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Therapists' Self-Efficacy and Experiences Managing Clinical Risk in Teletherapy: A Mixed Methods Exploration

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Title: Therapists' Self-Efficacy and Experiences Managing Clinical Risk in Teletherapy: A Mixed Methods Exploration
Language: English
Authors: Nigel Jaffe (ORCID 0000-0001-7405-8094), Stephanie Jarvi Steele (ORCID 0000-0001-7712-9134)
Source: British Journal of Guidance & Counselling. 2025 53(2):206-220.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 15
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Descriptors: Counselor Attitudes, Self Efficacy, Patients, At Risk Persons, Counseling Techniques, Intervention, Therapy, Evidence Based Practice, Risk Management, Self Destructive Behavior, COVID-19, Pandemics, Psychopathology, Counselor Client Relationship, Computer Simulation, Videoconferencing, Mental Health, Health Services
DOI: 10.1080/03069885.2024.2311209
ISSN: 0306-9885
1469-3534
Abstract: Before teletherapy usage grew dramatically during COVID-19, clinicians considered it less suitable for patients experiencing high-risk behaviours and related psychopathology (e.g., self-injurious thoughts and behaviours). This mixed methods study assesses clinicians' concerns by quantitatively and qualitatively exploring their experiences, satisfaction, and self-efficacy using teletherapy for high-risk patients. Mental healthcare providers (N = 75) completed a survey assessing teletherapy usage, attitudes, and risk assessment/management self-efficacy. Nine providers then completed semi-structured interviews on these topics. Clinicians reported more confidence assessing and managing risk in-person as compared to teletherapy, and they reported being more likely to treat high-risk patients face-to-face than virtually. Still, attitudes toward teletherapy were generally positive, and clinicians who confidently managed risk in-person also tended to be confident virtually, often reporting that they could administer evidence-based therapeutic interventions regardless of therapy modality. Qualitative analyses revealed both general and person-specific factors that conferred increased or diminished confidence when managing risk.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1478465
Database: ERIC
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  Value: <anid>AN0186912257;bjg01apr.25;2025Jul29.03:28;v2.2.500</anid> <title id="AN0186912257-1">Therapists' self-efficacy and experiences managing clinical risk in teletherapy: a mixed methods exploration </title> <p>Before teletherapy usage grew dramatically during COVID-19, clinicians considered it less suitable for patients experiencing high-risk behaviours and related psychopathology (e.g., self-injurious thoughts and behaviours). This mixed methods study assesses clinicians' concerns by quantitatively and qualitatively exploring their experiences, satisfaction, and self-efficacy using teletherapy for high-risk patients. Mental healthcare providers (N = 75) completed a survey assessing teletherapy usage, attitudes, and risk assessment/management self-efficacy. Nine providers then completed semi-structured interviews on these topics. Clinicians reported more confidence assessing and managing risk in-person as compared to teletherapy, and they reported being more likely to treat high-risk patients face-to-face than virtually. Still, attitudes toward teletherapy were generally positive, and clinicians who confidently managed risk in-person also tended to be confident virtually, often reporting that they could administer evidence-based therapeutic interventions regardless of therapy modality. Qualitative analyses revealed both general and person-specific factors that conferred increased or diminished confidence when managing risk.</p> <p>Keywords: teletherapy; clinician attitudes; telehealth; risk assessment; self-injurious thoughts and behaviours</p> <p>The COVID-19 pandemic and resulting social distancing practices have spurred a global shift from in-person mental healthcare to teletherapy, most commonly via real-time videoconferencing or phone calls (Gentry et al., [<reflink idref="bib23" id="ref1">23</reflink>]; Schulz et al., [<reflink idref="bib43" id="ref2">43</reflink>]; World Health Organization, [<reflink idref="bib48" id="ref3">48</reflink>]). Research suggests patients view teletherapy positively on the whole (Cottrell et al., [<reflink idref="bib15" id="ref4">15</reflink>]; Drerup et al., [<reflink idref="bib20" id="ref5">20</reflink>]; Zimmerman et al., [<reflink idref="bib49" id="ref6">49</reflink>]), and reviews of studies conducted even before the pandemic have shown that video- and tele-conferencing therapy is comparable to face-to-face therapy in treatment outcome (e.g. symptom reduction) and adherence (Backhaus et al., [<reflink idref="bib4" id="ref7">4</reflink>]; Barak et al., [<reflink idref="bib7" id="ref8">7</reflink>]; Carlbring et al., [<reflink idref="bib10" id="ref9">10</reflink>]; Hilty et al., [<reflink idref="bib29" id="ref10">29</reflink>]; Irvine et al., [<reflink idref="bib30" id="ref11">30</reflink>]; Krzyzaniak et al., [<reflink idref="bib33" id="ref12">33</reflink>]; Matsumoto et al., [<reflink idref="bib35" id="ref13">35</reflink>]; Richards & Viganó, [<reflink idref="bib41" id="ref14">41</reflink>]). Nevertheless, use of teletherapy prior to the pandemic was limited, both in the U.S. and globally (Appleton et al., [<reflink idref="bib2" id="ref15">2</reflink>]; Connolly et al., [<reflink idref="bib13" id="ref16">13</reflink>]; Cowan et al., [<reflink idref="bib16" id="ref17">16</reflink>]), and it remains to be seen whether teletherapy will stay as widespread in years to come.</p> <p>Pre-pandemic barriers such as unfamiliarity with teletherapy and lack of technological infrastructure (Kruse et al., [<reflink idref="bib32" id="ref18">32</reflink>]) have been largely eliminated now that videoconferencing systems like Zoom are near-ubiquitous in their usage and cultural acceptance (Hacker et al., [<reflink idref="bib28" id="ref19">28</reflink>]), such as in the workplace (Carolan et al., [<reflink idref="bib11" id="ref20">11</reflink>]) and schools (Percy et al., [<reflink idref="bib38" id="ref21">38</reflink>]). As such, providers' acceptance (or lack thereof) has emerged recently as a leading factor that may determine whether widespread implementation of teletherapy will succeed (Connolly et al., [<reflink idref="bib13" id="ref22">13</reflink>]; Cottrell et al., [<reflink idref="bib15" id="ref23">15</reflink>]; Cowan et al., [<reflink idref="bib16" id="ref24">16</reflink>]; Guinart et al., [<reflink idref="bib27" id="ref25">27</reflink>]; Kruse et al., [<reflink idref="bib32" id="ref26">32</reflink>]; Rettinger et al., [<reflink idref="bib40" id="ref27">40</reflink>]). There is evidence to suggest providers have had a positive enough experience using teletherapy during the pandemic that they plan to continue offering it moving forward (APA, [<reflink idref="bib1" id="ref28">1</reflink>]; Gentry et al., [<reflink idref="bib23" id="ref29">23</reflink>]). Still, further investigations of providers' perspectives are necessary to understand how rates of teletherapy usage may change as social distancing practices continue to loosen and in-person therapy returns as the "norm" (Aref-Adib & Hassiotis, [<reflink idref="bib3" id="ref30">3</reflink>]; Gentry et al., [<reflink idref="bib23" id="ref31">23</reflink>]).</p> <p>Although therapists view teletherapy positively on the whole, they appear to consider it less acceptable and suitable for patients who are engaging in high-risk behaviours (e.g. self-injurious thoughts and behaviours [SITBs], problematic substance/alcohol use, disordered eating) (Miu et al., [<reflink idref="bib36" id="ref32">36</reflink>]). These harmful behaviours are common and may manifest as a result of many different disorders across a spectrum of severity, as well as in people who are not experiencing a diagnosable disorder (Fox et al., [<reflink idref="bib21" id="ref33">21</reflink>]; Galmiche et al., [<reflink idref="bib22" id="ref34">22</reflink>]; Rogers et al., [<reflink idref="bib42" id="ref35">42</reflink>]). Despite their prevalence, the literature on teletherapy for patients experiencing high-risk behaviours is limited. Before the pandemic, studies suggested clinicians viewed teletherapy primarily as a crisis intervention tool or for increasing supplemental patient contact, not as a way to provide evidence-based psychotherapies to high-risk patients (Gilmore & Ward-Ciesielski, [<reflink idref="bib24" id="ref36">24</reflink>]; Ward-Ciesielski et al., [<reflink idref="bib47" id="ref37">47</reflink>]).</p> <p>Clinicians have reported concerns about using teletherapy, including the inability to physically intervene on patients in crisis, arrange for a visit to emergency services, or complete a thorough risk assessment (Gilmore & Ward-Ciesielski, [<reflink idref="bib24" id="ref38">24</reflink>]). Indeed, assessing and managing risk have been identified as the elements of teletherapy that providers are least comfortable with, largely due to the reduced visibility of nonverbal cues (Cowan et al., [<reflink idref="bib16" id="ref39">16</reflink>]; Gilmore & Ward-Ciesielski, [<reflink idref="bib24" id="ref40">24</reflink>]; Luxton et al., [<reflink idref="bib34" id="ref41">34</reflink>]). As a result, even though evaluation interviews and behavioural risk assessments (e.g. covering SITBs or substance use) can be conducted effectively via teletherapy, some clinicians have low task-specific self-efficacy, or confidence in one's own ability to perform certain tasks in future situations (Bandura, [<reflink idref="bib5" id="ref42">5</reflink>]; Bistre et al., [<reflink idref="bib8" id="ref43">8</reflink>]). Low self-efficacy may lead to avoidance of the actions in question, whereas high self-efficacy can promote more thorough efforts (Bandura & Cervone, [<reflink idref="bib6" id="ref44">6</reflink>]), suggesting that promoting clinicians' confidence in their ability to assess and manage risk virtually is key to ensuring that clinicians actually do so effectively (Delgadillo et al., [<reflink idref="bib19" id="ref45">19</reflink>]).</p> <p>Now that most clinicians know what it is like to work with patients virtually due to pandemic-related changes in service delivery, the opportunity is ripe to compare their experiences with virtual and in-person therapy. A deeper understanding of clinicians' reasons for hesitancy would allow training programmes to better develop their risk assessment (and risk management) self-efficacy, factors that may play an important role in ensuring high-quality virtual care for high-risk patients (Cramer et al., [<reflink idref="bib17" id="ref46">17</reflink>]).</p> <hd id="AN0186912257-2">Study aims</hd> <p>The current study builds on prior findings by way of a mixed methods approach, combining both quantitative and qualitative analyses to examine therapists' experiences, satisfaction, and self-efficacy in risk assessment and management in teletherapy. Specific aims were to: 1) Compare clinicians' experiences on self-report measures rating their satisfaction with and self-efficacy regarding delivery of mental health services in-person vs. virtually, 2) use qualitative interviews to add nuance to quantitative survey results regarding clinicians' attitudes toward teletherapy and their perceived risk assessment/management self-efficacy through semi-structured interviews about experiences with teletherapy, and 3) employ exploratory mixed methods analyses to integrate survey and interview data in the qualitative subsample.</p> <hd id="AN0186912257-3">Methods</hd> <p></p> <hd id="AN0186912257-4">Participant recruitment</hd> <p>Mental healthcare professionals (N = 75) with experience providing teletherapy during the pandemic were recruited from an international professional listserv for mental healthcare providers and researchers who primarily identify with cognitive and/or behavioural theoretical orientations. At the end of the survey, participants could choose to give consent to participate in a semi-structured follow-up interview; nine survey respondents gave consent and completed hour-long interviews. Signups were closed once the target number of interviewees was reached, taking into account research suggesting that around 10 interviews would typically be sufficient in exploratory research to reach "data saturation," the point at which all, or nearly all, of the relevant themes (codes) have been discovered (Guest et al., [<reflink idref="bib26" id="ref47">26</reflink>]). Ethics approval was granted by the Institutional Review Board of Williams College.</p> <hd id="AN0186912257-5">Quantitative procedure and instrument</hd> <p>For the quantitative portion of the study, we designed an online survey using established measures and following the recent literature (Connolly et al., [<reflink idref="bib12" id="ref48">12</reflink>]; Connolly et al., [<reflink idref="bib13" id="ref49">13</reflink>]; Delgadillo et al., [<reflink idref="bib19" id="ref50">19</reflink>]; Guinart et al., [<reflink idref="bib27" id="ref51">27</reflink>]; Schuster et al., [<reflink idref="bib44" id="ref52">44</reflink>]). Along with demographics (including professional experience), participants reported characteristics of their patient population. Next, participants reported which teletherapy modalities they use (e.g. videoconferencing, telephone, text messaging) and rated their experiences with each modality. Several measures were then adapted from surveys created by Guinart et al. ([<reflink idref="bib27" id="ref53">27</reflink>]) and Schuster et al. ([<reflink idref="bib44" id="ref54">44</reflink>]) in which participants were asked to report agreement or disagreement with specific positive elements and challenges they may have experienced while using teletherapy. Participants reported what percentage of their caseload they want to treat via teletherapy after the pandemic and which factors they expect to influence future usage of teletherapy.</p> <p>Finally, we assessed perceived self-efficacy with regard to risk assessment and management in the context of mental healthcare, using the Risk Assessment and Management Self-Efficacy Scale (RAMSES; Delgadillo et al., [<reflink idref="bib19" id="ref55">19</reflink>]). Each item is formulated as a specific task, and respondents rate their perceived self-efficacy on a Likert scale ranging from 0 (<emph>No confidence in ability to perform the task</emph>) to 10 (<emph>Complete confidence in ability to perform the task</emph>). The scale contains three subscales: assessment (six items), management (eight items), and referral (four items). Participants responded to the RAMSES twice: once under directions to specifically consider their experiences treating patients in-person, and once considering only their experiences treating patients virtually. Delgadillo et al. ([<reflink idref="bib19" id="ref56">19</reflink>]) found that the RAMSES has high internal consistency, with a Cronbach's alpha of.96. Reliability in the current sample was also excellent, with Cronbach's alpha of.94 for the whole scale when considering in-person treatment and.97 for the whole scale when considering virtual treatment. For the assessment, management, and referral subscales in-person, Cronbach's alpha was.89,.89, and.90, respectively, while virtual subscale alpha scores were.92,.93, and.92, respectively.</p> <hd id="AN0186912257-6">Qualitative interview procedure</hd> <p>The first author conducted semi-structured, one-on-one Zoom (<emph>n = </emph>8) and phone (<emph>n</emph> = 1) interviews with participants. Both authors had previous experience conducting qualitative interviews; the second author supervised the first author in all qualitative procedures. The interviewer did not have previous relationships with participants, nor did they have contact with participants after interviews. Participants were told that the interviewers were researchers interested in clinicians' experiences treating patients via teletherapy.</p> <p>A semi-structured interview protocol (available upon request) was developed through an iterative process. First, hour-long interviews were conducted with three participants using an initial set of questions based on current literature (Connolly et al., [<reflink idref="bib12" id="ref57">12</reflink>]; Connolly et al., [<reflink idref="bib13" id="ref58">13</reflink>]; Delgadillo et al., [<reflink idref="bib19" id="ref59">19</reflink>]; Guinart et al., [<reflink idref="bib27" id="ref60">27</reflink>]; Schuster et al., [<reflink idref="bib44" id="ref61">44</reflink>]) regarding therapists' experiences with and attitudes toward teletherapy, especially for suicidal or other high-risk patients. After the first three interviews, the authors revised and expanded the protocol to create the final guide used for the remaining interviews. From there, six more participants were interviewed. All participants consented to have the interview audio recorded (duration: <emph>M</emph> = 51 min).</p> <hd id="AN0186912257-7">Qualitative data analysis</hd> <p>Qualitative interviews were transcribed with the widely used Otter.ai software (Corrente & Bourgeault, [<reflink idref="bib14" id="ref62">14</reflink>]) and thoroughly reviewed by hand to check for transcription errors. Transcripts were then coded using a Straussian grounded theory approach (Glaser & Strauss, [<reflink idref="bib25" id="ref63">25</reflink>]). In the Straussian school of grounded theory, the researcher approaches the analytical process with somewhat structured questions and preconceived ideas in mind about the topic. The first step of qualitative data analysis is "open coding," where the researcher notes common, overarching themes across the interviews. Words and phrases are grouped together under emerging conceptual categories (codes) generated by the researcher. The next step is "axial coding," where the researcher returns to the set of codes in order to identify connections and relationships between the different concepts.</p> <p>Coding was completed in parallel by the two authors (Strauss & Corbin, [<reflink idref="bib45" id="ref64">45</reflink>]), who separately completed open coding using one interview transcript before synthesising the two code lists. Both authors completed consensual coding (i.e. comparing and discussing codes) along with a trained undergraduate research assistant. The first author then coded the remaining eight transcripts using the revised code list, while the research assistant coded three for reliability. The research assistant and first author attained high levels of inter-coder agreement, with Kappa =.72 (Brennan & Prediger, [<reflink idref="bib9" id="ref65">9</reflink>]). All interviews and codes were also reviewed by the second author.</p> <hd id="AN0186912257-8">Mixed methods: explanatory sequential mixed methods design (QUAN → qual)</hd> <p>Mixed methods research is defined as "the collection and 'mixing' or integration of both quantitative and qualitative data in a study" (Creswell, [<reflink idref="bib18" id="ref66">18</reflink>], p. xxiv). Given study aims involving the idiosyncratic experiences and attitudes of clinicians using teletherapy to treat complex patients, the mixed methods approach allows us to combine group-level statistical analyses with a detailed, interpretive exploration of the unique experiences of each of our interview participants.</p> <p>The current study employs an explanatory sequential mixed-methods design (Creswell, [<reflink idref="bib18" id="ref67">18</reflink>]), which has been identified as particularly well-suited approach for the study of teletherapy because the integration of multiple methods allows for a deeper understanding of stakeholders' experiences and perspectives (Cottrell et al., [<reflink idref="bib15" id="ref68">15</reflink>]). Here, the "explanatory" feature refers to the aim of using qualitative data to help explain quantitative results (Creswell, [<reflink idref="bib18" id="ref69">18</reflink>], p. 224), and the "sequential" feature refers to the data collection method (Teddlie & Yu, [<reflink idref="bib46" id="ref70">46</reflink>]), in which quantitative sampling (e.g. a survey) is followed by qualitative sampling from the survey pool (e.g. survey respondents are contacted for follow-up interviews). The "QUAN → qual" notation refers not only to the sequential nature of the data collection, but also to the priority placed on each method: in this case, quantitative methods were primary, and qualitative methods served to build on and explain the quantitative analysis (Morgan, [<reflink idref="bib37" id="ref71">37</reflink>]). In sum, the "mixing" in this design occurs as part of data collection, data analysis, and interpretation of results to allow for a deeper understanding of therapists' usage of teletherapy, both in terms of group-level patterns and the subjective experiences of individuals.</p> <hd id="AN0186912257-9">Results</hd> <p></p> <hd id="AN0186912257-10">Participant characteristics</hd> <p>Survey respondents (N = 75; M<subs>age</subs> = 36.59, SD<subs>age</subs> = 10.14) were predominantly white (88%), cisgender female (76%), cognitive–behavioural (87%) therapists with an average of 9.41 years of professional experience (<emph>SD</emph> = 8.24). Participants reported using videoconferencing to see around 69% of their caseload on average, while 35 (47%) reported treating patients (11% of their caseload on average) via phone calls. The highest degree participants held tended to be an M.A./M.S. (<emph>n</emph> = 32; 43%) or Ph.D. (<emph>n</emph> = 29; 39%), while 11% (<emph>n</emph> = 8) held an M.S.W., and the remainder held either a Psy.D. (<emph>n</emph> = 2; 3%) or another graduate degree (<emph>n </emph>= 4; 5%). The most common clinical setting was private practice (<emph>n</emph> = 31; 41%), followed by outpatient clinics (<emph>n</emph> = 22; 29%), and hospitals (<emph>n </emph>= 15; 20%). Participants reported seeing 17 clients per week on average (<emph>SD</emph> = 12). When asked to select the three most common disorders they see in their practice, a majority of participants chose major depressive disorder (<emph>n</emph> = 52; 69%), generalised anxiety disorder (<emph>n</emph> = 49; 65%), or post-traumatic stress disorder (<emph>n</emph> = 41; 55%), while 24% (<emph>n</emph> = 18) selected borderline personality disorder. Participants reported that they frequently treat patients engaging in high-risk behaviours (see Figures 1 and 2). When asked if they had received teletherapy-specific training, one in five reported receiving extensive (<emph>n </emph>= 2; 3%) or lots (<emph>n</emph> = 13; 17%) of training, almost half reported receiving "some" training (<emph>n</emph> = 33; 44%), and about a third reported receiving minimal (<emph>n</emph> = 15; 20%) or no (<emph>n</emph> = 12; 16%) training. See Tables 1 and 2 for additional demographic and teletherapy usage information, including comparisons of survey vs. interview respondent characteristics.</p> <p>Graph: Figure 1. Clinicians' Reported Frequencies of High-Risk Behaviours in Their Caseloads: Entire Sample. Note. NSSI = non-suicidal self-injury</p> <p>Graph: Figure 2. Clinicians' Reported Frequencies of High-Risk Behaviours in Their Caseloads: Qualitative Subsample. Note. NSSI = non-suicidal self-injury</p> <p>Table 1. Demographics of Participants in Entire Sample and Qualitative Subsample.</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Characteristics</td><td>Quan. Sample (N = 75)</td><td>Qual. Subsample (N = 9)</td></tr><tr><td><italic>n</italic></td><td>%</td><td><italic>n</italic></td><td>%</td></tr></thead><tbody><tr><td>Gender</td><td /><td /><td /><td /></tr><tr><td /><td>Cisgender male</td><td char=".">15</td><td char=".">20</td><td char=".">5</td><td char=".">56</td></tr><tr><td /><td>Cisgender female</td><td char=".">57</td><td char=".">76</td><td char=".">4</td><td char=".">44</td></tr><tr><td /><td>NB/NC</td><td char=".">3</td><td char=".">4</td><td char=".">0</td><td char=".">0</td></tr><tr><td>Racial/ethnic identity</td><td /><td /><td /><td /></tr><tr><td /><td>White/Caucasian</td><td char=".">66</td><td char=".">88</td><td char=".">9</td><td char=".">100</td></tr><tr><td /><td>Asian</td><td char=".">6</td><td char=".">8</td><td char=".">0</td><td char=".">0</td></tr><tr><td /><td>Hispanic/Latinx</td><td char=".">3</td><td char=".">4</td><td char=".">0</td><td char=".">0</td></tr><tr><td /><td>Black or Afr. American</td><td char=".">1</td><td char=".">1</td><td char=".">0</td><td char=".">0</td></tr><tr><td /><td>Other race/ethnicity</td><td char=".">5</td><td char=".">7</td><td char=".">0</td><td char=".">0</td></tr><tr><td>Highest degree to date</td><td /><td /><td /><td /></tr><tr><td /><td>M.A./M.S.</td><td char=".">32</td><td char=".">43</td><td char=".">2</td><td char=".">22</td></tr><tr><td /><td>M.S.W.</td><td char=".">8</td><td char=".">11</td><td char=".">2</td><td char=".">22</td></tr><tr><td /><td>Ph.D.</td><td char=".">29</td><td char=".">39</td><td char=".">5</td><td char=".">56</td></tr><tr><td /><td>Psy.D.</td><td char=".">2</td><td char=".">3</td><td char=".">0</td><td char=".">0</td></tr><tr><td /><td>Other terminal degree</td><td char=".">4</td><td char=".">5</td><td char=".">0</td><td char=".">0</td></tr><tr><td>Therapeutic specialisations</td><td /><td /><td /><td /></tr><tr><td /><td>CBT</td><td char=".">65</td><td char=".">87</td><td char=".">8</td><td char=".">89</td></tr><tr><td /><td>DBT</td><td char=".">28</td><td char=".">37</td><td char=".">6</td><td char=".">67</td></tr><tr><td /><td>Family therapy</td><td char=".">7</td><td char=".">9</td><td char=".">0</td><td char=".">0</td></tr><tr><td /><td>Addiction counseling</td><td char=".">9</td><td char=".">12</td><td char=".">0</td><td char=".">0</td></tr><tr><td /><td>Group therapy</td><td char=".">5</td><td char=".">7</td><td char=".">0</td><td char=".">0</td></tr><tr><td /><td>Existential therapy</td><td char=".">1</td><td char=".">1</td><td char=".">0</td><td char=".">0</td></tr><tr><td /><td>Person-centered therapy</td><td char=".">8</td><td char=".">11</td><td char=".">1</td><td char=".">11</td></tr><tr><td /><td>Psychodynamic therapy</td><td char=".">8</td><td char=".">11</td><td char=".">1</td><td char=".">11</td></tr><tr><td /><td>ACT</td><td char=".">20</td><td char=".">27</td><td char=".">2</td><td char=".">22</td></tr><tr><td /><td>EFT</td><td char=".">3</td><td char=".">4</td><td char=".">0</td><td char=".">0</td></tr><tr><td /><td>SFBT</td><td char=".">7</td><td char=".">9</td><td char=".">1</td><td char=".">11</td></tr><tr><td /><td>Other</td><td char=".">10</td><td char=".">13</td><td char=".">0</td><td char=".">0</td></tr><tr><td>Clinical setting</td><td /><td /><td /><td /></tr><tr><td /><td>Hospital</td><td char=".">15</td><td char=".">20</td><td char=".">3</td><td char=".">33</td></tr><tr><td /><td /><td>Public general hospital</td><td char=".">6</td><td char=".">8</td><td char=".">1</td><td char=".">11</td></tr><tr><td /><td /><td>Private gen. hospital</td><td char=".">4</td><td char=".">5</td><td char=".">1</td><td char=".">11</td></tr><tr><td /><td /><td>VA medical centre</td><td char=".">5</td><td char=".">7</td><td char=".">1</td><td char=".">11</td></tr><tr><td /><td>Private Practice</td><td char=".">31</td><td char=".">41</td><td char=".">2</td><td char=".">22</td></tr><tr><td /><td /><td>Individ. priv. practice</td><td char=".">19</td><td char=".">25</td><td char=".">2</td><td char=".">22</td></tr><tr><td /><td /><td>Group priv. practice</td><td char=".">9</td><td char=".">12</td><td char=".">0</td><td char=".">0</td></tr><tr><td /><td>Academic medical centre</td><td char=".">9</td><td char=".">12</td><td char=".">1</td><td char=".">11</td></tr><tr><td /><td>Primary care</td><td char=".">4</td><td char=".">5</td><td char=".">1</td><td char=".">11</td></tr><tr><td /><td>Behavioural health setting</td><td char=".">7</td><td char=".">9</td><td char=".">1</td><td char=".">11</td></tr><tr><td /><td>Outpatient clinic</td><td char=".">22</td><td char=".">29</td><td char=".">4</td><td char=".">44</td></tr><tr><td /><td>Training clinic</td><td char=".">10</td><td char=".">13</td><td char=".">2</td><td char=".">22</td></tr><tr><td /><td>Counseling/guidance centre</td><td char=".">3</td><td char=".">4</td><td char=".">1</td><td char=".">11</td></tr><tr><td /><td>Student counseling centre</td><td char=".">3</td><td char=".">4</td><td char=".">0</td><td char=".">0</td></tr><tr><td /><td>Specialized health service</td><td char=".">2</td><td char=".">3</td><td char=".">1</td><td char=".">11</td></tr><tr><td /><td>Rehabilitation facility</td><td char=".">1</td><td char=".">1</td><td char=".">0</td><td char=".">0</td></tr><tr><td /><td>Community health centre</td><td char=".">6</td><td char=".">8</td><td char=".">1</td><td char=".">11</td></tr><tr><td /><td>Criminal justice setting</td><td char=".">1</td><td char=".">1</td><td char=".">0</td><td char=".">0</td></tr><tr><td /><td>Other human service setting</td><td char=".">1</td><td char=".">1</td><td char=".">0</td><td char=".">0</td></tr><tr><td>Teletherapy-specific training</td><td /><td /><td /><td /></tr><tr><td /><td>Extensive training</td><td char=".">2</td><td char=".">3</td><td char=".">0</td><td char=".">0</td></tr><tr><td /><td>Lots of training</td><td char=".">13</td><td char=".">17</td><td char=".">2</td><td char=".">22</td></tr><tr><td /><td>Some training</td><td char=".">33</td><td char=".">44</td><td char=".">3</td><td char=".">33</td></tr><tr><td /><td>Minimal training</td><td char=".">15</td><td char=".">20</td><td char=".">1</td><td char=".">11</td></tr><tr><td /><td>No training</td><td char=".">12</td><td char=".">16</td><td char=".">3</td><td char=".">33</td></tr></tbody></table> </ephtml> </p> <p>1 Note. NB/NC = gender non-binary or non-conforming; CBT = cognitive-behavioural therapy; DBT = dialectical behavior therapy; ACT = acceptance and commitment therapy; EFT = emotion-focused therapy; SFBT = solution-focused brief therapy; VA = veterans affairs. Because participants were asked to select whichever options they identified with, the totals for some categories add up to more than 100%.</p> <p>Table 2. Teletherapy Usage Among Quantitative and Qualitative Therapist Sample.</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Modality</td><td>Quantitative Sample (N = 75)</td><td>Qualitative Subsample (N = 9)</td></tr><tr><td><italic>n</italic> (%)</td><td>% clients</td><td>Mean Satisfaction</td><td><italic>n</italic> (%)</td><td>% clients</td><td>Mean Satisfaction</td></tr></thead><tbody><tr><td>VCT</td><td char="(">75 (100)</td><td char=".">69</td><td char=".">4.04</td><td char="(">9 (100)</td><td char=".">48</td><td char=".">3.89</td></tr><tr><td>Phone calls</td><td char="(">35 (47)</td><td char=".">11</td><td char=".">3.54</td><td char="(">4 (44)</td><td char=".">19</td><td char=".">3.50</td></tr><tr><td>Text messaging</td><td char="(">10 (13)</td><td char=".">20</td><td char=".">3.33</td><td char="(">1 (11)</td><td char=".">70</td><td char=".">2.00</td></tr><tr><td>Voice messaging</td><td char="(">2 (3)</td><td char=".">30</td><td char=".">2.50</td><td char="(">1 (11)</td><td char=".">30</td><td char=".">2.00</td></tr></tbody></table> </ephtml> </p> <p>2 Note. VCT = videoconferencing therapy; % clients = among respondents who are using each modality, mean portion of caseload they are treating via the modality in question. Mean satisfaction scale was rated from 1 ("very poor") to 5 ("excellent").</p> <hd id="AN0186912257-11">Attitudes toward teletherapy</hd> <p>Participants expressed positive attitudes toward teletherapy on the whole. The vast majority of survey respondents (<emph>n</emph> = 58; 77%) said their experience with videoconferencing had been "Excellent," or "Good," and all but one of the remaining (<emph>n</emph> = 16; 21%) said it had been "Fair." Two-thirds of the interviewees (<emph>n</emph> = 6) expressed distinctly positive attitudes about teletherapy (P10: "I think it's a great tool to have"), although few went so far as to say that they preferred it over in-person therapy. Qualitative data suggest therapists consider it their professional duty to continue offering teletherapy, in part because patients want to use it; four interviewees responded to questions about their own opinions by mentioning instead that their patients like it (P22: "the patient feedback is wonderful"). Similarly, some interviewees who were not particularly enthusiastic about teletherapy expressed a willingness to use it so long as certain conditions are met. A remark from P31 is representative: "As long as they're safe, and they feel like they're progressing, then I don't have any issues with telehealth."</p> <hd id="AN0186912257-12">Usage of teletherapy for high-risk behaviours</hd> <p>Although attitudes toward teletherapy were generally positive, participants were more hesitant when considering high-risk patients in particular (see Table 3 for examples of qualitative data related to teletherapy and high-risk patients). Paired samples <emph>t</emph>-tests revealed that participants reported significantly higher frequencies of suicidality, NSSI, substance use/abuse, and disordered eating in their overall practice as compared to teletherapy (all <emph>p</emph>s ≤.01), suggesting that clinicians are more likely to treat high-risk behaviours face-to-face instead of virtually. Almost half (<emph>n</emph> = 34; 45%) of participants said that the severity of their patient's symptoms would factor into their decision about whether to meet in-person or via teletherapy. Looking toward the future, participants said they would like to continue using telehealth with 53% of their clients on average, but that proportion dropped to 38% (<emph>SD</emph> = 31.42) when they were asked to specifically consider their work with patients that engage in high-risk behaviours. A paired samples <emph>t</emph>-test comparing responses to the two questions among participants who answered both (<emph>n</emph> = 63) showed that the difference was significant, <emph>t</emph>(<reflink idref="bib62" id="ref72">62</reflink>) = 7.14, <emph>p</emph> <.001, two-tailed.</p> <p>Table 3. Clinician Perceptions of Teletherapy for High-Risk Issues: Qualitative Data.</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Code</td><td>Sub-codes</td><td>Example participant quotes</td></tr></thead><tbody><tr><td>Plans/preferences for future</td><td /><td>"I would be comfortable with a majority telehealth and saving in-person either for people that do have maybe more imminent risk behaviors. Or people that just feel more comfortable talking to someone in person." [P22]</td></tr><tr><td>Patient population and disorders</td><td>SMI or high-risk behaviours</td><td>"I have a very large caseload, a very large proportion of individuals who are at high risk." [P4]</td></tr><tr><td>Current balance of in-person vs virtual clients</td><td>Severity influencing choice of modality</td><td>"It's kind of a fool's errand to rely solely on diagnosis for making those decisions. Because there's just so much range, right, in terms of what someone's going to actually be presenting like, and whether or not safety issues are even a thing for them." [P10]</td></tr><tr><td>Challenges with teletherapy</td><td>Can't see patient's body</td><td>"I'm sure that there are some things that I wouldn't be able to see, like, are they underweight? Are there any, you know, possibilities of an eating disorder? Are there any marks of self harm that I can see?" [P31]</td></tr><tr><td /><td>Challenging symptoms (e.g. psychosis, dissociation)</td><td>"I was treating someone with selective mutism ... with telehealth, it all just shut down and I couldn't get a word out of him. He wasn't engaging at all." [P9]</td></tr><tr><td /><td>Technical difficulties</td><td>"If their internet or my internet is unstable, those sessions feel really disjointed to me. And I'm kind of like, 'Did they get anything out of it?'" [P22]</td></tr><tr><td /><td>Patient privacy</td><td>"If there are privacy concerns, you know, they live in a smaller home, or they don't have their own room or their own space where they could privately talk with me. Those are the kind of scenarios that I would encourage them to come into my office." [P9]</td></tr><tr><td /><td>Distraction (patient or therapist)</td><td>"Also, I have noticed in the last two years a lot of distraction in session over telehealth – moms who have toddlers on their laps during therapy, phones ringing, people in their cars – and that is going to impact the quality of our work." [P11]</td></tr><tr><td>Advantages of teletherapy</td><td>Therapy can be conducted effectively this way</td><td>"Coping skills can be taught by tele just as easily as they are in person." [P26]</td></tr><tr><td /><td>Accessibility of telehealth</td><td>"One of the main reasons being, the access that it has provided to folks who otherwise, because of either geographical issues, mobility issues, or chronic illness issues, would never have come in." [P23]</td></tr><tr><td>Risk assessment & diagnosis</td><td>Assessing substance use</td><td>"There probably are cues that you miss. Like, if someone is coming in with alcohol on their breath, clearly, you're not gonna smell that via telehealth." [P22]</td></tr><tr><td /><td>Assessing self-harm (incl. suicide, NSSI)</td><td>"Often somebody will come in and they're wearing shorts and they have self harm on their legs, or they have been self harming on their wrists or their arms. And I'll never see that over telehealth." [P11]</td></tr><tr><td>Managing risk</td><td>Managing self harm, suicidality</td><td>"I have patients who I'm managing risk, managing suicide risk, via telehealth, and I feel comfortable with that because I feel like we have a good relationship." [P9]</td></tr><tr><td /><td>Control over the situation</td><td>"I do feel like I have more control over the situation when they're in person." [P31]</td></tr><tr><td /><td>General crisis situations</td><td>"I would say the most challenging part of doing telehealth with this outpatient population is when there are crises, and I'm not actually in the same space with a patient who might need an intervention." [P11]</td></tr></tbody></table> </ephtml> </p> <p>Integration of quantitative and qualitative results describing current and future usage of teletherapy is presented in Table 4. Several interviewees alluded to the idea that higher-risk patients might be better suited for in-person treatment, but others were more ambivalent. P22 said they would be "comfortable with a majority telehealth and saving in-person ... for people that do have maybe more imminent risk behaviors." On the other hand, P10 said they consider it "kind of a fool's errand to rely solely on diagnosis for making those decisions" because of the wide range of ways that different patients may present even within a single diagnostic category. Several participants cited discomfort with a perceived lack of control over the patient's environment in acute situations, and all mentioned that teletherapy limited how fully they could see the patient (in referring to how this missing information may impact assessment especially).</p> <p>Table 4. Exploratory Mixed Methods Results: Current and Future Teletherapy Usage.</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Participant, Age, Gender</td><td>Clinical setting</td><td>% video</td><td>Rate video experience</td><td>% cont. tele</td><td>% cont. tele high-risk</td><td>Qualitative perspective on future teletherapy usage</td></tr></thead><tbody><tr><td>#4, 36, F</td><td>Hospital, outpatient clinic</td><td char=".">35</td><td>Good</td><td char=".">50</td><td char=".">50</td><td>"My approach is more case by case what makes the most sense for them ... being mindful of risk and engagement and if one has the ability to remain engaged via telehealth if they're high risk."</td></tr><tr><td>#10, 33, F</td><td>Hospital</td><td char=".">60</td><td>Good</td><td char=".">60</td><td char=".">50</td><td>"I do hope that at least video will hang around and be a regular tool that we implement with patients going into the future. I think it adds a lot of flexibility."</td></tr><tr><td>#31, 25, F</td><td>Outpatient clinic</td><td char=".">30</td><td>Fair</td><td char=".">5</td><td>–</td><td>"It's not my preference. If it works well for some people, it's about them, it's not about me. I don't want that to be my whole caseload."</td></tr><tr><td>#9, 32, M</td><td>Outpatient clinic</td><td char=".">15</td><td>Good</td><td char=".">10</td><td char=".">10</td><td>"So long as it's an option, so long as insurance companies are covering that, I'd like it to be something that I offer."</td></tr><tr><td>#23, 50, M</td><td>Primary care</td><td char=".">56</td><td>Good</td><td char=".">35</td><td char=".">20</td><td>"I think there's so many pros to it, that even when things are safer in the world, I think it'll still be desirable, for me. It's not something I would want to continue to do all day, every day."</td></tr><tr><td>#22, 32, M</td><td>Training clinic</td><td char=".">50</td><td>Excellent</td><td char=".">80</td><td char=".">80</td><td>"I would be comfortable with a majority telehealth and saving in person ... for people that do have maybe more imminent risk behaviors."</td></tr><tr><td>#2, unknown, M</td><td>Hospital</td><td char=".">71</td><td>Excellent</td><td char=".">90</td><td char=".">80</td><td>"I probably would like the two days in, three days out ... I think it's mostly convenience."</td></tr><tr><td>#26, 53, M</td><td>Private practice</td><td char=".">20</td><td>Fair</td><td char=".">10</td><td>–</td><td>"This is the way of the future. You've got to get used to it because it's going to be happening, whether you like it or not."</td></tr><tr><td>#11, 37, F</td><td>Private practice, outpatient/training clinic</td><td char=".">91</td><td>Fair</td><td char=".">20</td><td>–</td><td>"I far prefer being in person ... the decision to see patients virtually – that decision doesn't belong to me, that belongs to the administration of a huge health system."</td></tr></tbody></table> </ephtml> </p> <p>3 Note. "% video" refers to the percentage of each participant's clients whom they see via videoconferencing. "Rate video experience" refers to how participants rated their experience with videoconferencing. "% cont. tele" refers to the proportion of clients each participant wants to see over teletherapy in the future; "% cont. tele high-risk" refers to the proportion of <emph>high-risk</emph> clients each participant wants to see over teletherapy in the future. M = cisgender man, F = cisgender female.</p> <hd id="AN0186912257-13">Risk assessment and management via teletherapy</hd> <p>Integration of quantitative and qualitative results describing risk assessment and management via teletherapy is presented in Table 5. Regarding the full survey, paired samples <emph>t</emph>-tests determined that participants reported significantly higher levels of perceived risk assessment and management self-efficacy in person as compared to teletherapy on the RAMSES composite score (<emph>t</emph>(<reflink idref="bib68" id="ref73">68</reflink>) = 5.55, <emph>p</emph> <.001, two-tailed), as well as all three subscales. The composite RAMSES scores for in-person correlated strongly with virtual composite scores (<emph>r</emph> =.84, <emph>p</emph> <.001), suggesting that participants who were very confident assessing and managing risk in person were also likely to be highly confident doing so virtually (and, similarly, those who lacked confidence in person also tended to lack confidence virtually). On the three in-person subscales, the minimum score participants reported was 4, whereas the minima on the virtual subscales were 2.33, 2.38, and 2.25 for risk assessment, management, and referral. These disparities suggest that the participants who scored at the low end for confidence in their abilities <emph>in-person</emph> were still more confident than the participants who were at the low end for confidence in their abilities <emph>virtually</emph>. We found modest but significant Spearman's rank correlations between virtual RAMSES scores and the number of high-risk patients participants reported seeing over teletherapy (<emph>r</emph> =.35, <emph>p</emph> <.001), the number of training sources they had received in risk assessment/management (<emph>r</emph> =.39, <emph>p</emph> <.001), as well as with participants' intentions to continue using teletherapy after the pandemic in general (<emph>r</emph> =.39, <emph>p</emph> =.001) and for high-risk patients in particular (<emph>r</emph> =.42, <emph>p</emph> <.001). There was no significant association between teletherapy-specific training and virtual RAMSES scores.</p> <p>Table 5. Exploratory Mixed Methods Results: Risk Assessment and Management In-Person and in Teletherapy.</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Participant, Age, Gender</td><td>NSSI</td><td>Suicidality</td><td>RAMSES in-person</td><td>RAMSES virtual</td><td>Qualitative perspective on assessing/managing risk in teletherapy</td></tr></thead><tbody><tr><td>#4, 36, F</td><td>Very often</td><td>Very often</td><td char=".">9.61</td><td char=".">9.33</td><td>"I feel like I've been practicing long enough I'm comfortable either way ... if you asked me this question 10 years ago, I would definitely say I'd prefer in person. Now I'd say I'm equally comfortable either way."</td></tr><tr><td>#10, 33, F</td><td>Very often</td><td>Often</td><td char=".">9.50</td><td char=".">9.50</td><td>"I think it is easier to get a better feel and sense for some patients, the severity of the situation, when you're actually laying eyes on them in person."</td></tr><tr><td>#31, 25, F</td><td>Often</td><td>Sometimes</td><td char=".">8.39</td><td char=".">6.78</td><td>"I'm sure that there are some things that I wouldn't be able to see, like, are they underweight? Are there any, you know, possibilities of an eating disorder? Are there any marks of self harm that I can see?"</td></tr><tr><td>#9, 32, M</td><td>Often</td><td>Often</td><td char=".">9.00</td><td char=".">8.56</td><td>"I think you might lose some of those more subtle body language cues, but I think that you can still do a really comprehensive and appropriate safety assessment."</td></tr><tr><td>#23, 50, M</td><td>Sometimes</td><td>Often</td><td char=".">8.16</td><td char=".">8.06</td><td>"I don't have a lot of confidence in doing a really good assessment when I can't see somebody."</td></tr><tr><td>#22, 32, M</td><td>Almost never</td><td>Almost never</td><td char=".">9.44</td><td char=".">9.44</td><td>"I take a functional perspective to those behaviors ... we talk about how they can use some of the skills that they're practicing to target those ... And all those things that I would do in-person, I'm able to do via telehealth."</td></tr><tr><td>#2, unknown, M</td><td>Often</td><td>Often</td><td char=".">8.72</td><td char=".">8.72</td><td>"In my experience, if they are having those thoughts [of self harm], they're more likely to join the session from their phone than have to leave the house and drive to our location and come in in-person."</td></tr><tr><td>#26, 53, M</td><td>Often</td><td>Very often</td><td char=".">8.61</td><td char=".">6.44</td><td>"I'd want to keep it more low risk than anything else, if I could. I have seen suicidal people by tele, so you know, it happens. We go through the CAMS, we talk about what's driving the suicidality."</td></tr><tr><td>#11, 37, F</td><td>Very often</td><td>Very often</td><td char=".">8.56</td><td char=".">5.83</td><td>"I'm never going to be able to smell the odor of alcohol on someone, or see an abscess, or a mark on someone's body very well over telehealth. And so I can't say that I even know what's been missed ... And that makes me uncomfortable."</td></tr></tbody></table> </ephtml> </p> <p>4 Note<emph>.</emph> RAMSES = Risk Assessment and Management Self-Efficacy Scale, rated from 1 (<emph>No confidence</emph>) to 10 (<emph>Complete confidence</emph>). M = cisgender man, F = cisgender female.</p> <p>Risk assessment and management were referenced 79 times across all nine interviews. In general, interviewees were fairly confident in their ability to perform an adequate risk assessment over telehealth, although all participants mentioned the issue of not being able to see the patient as clearly on videoconferencing platforms and potentially failing to catch valuable information. P4 captured the general attitude well: "I would say "just as effective" with the caveats that we both have good internet connections, that they're savvy in using technology, that we're not being interrupted frequently, that the patient's in a secure private location where they can talk freely." Despite the potentially meaningful differences between in-person and teletherapy, several participants mentioned that they are able to feel more confident in assessing and managing risk because they administer structured, evidence-based protocols like the Columbia–Suicide Severity Rating Scale (CSSRS; Posner et al., [<reflink idref="bib39" id="ref74">39</reflink>]) or the Collaborative Assessment and Management of Suicidality (CAMS; Jobes, [<reflink idref="bib31" id="ref75">31</reflink>]).</p> <hd id="AN0186912257-14">Discussion</hd> <p>Although clinicians generally perceive teletherapy positively, further research is needed to better understand their experiences treating high-risk patients over teletherapy, as well as their decisions around the use of teletherapy for high-risk patients now that COVID-related restrictions have lessened. Results of the current study suggest that clinicians prefer to treat high-risk patients in-person—especially considering the difficulty of assessing and managing risk virtually – but they are also willing and able to do so via teletherapy. The clinicians in this sample frequently treat high-risk behaviours, especially suicidality and NSSI. Results suggest that high-risk patients are treated face-to-face at disproportionate rates. This trend was mirrored in therapists' plans for after the pandemic: they said they want to use telehealth with 53% of their clients overall but with only 38% of their high-risk patients, on average. Not all participants in the present study had full control over which patients they treat in-person and virtually, underlining the need for healthcare authorities to give clinicians as much leeway as is reasonable and safe in order to maximise their comfort and confidence in treating higher-risk patients.</p> <p>Importantly, the current study is the first to our knowledge to use a mixed methods approach to explore the treatment of high-risk patients via teletherapy. Qualitative data revealed that participants are generally willing to treat high-risk patients virtually given certain circumstances (e.g. a good internet connection and the patient having a private space where they can talk freely). Many of the stipulations participants mentioned – conditions they want to be met if they are to feel confident working with high-risk patients via teletherapy – mirror commonly cited disadvantages of teletherapy (Guinart et al., [<reflink idref="bib27" id="ref76">27</reflink>]; Schuster et al., [<reflink idref="bib44" id="ref77">44</reflink>]), suggesting that the modality inherently presents some shortcomings when it comes to high-risk patients. In order to adequately assess risk and form a case conceptualisation, therapists often feel they need (or at least strongly prefer) to be able to see the patient, if only via video – and the view offered in videoconferencing is itself not enough for many of the interviewees to feel confident that they are not missing important clinical information. The participants who were more assured in assessing and managing risk were those who felt prepared to implement tools or strategies like the CAMS or the CSSRS, suggesting that training in evidence-based risk assessment/management tools may have a large impact on therapist confidence regardless of modality.</p> <p>It is worth emphasising that risk assessment/management skill levels vary between different therapists, and those who are confident in these skills in-person also tend to be confident in applying these skills virtually. Qualitative results suggest that the skills that serve therapists well in working with high-risk patients in person transfer to teletherapy, highlighting the importance of receiving evidence-based training in assessing and treating high-risk behaviours in-person, regardless of plans to use teletherapy in the future. Participants who reported the highest levels of virtual risk assessment and management self-efficacy tended to see more high-risk patients over teletherapy, and both self-efficacy and the number of high-risk patients participants were seeing over teletherapy were quite high in this sample. Unsurprisingly, participants who felt more confident about assessing and managing risk over teletherapy were also more open to the idea of continuing with teletherapy in the future for patients in general, and high-risk patients in particular.</p> <p>Despite these interesting findings, several limitations warrant mention. The sample was obtained through a single large professional listserv, with participants practicing in different countries and professional/clinical settings, limiting the generalizability of the results. Participants self-selected to participate in both the survey and interview, and these samples included participants who had relevant experiences with teletherapy and high-risk patients specifically. We relied on self-report measures to gather information about therapists' caseloads and the frequency of their teletherapy usage. Although we included a question assessing whether participants had received teletherapy-specific training, we did not establish whether this training took place during or before the pandemic, and the extent to which participants actually used teletherapy prior to the pandemic was not measured in our survey. It is essential that future work examine these factors in the context of clinicians' experiences pivoting to teletherapy. In understanding teletherapy usage, the perspectives of treatment providers must be balanced with patient attitudes, and researchers must also continue to investigate treatment processes and outcomes in teletherapy. Finally, given the small size of the qualitative sample, the results of this study are best regarded as exploratory, in the sense that qualitative and mixed methods analyses help us to make sense of quantitative findings and suggest directions for future inquiry, but our goal is not to make sweeping nomothetic claims from qualitative or mixed methods analyses outward. Larger qualitative sample sizes and more advanced designs, such as embedded mixed methods approaches – where qualitative data can be collected within a larger study of a different design, such as a randomised controlled trial – would expand the ways in which researchers can leverage qualitative and mixed methods analyses to understand therapists' experiences and attitudes.</p> <p>By forcing a universal switch to teletherapy, the COVID-19 pandemic radically changed the mental healthcare landscape, and the current study shows that therapists have not felt as confident or comfortable providing therapy to high-risk patients as they have for other patient populations. Still, there is a close link between effective risk assessment and management in teletherapy and in-person, as therapists rely on the same skills in each modality. On a methodological level, our study highlights the analytical utility of a mixed methods approach. On the whole, it is clear that teletherapy will continue to be an essential tool in mental healthcare service delivery, suggesting important new areas of training and professional development for therapists at all levels of experience and across therapeutic settings.</p> <hd id="AN0186912257-15">Acknowledgements</hd> <p>The authors would like to thank Lea Elton for her assistance transcribing and coding interviews. The authors are also grateful to the individuals who participated in this study.</p> <hd id="AN0186912257-16">Data availability statement</hd> <p>Anonymized data that support the findings of this study are available from the corresponding author, N.M.J., upon reasonable request.</p> <hd id="AN0186912257-17">Disclosure statement</hd> <p>No potential conflict of interest was reported by the author(s).</p> <ref id="AN0186912257-18"> <title> References </title> <blist> <bibl id="bib1" idref="ref28" type="bt">1</bibl> <bibtext> APA. 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  Data: <searchLink fieldCode="DE" term="%22Counselor+Attitudes%22">Counselor Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Self+Efficacy%22">Self Efficacy</searchLink><br /><searchLink fieldCode="DE" term="%22Patients%22">Patients</searchLink><br /><searchLink fieldCode="DE" term="%22At+Risk+Persons%22">At Risk Persons</searchLink><br /><searchLink fieldCode="DE" term="%22Counseling+Techniques%22">Counseling Techniques</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Therapy%22">Therapy</searchLink><br /><searchLink fieldCode="DE" term="%22Evidence+Based+Practice%22">Evidence Based Practice</searchLink><br /><searchLink fieldCode="DE" term="%22Risk+Management%22">Risk Management</searchLink><br /><searchLink fieldCode="DE" term="%22Self+Destructive+Behavior%22">Self Destructive Behavior</searchLink><br /><searchLink fieldCode="DE" term="%22COVID-19%22">COVID-19</searchLink><br /><searchLink fieldCode="DE" term="%22Pandemics%22">Pandemics</searchLink><br /><searchLink fieldCode="DE" term="%22Psychopathology%22">Psychopathology</searchLink><br /><searchLink fieldCode="DE" term="%22Counselor+Client+Relationship%22">Counselor Client Relationship</searchLink><br /><searchLink fieldCode="DE" term="%22Computer+Simulation%22">Computer Simulation</searchLink><br /><searchLink fieldCode="DE" term="%22Videoconferencing%22">Videoconferencing</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health%22">Mental Health</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Services%22">Health Services</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1080/03069885.2024.2311209
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0306-9885<br />1469-3534
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Before teletherapy usage grew dramatically during COVID-19, clinicians considered it less suitable for patients experiencing high-risk behaviours and related psychopathology (e.g., self-injurious thoughts and behaviours). This mixed methods study assesses clinicians' concerns by quantitatively and qualitatively exploring their experiences, satisfaction, and self-efficacy using teletherapy for high-risk patients. Mental healthcare providers (N = 75) completed a survey assessing teletherapy usage, attitudes, and risk assessment/management self-efficacy. Nine providers then completed semi-structured interviews on these topics. Clinicians reported more confidence assessing and managing risk in-person as compared to teletherapy, and they reported being more likely to treat high-risk patients face-to-face than virtually. Still, attitudes toward teletherapy were generally positive, and clinicians who confidently managed risk in-person also tended to be confident virtually, often reporting that they could administer evidence-based therapeutic interventions regardless of therapy modality. Qualitative analyses revealed both general and person-specific factors that conferred increased or diminished confidence when managing risk.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2025
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1478465
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1478465
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1080/03069885.2024.2311209
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 15
        StartPage: 206
    Subjects:
      – SubjectFull: Counselor Attitudes
        Type: general
      – SubjectFull: Self Efficacy
        Type: general
      – SubjectFull: Patients
        Type: general
      – SubjectFull: At Risk Persons
        Type: general
      – SubjectFull: Counseling Techniques
        Type: general
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Therapy
        Type: general
      – SubjectFull: Evidence Based Practice
        Type: general
      – SubjectFull: Risk Management
        Type: general
      – SubjectFull: Self Destructive Behavior
        Type: general
      – SubjectFull: COVID-19
        Type: general
      – SubjectFull: Pandemics
        Type: general
      – SubjectFull: Psychopathology
        Type: general
      – SubjectFull: Counselor Client Relationship
        Type: general
      – SubjectFull: Computer Simulation
        Type: general
      – SubjectFull: Videoconferencing
        Type: general
      – SubjectFull: Mental Health
        Type: general
      – SubjectFull: Health Services
        Type: general
    Titles:
      – TitleFull: Therapists' Self-Efficacy and Experiences Managing Clinical Risk in Teletherapy: A Mixed Methods Exploration
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Nigel Jaffe
      – PersonEntity:
          Name:
            NameFull: Stephanie Jarvi Steele
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 01
              Type: published
              Y: 2025
          Identifiers:
            – Type: issn-print
              Value: 0306-9885
            – Type: issn-electronic
              Value: 1469-3534
          Numbering:
            – Type: volume
              Value: 53
            – Type: issue
              Value: 2
          Titles:
            – TitleFull: British Journal of Guidance & Counselling
              Type: main
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