Perspectives Among Patients and Counselors with Tele-Counseling in the COVID-19 Pandemic

Introduction: Medication for opioid use disorders (MOUD) is the evidence-based standard of care in efforts to address the opioid epidemic. The COVID-19 pandemic has provided a natural experiment with rapid changes in regulation and policy that have changed the access and delivery of MOUD and, in particular, the move from in-person to virtual platforms (e.g. telephone) for counseling services. It is currently unclear how the therapeutic relationship between patients and counselors has changed as a result. Understanding its impact on the therapeutic relationship may assist in identifying how recent changes should be adopted in the long term to improve the quality of care and treatment engagement/retention and reduce rates of relapse and overdose.

Methods: Participants were recruited in Rhode Island via a partnership between CODAC Behavioral Healthcare and Brown University. Participants (n = 106 patients; n = 29 counselors) completed a survey with open-ended questions that included the following domains: (1) Satisfaction with telephone counseling, (2) Perceived convenience of telephone counseling, (3) Changes to the therapeutic relationship due to telephone counseling, (4) Impact on substance use recovery, and (5) General feedback. Responses were coded by two independent raters using thematic analysis to generate a codebook, and another two independent raters coded the responses into thematic categories. Codes were subsequently organized into themes and sub-themes (covering 98% and 100% of patients’ and counselors’ responses). Interrater reliability for coding of patients’ responses ranged from .89 to .95, and from .63 to .94 for counselors’ responses.

Results: Overall, both patients and counselors reported that telephone counseling improved the therapeutic relationship and helped ameliorate person-level barriers. Among both patients and counselors, improved therapeutic relationship factors included: (1) an increased sense of accountability between the patient and counselor, (2) more efficient use of counseling time, and (3) a greater sense of perceived counselor support and access. In addition, patients reported feeling more empowered in their substance use recovery after the shift to telephone counseling. Improved person-level factors included: (1) greater flexibility for one’s personal and work schedule and (2) an increased sense of safety amidst the pandemic from reduced face-to-face contact. In addition, patients reported that telephone counseling resolved transportation barriers to attending in-person counseling. However, both patients and counselors highlighted some potential problems with telephone counseling, including a lack of privacy from counseling at home and an impersonal experience. Furthermore, counselors also felt that telephone counseling made their workflow more tedious.

Conclusion: Telephone counseling may improve the therapeutic relationship between patients and counselors and can address person-level factors that result in an improved therapeutic experience for both counselors and patients. However, telephone counseling presents its own set of challenges that should be investigated further to improve the quality of care and long-term patient outcomes.

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