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A qualitative study of the use of Skype for pschotherapy consultations in the Ukraine Sisira Edirippulige

Summary
There has been rather limited use of Skype for health and medical purposes. We investigated the use of Skype for delivering psychotherapy services in the Ukraine. A provider questionnaire was distributed to all delegates (n¼50) at the Annual Symposium of Psychotherapists. One copy of a client questionnaire was also given to each service provider and they were instructed to request their next client to complete the survey. In total, 29 providers and 23 clients responded to the questionnaire. The majority of clients (61%) and providers (72%) had used Skype for a range of services. The services they provided were related to a wide range of paradigms including psycho-analysis, psycho-drama, Gestalt therapy, cognitive behavioural therapy and existential therapy. A key reason for using Skype was to allow practitioners to contact clients who were not easily accessible, e.g. those who lived in other countries. Most practitioners (n¼24) thought their clients considered the services received on Skype were good or excellent. All 26 practitioners charged for Skype consultations. The majority of clients and providers showed high satisfaction with the use of Skype for psychotherapy services.

Accepted: 14 August 2013

Introduction


Skype is a free software application that allows personal computers and mobile devices to use voice and video calls, instant messaging and file transfer via the Internet. Its ease of use and low cost have made Skype extremely popular among the general public. Apart from a few case reports and feasibility studies, the literature relating to the use of Skype for health and medical purposes is limited. A review conducted in 2010 indicated that the evidence base for the use of Skype in health and medical-settings is poor. (1)

In a study conducted in the UK, Skype was used by an allied health team to seek advice from a specialist hand therapist and a surgeon to provide follow up treatments to the patients. The study concluded that Skype enabled the allied health team to communicate with specialists and patients reported positive clinical outcomes, including a reduction in anxiety regarding the management of serious hand injuries. (2)

Another case report relating to an inpatient palliative service escribed the use of Skype to communicate with family and riends. The study found that communication using Skype was feasible, and both patients and families had high satisfaction. (3)

A study that used Skype to provide lactation consultations to mothers (n¼12) found that the technique was very useful. (4) Another study that carried out functional assessment using Skype compared it with outpatient reviews, and found no clinically significant differences in the outcomes. The authors concluded that Skype can be used as an alternative to goniometry in clinical settings. A survey of patients showed that 93% of patients (n¼29)
preferred the use of Skype for follow-up, mainly due to the convenience and cost-saving involved. (5) Another study aimed at testing the usefulness of Skype for transferring real-time pathology images for interpretation by experienced pathologists. The study found a high concordance between surgical pathologists. (6)

There appear to be no published reports about the use of Skype for psychotherapy. The purpose of the present study was to examine the level of Skype use by psychotherapists for providing services to their clients in the Ukraine. We also examined the perceptions of both service providers and clients regarding the use of Skype.

Methods


A questionnaire was developed in Russian to examine the level of use and the perceptions toward Skype of service providers and clients. The questionnaire was pilot-tested using 5 service providers and 5 clients and the feedback was used to improve the survey instrument. The provider questionnaire was distributed to all delegates (n¼50) at the Annual Symposium of Psychotherapists in the Ukraine, which was held in Kiev in October 2012.

One copy of the client questionnaire was also given to each service provider and they were instructed to request their next client to complete the survey. Both service providers and clients were asked to return the completed questionnaires using the stamped envelopes provided.

The information gathered by the questionnaires included demographic details of the participants, the level of Skype use in relation to services and the perceptions of Skype use. Several free-text questions were used to acquire more detailed opinions from the service providers and clients. The study was approved by the appropriate ethics committee.

Results


A total of 23 clients (response rate 46%) and 29 providers (response rate 58%) completed and returned the questionnaires. The majority of clients (n¼21; 91%) were below 50 years of age and were female (n¼20; 87%). All of the clients claimed to have tertiary level education. They received a range of services including psychotherapy, psychology consultations and coaching. The majority of clients (n¼19; 83%) were ongoing clients of the services while only 4 clients were first time clients. The demographic details of the clients are summarised in Table 1 (see online archive, XXXX).

Asked if they had used Skype for receiving services, 14 (61%) clients said ‘yes’ while 9 (39%) said ‘no’ (Table 2). Psychotherapy was the main service that the clients received using Skype. Ten clients (39%) had been using Skype for up to 6 months with their service provider. One client had used Skype over 1year. More than half of clients thought that they used Skype consultations for about 50% of the service they received. Nearly half of the clients (n¼11; 48%) paid for the services they received using Skype. Asked ‘What is the most compelling reason for using Skype for receiving services’ all clients pointed to the ‘absence of other methods’ as the main reason.

We asked clients to comments on the positive and negative aspects of services they received using Skype. (Table 3 and 4)

Provider survey


The majority of practitioners were female (n¼21, 72%). The practitioners were mainly 31-50 years of age. The providers’ educational background was diverse including psychotherapy, psychology, medicine and humanities. The demographic details of the providers are summarised in Table 5.

The services they provided were related to a wide range of paradigms including psycho-analysis, psycho-drama, Gestalt therapy, cognitive behavioural therapy and existential therapy. The majority had been working for more than 10 years as practitioners. All of the respondents practised in the private sector while a small number of practitioners provided services through public clinics too. All participants had access to the Internet and 26 of them said that they use the Internet to communicate with their clients.

Most providers (89%;n¼26) mentioned that they used Skype to provide services to their clients, see Table 6. Many of them had used Skype for at least 1 year and they used Skype to provide services several times a week. 92% (n¼24) of practitioners mentioned that up to about 20% of their services could be carried out using Skype. Most practitioners used both face-to-face and Skype for providing services. Nine service providers mentioned that the first consultation was always faceto-face and then the subsequent meetings might be conducted over Skype, while 4 practitioners did not exclude the first consultation via Skype.

Asked ‘What is the most compelling reason for using Skype’ all 26 participants mentioned that ‘My clients live in other cities or other countries’.

The majority of practitioners rated their work on Skype as good or excellent. Most practitioners (n¼24) thought their clients considered the services received on Skype were good or excellent. All 26 practitioners charged for Skype consultations. 19 practitioners charged the same amount for Skype-based services as for normal consultations; 6 practitioners charged less. Only one practitioner charged higher fees. All 26 practitioners who used Skype for providing services had not experienced any difficultywith the authorities relating to the use of this method.

Discussion


One important requirement for conducting successful video consultations is the availability of clear video images and audio. Studies have shown that the ability to carry out successful teleconsultations depends on the quality of video and audio. (7) Clinician and patient satisfaction of video consultations are also often dependent on the quality of the connection. (8) A number of studies have shown that high quality videoconferencing with commercial videoconferencing equipment and reliable networks such as ISDN can facilitate telemedicine consultations. However, such systems are not universally available and are often expensive. Skype is free and easily available. Due to the popularity of Skype for general communication, many people are familiar with it.

Our study showed a key reason for using Skype was to allow practitioners to contact clients who were not easily accessible. A number of practitioners noted that they often used Skype to contact people who live in distant places, including those who live in other countries. Many people moved away from the Ukraine after the disintegration of the Soviet Union, but they retain a desire to use services from familiar mental health professionals.
Skype provides both practitioners and clients with an acceptable medium for communication. Clients pointed out a number of advantages provided by Skype, mainly that they can access services regardless of distance. For some clients this was the only possible way of receiving such a service.

The majority of providers used Skype for follow upcon sultations. In most cases, professionals conducted their first consultation face to face and then if necessary they used Skype for subsequent consultations. Our study showed that not all aspects of the practice can be carried out using Skype. Some providers mentioned that they could not undertake certain aspects of therapies by Skype due to poor video and audio quality. Therefore the practitioners were selective in the use of Skype for
the most suitable aspects of their practice.

All practitioners mentioned that they had no difficulties relating to the Skype use for their practice by the professional organisation. It is often mentioned that a communications medium like Skype may be associated with ethical, legal and confidentiality problems. However, as the present study showed, not only providers and clients, but also the professional organisations did not consider these matters to represent barriers to the use of Skype for providing psychotherapy services. This suggests that while privacy, security and confidentiality may be major concerns in certain industrialised countries, the need for service is the driving force for using telemedicine in low resource settings. A small number of providers and clients were also reluctant to use Skype for various reasons such as lack of trust and low technical quality.

While the present study contributes to the evidence for Skype use in health care, several limitations of the study must be noted. The results were based on provider and client perceptions and the effect of the technique on health outcomes was not investigated. In addition, the study was based on a small number of participants who may not be representative of the general population.

The use of Skype for medical and health practices is an example of adapting a commonly available technology for delivering care services. It seems reasonable to assume that tools such as Skype will become more widely used in future


Acknowledgments


We are grateful for the comments provided by Nigel Armfield
and Jennylee Wood of the Centre for Online Health.

References


1. Armfield NR, Gray LC, Smith AC. Clinical use of Skype: a review of the evidence base. J Telemed Telecare 2012;18:125–7.

2. McMullen E. Use of audiovisual equipment (Skype) for the treatment of hand injuries for remote consultations. Hand Ther 2012;17:42–6.

3. Brecher DB. The use of Skype in a community hospital inpatient palliative medicine consultation service. J Palliat Med 2013;16:110–12.

4. Habibi M, Hedberg S, Magnuson E, Kavanagh K. Using Skype for breastfeeding consultation: feasibility study to determine accuracy of diagnosis and referral. See https://apha.confex.com/apha/138am/webprogram/Paper222987.
html (last checked 14 August 2013).

5. Good DW, Lui DF, Leonard M, Morris S, McElwain JP. Skype: a tool for functional assessment in orthopaedic research.J Telemed Telecare2012;18:94–8.

6. Sirintrapun SJ, Cimic A. Dynamic nonrobotic telemicroscopy via skype: a cost effective solution to teleconsultation. J Pathol Inform2012;3:28.

7. Lemaire ED, Boudrias Y, Greene G. Technical evaluation of a low-bandwidth, Internet based system for teleconsultations. J Telemed Telecare2000;6:163–7.

8. Ekeland AG, Bowes A, Flottorp S. Effectiveness of telemedicine: a systematic review of reviews. Int J Med Inform
2010;79:736–71.

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(1)Centre for Online Health, University of Queensland, Brisbane, Australia
(2) Department of Psychotherapy, Tavricheskiy National University, Simferopol, Ukraine

(3) Psytron Consultants, Kiev, Ukraine Corresponding author:
Dr Sisira Edirippulige, Centre for Online Health, Level 3, oundation
Building, Royal Children’s Hospital, Herston, QLD 4029, Australia.

Email: s.edirippulige@uq.edu.au
 


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