly impact the therapeutic process. Further, these types of lack of disclosures are likely reflective of the therapeutic alliance (i.e., decreased rapport influencing a decreased desire to discuss these topics). Indeed, Hart et al. (2024) demonstrated that increased frequency of deception related to having a less positive therapeutic alliance and therapeutic outcomes. They also demonstrated that if a more positive therapeutic alliance can be fostered, then there would be more positive treatment outcomes. In non-therapeutic settings, rapport has been readily demonstrated as increasing the likelihood of garnering truthful information (Brimbal et al., 2021; Jenner & Myers, 2019; Meissner, 2021). Taken together, the current results, as well as Hart et al. (2024), accentuate the need for therapists to continue ensuring that rapport is readily established within therapeutic settings. Clients in the present study also reported lying about therapy logistics (i.e., being late for their session), which could also likely be reflective of the level of rapport. For example, a client may maintain a positive relationship with their therapist and are concerned that being late for an unapproved reason may harm the relationship and would therefore engage in a ‘white lie’ (i.e., tell a lie to spare the feelings of another) in an attempt to maintain the relationship. Another potential explanation relates to feelings of shame, to which prior research has demonstrated that experiencing shame increases rates of non-disclosure (i.e., lie by omission; Hill et al., 1993; 113 Macdonald & Morley, 2001). Intriguingly, two clients in the present study directly acknowledged shame as a motivating factor for being deceptive in therapy. This is also in line with Blanchard and Farber (2020) who demonstrated that feelings of shame related to discussing suicidal ideation increased the likelihood of a client either withholding or providing untruthful information about the same. Regardless of the topics that clients may lie about in therapy, it is likely that the levels of rapport are a substantial contributing factor and provide areas for future research. Clients in the current study also endorsed being more likely to provide untruthful information VCP, while psychologists rated them as being equally likely to provide untruthful information across communication modalities. However, when psychologists were directly asked to indicate how many lies they believe are told during a therapy session, they reported a higher rate for FtF therapy. Interestingly, there is a discrepancy between the communication medium that clients and psychologists report as being more likely to be conducive to conveying untruthful information. Although the majority of psychologists in the present study endorsed currently utilizing VCP (and expecting to continue using it), there was a high rate of psychologists who endorsed either solely engaging in FtF therapy or minimally utilizing VCP prior to the COVID-19 pandemic. Given that the majority of psychologists would have substantially more experience overall with FtF therapy, they could be basing their belief of a higher incidence of lies in FtF therapy simply because this is what they have the most experience with and feel more knowledgeable about. Moreover, psychologists maintained a Truth Bias overall and when questioned still could have assumed that, since clients are generally truthful, they are equally truthful across communication modalities. It is worth noting that psychologists in the current study endorsed 114 having minimal to moderate levels of familiarity with deception research. Considering this, they were likely not familiar with the CMC-based deception literature to further inform their estimates of clients’ truthfulness. For example, additional training or review of this literature would have highlighted that prior research has demonstrated a higher frequency of deception in videoconferencing platforms as compared to face-to-face (e.g., Hancock et al., 2004). The perceptions of deception across communication modalities within a therapeutic context could also be influenced by psychologists’ confidence, and ability, to detect deceit. The ability to detect deception was rated as moderately to highly important and equally important (i.e., non-significant difference) across communication modalities by both psychologists and graduate student clinicians. This is likely related to the (potential) considerable ethical and treatment planning considerations that would be impacted if a client were to provide untruthful information. For instance, as considered earlier, a client may not be credible about their suicidal ideation (Blanchard & Farber, 2020). This not only holds important treatment implications (Hart et al., 2024) and pressing concerns for the well-being of the client, but it can also influence the therapist’s ethical decision-making in terms of disclosing confidential information. Moreover, it is also possible that therapists view deception as an important consideration as it could be an indicator of the quality of the therapeutic relationship. For instance, a client consistently disclosing truthful information might indicate a positive relationship with the therapist. Indeed, as discussed, Hart et al. (2024) documented that clients who more readily provided untruthful information in therapy had a poor therapeutic alliance with their therapist. Given that the veracity of the disclosures has important implications, and is likely reflective of rapport, it is also imperative to consider therapists’ ability to make accurate credibility judgements. 115 Psychologists in the current study maintained a 46.75% overall deception detection accuracy rate. While somewhat lower, this was not significantly different from reliable and consistent findings that demonstrate an accuracy rate of approximately 54% (Bond & DePaulo, 2006; Levine et al., 2021), and was consistent with the current study’s hypothesis. The overall accuracy for deception detection accuracy might be at least partially explained by the difference between the percentage of truthful clients correctly identified (70.01%) and the percentage of deceptive clients correctly identified (23.75%). Indeed, this is a difference of approximately 46.26%. Therefore, the overall accuracy percentage is likely multifaceted, with the lower deceptive client accuracy rates reducing the overall accuracy percentage. The finding that therapists maintain a higher truthful client accuracy percentage is in line with prior research assessing deception detection accuracy, to which the Truth-Default Theory has been proposed as a likely explanation. The Truth Default Theory (TDT), as discussed, highlights the presence of a Truth Bias (Levine, 2014; 2022). The Truth Bias asserts, as discussed, that in general, people will assume that they are being told the truth by another person (i.e., biased towards believing others), and that significant information is required in order to alter that assumption (Levine, 2014). Prior research has demonstrated that both non-therapists (Levine et al., 2022) and therapists (Curtis, 2013; Kottler & Carlson, 2011) maintain a Truth Bias. As such, it is likely that psychologists in the current study were similarly prone (or perhaps more prone) to maintaining a Truth Bias as evidenced by the 46.26% difference in accuracy levels between truthful and deceptive messages correctly identified. Curtis and Hart (2015) also illustrated an enhanced assumption of honesty that therapists reported within the therapeutic relationship and suggested that this was unique to therapists as compared to members of the general population. Given the uniqueness of the 116 therapeutic relationship, psychologists likely have an enhanced Truth Bias given the inherent assumption that clients are typically being genuine and open with them. It would arguably be very difficult to develop genuine rapport in therapy without this belief. Further, an important consideration is the potential harm to the therapeutic relationship if a therapist inaccurately and routinely perceives a client as potentially being deceitful, which could be detrimental to the client’s treatment progress. Indeed, the psychologists’ average openness and honesty ratings of their clients were well-above 50% in the current study, reiterating and accentuating the presence of a Truth Bias. Taken together, maintaining a Truth Bias likely negatively impacted psychologists’ ability to detect deceit for the current stimuli, but may also be viewed as a positive (i.e., inherently believe clients so as to not affect the therapeutic relationship) given the uniqueness of the therapeutic relationship as highlighted by Curtis and Hart (2015). Psychologists in the current study could have also been relying upon non-reliable cues to deceit to guide their credibility judgement. Interestingly, a whole host of non-verbal cues to deceit have been readily discussed in the literature (e.g., Ekman et al, 1999), but have repeatedly been demonstrated to be non-reliable and non-valid (Brennen & Magnussen, 2020; Davis & Markus, 2006; Vrij et al., 2019; Vrij, 2008). Despite evidence documenting that non-verbal cues to deceit are unreliable, there continues to be a misbelief that they are valid cues (Brennen & Magnussen, 2020; Vrij et al., 2019). Further, it has been illustrated that therapists also maintain inaccurate beliefs about cues to deceit (Curts & Hart, 2015; Dickens & Hart, 2019). As such, psychologists in the current study also might have been trusting unreliable non-verbal cues to deceit. Perhaps tellingly, psychologists reported only having minimal-to-moderate amounts of exposure to deception research, potentially indicating decreased knowledge about valid (and invalid) cues to deceit. This is surprising given the high-stakes nature of some of the client 117 concerns that are addressed in therapy (e.g., suicidal ideation) and is certainly an area that perhaps therapists can engage in increased training and knowledge acquisition. Importantly, psychologists only viewed pre-recorded stimuli, which impacts the ecological validity of the current study. Results (including credibility judgment performance) very well could also have been impacted by the non-interactive nature of the task which certainly would not be the case in a genuine therapeutic setting. Decreased ecological validity has been similarly cited as an integral and consistent issue in deception research (Burgoon, 2015; Rosenbaum et al., 2014; Vrij, 2008; 2019). Enhancing some of the conditions present in a real therapeutic setting could be one way to facilitate a clearer estimate of therapists’ credibility assessment skills in therapeutic settings, and how that relates to their overall clinical competencies. For instance, in the current study there would be no genuine rapport (let alone any type of relationship) between the therapist and the individuals in the videos they observed which is distinctly different than a genuine therapeutic process. In sum, future research should aim to increase ecological validity unique to the therapeutic process. Prior to completing the credibility assessment task, psychologists’ and graduate student clinicians’ general confidence in their ability to detect deception was self-rated to be in the moderate range. Moreover, their confidence in their ability to detect deceit was not significantly different across communication mediums. The overall confidence ratings resulting from the credibility assessment task also remained in the moderate range (i.e., 56.24%), and were not significantly correlated with deception accuracy. Prior research has collated therapists’ perceptions about their ability to detect deceit and found similar confidence ratings (i.e., moderate confidence), indicating that they perceived themselves as having a 50/50 chance of correctly identifying if someone was being deceitful (Curtis & Hart, 2015; Dickens & Curtis, 118 2019). As such, the current findings are in line with prior research but may be further explained by the varying levels of confidence and the associated deception detection accuracy rates. A calibration analysis in the current study revealed that psychologists’ deception detection accuracy ratings were more in line with their confidence ratings for the lower confidence group, while individuals in the high confidence group were not as calibrated (i.e., confidence and deception detection accuracy were misaligned). Previous research considering the relationship between confidence and deception detection accuracy has yielded mixed results (Smith & Leach, 2019; Volz et al., 2022). The Truth Bias could provide a partial explanation for the current findings as psychologists may (as discussed) more readily assume and be confident that clients are being truthful despite continuing to be at chance levels at detecting deceit. Moreover, some prior research has documented an “overconfidence effect” in which individuals with higher confidence have lower deception detection accuracy (DePaulo et al., 1997) including amongst law enforcement (Yarbrough, 2020). Studies that have documented an “overconfidence effect” suggest that perceptions of enhanced knowledge or training about an individual’s behavior, including deception, leads to an overconfidence. While it is unclear how many psychologists receive enhanced training about deception, perhaps psychologists in the high confidence group in the current study received a more substantive amount of training on credibility detection. Psychologists may have also maintained an assumption that due to their knowledge about general behavior as a result of their academic and clinical therapy training, they would have an increased likelihood of accurately detecting if someone was deceitful. It must be again acknowledged that the sample size for the confidence groups was small (n = 6), and interpretation of the relationship between confidence and deception detection accuracy should be considered with caution. 119 Psychologists’ overall deception detection ability was not significantly related to their overall perceived clinical competencies for each of the communication modalities. The training that psychologists receive primarily focuses on the essential elements of being effective practitioners (i.e., establishing and maintaining rapport, developing of a therapeutic orientation, etc.), to which detecting deceit is not as readily discussed as a clinical competency (Curtis & Hart, 2016). Since the majority of psychologists are not trained to detect deceit, their credibility assessment accuracy is not potentially enhanced like other therapeutic skills that received increased focus during their training. The current study also assessed the relationship between overall therapeutic competencies (i.e., summary score of Section J of the TCPR) and overall deception detection accuracy (i.e., 46.75%), and did not assess the relationship between credibility assessment accuracy and specific therapeutic competencies. For instance, and as discussed, prior research has demonstrated the importance of rapport in eliciting genuine disclosures (e.g., Meissner, 2021). It would be interesting in future research to assess the relationship between a therapist’s ability to develop a positive therapeutic alliance and their credibility assessment accuracy. It should be reiterated that, unless they are in specific clinical contexts, therapists may be prone (which may also enhance the therapeutic process) to relying on a Truth Bias. However, there may be sub-disciplines within psychology (e.g., forensic psychology) in which there is increased exposure to deception. Interestingly, it has been demonstrated that forensic psychologists tend to more readily maintain a lie bias (Dickens & Curtis, 2019), which may also impact credibility assessment accuracy. Taken together, perhaps additional training (e.g., workshops, online resources, etc.) should be included to more general and specific clinical settings about deception within therapy. Indeed, this should be an area of future research to 120 examine if forensic psychologists’ ability to detect deceit is both enhanced and/or more readily related to their overall clinical competencies. Notwithstanding, the above findings and considerations provide various worthwhile avenues for future research. 4.7 Limitations & Future Directions The current study is not without its limitations, which provide robust areas for future research. An aforementioned primary limitation of the current series of studies is the sample size. The sample size was limited to the extent that some inferential statistics could not be completed, specifically for the graduate student clinician and client surveys (i.e., study one). This does impact generalizability and what conclusions can be derived from its results. Although the sample size was small in study one, it proved sufficient enough to not only identify themes through the qualitative analysis (i.e., client’s comfort disclosing information, perceived believability, etc.), but also provide important directions for future studies. Indeed, other qualitative research has maintained similar sample sizes (e.g., Boddy, 2016), which can range anywhere from samples of as low as two (Fugard & Potts, 2015). Moreover, other research has noted that the nature of the population being studied will also impact the sample size, in that more unique samples often decrease opportunities to elicit more responses and data (Sarfo et al., 2021). This is often the case when surveying clients who are actively accessing mental health services. Further, as considered above, study two did obtain a sample size that was substantial enough to complete some inferential statistics, along with additional important qualitative insights. Prior studies investigating the credibility assessment accuracy of specialized populations also had comparable sample sizes, including for law enforcement personnel (Ekman & O’Sullivan, 1991; Hartwig et al., 2004; Semrad & Scott-Parker, 2020; Wachi et al., 2017; Vrij et al., 2001), polygraphers (Ekman & O’Sullivan, 1991), and individuals convicted of a criminal 121 offence (Bond, 2007). There has also been research investigating VCP that has obtained similar sample sizes (e.g., Cataldo et al., 2023). Notably, with regard to the qualitative analysis, similar themes arose across studies one and two, indicating high replicability of findings and suggesting that the current themes reached saturation. Nonetheless, future studies may seek to have studies that focus solely on clinical competencies and deception separately in an effort to garner more detailed data related to each associated topic. Despite the sample size for study two being adequate and appropriate to perform inferential statistics, there was a high rate of individuals (67 participants) completing less than 5% (primarily 0% and 1%) who were not included in the analyses. Moreover, even though 98 organizations were contacted to distribute the survey, only 18 distributed it, which resulted in a final sample of 27 participants (i.e., high non-response rate). It should be reiterated that data collection procedures were altered approximately at the mid-point in order to increase the sample size. Nonetheless, study two potentially has a participation/non-response bias in which it is unclear whether those who completed the survey are different than those who did not complete the survey, which could impact generalizability. This is a bias that is inherent with most survey research given significant attrition rates (Holtom et al., 2022; Spennemann, 2022), specifically for web-based surveys (Hochheimer et al., 2019). Ironically, considering the focus of the research, the survey was distributed electronically via email and social media. It is therefore unclear whether those who completed the survey had increased comfort with VCP due to a generally enhanced comfort with technology as compared to those who do not as readily use or rely on social media or email. Future studies should seek to increase the variability of survey response formats (i.e., technology-based, paper/pencil, etc.) as well as seek further avenues to increase response rates (i.e., decrease survey length). 122 Research has also documented that despite utilizing various data collection methods (i.e., email distribution, social media, follow-ups, etc.) there continues to be low response rates (Koning et al., 2021; Spennemann, 2022). For example, Koning et al. (2021) described “a recent unpublished collaborative…. where despite survey reminders, social media dissemination, and extension of data collection period, the survey was met with only 13 responses from across the continent of Africa.” Various reasons have been proposed for the low response rates including the medium of data collection (i.e., email, paper/pencil, social media), survey population, and survey length, amongst others (Hochheimer et al., 2019; Holtom et al., 2022; Spennemann, 2022). Koning et al. (2021) also acknowledged that there has been an increase in the number of surveys distributed during COVID-19. The authors proposed that due to the increased rate of surveys, respondents are fatigued with the overwhelming number of surveys that they are being asked to complete, which is influencing a higher prevalence of non-responses. A similar phenomenon could be occurring for research specifically investigating VCP as there has been a substantial increase in VCP related research, including surveys, since COVID-19 (e.g., Messin & Löffler-Staska, 2021). Spennemann (2022) also recently found that although social media distribution can ‘reach’ a wider audience, it can have a lower response rate as compared to other survey distribution approaches. The initial organizations that distributed the survey in the present study included social media distribution, during which time there was the highest rate of non-responses. Further, the social media posts that were published did not include the eligibility criteria (given inherent character/word limits) and as such, participants would not have been aware of the eligibility criteria until they clicked on (and began) the survey with the informed consent process. Those non-registered psychologists who might have been interested may have ultimately read the eligibility criteria and exited (resulting in a 0% response rate). 123 It is also important to consider that the graduate student clinician and client samples were from a university clinic. There are unique characteristics of a university clinic (i.e., decreased cost of services, enhanced supervision models) that potentially limit the generalizability outside of North American university-based psychology training clinics. Specifically, the low cost of services provided by the clinic likely provided increased opportunity to receive services for clients who experience finances as a barrier to accessing evidence-based mental health services. The decreased barriers to service may have impacted the variability of client presentations, making the results from the current study unique to other clinics that have reduced fees as part of their services. Future studies should seek to expand the current findings to other mental healthcare settings, such as private practice clinics, community and/or provincially operated clinics, and hospital/psychiatric settings (amongst others). A further avenue for future studies to consider is to garner clients’ perspectives of therapists’ clinical competencies across communication mediums. The current study only queried therapists’ perceptions of their own clinical competencies. To obtain a more client perspective, questionnaires such as the TCPR could be adapted to allow for a direct comparison of therapist and client perceptions of clinical skills. As discussed, research has noted that there tends to be a discrepancy between client and therapist perspectives of concepts in therapy (Leach, 2005; Thompson, 2003), while minimal research has considered client perspectives within a VCP context. A similar discrepancy might be present for client and therapist perspectives of clinical skills, specifically across communication mediums. An alternative method is to have supervising therapists/psychologists view recordings of therapy sessions across communication modalities and then rate therapist clinical competencies across the mediums. It is also acknowledged that the current study only garnered psychologists’ and 124 clinicians’ perspectives of their own skills, which may be more readily subject to bias. However, as a first step at elucidating clinical skills in various communication mediums, it provided valuable information to consider the views of the subjects themselves. Notwithstanding, eliciting a separate perspective, either through supervising clinicians or by the clients themselves, may further elucidate how clinical skills are (or are not) effective depending upon the communication modality. The current series of studies focused on considering already established clinical competencies and investigating whether they transferred to VCP. Given that VCP is being more readily adopted, considering how to conduct therapy within a videoconferencing setting could in and of itself be a clinical competency to consider. For instance, Békés et al. (2023a) developed the Teletherapy Intervention Scale to assess the implementation of interventions that are directly relevant to VCP (e.g., expressing curiosity about home environment, verbally expressing information, etc.). It was found that the scale was positively related to more positive therapeutic alliance and presence in VCP, as well as an increased likelihood of engaging in VCP in the future. There could be specific competencies and skills that are inherent to VCP, but not to FtF therapy (and vice versa). For instance, Full et al. (2024) identified that VCP presented more challenges related to the ‘therapeutic frame’ (i.e., blurring of start and end of sessions, expectations of online therapy discussed during consent process, confidentiality related to being in a client’s home), to which the therapeutic frame could be a specific area of competency for therapists to consider. This is an area for future research to perhaps differentiate the shared, but also unique, clinical competencies specific to each communication medium. Qualitative methodologies would be uniquely suited to initially investigate this in order to garner the competencies that are unique to each communication medium, which can then be thoroughly 125 tested through the development of brief measures (as in the case of Békés et al., 2023) and outcome-based studies. Future studies could also investigate how training that incorporates VCP as a clinical competency impacts therapists’ skills within a non-FtF setting. As noted above, this would appear to be one of the first studies to assess therapists’ ability to detect deceit within therapy by requesting that psychologists engage in a task that was aimed to best approximate elements of a VCP session. In fact, a consistent theme acknowledged within prior research is that there has been scant research thoroughly considering deception within therapy (e.g., Curtis & Hart, 2015; Farber et al., 2019). However, similar to a host of prior literature investigating deception (e.g., Burgoon, 2015; Rosenbaum et al., 2014; Vrij, 2008; 2019), and as considered above, the current study lacked ecological validity for a genuine therapeutic context. It should be noted that efforts were made to ensure that there was increased ecological validity, such as not providing the questions beforehand to the acting ‘clients’ during the recording process and requesting that they act as if they were in a therapy setting. However, the credibility assessment task utilized recordings and therapists did not engage in an actual interaction with clients to make a credibility assessment. Moreover, although ‘clients’ provided truthful information, they were also requested to provide untruthful information and prompted to “play the role of a client.” It is admittedly therefore unclear whether the credibility assessment task was accurately assessing deception, or the ‘clients’ ability to play the role of a client. Lastly, the recordings were created to be reflective of a VCP session as compared to a FtF session, and it is therefore unclear if there would be similar deception detection accuracy rates in FtF therapy where the client and therapist are within the same physical space. Potential avenues to address these limitations include having recordings of either mock or realistic VCP and FtF therapy sessions to be viewed by clinicians or ask them to engage in a mock therapy session with a 126 confederate and then subsequently rate credibility. It is acknowledged that there are significant and integral ethical considerations to be considered in designing such a study. Despite these considerations, efforts should be made in order to increase the ecological validity of credibility assessment tasks in therapeutic settings, especially given the array of ethical considerations if a client were to provide untruthful information about a sensitive topic (i.e., suicidal ideation). The deception stimuli utilized in the current study requested that ‘clients’ lie by providing complete fabrications. However, the spectrum and types of deception varies and can range from complete fabrications to half-truths, withholding information (i.e., lie by omission), or exaggerations (Vrij, 2008). Farber et al. (2019) noted that there tends to be a higher prevalence of ‘passive dishonesty’ (i.e., withholding information by avoiding specific topics) within therapy. A clear future direction is to consider therapists’ ability to detect other forms of deception within a therapeutic context, specifically withholding information. It is acknowledged that designing a study, or more specifically stimuli, related to withholding information maintains methodological constraints. For instance, asking ‘clients’ to engage in a mock session and withhold information still requires that they provide some sort of information about a directed topic. This can become more akin to a half-truth as compared to withholding information. Nonetheless, considering therapists’ ability to detect other forms of deception within a therapeutic context should be readily considered. As considered above, a reported theme was that the experiences of VCP and the effectiveness of clinical competencies can be dependent upon client characteristics as compared to the communication medium. Future research may seek to consider the individual difference factors that may allow clients to benefit from either VCP or FtF therapy more readily. There could be an interaction effect between communication medium and both clients and therapists. 127 Potential individual difference factors to consider that may interact with the communication medium include personality traits, diagnostic presentation(s), or general (and non-diagnostic) levels of anxiety (amongst others). Indeed, Møller et al. (2022a) also found that clients whose diagnostic/clinical presentation were not as severe, or complex, would more readily consider engaging in VCP. Lastly, the relationship between the therapist and client (i.e., therapeutic alliance) should also be considered as a moderating factor for clients engaging in VCP as compared to FtF therapy. For example, levels of rapport might moderate whether a client is more likely to engage (or disclose) in VCP or FtF therapy, and whether their comfort disclosing information remains consistent across the communication mediums even with consistently weaker or positive rapport. In sum, future research should more readily consider client characteristics that may moderate how effective therapists’ clinical skills are across communication modalities. Finally, future research may consider adopting a longitudinal design to assess therapists’ effectiveness of their clinical skills across communication modalities over the course of a treatment program. For instance, similar to Lin et al. (2024), it may be worthwhile to have two groups of clients engage in therapy, where one group begins the therapeutic relationship in-person while the other begins therapy through videoconferencing. Subsequently, the clients would transfer communication modalities approximately halfway through their treatment program and the effectiveness of therapists’ clinical skills as they transfer communication mediums can be observed. Indeed, this would also be an opportunity to garner both client and clinician perspectives on clinical competencies across communication mediums. Moreover, this design could also provide insight into whether there is a benefit of altering the communication medium as a tool for therapists. For example, a client who experiences increased social anxiety 128 may prefer to begin therapy via videoconferencing as it offers decreased in-person interaction that elevates their anxiety. However, altering the communication modality from videoconferencing to in-person may allow for the therapist and client to engage in exposure and response prevention exercise(s) within a safe setting through FtF therapy. The reverse may also be true for clients who have completed a thorough treatment program in FtF therapy, with VCP as an effective option for brief follow-up sessions. Although these may be worthwhile study designs, it is reiterated that specific ethical considerations would have to be addressed prior to engaging in this type of design (i.e., ensuring that it is in the best benefit for the client, informed consent about the process, etc.). 4.8 Implications & Conclusion There are a number of both intriguing and important findings in the current series of studies. They are also unique in that the present series of studies elicited both client and therapists’/psychologists’ perspectives of VCP and phone therapy when compared to FtF therapy. Foremost, the present study provided increased insight into therapists’ clinical skills across communication modalities. Importantly, it demonstrated that therapists perceived themselves as continuing to be effective in VCP, while also not feeling competent in phone therapy. This has implications for therapist training and workshops, which could include more readily offering training for therapists who are providing, or hoping to provide, phone therapy. Indeed, phone therapy continues to be utilized to deliver psychological services (Irvine et al., 202), including to remote areas and for crisis intervention (Coman et al., 2001; Lester et al., 2012). Further, some clients who are not comfortable with technology or videoconferencing still prefer phone therapy if they are unable or unwilling to attend in person (Taylor, 2011). A further implication from the present study with regard to VCP is that therapists can have increased 129 awareness about how their perceptions of clinical competencies fluctuate across communication mediums, thereby allowing them to reflect on the communication modality that they would like to employ based on their levels of comfort. Intriguingly, our thematic analyses demonstrated that perhaps an equally important and relevant factor to consider when investigating clinical skills and experiences of therapy across communication mediums is client characteristics. In particular, the thematic analyses found that clients had varying levels of comfort disclosing information across communication mediums. Indeed, the varied nature of clients’ responses is reflective of the themes that arose from psychologists’ and graduate student clinicians’ perceptions that individual difference factors have an important (and perhaps more relevant role) for disclosing information as compared to the communication medium. The potential implications of this cannot be overstated as this suggests that therapists should be cognizant of the individual differences that clients are presenting with (e.g., general comfort, personality, anxiety, etc.) which may inform how clients are engaging in different communication platforms. Another potential implication from this research is that there should be a thorough discussion between the client and therapist as to the communication medium that is going to be utilized within therapy. This conversation should also consider items such as ease of access and client characteristics (i.e., levels of comfort, anxiety, etc.). Indeed, the current study appears to support the implementation of either FtF therapy or VCP when it is considered within the context of the client. Despite clinicians rating themselves as being equally effective in both VCP and FtF, they also reported feeling drowsier, more bored, and inattentive during VCP as compared to FtF therapy. This could have negative downstream effects on clinical skills. For example, increased inattentiveness may result in the therapist not as readily identifying or processing the client’s 130 primary concern (or other mitigating factors), which decreases their ability to provide an effective intervention. The potential varied nature of the negative downstream effects of therapists feeling drowsier, more bored, and inattentive in therapy should be explored more in future research. In order to mitigate the potential negative downstream effects, it could be helpful for therapists to include more breaks between clients who are solely VCP in an effort to re-engage themselves and increase their energy for subsequent clients. This would allow therapists to ensure that they are continuing to be effective across their clients and negate against the potential downstream impact that boredom, drowsiness, and inattentiveness may have on their clinical skills. Therapists could also consider seeking out avenues to decrease a sense of boredom during VCP, such as engaging in specific self-care exercises (e.g., mindfulness, grounding) prior to a therapy session. Considering credibility judgments, psychologists maintained a similar deception detection accuracy rate as found in prior literature (e.g., Bond & DePaulo, 2006), which could be related to a Truth Bias. Interestingly, it was noted that clients endorsed providing more untruthful information in VCP as compared to FtF therapy. Even considering the small sample size, it should motivate future research to examine if this reported increased amount of deception compared to FtF is consistent with our study. This has potential implications for how therapists decide which communication modality to utilize when engaging with certain clients as a therapist may purposefully select a particular type of communication medium to enhance genuine disclosures. As discussed, untruthful statements in VCP that are not being detected by therapists could have negative treatment planning implications and severe consequences (i.e., safety planning for suicidal ideation). 131 It should be reiterated and emphasized that although credibility assessment accuracy in therapy has important treatment implications, incorrectly and consistently classifying a client as deceptive could have equally important implications. It is likely more harmful than good for a therapist to consistently be considering and concerned about if a client is being truthful. This should be considered as more of a tertiary goal that acknowledges clinicians to be mindful of the possibility, but endeavouring to not become overly suspicious (unless the context of the session potentially requires it). Considering it as more of a primary objective would not only likely harm the therapeutic alliance but would also increase the cognitive load experienced by the therapist, potentially impacting their therapeutic effectiveness. Rather, therapists should only ensure they are aware that clients can (on occasion) provide untruthful information. In such cases, therapists should rely on their already established therapeutic competencies to address inaccurate information if deemed clinically appropriate. Indeed, it would be recommended in only rare circumstances that a therapist directly acknowledge or confront a client for being untruthful. For instance, if a therapist is concerned about the credibility of the information that clients are providing, they should seek to ensure that there is adequate rapport within the therapeutic relationship, specifically within VCP. However, it should be noted that deceit within therapy could be an indicator of positive rapport (i.e., client wanting to spare the feelings of the therapist) or of negative rapport (i.e., client feeling invalidated by their therapist). The potential explanations for lying in therapy are something the therapist may want to contemplate further within the therapeutic process. Reiterating that therapy is a safe, non-judgmental space could also assist in optimizing the potential for eliciting truthful information. If a therapist becomes concerned about deceit within VCP, they may also consider alternating to FtF therapy given that patients in the current study reported being less likely to be deceitful and less believable in FtF 132 therapy. In summary, therapists should be cognizant of deception within therapy, how that potentially interacts with the communication medium, how that may influence their delivery of therapeutic services, and engage in deliberate and reflective decision-making if they were to address it. Mental health services are also experiencing an unprecedented shift, not only with regard to VCP, but also in response to the significant advancements in technology, such as chatbots, artificial intelligence, virtual reality, and augmented reality (amongst others; Benrimoh et al., 2022; Harvey et al., 2022; Ogugua et al., 2024). Indeed, the current series of studies should be contextualized within the broader scope of research addressing the use of technology within mental health services. For instance, the advantages of other technology-based mental health services mirror those cited for VCP (e.g., increased affordability, increased access for clients in rural and remote regions, etc.; Harvey et al., 2022). However, there is also ongoing and integral discussion related to the ethical considerations (e.g., confidentiality) related to technology-based mental health services (Ogugua et al., 2024). Nonetheless, some initial research has noted that individuals may actually feel more comfortable disclosing to an artificial intelligence based mental health service (i.e., chatbot) as compared to FtF therapy due to decreased feelings of shame (Palmer & Schwan, 2022). Interestingly, this has also been suggested as an advantage of VCP (Glass & Bickler, 2022). In fact, the client dependency theme that was consistently raised in the current studies likely reflects how clients will interact with other technology-based mental health services in the future. For instance, some clients (i.e., those who experience increased feelings of shame, comfortability with technology) may more readily engage with an artificial intelligence based service as compared to those who experience moderate levels of shame (and may access VCP) and those who experience reduced levels of shame (who may access FtF 133 therapy). It could also be that chatbots are more conducive for supportive or maintenance psychotherapy (i.e., maintain gains achieved in prior treatment), whereas VCP and FtF therapy may be more conducive for more ‘traditional’ psychotherapy. As technology continues to advance, it will be important for mental health professionals, and the field of psychology, to continue investigating what clinical competencies are unique to specific technology-based services and whether the provided services continue to remain effective and efficacious. There are various directions for future research based on the present findings and other ongoing investigations. Importantly, the current research adds to the minimal extant research considering therapists’ clinical competencies in VCP, which appears to be more readily gaining research attention (e.g., Lin et al., 2024). However, a clear future direction is to consider the unique clinical competencies inherent to VCP that are not as readily inherent to FtF therapy (and vice versa). This may provide increased insight about how therapists can remain, or perhaps become even more competent, when delivering VCP. Moreover, this may also address the ongoing comments by therapists (e.g., Aafis-Dorn et al., 2024) that there is something unique to VCP that does not allow it to be the same experience as FtF therapy. Some have suggested that this is related to therapeutic presence (Geller, 2020), but how therapeutic presence relates to therapists’ clinical competencies in VCP is yet to be addressed and should be a future research direction. Moreover, the relationship between credibility assessment for other forms of deception (e.g., lie by omission) and therapeutic competencies is an additional area of investigation. Regardless of the concept or domain being investigated, a longitudinal or cross-sectional design should be adopted when considering therapy across communication modalities. For example, the current study suggested that within an individual session therapists are feeling more bored, drowsy, and inattentive, but the long-term impact of these feelings on both competencies and 134 clinical outcomes is an integral area for future research. A long-term follow-up study monitoring therapists’ competencies session-to-session as they either remain in a single communication modality or as they change communication modalities, would be very beneficial. This type of research would not only provide insight into how effective therapists are across communication modalities, but could also shed light into how different clients respond to differing communication modalities. The present series of studies fills a void in existing literature by examining how therapists conceptualize their clinical skills across different communication mediums. This project was unique in that it collected first-hand experiences from both therapists and clients, increasing its applied utility. Specifically, the study provided clarity that therapists generally perceive their clinical competencies to be comparable across FtF and VCP therapy, but that they are perceived as being significantly impacted in phone therapy. Relatedly, while therapists may feel competent in VCP, they also report experiencing increased boredom, drowsiness, and inattentiveness. Moreover, client individual differences were indicated as perhaps a more relevant factor to consider in combination with the communication medium. Specifically, client characteristics may have a particular impact on their comfort disclosing information in therapy across communication modalities as compared to the communication medium itself. For example, psychologists and graduate student clinicians reported that (in their perception) general levels of openness about one’s personal history more readily play a role in how clients disclose information in therapy, as compared to the session being in-person or virtual. Lastly, clients reported being more likely to provide untruthful statements in VCP, while therapists’ ability to detect deceit (specifically in a mock VCP session) is in most contexts likely impacted by a Truth Bias. While this is relevant to all therapeutic settings, this may have the most impact in high- 135 stakes situations and settings where disclosing credible information is incredibly pertinent to ethical decision-making (e.g., suicidal risk assessment). For therapists to remain ethical and competent, it is important that they practice in a communication medium that optimizes their interpersonal competencies to work effectively and safely with their clients. The current study has facilitated a more refined understanding of aspects of therapists’ and clients’ experiences across communication mediums. Hopefully, this will serve to increase therapeutic adherence and treatment efficacy in an increasingly virtually mediated world. 136 References Aafjes-Van Doorn, K., Békés, V., Luo, X., & Hopwood, C. J. (2024). Therapists’ perception of the working alliance, real relationship and therapeutic presence in in-person therapy versus tele-therapy. Psychotherapy Research, 34(5), 574–588. https://doi.org/10.1080/10503307.2023.2193299 Abel, E. A., Glover, J., Brandt, C. A., & Godleski, L. (2017). Recommendations for the reporting of Telemental Health (TMH) literature based on a systematic review of Clinical Video Teleconferencing (CVT) and depression. Journal of Technology in Behavioral Science, 2, 28-40. https://doi.org/10.1007/s41347-016-0003-1 Abrahamsson, N., Ahlund, L., Ahrin, E., & Alfonsson, S. (2018). Video-based CBT-E improves eating patterns in obese patients with eating disorder: A single case multiple baseline study. Journal of Behavior Therapy and Experimental Psychiatry, 61, 104–112. https://doi.org/10.1016/j.jbte p.2018.06.010 Acierno, R., Gros, D. F., Ruggiero, K. J., Hernandez-Tejada, B. M. A., Knapp, R. G., Lejuez, C. W., . . . & Tuerk, P. W. (2016). Behavioral activation and therapeutic exposure for posttraumatic stress disorder: A noninferiority trial of treatment delivered in person versus home-based telehealth. Depression and Anxiety, 33, 415–423. https://doi.org/10.1002/da.22476 Ahlström, K., Von Below, C., Forsström, D., & Werbart, A. (2022). Therapeutic encounters at the onset of the COVID-19 pandemic: Psychodynamic therapists’ experiences of transition to remote psychotherapy. Psychoanalytic Psychotherapy, 36(3), 256-274. https://doi.org/10.1080/02668734.2022.2058988 Alqahtani, M. M. J., Alkhamees, H. A., Alkhalaf, A. M., Alarjan, S. S., Alzahrani, H. S., AlSaad, 137 … & Alqahtani, K. M. M. (2021). Toward establishing telepsychology guideline. Turning the challenges of COVID-19 into opportunity. Ethics, Medicine, and Public Health, 16, 100612. https://doi.org/10.1016/j.jemep.2020.100612 Alvandi, E. O. (2019). Cybertherapogy: A conceptual architecting of presence for counselling via technology. International Journal of Psychology and Educational Studies, 6(1), 30-45. https://doi.org/10.17220/ijpes.2019.01.004 American Psychological Association (2013). Guidelines for the practice of telepsychology. American Psychologist. Retrieved from https://www.apa.org/pubs/journals/features/amp-a0035001.pdf Andraszewicz, S., Scheibehenne, B., Rieskamp, J., Grasman, R., Verhagen, J., & Wagenmakers, E. J. (2015). An introduction to Bayesian hypothesis testing for management research. Journal of Management, 41(2), 521-543. https://doi.org/10.1177/0149206314560412 Ardito, R. B., & Rabellino, D. (2011). Therapeutic alliance and outcome of psychotherapy: Historical excursus, measurements, and prospects for research. Frontiers in Psychology, 2(270), 1-11. https://doi.org/10.3389/fpsyg.2011.00270 Aron, A., Melinat, E., Aron, E. N., Vallone, R. D., & Bator, R. J. (1997). The experimental generation of interpersonal closeness: A procedure and some preliminary findings. Personality and Social Psychology Bulletin, 23(4), 363-377. https://doi.org/10.1177/0146167297234003 Backhaus, A., Agha, Z., Maglione, M. L., Repp, A., Ross, B., Zuest, D., ... & Thorp, S. R. (2012). Videoconferencing psychotherapy: A systematic review. Psychological Services, 9, 111–131. https://doi.org/10.1037/a0027924 138 Barrett, J. A., Calvert, F. L., Gonsalvez, C. J., & Shires, A. G. (2023). A qualitative investigation into perceptions of scientist-practitioner competence within supervision during psychology training programmes. Australian Psychologist, 58(2), 80-93. https://doi.org/10.1080/00050067.2022.2125282 Batastini, A. B., Guyton, M. R., Bernhard, P. A., Folk, J. B., Knuth, S. B., Kohutis, E. A., Lugo, A., Stanfill, M. L., & Tussey, C. M. (2023). Recommendations for the use of telepsychology in psychology-law practice and research: A statement by American Psychology-Law Society (APA Division 41). Psychology, Public Policy, and Law, 29(3), 255–271. https://doi.org/10.1037/law0000394 Batastini, A. B., Paprzycki, P., Jones, A. C. T., MacLean, N. (2021). Are videoconferenced mental and behavioral health services just as good as in-person? A meta-analysis of a fast-growing practice. Clinical Psychology Review, 81, 1-22. https://doi.org/10.1016/j.cpr.2020.101944 Batastini, A. B., & Vitacco, M. J.(2020). Forensic mental health evaluations in the digital age: A practitioner’s guide to using internet-based data. Springer Nature Switzerland AG. https://doi.org/10.1007/978-3-030-33908-1 Baumann, E. C., & Hill, C. E. (2018). Client concealment and disclosure of secrets in outpatient psychotherapy. In Disclosure and Concealment in Psychotherapy (pp. 53-75). Routledge. Békés, V., & Aafjes-van Doorn, K. (2020). Psychotherapists’ attitudes toward online therapy during the COVID-19 pandemic. Journal of Psychotherapy Integration, 30(2), 238–247. https://doi.org/10.1037/int0000214 Békés, V., Aafjes-van Doorn, K., Luo, X., Prout, T. A., & Hoffman, L. (2021). Psychotherapists’ 139 challenges with online therapy during COVID-19: Concerns about connectedness predict therapists’ negative view of online therapy and its perceived efficacy over time. Frontiers in Psychology, 12, 705699. https://doi.org/10.3389/fpsyg.2021.705699 Békés, V., Aafjes-van Doorn, K., Luo, X., Balarajan, S., & Hopwood, C. J. (2023a). Mastery of teletherapy is related to better therapeutic relationship and presence in teletherapy: The development of the teletherapy intervention scale. Frontiers in Psychology, 14, 1206960. https://doi.org/10.3389/fpsyg.2023.1206960 Békés, V., Ménard, C. G., Schmitz, N., & Aafjes-van Doorn, K. (2023b). Therapist-reported differences between teletherapy via phone and via videoconferencing. Brain Sciences, 13(12), 1714. https://doi.org/10.3390/brainsci13121714 Bergman, M. M. (2008). Advances in mixed methods research: Theories and applications. Advances in Mixed Methods Research, 1-200. Bell, F. L. (2013). Psychotherapy via Skype: A therapist’s experience. The Psychiatrist, 37(4), 144-145. https://doi.org/10.1192/pb.37.4.144 Benrimoh, D., Chheda, F. D., & Margolese, H. C. (2022). The best predictor of the future—the metaverse, mental health, and lessons learned from current technologies. JMIR Mental Health, 9(10), e40410. https://doi.org/10.2196/40410 Ben-Porath, D. D. (2015). Orienting clients to telephone coaching in dialectical behavior therapy. Cognitive and Behavioral Practice, 22(4), 407-414. https://doi.org/10.1016/j.cbpra.2014.02.004 Ben-Salmon, A., Erez, O., & Crystal-Lilov, A. (2021). Zoom therapy: Online clinical setting – compromise or an opportunity? Academic Journal of Clinical Psychology and Mental Health, 1(1), 1-3. 140 Berryhill, M. B., Culmer, N., Williams, N., Halli-Tiemey, A., Betancourt, A., Roberts, H., & King, M. (2019a). Videoconferencing psychotherapy and depression: A systematic review. Telemedicine and e-Health, 25, 435-446. https://doi.org/10.1089/tmj.2018.0058 Berryhill, M. B., Halli-Tierney, A., Culmer, N., Williams, N., Betancourt, A., King, M., & Ruggles, H. (2019b). Videoconferencing psychological therapy and anxiety: A systematic review. Family Practice, 36(1), 53-63. https://doi.org/10.1093/fampra/cmy072 Beyea, D. G., Lim, C., Lover, A., Foxman, M., Ratan, R. R., & Leith, A. (2024). How bad is Zoom fatigue? A meta-analytical examination of research on the antecedents of videoconference fatigue. SSRN. Retrieved from https://papers.ssrn.com/sol3/papers.cfm?abstract_id=4758266 Blanchard, M., & Farber, B. A. (2016). Lying in psychotherapy: Why and what clients don’t tell their therapist about therapy and their relationship. Counselling Psychology Quarterly, 29(1), 90–112. https ://doi.org/10.1080/09515 070.2015.1085365 Blanchard, M., & Farber, B. A. (2020). “It is never okay to talk about suicide”: Patients’ reasons for concealing suicidal ideation in psychotherapy. Psychotherapy Research, 30(1), 124–136. https://doi.org/10.1080/10503307.2018.1543977 Bond, G. D. (2007). Deception detection expertise. Law and Human Behavior, 32, 339-351. https://doi.org/10.1007/s10979-007-9110-z Bond, C. F., & DePaulo, B. M. (2006). Accuracy of deception judgments. Personality and Social Psychology Review, 10(3), 214-234. doi:10.1207/s15327957pspr1003_2 Bouchard, S., Allard, M., Robillard, G., Dumoulin, S., Guitard, T., Loranger, C.,…& Corno, G. 141 (2020). Videoconferencing psychotherapy for panic disorder and agoraphobia: Outcome and treatment processes from a non-randomized non-inferiority trial. Frontiers in Psychology, 11, 2164. https://doi.org/10.3389/fpsyg.2020.02164 Bouchard, S., Paquin, B., Payeur, R., Allard, M., Rivard, V., Fournier, T., . . . & Lapierre, J. (2004). Delivering cognitive-behavior therapy for panic disorder with agoraphobia in videoconference. Telemedicine Journal and e-Health, 10, 13–25. https://doi.org/10.1089/ 153056204773644535 Boumparis, N., Schulte, M. H., & Riper, H. (2019). Digital mental health for alcohol and substance use disorders. Current Treatment Options in Psychiatry, 6, 352-366. https://doi.org/10.1007/s40501-019-00190-y Braun, V., & Clarke, V. (2019). Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health, 11(4), 589-597. https://doi.org/10.1080/2159676X.2019.1628806 Braun, V., Clarke, V., & Rance, N. (2014). How to use thematic analysis with interview data. In A. Vossler, & N. Moller (Eds.), The counselling & psychotherapy research handbook (pp. 183–197). Sage. Brennen, T., & Magnussen, S. (2020). Research on non-verbal signs of lies and deceit: A blind alley. Frontiers in Psychology, 11, 613410. https://doi.org/10.3389/fpsyg.2020.613410 Bremer, B. A., Foxx, R. M., Lee, M., Lykins, D., Mintz, V. R., & Stine, E. (2001). Potential clients' beliefs about the relative competency and caring of psychologists: Implications for the profession. Journal of Clinical Psychology, 57(12), 1479-1488. https://doi.org/10.1002/jclp.1111 142 Brimbal, L., Meissner, C. A., Kleinman, S. M., Phillips, E. L., Atkinson, D. J., Dianiska, R. E., Rothweiler, J. N., Oleszkiewicz, S., & Jones, M. S. (2021). Evaluating the benefits of a rapport-based approach to investigative interviews: A training study with law enforcement investigators. Law and Human Behavior, 45(1), 55–67. https://doi.org/10.1037/lhb0000437 Browning, M. E., Morena, A., Gould, E. R., & Lloyd-Richardson, E. E. (2023). Brief ACT for undergraduates: A mixed-methods pilot investigation of acceptance and commitment therapy delivered over Zoom. Journal of College Student Psychotherapy, 37(3), 279-299. https://doi.org/10.1080/87568225.2022.2029659 Burgoon, J. K. (2015). Rejoinder to Levine, Clare et al.'s comparison of the Park–Levine probability model versus interpersonal deception theory: Application to deception detection. Human Communication Research, 41(3), 327-349. https://doi.org/10.1111/hcre.12065 Burgoon, J. K., & Buller, D. B. (2008). Interpersonal deception theory. In L. A. Baxter & D. O. Braithewaite (Eds.), Engaging theories in interpersonal communication: Multiple perspectives (pp. 227–239). Sage. Burgoon, J. K., Chen, F., & Twitchell, D. P. (2010). Deception and its detection under synchronous and asynchronous computer-mediated communication. Group Decision and Negotiation, 19(4), 345–366. https://doi.org/10.1007/s10726-009-9168-8 Burgoon, J.K., Stoner, G. A., Bonito, J. A., & Dunbar, N. E. (2003). "Trust and deception in mediated communication," 36th Annual Hawaii International Conference on System Sciences. https://doi.org/10.1109/HICSS.2003.1173792. Cameron, S. K., Rodgers, J., & Dagnan, D. (2018). The relationship between the therapeutic 143 alliance and clinical outcomes in cognitive behaviour therapy for adults with depression: A meta‐analytic review. Clinical Psychology & Psychotherapy, 25(3), 446-456. https://doi.org/10.1002/cpp.2180 Canadian Psychological Association (2023). CPA guidelines on telepsychology. Retrieved from https://cpa.ca/docs/File/Practice/Telepsychology_Guidelines-September_2023-EN_FINAL.pdf Canadian Psychology Association (2004). Mutual recognition agreement. Retrieved from https://cpa.ca/docs/File/MRA2004.pdf Carlson, J. R., George, J. F., Burgoon, J. K., Adkins, M., & White, C. H. (2004). Deception in computer-mediated communication. Group Decision and Negotiation, 13, 5-28. https://doi.org/10.1023/B:GRUP.0000011942.31158.d8 Chapman, A. L. (2018). Phone coaching in dialectical behavior therapy. Guilford Publications. Cataldo, F., Mendoza, A., Chang, S., Buchanan, G., & Van Dam, N. T. (2023). Enhancing therapeutic processes in videoconferencing psychotherapy: Interview study of psychologists’ technological perspective. JMIR Formative Research, 7(1), e40542. https://doi.org/10.2196/40542 Chen, J. A., Chung, W. J., Young, S. K., Tuttle, M. C., Collins, M. B., Darghouth, S. L., . . . & Huffman, J. C. (2020). COVID-19 and telepsychiatry: Early outpatient experiences and implications for the future. General Hospital Psychiatry, 66, 89–95. https://doi.org/10.1016/j.genhosppsych.2020. 07.002 Cipolletta, S., Frassoni, E., & Faccio, E. (2018). Construing a therapeutic relationship online: An analysis of videoconference sessions. Clinical Psychologist, 22(2), 220–229. 144 https://doi.org/10.1111/cp.12117 Coman, G. J., Burrows, G. D., & Evans, B. J. (2001). Telephone counselling in Australia: Applications and considerations for use. British Journal of Guidance & Counselling, 29(2), 247-258. https://doi.org/10.1080/03069880124904 Connolloy, S. L., Stolzmann, K. L., Heyworth, L., Weaver, K. R., Bauer, M. S., & Miller, C. J. (2021). Rapid increase in telemental health within the department of veterans affairs during the COVID-19 pandemic. Telemedicine and eHealth, 27(4), 454-458. http://doi.org/10.1089/tmj.2020.0233 Creswell, J.W. (2003). Research design: Qualitative, quantitative, and mixed methods approaches. Sage Publications. Curtis, D. A. (2013). Therapists' beliefs and attitudes towards client deception. Texas Woman's University. Retrieved from https://www.proquest.com/openview/02e84e9c2af8abb8ff70d397af22d2a5/1?pq-origsite=gscholar&cbl=18750 Curtis, D. A., & Hart, C. L. (2015). Pinocchio’s nose in therapy: Therapists’ beliefs and attitudes toward client deception. International Journal for the Advancement of Counselling, 37, 279-292. https://doi.org/10.1007/s10447-015-9243-6 Curtis, D. A., & Hart, C. L. (2019). Deception in psychotherapy: Frequency, typology and relationship. Counselling & Psychotherapy Research, 20(1), 106-115. https://doi.org/10.1002/capr.12263 Dacillo, M. J. F., Dizon, J. K. M., Ong, E. J. T., Pingol, A. M. L., & Cleofas, J. V. (2022). 145 Videoconferencing fatigue and online student engagement among Filipino senior high school students: A mixed methods study. Frontiers in Education, 7. https://doi.org/10.3389/feduc.2022.973049 Daft, R. L., & Lengel, R. H. (1986). Organizational information requirements: Media richness and structural design. Management Science, 32(5), 554–571. https://doi.org/10.1287/mnsc.32.5.554 Dawadi, S., Shrestha, S., & Giri, R. A. (2021). Mixed-methods research: A discussion on its types, challenges, and criticisms. Journal of Practical Studies in Education, 2(2), 25-36 https://doi.org/10.46809/jpse.v2i2.20 Davis, M., & Markus, K. A. (2006). Misleading cues, misplaced confidence: An analysis of deception detection patterns. American Journal of Dance Therapy, 28, 107-126. https://doi.org/10.1007/s10465-006-9018-z Davis, K. A., Zhao, F., Janis, R. A., Castonguay, L. G., Hayes, J. A., & Scofield, B. E. (2024). Therapeutic alliance and clinical outcomes in teletherapy and in-person psychotherapy: A noninferiority study during the COVID-19 pandemic. Psychotherapy Research, 34(5), 589–600. https://doi.org/10.1080/10503307.2023.2229505 Deighton, R. M., Gurris, N., & Traue, H. (2007). Factors affecting burnout and compassion fatigue in psychotherapists treating torture survivors: Is the therapist's attitude to working through trauma relevant? Journal of Traumatic Stress, 20(1), 63-75. https://doi.org/10.1002/jts.20180 DePaulo, B. M., & Bell, K. L. (1996). Truth and investment: Lies are told to those who care. Journal of Personality and Social Psychology, 71, 703–716. https://doi.org/10.1037/0022-3514.71.4.703 146 DePaulo, B. M., Charlton, K., Cooper, H., Lindsay, J. J., & Muhlenbruck, L. (1997). The accuracy-confidence correlation in the detection of deception. Personality and Social Psychology Review, 1(4), 346–357. https://doi.org/10.1207/s15327957pspr0104_5 Dew, A., Bulkeley, K., Veitch, C., Bundy, A., Gallego, G., Lincoln, M., ... & Griffiths, S. (2013). Addressing the barriers to accessing therapy services in rural and remote areas. Disability and Rehabilitation, 35(18), 1564-1570. https://doi.org/10.3109/09638288.2012.720346 Dickens, C. R., & Curtis, D. A. (2019). Lies within the law: Therapist beliefs and attitudes about deception. Journal of Forensic Psychology Research and Practice, 19(5), 359-375. https://doi.org/10.1080/24732850.2019.1666604 Dunbar, N. E., Jensen, M. L., Tower, D. C., & Burgoon, J. K. (2014). Synchronization of nonverbal behaviors in detecting mediated and non-mediated deception. Journal of Nonverbal Behavior, 38, 355-376. https://doi.org/10.1007/s10919-014-0179-z Dunbar, N. E., Jensen, M. L., Burgoon, J. K., Kelley, K. M., Harrison, K. J., Adame, B. J., & Bernard, D. R. (2015). Effects of veracity, modality, and sanctioning on credibility assessment during mediated and unmediated interviews. Communication Research, 42(5), 649-674. https://doi.org/10.1177/0093650213480175 Ebardo, R., Padagas, R., & Trapero, H. (2021). Do boredom, escapism, apathy, and information overload lead to Zoom fatigue. In Proceedings of the 29th International Conference on Computers in Education, 2, 372-379. Retrieved from https://icce2021.apsce.net/wp-content/uploads/2021/12/ICCE2021-Vol.II-PP.-372-379.pdf Edelbluth, S., Schwartz, B., & Lutz, W. (2024). The effects of switching to video therapy on in-session processes in psychotherapy during the COVID-19 pandemic. Administration 147 and Policy in Mental Health and Mental Health Services Research, 1-11. https://doi.org/10.1007/s10488-024-01361-7 Ekberg, J., Timpka, T., Bång, M., Fröberg, A., Halje, K., & Eriksson, H. (2011). Cell phone- supported cognitive behavioural therapy for anxiety disorders: A protocol for effectiveness studies in frontline settings. BMC Medical Research Methodology, 11, 1-7. https://doi.org/10.1186/1471-2288-11-3 Eftychiou, L., & Morr, C. (2017). Mobile mental health virtual communities: Challenges and opportunities. The Digitization of Healthcare, 257-275. https://doi.org/10.1057/978-1-349-95173-4_15 Eichenberg, C., Aranyi, G., Rach, P., & Winter, L. (2022). Therapeutic alliance in psychotherapy across online and face-to-face settings: A quantitative analysis. Internet Interventions, 29, 100556. https://doi.org/10.1016/j.invent.2022.100556 Ekman, P., & O'Sullivan, M. (1991). Who can catch a liar? American Psychologist, 46(9), 913– 920. https://doi.org/10.1037/0003-066X.46.9.913 Ekman, P., O’Sullivan, M., & Frank, M. (1999). A few can catch a liar. Psychological Science, 10(3), 263-266. Eskritt, M., Fraser, B., & Bosacki, S. (2021). Did you just lie to me? Deception detection in face to face versus computer mediated communication. Journal of Social Psychology, 1-14. https://doi.org/10.1080/00224545.2021.1933884 Ertelt, T. W., Crosby, R. D., Marino, J. M., Mitchell, J. E., Lancaster, K., & Crow, S. J. (2011). Therapeutic factors affecting the cognitive behavioral treatment of bulimia nervosa via telemedicine versus face-to-face delivery. The International Journal of Eating Disorders, 44(8), 687–691. https://doi.org/10.1002/eat.20874 148 Fahlgren, M. K., Berman, M. E., & McCloskey, M. S. (2020). The role of therapeutic alliance in therapy for adults with problematic aggression and associated disorders. Clinical Psychology & Psychotherapy, 27(6), 858-886. https://doi.org/10.1002/cpp.2475 Farber, B. A., Blanchard, M., & Love, M. (2019). Secrets and lies in psychotherapy. American Psychological Association. https://doi.org/10.1037/0000128-000 Farber, B. A., & Sohn, A. E. (2007). Patterns of self-disclosure in psychotherapy and marriage. Psychotherapy: Theory, Research, Practice, Training, 44(2), 226–231. https://doi.org/10.1037/0033-3204.44.2.226 Fauville, G., Luo, M., Muller Queiroz, A. C., Bailenson, J. N., & Hancock, J. (2021). Nonverbal mechanisms predict zoom fatigue and explain why women experience higher levels than men. Retrieved from https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3820035 Fernandez-Alvarez, J., & Fernandez-Alvarez, H. (2021). Videoconferencing psychotherapy during the pandemic: Exceptional times with enduring effects? Frontiers in Psychology, 12. https://doi.org/10.3389/fpsyg.2021.589536 Fernandez, E., Woldgabreal, Y., Day, A., Pham, T., Fleich, B., & Abouojaoude, R. (2021). Live psychotherapy by video versus in-person: A meta-analysis of efficacy and its relationship to types and targets of treatment. Clinical Psychology and Psychotherapy. http://dx.doi.org/10.1002/cpp.2594 Figley, C. R. (2002). Compassion fatigue: Psychotherapists' chronic lack of self care. Journal of Clinical Psychology, 58(11), 1433-1441. https://doi.org/10.1002/jclp.10090 Fitt, S., & Rees, C. (2012). Metacognitive therapy for obsessive compulsive disorder by 149 videoconference: A preliminary study. Behaviour Change, 29, 213–229. https://doi.org/10. 1017/bec.2012.21 Fitzpatrick, K. M., Drawve, G., & Harris, C. (2020). Facing new fears during the COVID-19 pandemic: The state of America’s mental health. Journal of Anxiety Disorders, 75. https://doi.org/10.1016/j.janxdis.2020.102291 Foley, G. N., & Gentile, J. P. (2010). Nonverbal communication in psychotherapy. Psychiatry (Edgmont), 7(6), 38. Franklin, C. L., Cuccurullo, L. A., Walton, J. L., Arseneau, J. R., & Petersen, N. J. (2017). Face to face but not in the same place: A pilot study of prolonged exposure therapy. Journal of Trauma & Dissociation, 18, 116–130. https://doi.org/10.1080/15299732.2016.1205704 Fugard, A. J., & Potts, H. W. (2015). Supporting thinking on sample sizes for thematic analyses: A quantitative tool. International Journal of Social Research Methodology, 18(6), 669-684. https://doi.org/10.1080/13645579.2015.1005453 Full, W., Vossler, A., Moller, N., Pybis, J., & Roddy, J. (2024). Therapists' and counsellors' perceptions and experiences of offering online therapy during COVID‐19: A qualitative survey. Counselling and Psychotherapy Research, 24(2), 703-718. https://doi.org/10.1002/capr.12707 Geller, S. M. (2020). Cultivating online therapeutic presence: Strengthening therapeutic relationships in teletherapy sessions. Counselling Psychology Quarterly. https://doi.org/10.1080/09515070.2020.1787348 Giacco, L., Anguera, M. T., & Salcuni, S. (2020). The action of verbal and non-verbal 150 communication in the therapeutic alliance construction: A mixed methods approach to assess the initial interactions with depressed patients. Frontiers in Psychology, 11, 234. https://doi.org/10.3389/fpsyg.2020.00234 Gibbson, R. W., D’Amico, M., Jaffe, L., & Arbesman, M. (2011). Occupational therapy interventions for recovery in areas of community integration and normative life roles for adults with serious mental illness: A systematic review. American Journal of Occupational Therapy, 65(3), 247-256. https://doi.org/10.5014/ajot.2011.001297 Glass, V. Q., & Bickler, A. (2021). Cultivating the therapeutic alliance in a telemental health setting. Contemporary Family Therapy, 43, 189-198. https://doi.org/10.1007/s10591-021-09570-0 Glueckauf, R. L., Maheu, M. M., Drude, K. P., Wells, B. A., Wang, Y., Gustafson, D. J., & Nelson, E.-L. (2018). Survey of psychologists’ telebehavioral health practices: Technology use, ethical issues, and training needs. Professional Psychology: Research and Practice, 49(3), 205–219. https://doi.org/10.1037/pro0000188 Gonzalez, G. E., & Brossart, D. F. (2015). Telehealth videoconferencing psychotherapy in rural primary care. Journal of Rural Menta Health, 39(3-4), 137-152. http://dx.doi.org/10.1037/rmh0000037 Gray, R., & Brown, E. (2017). What does mental health nursing contribute to improving the physical health of service users with severe mental illness? A thematic analysis. International Journal of Mental Health Nursing, 26(1), 32-40. https://doi.org/10.1111/inm.12296 Goldin, P. R., Lindholm, R., Ranta, K., Hilgert, O., Helteenvuori, T., & Raevuori, A. (2019). 151 Feasibility of a therapist-supported, mobile phone–delivered online intervention for depression: Longitudinal observational study. JMIR Formative Research, 3(1), e11509. https://doi.org/10.2196/11509 Gunn, J. E., & Pistole, M. C. (2012). Trainee supervisor attachment: Explaining the alliance and disclosure in supervision. Training and Education in Professional Psychology, 6(4), 229–237. https://doi.org/10.1037/a0030805 Hall, S. B., Bartley, A. G., Wenk, J., Connor, A., Dugger, S. M., & Casazza, K. (2023). Rapid transition from in‐person to videoconferencing psychotherapy in a counselor training clinic: A safety and feasibility study during the COVID‐19 pandemic. Journal of Counseling & Development, 101(1), 84-95. https://doi.org/10.1002/jcad.12439 Hamatani, S., Numata, N., Matsumoto, K., Sutoh, C., Ibuki, H., Oshiro, K., . . . & Shimizu, E. (2019). Internet-based cognitive behavioral therapy via videoconference for patients with bulimia nervosa and binge-eating disorder: Pilot prospective single-arm feasibility trial. JMIR Formative Research, 3, e15738. https://doi.org/10.2196/15738 Hammond, T. E., Crowther, A., & Drummond, S. (2018). A thematic inquiry into the burnout experience of Australian solo-practicing clinical psychologists. Frontiers in Psychology, 8, 1996. https://doi.org/10.3389/fpsyg.2017.01996 Hancock, J. T., Thom-Santelli, J., & Ritchie, T. (2004). Deception and design: The impact of communication technology on lying behavior. Proceedings of the 2004 CHI Conference, 130–136. doi:10.1145/985692.985709 Hancock, J., & Woodworth, M. (2013). An “Eye” for an “I”: The challenges and opportunities 152 for spotting credibility in a digital world. In B. S. Cooper, D. Griesel, & M. Ternes (Eds.), Applied issues in investigative interviewing, eyewitness memory, and credibility assessment (pp. 325–340). Springer. Hancock, J., Woodworth, M. T., & Saurabh, G. (2010). See no evil: The effect of communication medium and motivation on deception detection. Group Decision and Negotiation, 19(4), 327-343. https://doi.org/10.1007/s10726-009-9169-7 Hart, C. L., Barnett, M., & Curtis, D. A. (2024). Client deception in therapy is associated with worse therapeutic relationships and perceived therapeutic outcomes. Counselling and Psychotherapy Research, 1-7. https://doi.org/10.1002/capr.12767 Hartwig, M., Granhag, P. A., Strömwall, L. A., & Vrij, A. (2004). Police officers’ lie detection accuracy: Interrogating freely versus observing video. Police Quarterly, 7(4), 429-456. https://doi.org/10.1177/1098611104264748 Harvey, P. D., Depp, C. A., Rizzo, A. A., Strauss, G. P., Spelber, D., Carpenter, L. L., ... & Torous, J. (2022). Technology and mental health: state of the art for assessment and treatment. American Journal of Psychiatry, 179(12), 897-914. https://doi.org/10.1176/appi.ajp.21121254 Heinonen, E., Lindfors, O., Laaksonen, M. A., & Knekt, P. (2012). Therapists' professional and personal characteristics as predictors of outcome in short-and long-term psychotherapy. Journal of Affective Disorders, 138(3), 301-312. https://doi.org/10.1016/j.jad.2012.01.023 Heinonen, E., Lindfors, O., Härkänen, T., Virtala, E., Jääskeläinen, T., & Knekt, P. 153 (2014). Therapists' professional and personal characteristics as predictors of working alliance in short‐term and long‐term psychotherapies. Clinical Psychology & Psychotherapy, 21(6), 475-494. https://doi.org/10.1002/cpp.1852 Hill, C. E., Thompson, B. J., Cogar, M. C., & Denman, D. W. (1993). Beneath the surface of long-term therapy: Therapist and client report of their own and each other's covert processes. Journal of Counseling Psychology, 40(3), 278–287. https://doi.org/10.1037/0022-0167.40.3.278 Hochheimer, C. J., Sabo, R. T., Perera, R. A., Mukhopadhyay, N., & Krist, A. H. (2019). Identifying attrition phases in survey data: Applicability and assessment study. Journal of Medical Internet Research, 21(8), e12811. https://doi.org/10.2196/12811 Holtom, B., Baruch, Y., Aguinis, H., & A Ballinger, G. (2022). Survey response rates: Trends and a validity assessment framework. Human Relations, 75(8), 1560-1584. https://doi.org/10.1177/001872672110707 Horvath, A. O. (1984). Working Alliance Inventory – Form T. Retrieved from http://wai.profhorvath.com/downloads Horvath, A. O., Re, A. C. D., Flückiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (pp. 25–69). Oxford University Press. https://doi.org/10.1093/acprof:oso/9780199737208.003.0002 Humer, E., Stippl, P., Pieh, C., Schimbock, W., & Probst, T. (2020). Psychotherapy via the internet: What programs do psychotherapists use, how well-informed do they feel, and what are their wishes for continuous education? International Journal of Environmental Research and Public Health, 17(21), 8182. https://doi.org/10.3390/ijerph17218182 154 Irvine, A., Drew, P., Bower, P., Brooks, H., Gellatly, J., Armitage, C. J., ... & Bee, P. (2020). Are there interactional differences between telephone and face-to-face psychological therapy? A systematic review of comparative studies. Journal of Affective Disorders, 265, 120-131. https://doi.org/10.1016/j.jad.2020.01.057 Jenner, B. M., & Myers, K. C. (2019). Intimacy, rapport, and exceptional disclosure: A comparison of in-person and mediated interview contexts. International Journal of Social Research Methodology, 22(2), 165-177. https://doi.org/10.1080/13645579.2018.1512694 Jones, N., & Moffitt, M. (2016). Ethical guidelines for mobile app development within health and mental health fields. Professional Psychology: Research and Practice, 47(2), 155–162. https://doi.org/10.1037/pro0000069 Kaeding, A., Sougleris, C., Reid, C., van Vreeswijk, M. F., Hayes, C., Dorrian, J., & Simpson, S. (2017). Professional burnout, early maladaptive schemas, and physical health in clinical and counselling psychology trainees. Journal of Clinical Psychology, 73(12), 1782-1796. https://doi.org/10.1002/jclp.22485 Kaplan, B. (2020). Seeing through health information technology: The need for transparency in software, algorithms, data privacy, and regulation. Journal of Law and the Biosciences, 7(1), lsaa062. https://doi.org/10.1093/jlb/lsaa062 Kim, S. K., Lee, M., Jeong, H., & Jang, Y. M. (2022). Effectiveness of mobile applications for patients with severe mental illness: A meta‐analysis of randomized controlled trials. Japan Journal of Nursing Science, 19(3), e12476. https://doi.org/10.1111/jjns.12476 Klooster, E., Koenders, N., Vermeulen-Holsen, J., Vos, L., van der Wees, P. J., & 155 Hoogeboom, T. J. (2022). Healthcare professionals feel empowered by implementing a hospital-based multifaceted intervention: A qualitative study using inductive thematic analysis. BMC Health Services Research, 22(1), 903. https://doi.org/10.1186/s12913-022-08310-w de Koning, R., Egiz, A., Kotecha, J., Ciuculete, A. C., Ooi, S. Z. Y., Bankole, N. D. A., ... & Kanmounye, U. S. (2021). Survey fatigue during the COVID-19 pandemic: An analysis of neurosurgery survey response rates. Frontiers in Surgery, 8, 690680. https://doi.org/10.3389/fsurg.2021.690680 Kottler, J. & Carlson, J. (2011). Duped: Lies and deception in psychotherapy. New York City, New York: Routledge/Taylor & Francis Group. Langarizadeh, M., Tabatabaei, M. S., Tavakol, K., Naghipour, M., Rostami, A., & Moghbeli, F. (2017). Telemental health care, an effective alternative to conventional mental care: A systematic review. Acta Informatica Medica, 25(4), 240. https://doi.org/10.5455/aim.2017.25.240-246 Latifi, R., & Doarn, C. R. (2020). Perspective on COVID-19: Finally, telemedicine at center stage. Telemedicine and e-Health, 26(9), 1106-1110. https://doi.org/10.1089/tmj.2020.0132 Landes, S. J., Matthieu, M. M., Smith, B. N., McBain, S. A., & Ray, E. S. (2021). Challenges and potential solutions to implementing phone coaching in dialectical behavior therapy. Cognitive and Behavioral Practice, 28(1), 66-76. https://doi.org/10.1016/j.cbpra.2019.10.005 Leach, M. J. (2005). Rapport: A key to treatment success. Complementary Therapies in Clinical Practice, 11(4), 262-265. https://doi.org/10.1016/j.ctcp.2005.05.005 156 Lee, E. B., Haeger, J. A., Levin, M. E., Ong, C. W., & Twohig, M. P. (2018). Telepsychotherapy for trichotillomania: A randomized controlled trial of ACT enhanced behavior therapy. Journal of Obsessive-Compulsive and Related Disorders, 18, 106–115. https://doi.org/10.1016/j.jocrd. 2018.04.003 Lee M. D., & Wagenmakers E. J. (2013). Bayesian modeling for cognitive science: A practical course. Cambridge, England: Cambridge University Press. Lester, D., & Rogers, J. R. (2012). Crisis intervention and counseling by telephone and the Internet. Charles C. Thomas Publisher. Leuchtenberg, S., Gromer, D., & Käthner, I. (2023). Videoconferencing versus face‐to‐face psychotherapy: Insights from patients and psychotherapists about comparability of therapeutic alliance, empathy and treatment characteristics. Counselling and Psychotherapy Research, 23(2), 389-403. https://doi.org/10.1002/capr.12538 Levine, T. R. (2014). Truth-default theory (TDT): A theory of human deception and deception detection. Journal of Language and Social Psychology, 33(4), 378–392. https://doi.org/10.1177/0261927x14535916 Levine, T. R., Daiku, Y., & Masip, J. (2022). The number of senders and total judgments matter more than sample size in deception-detection experiments. Perspectives on Psychological Science, 17(1), 191-204. https://doi.org/10.1177/1745691621990369 Levine, T. R., Park, H. S. & McCornack, S. A. (1999). Accuracy in detecting truths and lies: Documenting the “veracity effect”. Communication Monographs, 66, 125–144. Levine, T. R., Serota, K. B., & Punyanunt-Carter, N. M. (2022). Sender and receiver lie 157 frequencies and motives: Testing predictions from Truth-Default Theory. Southern Communication Journal, 87(3), 220-234. https://doi.org/10.1080/1041794X.2022.2052745 Levontin, L., Nakash, O., & Danziger, S. (2019). It takes two to self‐disclose: Incremental theorists facilitate others’ self‐disclosure more than do entity theorists. Journal of Personality, 87(6), 1264-1276. https://doi.org/10.1111/jopy.12473 Lin, T., & Anderson, T. (2024). Reduced therapeutic skill in teletherapy versus in‐person therapy: The role of non‐verbal communication. Counselling and Psychotherapy Research, 24(1), 317-327. https://doi.org/10.1002/capr.12666 Lin, T., Heckman, T. G., & Anderson, T. (2022). The efficacy of synchronous teletherapy versus in-person therapy: A meta-analysis of randomized clinical trials. Clinical Psychology: Science and Practice, 29(2), 167–178. https://doi.org/10.1037/cps0000056 Lin, T., Stone, S. J., & Anderson, T. (2024). A head start in the long race: Therapists are learning to adapt their therapeutic skills within teletherapy. Professional Psychology: Research and Practice. Advance online publication. https://doi.org/10.1037/pro0000572 Liu, L., Thorp, S. R., Moreno, L., Wells, S. Y., Glassman, L. H., Busch, A. C., ... & Agha, Z. (2019). Videoconferencing psychotherapy for veterans with PTSD: Results from a randomized controlled non-inferiority trial. Journal of Telemedicine and Telecare, 26, 507–519. https:// doi.org/10.1177/1357633X19853947 Lustgarten, S. D., Garrison, Y. L., Sinnard, M. T., & Flynn, A. W. (2020). Digital privacy in mental healthcare: Current issues and recommendations for technology use. Current Opinion in Psychology, 36, 25-31. https://doi.org/10.1016/j.copsyc.2020.03.012 Macdonald, J., & Morley, I. (2001). Shame and non-disclosure: A study of the emotional 158 isolation of people referred for psychotherapy. British Journal of Medical Psychology, 74(1), 1–21. https://doi.org/10.1348/000711201160731 Madigan, S., Racine, N., Cooke, J. E., & Korzak, D. J. (2021). COVID-19 and telemental health: Benefits, challenges, and future directions. Canadian Psychology, 62(15), 5-11. https://doi.org/10.1037/cap0000259 Mallen, M. J., Vogel, D. L., & Rochlen, A. B. (2005). The practical aspects of online counseling: Ethics, training, technology, and competency. The Counseling Psychologist, 33(6), 776-818. https://doi.org/10.1177/0011000005278625 Marcelle, E. T., Nolting, L., Hinshaw, S. P., & Aguilera, A. (2019). Effectiveness of a multimodal digital psychotherapy platform for adult depression: A naturalistic feasibility study. JMIR mHealth and uHealth, 7(1), e10948. https://doi.org/10.2196/10948 Markowitz, D. M. (2022). Revisiting the relationship between deception and design: A replication and extension of Hancock et al. (2004). Human Communication Research, 48(1), 158-167. https://doi.org/10.1093/hcr/hqab019 Marshall, J. M., Dunstan, D. A., & Bartik, W. (2021). Smartphone psychological therapy during COVID-19: A study on the effectiveness of five popular mental health apps for anxiety and depression. Frontiers in Psychology, 12, 775775. https://doi.org/10.3389/fpsyg.2021.775775 Marshall, J. M., Dunstan, D. A., & Bartik, W. (2020). Clinical or gimmickal: The use and effectiveness of mobile mental health apps for treating anxiety and depression. The Australian and New Zealand journal of psychiatry, 54(1), 20–28. https://doi.org/10.1177/0004867419876700 Martin, L. E. (2006). Lying in psychotherapy: Results of an exploratory study (Doctoral 159 dissertation). Retrieved from ProQuest dissertations and Theses database. (UMI No. 3253137). Martinengo, L., Van Galen, L., Lum, E., Kowalski, M., Subramaniam, M., & Car, J. (2019). Suicide prevention and depression apps’ suicide risk assessment and management: A systematic assessment of adherence to clinical guidelines. BMC Medicine, 17(1), 1-12. https://doi.org/10.1186/s12916-019-1461-z Matsumoto, K., Hamatani, S., Nagai, K., Sutoh, C., Nakagawa, A., & Shimizu, E. (2020). Long- term effectiveness and cost-effectiveness of videoconference-delivered cognitive behavioral therapy for obsessive-compulsive disorder, panic disorder, and social anxiety disorder in Japan: One-year follow-up of a single-arm trial. JMIR Mental Health, 7, e17157. https://doi.org/10.2196/17157 Matsumoto, K., Sutoh, C., Asano, K., Seki, Y., Urao, Y., Yokoo, M., . . . & Shimizu, E. (2018). Internet- based cognitive behavioral therapy with real-time therapist support via videoconference for patients with obsessive-compulsive disorder, panic disorder, and social anxiety disorder: Pilot single-arm trial. Journal of Medical Internet Research, 20, e12091. https://doi.org/10.2196/ 12091 McKim, C. A. (2017). The Value of Mixed Methods Research: A Mixed Methods Study. Journal of Mixed Methods Research, 11(2), 202- 222. https://doi.org/10.1177/1558689815607096 McQuaid, S. M., Woodworth, M., Hutton, E. L., Porter, S., & ten Brinke, L. (2015). Automated insights: Verbal cues to deception in real-life high-stakes lies. Psychology, Crime & Law, 21(7), 617-631. https://doi.org/10.1080/1068316X.2015.1008477 Mehrotra, A., Huskamp. H. A., Souza, J., Uscher-Pines, L., Rose, S., Landon, B. E., Jena, A. B., 160 & Busch, A. B. (2017). Rapid growth in mental health telemedicine use among rural Medicare beneficiaries, wide variation across states. Health Affairs, 36(5), 909-917. https://doi.org/10.1377/hlthaff.2016.1461 Meissner, C. A. (2021). “What works?” Systematic reviews and meta‐analyses of the investigative interviewing research literature. Applied Cognitive Psychology, 35(2), 322-328. https://doi.org/10.1002/acp.3808 Mendes-Santos, C., Weiderpass, E., Santana, R., & Andersson, G. (2020). Portuguese psychologists' attitudes toward internet interventions: Exploratory cross-sectional study. JMIR Mental Health, 7(4), e16817. https://doi.org/10.2196/16817 Messina, I., Gullo, S., Gelo, O., Giordano, C., & Salcuni, S. (2019). An overview of the Italian contribution to the international multisite SPRISTAD study on psychotherapy training. Research in Psychotherapy (Milano), 22(3), 418. https://doi.org/10.4081/ripppo.2019.418 Messina, I., & Löffler-Stastka, H. (2021). Psychotherapists' perception of their clinical skills and in-session feelings in live therapy versus online therapy during the COVID-19 pandemic: A pilot study. Research in psychotherapy (Milano), 24(1), 514. https://doi.org/10.4081/ripppo.2021.514 Messina, I., Gelo, O., Sambin, M., Bianco, F., Mosconi, A., Fenelli, A., …& Orlinsky, D. (2017). Trainees self-evaluation of their development as psychotherapists: An Italian contribution to an international collaborative study on psychotherapy training. Clinical Psychology & Psychotherapy, 25(2), 338-347. https://doi.org/10.1002/cpp.2165 Miller, R., Hilsenroth, M. J., & Hewitt, P. L. (2017). Perfectionism and therapeutic alliance: A review of the clinical research. Research in Psychotherapy: Psychopathology, Process, and Outcome, 20(1). https://doi.org/10.4081/ripppo.2017.264 161 Miller, G., & McDonald, A. (2020). Online art therapy during the COVID-19 pandemic. International Journal of Art Therapy, 25(4), 159-160. https://doi.org/10.1080/17454832.2020.1846383 Møller, A. M., Christensen, L. F., Hansen, J. P., & Andersen, P. T. (2022a). Patients’ acceptance of video consultations in the mental health services: A systematic review and synthesis of qualitative research. Digital Health, 8. https://doi.org/10.1177/20552076221075148 Møller, A. M., Hansen, J. P., & Andersen, P. T. (2022). Patients' experiences of home-based psychotherapy via videoconference: A qualitative study. Archives of Psychiatric Nursing, 39, 91-96. https://doi.org/10.1016/j.apnu.2022.03.004 Morriss, R., Patel, S., Malins, S., Guo, B., Higton, F., James, M., . . . & Tyrer, H. (2019). Clinical and economic outcomes of remotely delivered cognitive behaviour therapy versus treatment as usual for repeat unscheduled care users with severe health anxiety: A multicentre randomised controlled trial. BMC Medicine, 17, 16. https://doi.org/10.1186/s12916-019-1253-5v Muir, S. D., de Boer, K., Thomas, N., Seabrook, E., Nedeljkovic, M., & Meyer, D. (2020). Videoconferencing psychotherapy in the public sector: Synthesis and model for implementation. JMIR Mental Health, 7(1). https://mental.jmir.org/2020/1/e14996 Nadler, R. (2020). Understanding “Zoom fatigue”: Theorizing spatial dynamics as third skins in computer-mediated communication. Computers and Composition, 58, 102613. https://doi.org/10.1016/j.compcom.2020.102613 Nesher S. H., & Wehrt, W. (2022). Understanding “Zoom fatigue”: A mixed‐method approach. Applied Psychology, 71(3), 827-852. https://doi.org/10.1111/apps.12360 Nissen-Lie, H. A., Monsen, J. T., & Rønnestad, M. H. (2010). Therapist predictors of 162 early patient-rated working alliance: A multilevel approach. Psychotherapy Research, 20(6), 627-646. https://doi.org/10.1080/10503307.2010.497633 Norcross, J. C., & Wampold, B. E. (2011). Evidence-based therapy relationships: Research conclusions and clinical practices. Psychotherapy, 48(1), 98–102. https://doi.org/10.1037/a0022161 Nortje, A., & Tredoux, C. (2019). How good are we at detecting deception? A review of current techniques and theories. South African Journal of Psychology, 49(4), 491-504. https://doi.org/10.1177/0081246318822953 Norwood, C., Moghaddam, N. G., Malins, S., & Sabin‐Farrell, R. (2018). Working alliance and outcome effectiveness in videoconferencing psychotherapy: A systematic review and noninferiority meta‐analysis. Clinical Psychology & Psychotherapy, 25(6), 797-808. https://doi.org/10.1002/cpp.2315 Novak, M., Drummond, K. & Kumar, A. (2022) Healthcare professionals’ experiences with education in short term medical missions: An inductive thematic analysis. BMC Public Health 22, 997. https://doi.org/10.1186/s12889-022-13349-9 O'Connor, B. P. (2017). A first steps guide to the transition from null hypothesis significance testing to more accurate and informative Bayesian analyses. Canadian Journal of Behavioural Science / Revue canadienne des sciences du comportement, 49(3), 166–182. https://doi.org/10.1037/cbs0000077 Oducado, R. M. F., Fajardo, M. T. R., Parreño-Lachica, G. M., Maniago, J. D., Villanueva, P. M. 163 B., Dequilla, M. A. C. V., ... & Robite, E. E. (2021). Predictors of videoconference fatigue: Results from undergraduate nursing students in the Philippines. Asian Journal for Public Opinion Research, 9(4), 310-330. http://dx.doi.org/10.15206/ajpor.2021.9.4.310 Ogugua, J. O., Okongwu, C. C., Akomolafe, O. O., Anyanwu, E. C., & Daraojimba, O. D. (2024). Mental health and digital technology: a public health review of current trends and responses. International Medical Science Research Journal, 4(2), 108-125. https://doi.org/10.51594/imsrj.v4i2.754 Olds, K., & Hawkins, R. (2014). Precursors to measuring outcomes in clinical supervision: A thematic analysis. Training and Education in Professional Psychology, 8(3), 158–164. https://doi.org/10.1037/tep0000034 Oliveira, P. N., & Rizvi, S. L. (2018). Phone coaching in dialectical behavior therapy: Frequency and relationship to client variables. Cognitive Behaviour Therapy, 47(5), 383-396. https://doi.org/10.1080/16506073.2018.1437469 Ondrejková, N., & Halamová, J. (2022). Prevalence of compassion fatigue among helping professions and relationship to compassion for others, self‐compassion and self‐criticism. Health & Social Care in the Community, 30(5), 1680-1694. https://doi.org/10.1111/hsc.13741 Orlinsky, D. E., Botermans, J. F., & Rønnestad, M. H. (2001). Towards an empirically grounded model of psychotherapy training: Four thousand therapists rate influences on their development. Australian Psychologist, 36(2), 139-148. https://doi.org/10.1080/00050060108259646 Orlinsky, D., Rønnestad, M. H., Ambühl, H., Willutzki, U., Botersman, J.-F., Cierpka, M., John 164 Davis, & Davis, M. (1999). Psychotherapists' assessments of their development at different career levels. Psychotherapy: Theory, Research, Practice, Training, 36(3), 203–215. https://doi.org/10.1037/h0087772 Orlinsky, D. E., Strauss, B., Rønnestad, M. H., Hill, C., Castonguay, L., Willutzki, U., & Carlsson, J. (2015). A collaborative study of development in psychotherapy trainees. Psychotherapy Bulletin, 50(4), 21-25. Palmer, K. M., & Burrows, V. (2021). Ethical and safety concerns regarding the use of mental health–related apps in counseling: Considerations for counselors. Journal of Technology in Behavioral Science, 6(1), 137-150. https://doi.org/10.1007/s41347-020- 00160-9 Palmer, A., & Schwan, D. (2022). Beneficent dehumanization: Employing artificial intelligence and carebots to mitigate shame‐induced barriers to medical care. Bioethics, 36(2), 187-193. https://doi.org/10.1111/bioe.12986 Paulhus, D. L. (1998). Paulhus deception scales (PDS): the balanced inventory of desirable responding-7: user's manual. North Tanawanda, NY: Multi-Health Systems. Pipkin, A., Armitage, S., Knight, M., & Hogg, L. (2021). “A blank canvas of me”: An interpretive phenomenological analysis study of the experience of client self-disclosure in cognitive behavioral therapy for psychosis. Psychosis: Psychological, Social and Integrative Approaches, 13(3), 242-252. https://doi.org/10.1080/17522439.2021.1881597 Plano, V. L. & Ivankova, N. V. (2016). Mixed methods research. A guide to the field. Sage Publications. Pope, K. S., & Tabachnick, B. G. (1994). Therapists as patients: A national survey of 165 psychologists' experiences, problems, and beliefs. Professional Psychology: Research and Practice, 25(3), 247–258. https://doi.org/10.1037/0735-7028.25.3.247 Posluns, K., & Gall, T.L. (2020). Dear mental health practitioners, take care of yourselves: A literature review on self-care. International Journal of Advanced Counselling, 42, 1–20. https://doi.org/10.1007/s10447-019-09382-w Proudfoot, K. (2023). Inductive/Deductive hybrid thematic analysis in mixed methods tesearch. Journal of Mixed Methods Research, 17(3), 308-326. https://doi.org/10.1177/15586898221126816 Queiroz, A. C., Lee, A. Y., Luo, M., Fauville, G., Hancock, J. T., & Bailenson, J. N. (2023). Too tired to connect: Understanding the associations between video-conferencing, social connection and well-being through the lens of zoom fatigue. Computers in Human Behavior, 149, 107968. https://doi.org/10.1016/j.chb.2023.107968 Ratan, R., Miller, D. B., & Bailenson, J. N. (2022). Facial appearance dissatisfaction explains differences in zoom fatigue. Cyberpsychology, Behavior, and Social Networking, 25(2), 124-129. https://doi.org/10.1089/cyber.2021.0112 Reinhard, M.A., Sporer, S. L., & Scharmach, M. (2013). Perceived familiarity with a judgmental situation improves lie detection ability. Swiss Journal of Psychology, 72(1), 43–52. https://doi.org/10.1024/1421-0185/a000098 Richardson, M., Abraham, C., & Bond, R. (2012). Psychological correlates of university students' academic performance: A systematic review and meta-analysis. Psychological Bulletin, 138(2), 353–387. https://doi.org/10.1037/a0026838 Rodolfa, E., Bent, R., Eisman, E., Nelson, P., Rehm, L., & Ritchie, P. (2005). A cube model for competency development: Implications for psychology educators and 166 regulators. Professional Psychology: Research and Practice, 36(4), 347– 354. https://doi.org/10.1037/0735-7028.36.4.347 Rossell, S. L., Neill, E., Phillipou, A., Tan. E. J., Toh, W. L., Rheenen, T. E., & Meyer, D. (2021). An overview of current mental health in the general population of Australia during the COVID-19 pandemic: Results from the COLLATE project. Psychiatry Research, 296. https://doi.org/10.1016/j.psychres.2020.113660 Rosenbaum, S. M., Billinger, S., & Stieglitz, N. (2014). Let’s be honest: A review of experimental evidence of honesty and truth-telling. Journal of Economic Psychology, 45, 181-196. https://doi.org/10.1016/j.joep.2014.10.002 Rønnestad, M. H., Orlinsky, D. E., Schröder, T. A., Skovholt, T. M., & Willutzki, U. (2019). The professional development of counsellors and psychotherapists: Implications of empirical studies for supervision, training and practice. Counselling and Psychotherapy Research, 19(3), 214-230. https://doi.org/10.1002/capr.12198 Rummell, C. M. (2015). An exploratory study of psychology graduate student workload, health, and program satisfaction. Professional Psychology: Research and Practice, 46(6), 391–399. https://doi.org/10.1037/pro0000056 Ryan, G. W., & Bernard, H. R. (2003). Techniques to identify themes. Field methods, 15(1), 85-109. https://doi.org/10.1177/1525822X02239569 Sami, A. (2016). Integrating quantitative and qualitative data in mixed methods research— challenges and benefits. Journal of Education and Learning, 5(3), 288-296. Retrieved from http://www.ccsenet.org/journal/index.php/jel Sammons, M. T., VandenBos, G. R., Martin, J. N., & Elchert, D. M. (2020). Psychological 167 practice at six months of COVID-19: A follow-up to the first national survey of psychologists during the pandemic. Journal of Health Service Psychology, 46, 145-154. https://doi.org/10.1007/s42843-020-00024-z Sampaio, M., Navarro Haro, M. V., De Sousa, B., Vieira Melo, W., & Hoffman, H. G. (2021). Therapists make the switch to telepsychology to safely continue treating their patients during the COVID-19 pandemic. Virtual reality telepsychology may be next. Frontiers in Virtual Reality, 1, 576421. https://doi.org/10.3389/frvir.2020.576421 Sarfo, J. O., Debrah, T., Gbordzoe, N. I., Afful, W. T., & Obeng, P. (2021). Qualitative research designs, sample size and saturation: Is enough always enough. Journal of Advocacy, Research and Education, 8(3), 60-65. https://doi.org/10.13187/jare.2021.3.60 Satre, D. D., Meacham, M. C., Asarnow, L. D., Fisher, W. S., Fortuna, L. R., & Iturralde, E. (2021). Opportunities to integrate mobile app–based interventions into mental health and substance use disorder treatment services in the wake of COVID-19. American Journal of Health Promotion, 35(8), 1178-1183. https://doi.org/10.1177/08901171211055314 Schiller, B., Kuska, M., Becher-Urbaniak, S., Wimmer, E., Reisinger, M., & Mörtl, K. (2024). Online psychotherapy as a first clinical experience during the Covid-19 pandemic: A new generation of psychotherapists in the digital age. Heliyon, 10(8). https://doi.org/10.1016/j.heliyon.2024.e29464 Seivert, S., & Badowski, M. E. (2021). The rise of telemedicine: Lessons from a global pandemic. European Medical Journal: Innovations, 5(1), 64-69. Retrieved from https://emj.emg-health.com/wp-content/uploads/sites/2/2021/02/The-Rise-of-Telemedicine-Lessons-from-a-Global-Pandemic.pdf Semrad, M., & Scott-Parker, B. (2020). Police, personality and the ability to 168 deceive. International Journal of Police Science & Management, 22(1), 50-61. https://doi.org/10.1177/1461355719880568 Seuling, P. D., Fendel, J. C., Spille, L., Göritz, A. S., & Schmidt, S. (2023). Therapeutic alliance in videoconferencing psychotherapy compared to psychotherapy in person: A systematic review and meta-analysis. Journal of Telemedicine and Telecare, 1357633X231161774. https://doi.org/10.1177/1357633X231161774 Sherer, M., & Rogers, R. W. (1980). Effects of therapist's nonverbal communication on rated skill and effectiveness. Journal of Clinical Psychology, 36(3), 696-700. Shore, J. H., Schneck, C. D., Mishkind, M. C. (2020). Telepsychiatry and the coronavirus disease 2019 pandemic: Current and future outcomes of the rapid virtualization of psychiatric care. JAMA Psychiatry, 77, 1211-1212. https://doi.org/10.1001/jamapsychiatry.202 Simpson, S., Bell, L., Knox, J., & Mitchell, D. (2005). Therapy via videoconferencing: A route to client empowerment? Clinical Psychology & Psychotherapy, 12(2), 156–165. https://doi.org/10.1002/cpp.436 Simpson, S. G., & Reid, C. L. (2014). Therapeutic alliance in videoconferencing psychotherapy: A review. The Australian Journal of Rural Health, 22, 280-299. https://doi.org/10.1111/ajr.12149 Sinclair, S., Beamer, K., Hack, T. F., McClement, S., Raffin Bouchal, S., Chochinov, H. M., & Hagen, N. A. (2017). Sympathy, empathy, and compassion: A grounded theory study of palliative care patients’ understandings, experiences, and preferences. Palliative Medicine, 31(5), 437-447. https://doi.org/10.1177/0269216316663499 Six, S. G., Byrne, K. A., Tibbett, T. P., & Pericot-Valverde, I. (2021). Examining the 169 effectiveness of gamification in mental health apps for depression: Systematic review and meta-analysis. JMIR mental health, 8(11), e32199. https://doi.org/10.2196/32199 Smith, A. M., & Leach, A.-M. (2019). Confidence can discriminate between accurate and inaccurate lie decisions. Perspectives on Psychological Science, 1-10, 1062–1071. https://doi.org/10.1177/1745691619863431 Smith, K., Moller, N., Cooper, M., Gabriel, L., Roddy, J., & Sheehy, R. (2022). Video counselling and psychotherapy: A critical commentary on the evidence base. Counselling and Psychotherapy Research, 22(1), 92-97. https://doi.org/10.1002/capr.12436 Spennemann, D. H. (2022). Persistence and attrition among participants in a multi-page online survey recruited via Reddit’s social media network. Social Sciences, 11(2), 31. https://doi.org/10.3390/socsci11020031 Sprang, G., Clark, J. J., & Whitt-Woosley, A. (2007). Compassion fatigue, compassion satisfaction, and burnout: Factors impacting a professional's quality of life. Journal of Loss and Trauma, 12(3), 259-280. https://doi.org/10.1080/15325020701238093 Sprecher, S. (2021). Closeness and other affiliative outcomes generated from the Fast Friends procedure: A comparison with a small-talk task and unstructured self-disclosure and the moderating role of mode of communication. Journal of Social and Personal Relationships, 38(5), 1452-1471. https://doi.org/10.1177/0265407521996055 Stiefel, S. (2018). The chatbot will see you now: Protecting mental health confidentiality in software applications. The Columbia Science and Technology Law Review, 20, 333. Stecker, T., McHugo, G., Xie, H., Whyman, K., & Jones, M. (2014). RCT of a brief phone-based CBT intervention to improve PTSD treatment utilization by returning service members. Psychiatric Services, 65(10), 1232-1237. https://doi.org/10.1176/appi.ps.201300433 170 Stefan, A. M., Gronau, Q. F., Schönbrodt, F. D., & Wagenmakers, E. J. (2019). A tutorial on Bayes Factor Design Analysis using an informed prior. Behavior Research Methods, 51, 1042-1058. https://doi.org/10.3758/s13428-018-01189-8 Stoll, J., Müller, J. A., & Trachsel, M. (2020). Ethical issues in online psychotherapy: A narrative review. Frontiers in Psychology, 10. https://doi.org/10.3389/fpsyt.2019.00993 Stubbings, D. R., Rees, C. S., Roberts, L. D., & Kane, R. T. (2013). Comparing in-person to videoconference-based cognitive behavioral therapy for mood and anxiety disorders: Randomized controlled trial. Journal of Medical Internet Research, 15(11), e258. https://doi.org/10.2196/jmir.2564 Stubbings, D. R., Rees, C. S., & Roberts, L. D. (2015). New avenues to facilitate engagement in psychotherapy: The use of videoconferencing and text–chat in a severe case of obsessive‐compulsive disorder. Australian Psychologist, 50(4), 265-270. https://doi.org/10.1111/ap.12111 Street, C. N. H., & Masip, J. (2015). The source of the truth bias: Heuristic processing? Scandinavian Journal of Psychology, 56(3), 254-263. https://doi.org/10.1111/sjop.12204 Taylor, T. (2011). Video conferencing us talking face-to-face: Is video suitable for supportive dialogue? International Journal of Therapy and Rehabilitation, 18(7), 392-402. https://doi.org/10.12968/ijtr.2011.18.7.392 Theberge-Lapointe, N., Marchand, A., Langlois, F., Gosselin, P., & Watts, S. (2015). Efficacy of a cognitive-behavioural therapy administered by videoconference for generalized anxiety disorder. European Review of Applied Psychology, 65, 9–17. https://doi.org/10.1016/j.erap. 2014.10.001 Thomas, N., McDonald, C., de Boer, K., Brand, R. M., Nedeljkovic, M., & Seabook, L. (2021). 171 Review of the current empirical literature on using videoconferencing to deliver individual psychotherapist to adults with mental health problems. Psychology and Psychotherapy: Theory, Research, and Practice, 94, 954-883. https://doi.org/10.1111/papt.12332 Thompson, L., & McCabe, R. (2012). The effect of clinician-patient alliance and communication on treatment adherence in mental health care: A systematic review. BMC Psychiatry, 12, 87. https://doi.org/10.1186/1471-244X-12-87 Tilkidzhieva, E., Gelo, O. C., Gullo, S., Orlinsky, D. E., Mörtl, K., & Fiegl, J. (2019). Self‐ concept of relational skills in psychotherapy trainees: A pilot study. Counselling and Psychotherapy Research, 19(3), 311-320. https://doi.org/10.1002/capr.12217 Tuerk, P. W., Keller, S. M., & Acierno, R. (2018). Treatment for anxiety and depression via clinical videoconferencing: evidence base and barriers to expanded access in practice. Focus, 16(4), 363-369. https://doi.org/10.1176/appi.focus.20180027 van Swol, L. M., Braun, M. T., & Malhorta, D. (2012). Evidence for the Pinocchio effect: Linguistic differences between lies, deception by omissions, and truths. Discourse Processes, 49(2), 79-106. https://doi.org/10.1080/0163853X.2011.633331 Vaismoradi, M., Jones, J., Turunen, H., & Snelgrove, S. (2016). Theme development in qualitative content analysis and thematic analysis. Journal of Nursing Education and Practice, 6(5). https://doi.org/10.5430/jnep.v6n5p100 Vears, D. F., & Gillam, L. (2022). Inductive content analysis: A guide for beginning qualitative researchers. Focus on Health Professional Education: A Multi-disciplinary Journal, 23(1), 111-127. Retrieved from https://search.informit.org/doi/abs/10.3316/informit.455663644555599 172 Volz, S., Reinhard, M. A., & Müller, P. (2022). The confidence‐accuracy relation–A comparison of metacognition measures in lie detection. Applied Cognitive Psychology, 36(3), 673-684. https://doi.org/10.1002/acp.3953 Vrij, A. (2008). Detecting lies and deceit: Pitfalls and opportunities. Chichester, UK: Wiley. Vrij, A. (2019). Deception and truth detection when analyzing nonverbal and verbal cues. Applied Cognitive Psychology, 33(2), 160-167. https://doi.org/10.1002/acp.3457 Vrij, A., & Baxter, M. (1999). Accuracy and confidence in detecting truth and lies in elaborations and denials: Truth bias, lie bias and individual. Expert Evidence, 7, 25-36. https://doi.org/10.1023/A:1008932402565 Vrij, A., Edward, K., & Bull, R. (2001). Police officers' ability to detect deceit: The benefit of indirect deception detection measures. Legal and Criminological Psychology, 6(2), 185-196. https://doi.org/10.1348/135532501168271 Vrij, A., Hartwig, M., & Granhag, P. A. (2019). Reading lies: Nonverbal communication and deception. Annual Review of Psychology, 70, 295-317. https://doi.org/10.1146/annurev-psych-010418-103135 Vogel, P.A., Solem ,S., Hagen, K., Moen, E.M., Launes, G., Håland, Å.T., Hansen, B., Himle, J. A. (2014). A pilot randomized controlled trial of videoconference-assisted treatment for obsessive-compulsive disorder. Behavioural Research Theory, 63, 162-168. https://doi.org/10.1016/j.brat.2014.10.007 Wachi, T., Kuraishi, H., Watanabe, K., Otsuka, Y., Yokota, K., & Lamb, M. E. (2017). Police officers’ ability to detect lies within a deception paradigm. Psychology, Public Policy, and Law, 23(3), 301–311. https://doi.org/10.1037/law0000124 Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what 173 makes psychotherapy work. Routledge, New York. https://doi.org/10.4324/9780203582015 Wang, C. (2021). We don’t think this is a healthy therapeutic relationship: Therapist exposes BetterHelp’s problems in viral TikTok. Retrieved from https://www.dailydot.com/irl/therapist-explains-problems-betterhelp-tiktok/ Wang, K., Varma, D. S., & Prosperi, M. (2018). A systematic review of the effectiveness of mobile apps for monitoring and management of mental health symptoms or disorders. Journal of Psychiatric Research, 107, 73-78. https://doi.org/10.1016/j.jpsychires.2018.10.006 Watts, S., Mackenzie, A., Thomas, C., Griskaitis, A., Mewton, L., Williams, A., & Andrews, G. (2013). CBT for depression: A pilot RCT comparing mobile phone vs. computer. BMC Psychiatry, 13, 1-9. https://doi.org/10.1186/1471-244X-13-49 Watts, S., Marchand, A., Bouchard, S., Gosselin, P., Langlois, F., Belleville, G., & Dugas, M.J. (2020). Telepsychotherapy for generalized anxiety disorder: Impact on the working alliance. Journal of Psychotherapy Integration, 30, 208–225. https://doi.org/10.1037/int0000223 Wetzels, R., Matzke, D., Lee, M. D., Rouder, J. N., Iverson, G. J., & Wagenmakers, E. J. (2011). Statistical evidence in experimental psychology: An empirical comparison using 855 t-tests. Perspectives on Psychological Science, 6(3), 291-298. https://doi.org/10.1177/1745691611406923 Wickersham, A., Petrides, P. M., Williamson, V., & Leightley, D. (2019). Efficacy of mobile 174 application interventions for the treatment of post-traumatic stress disorder: A systematic review. Digital Health, 5, 2055207619842986. https://doi.org/10.1177/2055207619842986 Wiederhold, B. K. (2020). Connecting through technology during the coronavirus disease 2019 pandemic: Avoiding “Zoom Fatigue”. Cyberpsychology, Behavior, and Social Networking, 23(7), 437-438. https://doi.org/10.1089/cyber.2020.29188.bkw Wisniewski, H., Liu, G., Henson, P., Vaidyam, A., Hajratalli, N. K., Onnela, J. P., & Torous, J. (2019). Understanding the quality, effectiveness and attributes of top-rated smartphone health apps. BMJ Mental Health, 22(1), 4-9. https://doi.org/10.1136/ebmental-2018-300069 Wittson, C. L. (1965). Nebraska initiates cross-country TV psychiatry. Educational Screen and Audiovisual Guide, 44(11), 22-23. Yarbrough, J. R. (2020). The Science of Deception Detection: A Literature and Policy Review on Police Ability to Detect Lies. Journal of Criminal Justice and Law. https://doi.org/10.21428/b6e95092.388a0120 Yu, Z., Roberts, B., Snyder, J., Stuart, K., Wilburn, J., Pudwill, H., & Cortazzo, K. (2020). A pilot study of a videoconferencing-based binge eating disorder program in overweight or obese females. Telemedicine and e-Health, 27(3). https://doi.org/10.1089/tmj.2020.0070 Zhou, L., & Zhang, D. (2007). Typing or messaging? Modality effect on deception detection in computer-mediated communication. Decision Support Systems, 44(1), 188–201. https://doi.org/10.1016/j.dss.2007.03.012 175 Appendices Appendix A 1. How many years of therapy experience do you have? ___________ 2. How many direct client therapy hours do you have (estimate)?_____________ 3. Please rank your top 2-3 psychotherapy orientations that comprise your therapeutic approach (listed alphabetically): a. Acceptance and Commitment therapy (ACT) b. Cognitive-behavioral therapy (CBT) c. Dialectical-behavior therapy (DBT) d. Emotion-Focused therapy (EFT) e. Humanistic/Person Centred therapy f. Interpersonal Psychotherapy (IPT) g. Integrative therapy h. Psychodynamic/Psychoanalytic i. Other (please specify): ________ Definition of video-conferencing psychotherapy: Video-conferencing psychotherapy is a form of psychotherapy there is delivered through a video-conferencing platform that provides both audio and visual information. Some platforms include Skype, Zoom, Microsoft Teams, or even an internal health authority system, amongst others. 4. The COVID-19 pandemic has resulted in practitioners, at times, choosing to shift delivery of psychological services from in-person to online, typically through videoconferencing platforms. How much training have you had with conducting videoconferencing psychotherapy? 5. How would you describe your experience with the shift towards virtual/online services? 176 6. Did you conduct/offer video-conferencing psychotherapy before the COVID-19 pandemic? (Yes/no) a. If yes, please indicate how long you have been offering video-conferencing psychotherapy: ___________ 7. Please indicate the percentage of your therapy services that was offered virtually before the pandemic? 8. Please indicate the percentage of your therapy services that was offered virtually after the pandemic? a. Do you expect this percentage to be remain stable as you continue to offer services? Why or why not? 177 Appendix B 1. Which do you prefer as the communication medium for your psychological practice? a. Videoconferencing psychotherapy b. Face-to-face c. Combined/hybrid practice d. Other, please specify: _________ 2. How comfortable are you with using videoconferencing technology to deliver virtual services? a. Likert Scale ranging from 1 (“Very Uncomfortable”) to 5 “(Very Comfortable”) 3. Please rate your level of fatigue following a face-to-face therapy session. a. Likert Scale ranging from 1 (“Not at all fatigued”) to 5 (“Very fatigued”) 4. Please rate your level of fatigue following a videoconferencing therapy session. a. Likert Scale ranging from 1 (“Not at all fatigued”) to 5 (“Very fatigued”) 5. How does the level of general fatigue experienced when conducting a face-to-face therapy session compare to conducting videoconferencing psychotherapy? 6. Please rate your level of emotional fatigue following a face-to-face therapy session. a. Likert Scale ranging from 1 (“Not at all fatigued”) to 5 (“Very fatigued”) 7. Please rate your level of emotional fatigue following a videoconferencing therapy session. a. Likert Scale ranging from 1 (“Not at all fatigued”) to 5 (“Very fatigued”) 8. How does the level of emotional fatigue experienced when conducting a face-to-face therapy session compare to conducting videoconferencing psychotherapy? 9. Please rate your level of mental fatigue following a face-to-face therapy session. 178 a. Likert Scale ranging from 1 (“Not at all fatigued”) to 5 (“Very fatigued”) 10. Please rate your level of mental fatigue following a videoconferencing therapy session. a. Likert Scale ranging from 1 (“Not at all fatigued”) to 5 (“Very fatigued”) 11. How does the level of mental fatigue experienced when conducting a face-to-face therapy session compare to conducting videoconferencing psychotherapy? 12. Please rate your level of effort for face-to-face therapy. a. Scale ranging from 1 (“Extremely low”) to 7 “(Extremely high”) 13. Please rate your level of effort for videoconferencing psychotherapy. a. Scale ranging from 1 (“Extremely low”) to 7 (“Extremely high”) 14. How does the level of effort needed for a face-to-face therapy session compare to conducting videoconferencing psychotherapy? 15. Please describe your experience with conducting therapeutic exercises/interventions (i.e., challenging clients, reviewing homework exercises, goal setting, etc.) in video-conferencing psychotherapy. 179 Appendix C 1. Recently in your face-to-face therapy sessions, how often have you found yourself feeling ... (Response options are on a ten-point Likert scale, including 0 (“Never”), 2 (“Rarely”), 4 (“Occasionally”), 6 (“Fairly”), 8 (“Often”), 10 (“Very often”)) a. Anxious b. Bored c. Calm d. Challenged e. Creative f. Drowsy g. Engrossed h. Enthused i. Focused j. Inattentive k. Inspired l. Overwhelmed m. Pressured n. Relaxed o. Stimulated p. Tense q. Trapped 2. Recently in your videoconferencing psychotherapy sessions, how often have you found yourself feeling ... (Response options are on a ten-point Likert scale, including 0 (“Never”), 2 (“Rarely”), 4 (“Occasionally”), 6 (“Fairly”), 8 (“Often”), 10 (“Very often”)) a. Anxious b. Bored c. Calm d. Challenged e. Creative f. Drowsy g. Engrossed h. Enthused i. Focused j. Inattentive k. Inspired l. Overwhelmed m. Pressured n. Relaxed o. Stimulated p. Tense q. Trapped 180 Appendix D 1. How would you describe the effectiveness of your clinical competencies/skills in videoconferencing psychotherapy? a. How does this compare to face-to-face therapy? 2. How would you describe the effectiveness of your clinical competencies/skills when delivering services over the phone? Please elaborate. a. How does this compare to face-to-face therapy? 3. Currently, in face-to-face/in-person therapy/counseling… (Response options are on a ten-point Likert scale, including 0 (“Not at all”), 2 (“Slightly”), 4 (“Somewhat”), 6 (“Moderately”), 8 (“Much”), 10 (“Very much”) a. How effective are you at engaging patients/clients in a working alliance? b. How ‘natural’ (authentically personal) do you feel? c. How much mastery do you have of the techniques and strategies involved in practicing therapy? d. How well do you understand the moment- by-moment process in sessions? e. How effectively do you communicate your understanding and concern to clients? f. How well are you able to detect and deal the emotional reactions that your patients/clients have towards you? g. How good are you at making constructive use of your own personal reactions to patients/clients? h. How much precision, subtlety and finesse have you attained in your therapeutic work? i. How effective are you in helping your patients/clients? 181 4. Currently, in videoconferencing psychotherapy… (Response options are on a ten-point Likert scale, including 0 (“Not at all”), 2 (“Slightly”), 4 (“Somewhat”), 6 (“Moderately”), 8 (“Much”), 10 (“Very much”) a. How effective are you at engaging patients/clients in a working alliance? b. How ‘natural’ (authentically personal) do you feel? c. How much mastery do you have of the techniques and strategies involved in practicing therapy? d. How well do you understand the moment- by-moment process in sessions? e. How effectively do you communicate your understanding and concern to clients? f. How well are you able to detect and deal the emotional reactions that your patients/clients have towards you? g. How good are you at making constructive use of your own personal reactions to patients/clients? h. How much precision, subtlety and finesse have you attained in your therapeutic work? i. How effective are you in helping your patients/clients? 5. Currently, in phone therapy/counseling… (Response options are on a ten-point Likert scale, including 0 (“Not at all”), 2 (“Slightly”), 4 (“Somewhat”), 6 (“Moderately”), 8 (“Much”), 10 (“Very much”)) a. How effective are you at engaging patients/clients in a working alliance? b. How ‘natural’ (authentically personal) do you feel? c. How much mastery do you have of the techniques and strategies involved in practicing therapy? 182 d. How well do you understand the moment- by-moment process in sessions? e. How effectively do you communicate your understanding and concern to clients? f. How well are you able to detect and deal the emotional reactions that your patients/clients have towards you? g. How good are you at making constructive use of your own personal reactions to patients/clients? h. How much precision, subtlety and finesse have you attained in your therapeutic work? i. How effective are you in helping your patients/clients? 183 Appendix E Definition of lying: A successful or unsuccessful intentional attempt to try and mislead someone. Some lies are completely false statements, while others are truths with details made up or left out. 1. How familiar are you with the literature (i.e., books, journal articles) on deception? a. Likert scale ranging from 1 (“None”) to 7 (“Very Much”) 2. How confident are you that you can detect when clients are lying to you face-to-face? a. Likert scale ranging from 1 (“Not very confident”) to 7 (“Extremely confident”) 3. How confident are you that you can detect when clients are lying to you over videoconferencing? a. Likert scale ranging from 1 (“Not very confident”) to 7 (“Extremely confident”) 4. How often do you think clients lie to you face-to-face in therapy? a. Likert scale ranging from 1 (“Never”) to 7 “(Very often”) 5. How often do you think clients lie to you over videoconferencing in therapy? a. Likert scale ranging from 1 (“Never”) to 7 “(Very often”) 6. Please provide an estimate about how many lies you think a client would be inclined to tell in a face-to-face therapy session. 7. Please provide an estimate about how many lies you think a client would be inclined to tell in a videoconferencing therapy session. 8. How important is detecting client’s lies in face-to-face therapy? a. Likert scale ranging from 1 (“Not at all important”) to 7 (“Very important”) 9. How important is detecting client’s lies over videoconferencing in therapy? a. Likert scale ranging from 1 (“Not at all important”) to 7 (“Very important”) 184 10. How believable do you think clients are when providing inaccurate information face-to-face in therapy? a. Likert scale ranging from 1 (“Not at all believable”) to 7 (“Very believable”) 11. How believable do you think clients are when providing inaccurate information over videoconferencing in therapy? a. Likert scale ranging from 1 (“Not at all believable”) to 7 (“Very believable”) 185 Appendix F 1. How comfortable do you think clients are disclosing information face-to-face? a. Likert scale ranging from 1 (“Not at all comfortable”) to 5 (“Very comfortable”) 2. How comfortable do you think clients are disclosing information over videoconferencing? a. Likert scale ranging from 1 (“Not at all comfortable”) to 5 (“Very comfortable”) 3. How comfortable do you think clients are disclosing information in therapy face-to-face? a. Likert scale ranging from 1 (“Not at all comfortable”) to 5 (“Very comfortable”) 4. How comfortable do you think clients are disclosing information in therapy over videoconferencing? a. Likert scale ranging from 1 (“Not at all comfortable”) to 5 (“Very comfortable”) 5. How do you think a client’s comfort disclosing information face-to-face compares to a client’s comfort disclosing over videoconferencing? Please elaborate. 186 Appendix G 1. How comfortable do you feel disclosing information face-to-face? a. Likert scale ranging from 1 (“Not at all comfortable”) to 5 (“Very comfortable”) 2. How comfortable do you feel disclosing information over videoconferencing? a. Likert scale ranging from 1 (“Not at all comfortable”) to 5 (“Very comfortable”) 3. How comfortable do you feel disclosing information in therapy face-to-face? a. Likert scale ranging from 1 (“Not at all comfortable”) to 5 (“Very comfortable”) 4. How comfortable do you feel disclosing information in therapy over videoconferencing? a. Likert scale ranging from 1 (“Not at all comfortable”) to 5 (“Very comfortable”) 5. How does your comfort disclosing information face-to-face compare to your comfort disclosing over videoconferencing in therapy? Please elaborate. 187 Appendix H Definition of lying: A successful or unsuccessful intentional attempt to try and mislead someone. Some lies are completely false statements, while others are truths with details made up or left out. 1. How often would you say you lie face-to-face? a. Likert scale ranging from 1 (“Never”) to 7 (“Very often”) 2. How often would you say you lie over videoconferencing? a. Likert scale ranging from 1 (“Very rarely) to 7 “(Very often”) 3. Please provide an estimate about how many lies you think you tell face-to-face. 4. Please provide an estimate about how many lies you think you tell over videoconferencing. 5. How believable do you think you are when lying face-to-face? a. Likert scale ranging from 1 (“Not at all believable”) to 5 (“Very believable”) 6. How believable do you think you are when lying over videoconferencing? a. Likert scale ranging from 1 (“Not at all believable”) to 5 (“Very believable”) 7. If you were in a face-to-face therapy session, how often do you think you would lie? a. Likert scale ranging from 1 (“Never”) to 7 (“Very often”) 8. If you were in a videoconferencing therapy session, how often do you think you would lie? a. Likert scale ranging from 1 (“Very rarely) to 7 “(Very often”) 9. How do you think the frequency of lying in therapy face-to-face would compare to the frequency of lying over videoconferencing in therapy? Please elaborate. 10. Please provide an estimate about how many lies you think you would tell in a face-to-face therapy session. 188 11. Please provide an estimate about how many lies you think you would tell in a videoconferencing therapy session. 12. How believable do you think you would be when lying in therapy face-to-face? a. Likert scale ranging from 1 (“Not at all believable”) to 5 (“Very believable”) 13. How believable do you think you would be when lying in therapy over videoconferencing? a. Likert scale ranging from 1 (“Not at all believable”) to 5 (“Very believable”) 14. How does your perceived believability in face-to-face therapy compare to your perceived believability in videoconferencing therapy? Please elaborate. 189 Appendix I 1. Before making a telephone call, do you ever rehearse what you’re going to say? Why? 2. For what in your life do you feel most grateful? 3. If you could change anything about the way you were raised, what would it be? Why? 4. Is there something that you’ve dreamed of doing for a long time? Why haven’t you done it? 5. What is the greatest accomplishment in your life? 6. What is one of your most treasured memories? 7. How do you feel about your relationship with your mother or mother figure? 8. When did you last cry in front of another person? By yourself? Additional Question for Introduction Task 1. Complete this sentence “I wish I had someone with whom I could share…” 190 Appendix J 1. How long have you been a registered psychologist? 2. Please rank your top 2-3 psychotherapy orientations that comprise your therapeutic approach (listed alphabetically): a. Acceptance and Commitment therapy (ACT) b. Cognitive-behavioral therapy (CBT) c. Dialectical-behavior therapy (DBT) d. Emotion-Focused therapy (EFT) e. Humanistic/Person Centred therapy f. Interpersonal Psychotherapy (IPT) g. Integrative therapy h. Psychodynamic/Psychoanalytic i. Other (please specify): ________ 3. What is your current therapy work setting: a. Counselling centre b. Community Health Authority c. Hospital d. Veterans Affairs e. Military f. Private Practice g. Academic h. Mixed (please specify):__________ i. Other (please specify):_____________ 191 Definition of video-conferencing psychotherapy: Video-conferencing psychotherapy is a form of psychotherapy that is delivered through a video-conferencing platform that provides both audio and visual information. Some platforms include Skype, Zoom, Microsoft Teams, or even an internal health authority system, amongst others. 4. The COVID-19 pandemic has resulted in practitioners, at times, choosing to shift delivery of psychological services from in-person to online, typically through videoconferencing platforms. How much training have you had with conducting videoconferencing psychotherapy? 5. How would you describe your experience with the shift towards virtual/online services? 6. Did you conduct/offer video-conferencing psychotherapy before the COVID-19 pandemic? (Yes/no) a. If yes, please indicate how long you have been offering video-conferencing psychotherapy: ___________ 7. Please indicate the percentage of your psychological practice that was offered virtually before the pandemic? 8. Please indicate the percentage of your psychological practice that was offered virtually after the pandemic? a. Do you expect this percentage to be remain stable as you continue to offer services? Why or why not? Definition of mental health application: Mental health applications (sometimes called “e-health applications” or “mobile mental health applications”) are mobile/phone applications (i.e., apps) that offer comprehensive therapeutic treatment and/or diagnosis for a mental health disorder. This is primarily accomplished by connecting clients and therapists on these mental health 192 applications via text (occasionally via videoconferencing), or by delivering a self-paced intervention (i.e., online modules/course). Mental health applications are separate from videoconferencing psychotherapy in that clients are not guaranteed to work with the same therapists for some platforms, some mental health applications will choose a therapist for a client, and mental health applications offer 24/7 service. Some examples of mental health applications include BetterHelp, Talkspace, Bliss, and ReGain (amongst others). 1. Are you familiar with mental health applications? a. If yes, please elaborate. 2. What do you perceive as the advantages of mental health applications (e.g., BetterHelp) for potential clients? 3. What do you perceive as the disadvantages of mental health applications (e.g., BetterHelp) for potential clients? 4. What is your opinion on how effective mental health applications (such as BetterHelp) are in helping individuals with their mental health concerns? 193 Appendix K Definition of video-conferencing psychotherapy: Video-conferencing psychotherapy is a form of psychotherapy that is delivered through a video-conferencing platform that provides both audio and visual information. Some platforms include Skype, Zoom, Microsoft Teams, or even an internal health authority system, amongst others. 1. The COVID-19 pandemic has resulted in practitioners, at times, choosing to shift delivery of psychological services from in-person to online, typically through videoconferencing platforms. How much training have you had with conducting videoconferencing psychotherapy? 2. How would you describe your experience with the shift towards virtual/online services? 3. Did you conduct/offer video-conferencing psychotherapy before the COVID-19 pandemic? (Yes/no) a. If yes, please indicate how long you have been offering video-conferencing psychotherapy: ___________ 4. Please indicate the percentage of your psychological practice that was offered virtually before the pandemic? 5. Please indicate the percentage of your psychological practice that was offered virtually after the pandemic? a. Do you expect this percentage to be remain stable as you continue to offer services? Why or why not? 6. Which do you prefer as the communication medium for your psychological practice? a. Videoconferencing psychotherapy b. Face-to-face 194 c. Combined/hybrid practice d. Other, please specify: _________ 7. How comfortable are you with using videoconferencing technology to deliver virtual services? a. Likert Scale ranging from 1 (“Very uncomfortable”) to 5 “(Very Comfortable”) 8. Please rate your level of general fatigue following a face-to-face therapy session. a. Likert Scale ranging from 1 (“Not at all fatigued”) to 5 (“Very fatigued”) 9. Please rate your level of general fatigue following a videoconferencing psychotherapy session. a. Likert Scale ranging from 1 (“Not at all fatigued”) to 5 (“Very fatigued”) 10. How does the level of general fatigue experienced when conducting a face-to-face therapy session compare to the level of general fatigue experienced when conducting videoconferencing psychotherapy? 11. Please rate your level of emotional fatigue following a face-to-face therapy session. a. Likert Scale ranging from 1 (“Not at all fatigued”) to 5 (“Very fatigued”) 12. Please rate your level of emotional fatigue following a videoconferencing therapy session. a. Likert Scale ranging from 1 (“Not at all fatigued”) to 5 (“Very fatigued”) 13. How does the level of emotional fatigue experienced when conducting a face-to-face therapy session compare to the level of emotional fatigue experienced when conducting videoconferencing psychotherapy? 14. Please rate your level of mental fatigue following a face-to-face therapy session. a. Likert Scale ranging from 1 (“Not at all fatigued”) to 5 (“Very fatigued”) 195 15. Please rate your level of mental fatigue following a videoconferencing psychotherapy session. a. Likert Scale ranging from 1 (“Not at all fatigued”) to 5 (“Very fatigued”) 16. How does the level of mental fatigue experienced when conducting a face-to-face therapy session compare to the level of mental fatigue experienced when conducting videoconferencing psychotherapy? 17. Please rate your level of mental effort for face-to-face therapy. a. Scale ranging from 1 (“Extremely low”) to 7 “(Extremely high”) 18. Please rate your level of mental effort for videoconferencing psychotherapy. a. Scale ranging from 1 (“Extremely low”) to 7 “(Extremely high”) 19. How does the level of mental effort needed for a face-to-face therapy session compare to the level of mental effort needed for videoconferencing psychotherapy? 20. Please describe your experience in conducting therapeutic exercises/interventions (i.e., challenging clients, reviewing homework exercises, goal setting, etc.) in video-conferencing psychotherapy.
Thesis/Dissertation
eng
Psychology
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Woodworth, Michael T.
The therapist's dual reality : an investigation into the impact of videoconferencing psychotherapy (VCP) on therapists' perceptions of their clinical abilities
Text