How we never met – and wrote an article about it: Communication, relationship and ethics in video-based telepsychiatric consultations

By: Eva-Maria Frittgen, Joschka Haltaufderheide

During the first waves of the COVID-pandemic, videoconferencing quickly became one of the preferred ways of communicating. This was also the way how we as authors first met (and have met ever since without ever meeting in person) and started to think about the use of video-based consultations in healthcare: somewhat concerned about the sudden and ubiquitious use of videoconferencing, somehow curious and somehow disturbed by own experiences of the oddities of virtual presence. Scientific work may be one thing. But video-based consultations in healthcare are surely another, we thought.

In discussions about the use of new digital technologies in medicine, evaluation and assessment mostly relies on quantifiable outcome parameters. Analyses of the process itself and its qualities, on the other hand, are often relegated to the background. But isn’t this exactly what everybody was wondering about? The feeling that videoconferencing is like talking to a real person but somehow totally different? To our understanding, neglecting this difference is mostly due to an instrumental concept of technologies, understanding them as some kind of different means to the same end. However, the matter seems to be more complicated. From common-sense as well as from an ethical perspective, the very question of how an outcome is achieved can be of crucial relevance. In our paper, we illustrate this in considering the use of video-based consultations in psychiatry, which has experienced a considerable upswing in recent years due to the Corona pandemic.

Numerous studies about video-based consultations in psychiatry show hardly any differences in treatment results compared with those of face-to-face care in terms of clinical outcome, acceptance, adherence and patient satisfaction. However, evidence on videoconferencing in a variety of different fields indicates that there are extensive changes in the communication behavior in online conversations. This suggests that in telepsychiatry, process quality may be changed, since communication and relationship between therapist and patient play a central and ethically significant role in psychiatry.

In reviewing the effects of video-based consultations on communication between therapists and patients based on a common-sense understanding and existing empirical literature we find evidence that video-based consultations change the lived experience of communication. This is to employ a different view on technology, based on a postphenomenological perspective drawing attention to the question how the use of technology changes the way we can perceive the world and act in it. Categorizing these effects according to sensory, spatial and technical aspects and departing from a power-based model of therapeutic relationships, we then discuss the ethical significance of this changed communication situation, based on dimensions of respect for autonomy, lucidity, fidelity, justice and humanity.

We conclude that there is evidence for ethically relevant changes of the therapeutic relationship in video-based telepsychiatric consultations. These changes need to be more carefully considered in psychiatric practice, future studies and the development of programs for the conduction of video-based consultations. Against the background of the increased use of telepsychiatry, there is a lack of broad-based information and training for therapists and patients about communicational, relational and ethical aspects of video-based consultations. Only these would enable an informed decision about the use of them and also an optimization of the process quality.


Paper title: ‘Can you hear me?’: communication, relationship and ethics in video-based telepsychiatric consultations

Authors: Eva-Maria Frittgen1, Joschka Haltaufderheide2

Affiliations: 1. Center for Psychiatry Reichenau, Reichenau, Baden-Württemberg, Germany, 2. Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany

Competing interests: None declared.

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