Paper/Poster presented at American Psychological Association 1999: Boston

Paul L. Schneider, PhD

Mediators of Distance Communication Technologies in Psychotherapy:

Development of a Measure

Abstract

In this study a measure of comfort with psychotherapy via two-way video, two-way audio, and face-to-face communication modes was developed. 312 participants from two Midwestern Universities completed the Distance Communication Comfort Scale [DCCS] and the NEO Five Factor Inventory [NEO-FFI]. Individual items from the DCCS were found to distinctly load on three factors relating to each of the three communication modes. Correlations between scales ranged from .26 to -.38 suggesting three related, but distinct scales. Internal consistency levels of the three scales were high (Cronbach alpha’s ranged from .81 to .88.) Discriminatory validity was demonstrated by the low correlations with the NEO-FFI scales (.01 to .26). The DCCS holds much potential in future research on the effectiveness of psychotherapy via distance technologies.

Mediators of Distance Communication Technologies in Psychotherapy:

Development of a Measure

The use of telehealth, the delivery of health services over a distances via technology, continues to expand throughout the field of health services and specifically psychotherapy (Grigsby, 1997). However, very few studies have empirical examined the effectiveness of this method of delivery (Baer, Cukor, & Coyle, 1997). Furthermore, virtually no research has examined whether this type of treatment is suitable for all clients and if there are any mediating variables in treatment effectiveness.

The development of the Distance Communication Comfort Scale [DCCS] represents a first step in an effort to address a part of Paul’s (1967) question, "What kind of therapy, or elements thereof, benefits what kind of client?" as it applies to telehealth. In developing a study to determine the differential effectiveness of psychotherapy using different delivery systems I found very little empirical research on its use. Furthermore, I was unable to find any measures specifically aimed at looking at client characteristics that might interact with different distance delivery modes, such as two-way video and two-way audio.

Shoham-Salomon and Hannah (1991) indicate that it is imperative that the choice of aptitudes (mediating variables) be grounded in theory. Following this guideline I looked to the few studies in the area as well as in distance education and communication research. In the two-way audio literature several case reports indicate that some clients were more comfortable with phone therapy and that in some instances may have done better than they would have had face-to-face treatment been the primary mode. This suggests that comfort with two-way audio communication might be indicative of different outcomes in two-way audio and face-to-face situations.

The two-way video literature reveals a similar, though less striking phenomenon. In two-way video situations they reported occasional initial trepidation in the use of the technology, followed by a gradually increasing level of comfort. The communication literature offers some explanation for this phenomenon, noting that new technology may initially be detrimental to presence and communication comfort, but that as the user becomes more familiar with the medium, this effect will disappear (Held & Durlach, 1992). Given these factors, it would seem that comfort would at least initially play a part in the effectiveness of therapy.

Last, conventional wisdom suggests that people who are comfortable with communicating are more likely to benefit from talk therapy than those who are not comfortable. Thus, it would appear that it is especially important that comfort with the therapeutic situation is assessed when looking for treatment effects. For these reasons comfort with the different communication mediums was chosen as the variable most likely to have an effect in each of the three treatment modes (face-to-face, video, and audio).

The instrument most akin to this goal is one developed to assess equipment, comfort, and distractibility in a family counseling environment using two-way audio and two-way video (Hufford, Glueckauf, & Webb, 1999). This measure specifically sought to address these variables in a family system. Following the lead of Hufford, as well as work on comfort with technology in the distance education classrooms (Schneider & Reinhart, 1998) a measure to assess these variables in an individual counseling situation was developed.

The initial questions were based upon four different, but related areas of communication comfort: Ability to understand the counselor, ability to be understood, general like or dislike for the medium, and comfort with the medium. Using these four areas a total of 36 questions were developed. Nine questions for each of the four areas of communication comfort were developed with these nine questions evenly addressing the three communication mediums, two-way video, two-way audio, and face-to-face.

In this study we sought to establish that the developed measure reliably assessed the unique factors of comfort with video, audio, and face to face communication. Furthermore, these variables in themselves would be unique and not simply extensions of a major personality type such as extraversion or agreeability. The following are our hypotheses:

    1. The items will measure three related but distinct aspects of communication comfort (audio, video, face to face). Furthermore, the audio and video scales will be positively related to each other and negatively related to face to face. Video and audio communication share the unique aspect of communication through technology and distance as well as having a lesser degree of presence than face to face. It is this aspect that I expect to be demonstrated by the proposed relationships.
    2. Video and face to face communication will be positively related to Extraversion and Audio will have no relationship with Extraversion. Comfort with face to face situations and being seen on video are quite similar to the definitions and traits used to describe Extraversion. Likewise comfort with communication over two-way audio is not, at face value, related to the definition of Extraversion.

Method

Participants

Participants (n=312) came from two large Midwestern universities. These participants were in introductory education and psychology courses and received research credit for participating in the study. Participants ranged in age from 18 to 47 with a mean age of 21. The participants identified themselves as 6% African American, 11% Asian American, 78% Caucasian, 3% Hispanic, 1% Native American, and 1% Other.

Instruments

Distance Communication Comfort Scale (DCCS). Participants were asked to rate how strongly they agree with 36 statements. Each item is responded to using a six point rating scale (1 = strongly disagree and 6 = strongly agree).

NEO Five Factor Inventory (NEO-FFI) (Costa & McCrae, 1992) The NEO-FFI is a brief version of the NEO-PI revised (Costa & McCrae, 1992). The five scales measures the "Big 5" of personality, Extraversion, Agreeableness, Openness to Experience, Neuroticism, and Conscientiousness. The internal consistency levels (Cronbach's alpha) for the scales were between .70 and .85.

Analysis

Exploratory factor analysis was performed on the measure to determine its factor structure. We hypothesized that three factors would sufficiently explain the factor structure. Using these guidelines as well as a scree plot, initial factors were extracted. It was expected that the responses to the items would be distributed along a normal curve. In addition we were attempting to develop measures that would assess three unique factors. For these reasons Maxium Likelihood extraction and Varimax rotation were used. Following the initial extraction the number of factors was determined using our a prior hypothesis, eigen values, and a scree plot as guidelines. Next, individual items were analyzed. Item content and their contribution to individual scales were taken into consideration in determining which items to include in the final scales. Cronboch’s alpha’s were then computed for the final DCCS scales as well as the NEO-FFI scales. Finally, to establish discriminate validity, correlational analysis between the two measures was performed.

Results

The number of factors extracted was determined by the a priori hypothesis, a scree test, and initial eigen values. The initial values for the first six factors extracted were 10.03 (28%), 3.79 (11%), 3.03 (8%), 1.67 (5%), 1.21 (3%), and 1.14 (3%). Using these guidelines it was determined that three factors best explained the data structure. At this point item analysis and factor loadings were examined and items (nine) that loaded on multiple factors or whose contributions were insignificant were eliminated. The subsequent extraction and varimax rotation resulted in eigenvalues of 6.84 (25%), 3.17 (12%), 2.65 (10%) for the first 3 factors, which accounts for 47% of the total variance.

Table 1 shows the rotated factor loadings and communalities for each of the three factors after item trimming.

Table 1

DCCS Factor Loadings and Communalities

DCCS Item

1

Factor

2

3

Commmunalities

1r. talking on camera makes me uncomfortable

-.13

.51

-.04

.35

15r. difficulty understanding counselor on video

-.15

.56

.13

.40

19r. self-conscious when in front of camera

-.06

.50

-.05

.30

22. easy to maintain attention when using video

-.04

.62

.03

.41

27r. using video phone would be distracting

-.01

.74

.19

.58

3. talking over video would not detract ability to focus

-.08

.58

.01

.40

6r. hard to understand me over video

-.07

.52

.07

.33

9. discussing over video would be fun and interesting

-.70

.57

.11

.37

28. feel comfortable talking over video

-.10

.64

.21

.46

10. feel comfortable talking on telephone

-.01

.04

.73

.53

12r. hard to express myself on phone

-.04

.09

.37

.24

(table continues)

Table 1 (continued)

DCCS Item

1

Factor

2

3

Commmunalities

18. easy to maintain focus on telephone

-.07

.01

.49

.33

2. enjoy discussing problems on telephone

-.13

.01

.61

.41

21r. feel detached when talking on telephone

-.20

.20

.46

.39

24r. easily distracted when talking on telephone

-.16

.09

.42

.35

4. easier to concentrate on telephone

-.26

-.11

.55

.41

8r. dislike talking to therapist on telephone

-.14

.13

.78

.57

26r. understanding therapist would probably be difficult

-.16

.29

.52

.43

11. easier for counselor to understand in same room

.73

-.10

-.17

.59

14. easier for me to understand someone in same room

.62

-.15

-.25

.55

16r. being in the same room makes me uncomfortable

.56

-.02

-.09

.43

7. paying attention when in same room is easy

.65

-.16

.09

.49

(table continues)

Table 1 (continued)

DCCS Item

1

Factor

2

3

Commmunalities

29r. easily distracted when in same room

.45

.01

-.18

.34

35. more comfortable if in same room

.79

-.18

-.24

.69

5. prefer to talk with counselor in person

.77

-.09

-.15

.62

34. easier to concentrate when in the same room

.64

-.18

-.29

.55

31. enjoy discussing problems in same room

.73

-.14

-.07

.57

Note. Items with an r next to them are reverse scored. Full item descriptions can be found in Appendix A.

Examination of the item content suggests that: The first factor represents comfort with face-to-face communication. The second factor represents comfort with two-way video communication. The third factor represents comfort with two-way audio communication.

Reliability for these scales, as well as the NEO-FFI, were assessed using a measure of homogeneity, Cronbach’s alpha. The alphas for these scales are reported in Table 2. Last, correlational analysis was performed between the three DCCS scales and the five NEO-FFI scales (see Table 2).

Table 2

Correlations Between DCCS Scales and NEO-FFI Scales

 

Video

Audio

Face

Neuro

Extra

Open

Agree

Conc

Video

.82

 

 

 

 

 

 

 

Audio

.26**

.81

 

 

 

 

 

 

Face

-.31**

-.38**

.88

 

 

 

 

 

Neuro

-.14*

-.04

-.04

.85

 

 

 

 

Extra

.16**

-.08

.18**

-.44**

.84

 

 

 

Open

.07

.01

-.01

-.12*

.09

.73

 

 

Agree

-.06

-.00

.26**

-.28**

.34**

-.00

.76

 

Conc

-.01

.05

.18**

-.28**

.22**

-.16**

.19**

.79

Note. Video, Audio, and Face = the three DCCS scales; Neuro = Neuroticism; Extra = Extraversion; Open = Openness to Experience; Agree = Agreeability; Conc = Conscientiousness. Internal consistency estimates are provided on the main diagonal (a 's).

* p < .05. **p = .01.

Discussion

The purpose of this study was to develop a unique measure to assess the degree to which people felt comfortable with audio, video, and face-to-face communication mediums in a counseling situation. The results of this study suggest that the DCCS does indeed measure three distinct areas. As can been seen from the factor loadings of the exploratory factor analysis, each item loads highly on its respective factor. Examination of the individual item content gives credence to the idea that these factors are indeed differentially assessing comfort with face-to-face communication, two-way video communication, and two-way audio communication.

The next step in the development of this measure was to assess the reliability and validity. Using Cronbach’s alpha, reliability analysis suggests that the measures are homogenous and have an acceptable level of reliability for use with clinical populations. Validity for the scales was provided in a variety of ways. First, the items have strong face validity for each of the proposed constructs. Second, although the three factors are related, as one would suspect, they do appear to be measuring distinct factors as can be seen by their individual factor loadings and the correlational analysis. Examination of the data in Table 2 shows that the audio and video scales are positively related (r = .26) and the face-to-face scale is negatively related to these two variables (r = -.38 and r = -.31). As expected the non-technological situation that contains a higher level of presence, face-to-face, is negatively related to technological situations with a lower degree of presence, audio and video. Further studies will need to be conducted to assess the significance of the relationship between these and other contributing factors.

Evidence for discriminate validity was provided in a comparison between the NEO-FFI scales and the DCCS scales. The NEO-FFI scales represent each of the "Big 5" personality scales (Costa & McCrae, 1992). Examination of the correlational analysis in Table 2 clearly shows that the DCCS is not measuring one of the "Big 5" personality variables. Although these scales are clearly different, there are some relationships between the two sets of scales. The video and face-to-face scales are both positively related to extraversion (r = .16 and r = .18). This suggests that being on video or in a close face-to-face situation is more comfortable for people who are more extraverted. The only other relationships with similar strength are those between face-to-face and Agreeability and Conscientiousness (r = .26 and r = .18). Examination of the definition of Agreeability shows that these people like to be around people and enjoy social interaction. That this would be correlated with the DCCS face to face scale makes sense when presence is taken into account. One thing that the face to face situation typically conveys is a greater degree of initial presence. It seems likely that people who are more agreeable also enjoy a high degree of presence in their interactions and thus feel particularly comfortable in face to face situations.

The Conscientiousness variable is more difficult to explain. One aspect of the variable that could account for the relationship is the preference for situations in which they are familiar and are able to better predict what will happen. In the face to face communication the only novel aspect would be the interaction with a counselor. In the video and audio aspect, the interaction presents a greater number of variables and a lesser ability to predict. However, this is not a core aspect of Conscientiousness. Further studies that better tap into this area are needed before any definitive conclusion can be reached regarding this relationship.

The purpose of this study was to develop a measure to reliably assess comfort in a counseling situation in three different media. The results of the study suggest that the measure developed does indeed provide this type of assessment. Furthermore, these variables appear to be unique constructs not only when compared to each other, but also when compared to major personality variables.

REFERENCES

Baer, L. Cukor, P., Coyle, J. T. (1997). Telepsychiatry: Application of telemedicine. In R. L. Bashshur, J. H. Sanders, & G. W. Shannon (Eds.), Telemedicine: Theory and practice (pp. 265-290). Charles C Thomas: Springfield.

Costa, P.T., Jr., & McCrae, R. R. (1992). NEO-PI-R professional manual. Odessa, FL: Psychological Assessment Resources.

Grigsby, J. (1997). Telemedicine in the United States. In R. L. Bashshur, J. H. Sanders, & G. W. Shannon (Eds.), Telemedicine: Theory and practice (pp. 265-290). Charles C Thomas: Springfield.

Held, R. M., & Durlach, N. I. (1992). Telepresence. Presence, 1, 109-112.

Hufford, B. J., Glueckauf, R. L., & Webb, P. M. (1999). Home-based, interactive videoconferencing for adolescents with epilepsy and their families. Rehabilitation Psychology, 44, 1-18.

Paul, G. L. (1967). Strategy of outcome research in psychotherapy. Journal of Consulting Psychology, 31, 109-118.

Schneider, P. L. & Reinhart, J. (1998, August). The Relationship Between Environmental Perception, Satisfaction, Self-efficacy, and Anxiety in a Two-way Audio/Video Classroom. Poster presentation at APA, San Francisco, CA.

Shoham-Salomon, V. (1991). Introduction to special section on client¾ therapy interaction research. Journal of Consulting and Clinical Psychology, 59, 203-204.

 

APPENDIX A

DISTANCE COMMUNICATION COMFORT SCALE

Distance Communication Comfort Scale

Identifying Information:

Sex: M F Age: _____ Ethnicity: ___________________________

A number of statements are given below asking you how you feel about three different types of communication (two-way audio (telephone), two-way video (video phone), and face-to-face) that might be used when receiving counseling or psychotherapy. Although you may not have ever seen a therapist or a counselor, please indicate how you anticipate you would feel about each of the statements.

The scale uses a seven point scale, shown below, where 1 = strong disagreement and 7 = strong agreement. Read each statement and indicate how you generally feel using the given scale. There are no right or wrong answers. Do not spend too much time on any one statement but give the answer which seems to describe your general feelings.

1 2 3 4 5 6 7

Strongly Disagree Strongly Agree

You can indicate how you feel by choosing a number between 1 and 7. Circle the number that most closely represents how much you agree or disagree with the statement. There are no 'correct' responses; it is your

own views that are important.

It is important that you respond to every statement. Please circle the response that you think is the most appropriate.

  1. Talking to a counselor on camera would make me uncomfortable.

1

2

3

4

5

6

7

  • I think I would enjoy discussing problems with a counselor over the telephone.
  • 1

    2

    3

    4

    5

    6

    7

  • I think meeting and talking with a counselor over a video phone would not detract from my ability to focus.
  • 1

    2

    3

    4

    5

    6

    7

  • It’s easier to concentrate on what someone is saying when communicating over the telephone.
  • 1

    2

    3

    4

    5

    6

    7

  • I would prefer to talk to my counselor in person.
  • 1

    2

    3

    4

    5

    6

    7

  • I think a therapist would have a hard time understanding me if we communicated by two-way video.
  • 1

    2

    3

    4

    5

    6

    7

  • Paying attention to a counselor who was in the same room would be very easy.
  • 1

    2

    3

    4

    5

    6

    7

  • I think I would dislike talking to a therapist on the telephone.
  • 1

    2

    3

    4

    5

    6

    7

  • I think discussing problems with a counselor over a video phone would be fun and interesting.
  • 1

    2

    3

    4

    5

    6

    7

  • I would feel very comfortable talking to a therapist on the telephone.
  • 1

    2

    3

    4

    5

    6

    7

  • I think my counselor would have an easier time understanding me if we were in the same room.
  • 1

    2

    3

    4

    5

    6

    7

     

     

    1. I often find it hard to express myself when talking on the phone with another person.

    1

    2

    3

    4

    5

    6

    7

    1. It is easier for me to understand someone when I am in their physical presence.

    1

    2

    3

    4

    5

    6

    7

  • I would probably have some difficulty in understanding my counselor if I met him/her only through a two-way video system.
  • 1

    2

    3

    4

    5

    6

    7

  • Being in the same room with my counselor would make me uncomfortable.
  • 1

    2

    3

    4

    5

    6

    7

    1. I find it easy to maintain my focus when talking to someone over the telephone.

    1

    2

    3

    4

    5

    6

    7

  • I feel self conscious when in front of a camera.
  • 1

    2

    3

    4

    5

    6

    7

    1. I feel detached or far away when talking on the telephone.

    1

    2

    3

    4

    5

    6

    7

  • If I were communicating through a video phone I believe it would be easy to maintain my attention.
  • 1

    2

    3

    4

    5

    6

    7

    1. I become easily distracted when talking with someone on the telephone.

    1

    2

    3

    4

    5

    6

    7

    1. Understanding my counselor over the telephone would probably be difficult.

    1

    2

    3

    4

    5

    6

    7

  • Using a video phone to discuss problems with a counselor would be distracting.
  • 1

    2

    3

    4

    5

    6

    7

  • I would feel quite comfortable discussing my problems with a counselor over two-way video.
  • 1

    2

    3

    4

    5

    6

    7

  • I am easily distracted when conversing with someone who is in the same room.
  • 1

    2

    3

    4

    5

    6

    7

    1. I would enjoy discussing problems with a counselor who was in the same room as I.

    1

    2

    3

    4

    5

    6

    7

    1. I find it easier to concentrate on what someone is saying when we are in the same room.

    1

    2

    3

    4

    5

    6

    7

  • I would be more comfortable if my counselor was in the same room as I.
  • 1

    2

    3

    4

    5

    6

    7