Introduction
It is often claimed that the audio and video recording of cognitive behaviour therapy (CBT) sessions is a helpful adjunct to treatment (Macaskill, Reference Macaskill1996), and some therapists now routinely record sessions. Despite what appear to be considerable advantages, recording is seldom utilized in clinical practice. There are three main ways in which recordings can be used: (a) as a therapy aid, for patients to listen to or watch between sessions; (b) as part of therapy supervision; and (c) as part of a behavioural experiment set up during therapy sessions. The present study focuses on the first two applications, investigating the attitudes of both service users and therapists in the context of a specialist CBT clinic where recording of therapy sessions takes place routinely.
The rationale for providing recordings of therapy for review between sessions usually includes three factors. First, reviewing tapes provides a support for memory (Macaskill, Reference Macaskill1996). Typically, the client is asked to make notes as they go through the tape of: (a) what they learned in the session (as a few key bullet points); and (b) any issues they felt they wished to clarify or disagree with. It is usually intended that these are reviewed early in the next session. Reviewing recordings can also facilitate homework, in terms of understanding the rationale and the practical details of what has been agreed (Macaskill, Reference Macaskill1996). Second, good CBT helps the client to explore key meanings, and is likely to involve high levels of emotion; processing of the content of the session may be aided by later review of the recording, as the patient is likely to be less emotionally aroused at that time (Ford, Fallowfield, Hall and Lewis, Reference Ford, Fallowfield, Hall and Lewis1995). Sometimes, the therapist may ask the patient to focus on particular points in the session as part of the re-appraisal process. Third, the client can, if they wish, choose to share therapy sessions with other people (partners/family members) and thereby involve them in the process of supporting therapeutic change (Alpert, Reference Alpert1996). Similar factors apply to the use of recordings by therapists, with the emphasis usually being placed on the value of recordings in supervision. Note that audio recording is usually used for clients, with video often being more common for supervision, for both practical (availability of compatible playback equipment) and theoretical (the importance of non-verbal communication in the therapy context forming part of the supervisory process) reasons.
Whilst there is some empirical grounding relevant to the value of audio recording therapy sessions, some therapists reject its use on varied grounds, including but not confined to: (a) practical difficulties with recording technology; (b) therapist beliefs that patients will react negatively to the suggestion of recording or that patients will not use the recordings; (c) therapist beliefs that recordings will not be helpful; and (d) therapist anxiety. Some of these have previously been highlighted by Alpert (Reference Alpert1996).
There has been previous research examining attitudes towards recording physical health consultations. Oncology patients who were given recordings of their initial consultation were found to have positive attitudes towards them (McHugh et al., Reference McHugh, Lewis, Ford, Newlands, Rustin, Coombes, Smith, O'Reilly and Fallowfield1995). Moreover, a separate study found that oncology patients who were given recordings were more satisfied with treatment relative to those who were not (Ong et al., Reference Ong, Visser, Lammes, Van Der Velden, Kuenen and de Haes2000). In the study by Ong et al. (Reference Ong, Visser, Lammes, Van Der Velden, Kuenen and de Haes2000), 75% of oncology patients who received a recording of their consultation subsequently listened to their audiotape, with 73% of these having listened to it with another person.
Recording therapy sessions for patients' use or supervision is presumed by many as being likely to create unhelpful levels of anxiety in both therapists and patients, and therapists have been known to cite the protection of their patients as their main objection to recording sessions (Alpert, Reference Alpert1996). Such discussion needs to be informed by data of the type gathered in the present study.
The specific issues examined in the current study were:
• The range of technology available to patients in order to listen to audio recordings, and what their preferences for the format of recordings were.
• Whether patients attending a centre that routinely recorded therapy sessions listened to recordings (and in what way).
• What patient attitudes towards recording therapy sessions were at the end of therapy, in terms of both their personal use and their use for therapist peer supervision purposes.
• How patients perceived their discussion about recordings with their therapist.
• Therapists' awareness of the extent to which patients listen to recordings.
• What therapists' attitudes towards recording therapy sessions are, both for patient use and for their own supervision.
Method
Setting
The study was conducted at a specialist treatment and research centre for anxiety disorders where CBT sessions are routinely recorded. Further information about the use of recordings can be found on the centre's website http://psychology.iop.kcl.ac.uk/cadat/general-information/FAQs.aspx
Participants
Patients. Data were collected over a 9-month period between September 2006 and June 2007. The response rate for the start-of-therapy questionnaire was 53% (n = 72). Of these, 78% were being treated for social anxiety, 63% for OCD, 48% for panic disorder, and 24% for PTSD. The response rate for the end-of-therapy questionnaire was 49% (n = 31). Fifty-two percent of these participants were being treated for social anxiety, 90% for OCD, 33% for panic disorder, and 27% for PTSD.
Therapists. Eighty-three percent (n = 15) of the therapists working at the centre also participated.
Materials
Three specifically designed questionnaires were used. These included two questionnaires for patients to complete: a start-of-therapy questionnaire exploring what equipment they owned to listen to audio material and preferences regarding the format of recordings; and an end-of-therapy questionnaire identifying patients' behaviour and attitudes towards recordings. The third was a questionnaire for therapists to complete and this examined therapists' behaviour and attitudes towards recordings. The questionnaires elicited a combination of descriptive and qualitative responses.
Procedure
The start-of-therapy questionnaire was given to patients at their first session of therapy and the end-of-therapy patient questionnaire was given at the penultimate therapy session. Therapists were asked to complete the therapist questionnaire in a general manner (i.e. without necessarily thinking about their current patients but of their personal experience of recording therapy sessions as a whole). Open ended questions were analysed using thematic analysis. The average rate of concordance in the assignment of themes across all qualitative data was 82%, based on two independent raters. This suggests a high level of reliability.
Results
Patient start-of-therapy data
Audio equipment owned by patients and format preferences for receiving therapy recordings. At the start of therapy, patients were asked to indicate what equipment they had available to listen to audio material. The most common device was a compact disc (CD) player, which was owned by 92% (n = 66) of patients, followed by a tape cassette player, which 80% (n = 57) of patients owned. Only one patient did not own either a CD or tape cassette player. Fifty-four percent (n = 39) of patients owned an MP3 player (e.g. an IPod). Eight percent (n = 6) of patients owned an “other” device, which included computers, an MP4 player and a mini-disc player. There was a trend for patients to prefer to receive their therapy recordings on CD but this was not statistically significant using a Friedman ANOVA (X2 = 3.48, df = 3, p>.05).
Patient end-of-therapy data
Patients' behaviour towards therapy recordings. Ninety-seven percent (n = 30) of patients stated that they had been given recordings of their therapy sessions by their therapist and asked to listen to them between sessions, whereas only 3% (n = 1) said that they had not. When asked about the frequency of this, 81% (n = 25) said “Every session”, 13% (n = 4) selected “In more than half of sessions”, 3% (n = 1) reported “In less than half of sessions” and 3% said “Not at all” (n = 1).
Ninety percent (n = 28) of patients said that they had listened to their recordings to some extent between therapy sessions, and 10% (n = 3) said they had not. When asked how often they had listened to their recordings, 50% (n = 15) responded “At least once”, 23% (n = 7) selected “Sometimes”, 20% (n = 6) said “More than once” and 7% (n = 2) responded “Not at all”.
Patients were asked what they did with the recordings between therapy sessions, if they had listened to them. The most frequently endorsed strategies included “Discussed some parts with my therapist” which 61% (n = 17) of patients endorsed and “Made notes about the session” which 36% (n = 10) of patients selected. Less common strategies endorsed were “Only listened to the beginning” (18% of patients; n = 5), “Only listened to the end” (14% of patients; n = 4), “Only listened to the middle” (11% of patients; n = 3), and “Listened to it with another person” (4% of patients; n = 1).
Seventy-three percent (n = 19) of patients said that they would keep their recordings after therapy had ended, 19% (n = 5) said that they would return them to their therapist, 4% (n = 1) said that they would only keep selected ones, and 4% (n = 1) said that they would destroy/erase them.
Patients' attitudes towards therapy recordings
Patients were then asked a number of open-ended questions to explore their attitudes towards recording therapy sessions. Full details of the extracted themes can be found in the extended report. “What is your opinion about recording and listening to therapy sessions?” The responses were generally positive, and the most common themes that were generated were that recordings were a good idea/helpful (63%; n = 19), that they served as a memory aid for the session (27%; n = 8), and helped assimilate new information (23%; n = 7). However, 17% (n = 5) of patients thought that they might be problematic if patients were self-critical/self-conscious of hearing their own voice on recordings. A range of other low frequency responses, reflecting both positive and negative attitudes, were also made and can be found in the full report.
Patients were next asked, “Can you think of any advantages of recording and listening to therapy sessions? Please describe”. The most commonly generated themes included the recordings serving as a memory aid for sessions (50%; n = 12), being useful for relapse prevention/self-help (25%; n = 6), to help assimilate new knowledge/aid learning (21%; n = 5), to provide an objective view of the self/anxiety disorder (17%; n = 4), and to provide support outside of therapy sessions (13%; n = 3).
Patients were then asked, “Can you think of any disadvantages of recording and listening to therapy sessions? Please describe”. The most common themes were that there were no disadvantages (44%; n = 12), practical issues such as finding time and privacy (19%; n = 5), and being self-conscious/disliking the sound of their own voice (15%; n = 4).
Next, patients were asked, “Do you think recording and listening to your therapy sessions has improved the efficiency of your treatment?” Fifty-seven percent (n = 16) of patients thought that this “Made therapy much more efficient”, 25% (n = 7) thought it “Made therapy slightly more efficient” and 18% (n = 5) thought it made “No difference”. No patients thought recordings had been detrimental to the efficiency of their therapy.
Patients were then asked, “Have you experienced any obstacles when recording or listening to your recordings?” Fifty-seven percent (n = 17) responded “No” and 43% (n = 13) said “Yes”. The obstacles most typically encountered included the poor quality of recordings (21%; n = 5) and finding privacy (17%; n = 4) and time (13%; n = 3) to listen to recordings.
Patients were then asked, “Do you think you have received enough information about the reasons for recording therapy sessions?” Eighty-seven percent (n = 27) of patients said “Yes” and 13% (n = 4) said “No”. Of those who felt they had not received enough information, all were suffering from social anxiety and all said that they would have liked more information.
Patients' attitudes towards therapy recordings being used for therapist peer supervision purposes
Patients were also asked about their attitudes towards the centre using therapy recordings for therapist (peer) supervision purposes. Table 1 displays patients' responses towards a number of questions regarding this. The results suggest that patients generally had favourable attitudes towards the use of therapy recordings for therapist peer supervision purposes. The majority of patients were happy about their use in this way, and were confident that they would have been used in a professional manner.
Table 1. Patients' attitudes towards the use of recordings for therapist peer supervision purposes
Patients' overall attitudes towards therapy recordings
Finally, patients were given three summary statements regarding their overall attitude towards recording therapy sessions. To the statement, “I have listened to the recordings”, 90% (n = 28) of patients responded “Yes” and 10% (n = 3) selected “No”. To the statement, “Overall, I have found listening to the recordings helpful”, 80% (n = 24) of patients responded “Yes” and 20% (n = 6) said “No”. Lastly, to the statement, “Overall, I have found listening to the recordings difficult to do”, 63% (n = 19) of patients said “No” and 37% selected “Yes” (n = 11).
Therapist data
Therapists' self reported behaviour and beliefs about patients' behaviour towards therapy recordings. When therapists were asked how often they typically gave patients recordings of their therapy sessions and asked patients to listen to them between therapy sessions, 80% (n = 12) responded “Every session” and 13% (n = 2) selected “In more than half of sessions”. When therapists were asked how often they reviewed patients' reactions to their recordings during subsequent sessions, around 53% (n = 8) responded “In more than half of sessions”, 27% (n = 4) selected “every session”, 13% (n = 2) chose “In half of sessions” and 7% (n = 1) responded “In less than half of sessions”.
When asked how often they thought patients typically listened to therapy recordings between each session, 67% (n = 10) responded “Sometimes” and 33% (n = 5) selected “At least once”. When asked what they thought patients did with recordings between therapy sessions, the most frequently endorsed strategy was “Discuss some parts with (therapist)” which 80% (n = 12) of therapists endorsed. Less common strategies endorsed were “Write notes” (33%; n = 5) and “Listen to it with another person” (33%; n = 5).
Therapists were then asked about their experience of what patients generally did with their recordings after therapy finished. On average, therapists estimated that 70% of the time patients kept them, 22% of the time patients only kept selected ones, 17% of the time patients returned them to therapists, and 11% of the time patients destroyed/erased them.
Therapists' attitudes towards therapy recordings
As with patients, therapists were then asked a number of open-ended questions to explore their attitudes towards therapy recordings, of which comprehensive details can be found in the full report. Firstly, therapists were asked “What is your opinion about recording and listening to therapy sessions?” The most common themes generated were that recordings were a good idea/helpful (93%; n = 13), that recordings serve as a memory aid (29%; n = 4), help assimilate new information (29%; n = 4), aids understanding of problem/therapy (21%; n = 3), can be useful for relapse prevention (21%; n = 3) and can serve as a homework prompt (21%; n = 3).
Therapists were next asked, “Can you think of any advantages of recording sessions and asking your patients to listen to them? Please describe”. Common themes extracted included recordings serving as a memory aid (92%; n = 11), prompting thinking/reflection (33%; n = 4), helps engagement between sessions (25%; n = 3), allow patients to share recordings with others (25%; n = 3) and serving as a homework prompt (25%; n = 3).
Therapists were then asked, “Can you think of any disadvantages of recording sessions and asking your patients to listen to them? Please describe”. Common themes included recordings being upsetting/distressing for patients to listen to (43%; n = 6), confidentiality problems (29%; n = 4), patients feeling self-conscious (29%; n = 4), practical issues (21%; n = 3) and being problematic if patients do not listen to them and therapists continue to ask them weekly (21%; n = 3).
Therapists were then asked, “How much do you think recording sessions and asking your patients to listen to them improves the efficiency of treatment, on average?” Sixty percent (n = 9) responded “Made therapy slightly more efficient”, 33% (n = 5) selected “Made therapy much more efficient”, whilst 7% (n = 1) did not respond.
Therapists were also asked, “Are there any obstacles you think your patients experience when you record or when they listen to their therapy sessions? If so, please describe them”. Eighty-seven percent (n = 13) responded “Yes” and 7% (n = 1) selected “No”. Common obstacles generated included a lack of privacy (54%; n = 7), not owning a tape cassette player (54%; n = 7), finding the time (46%; n = 6), patients disliking the sound of their own voice (46%; n = 6) and distress caused to patients by listening to recordings (38%; n = 5).
Therapists' attitudes towards therapy recordings being used for therapist peer supervision purposes
Therapists were also asked for their attitudes towards the use of recordings for therapist peer supervision purposes, which is routine practice at the centre. The questions regarding this, and the therapists' responses, are displayed in Table 2. Therapists generally had favourable attitudes towards the use of recordings for supervision purposes. Although none of the therapists were worried about this, almost half felt uneasy about it with over an additional quarter being unsure whether they felt uneasy or not. None of the therapists expressed that they did not want their recordings to be used in this way, and the majority felt that recordings are used in a professional manner and made therapists better practitioners.
Table 2. Therapists' attitudes towards the use of recordings for peer supervision purposes
Therapists' overall attitudes towards therapy recordings
Finally, therapists were asked three summary questions. Eighty-seven percent (n = 13) responded “Yes” and 13% (n = 2) selected “No” to the question, “Overall, patients listen to the recordings?”. One-hundred percent (n = 15) responded “Yes” when asked, “Overall, listening to recordings is helpful”. Lastly, 87% (n = 13) responded “Yes” and 13% (n = 2) selected “No” when asked, “Overall, listening to recordings is difficult for the patient to do”.
Discussion
The majority of patients reported that they were given their therapy recordings and asked to listen to them between sessions by their therapists every session. Therapist data were similar. Over 50% of therapists typically reviewed patients' understanding and reactions to these recordings in more than half of sessions. Almost all patients reported listening to their therapy recordings to some extent, and 50% said that they did this “At least once” between all therapy sessions. There was some evidence that therapists might underestimate the frequency that patients listened to recordings between sessions, given that the majority of therapists believed that patients generally listened to their therapy recordings only “Sometimes”.
Generally, patients and therapists reported positive attitudes towards recording therapy sessions. Patients and therapists generated many advantages of the use of recordings. The most common advantage generated by both patients and therapists was that recordings served as a memory aid. Many patients could not think of any disadvantages to recording therapy sessions, although some were mentioned. The most common were practical issues (e.g. privacy) and disliking the sound of their own voice/feeling self-conscious. Therapists generated a variety of disadvantages to recording therapy sessions, including this being distressing/upsetting to patients, potential confidentiality issues, and patients being self-conscious about hearing their own voice. It is interesting to note that distress/upset caused to patients was the most common disadvantage generated by therapists, whereas only one patient mentioned this (“increased anxiety”) as a disadvantage. Therapists may therefore tend to over-estimate the amount of distress that listening to recordings causes to patients.
Over half of patients thought that therapy recordings “Made therapy much more efficient”. The majority of therapists thought that recordings made therapy “Slightly more efficient”. This suggests that therapists believed recordings to affect the efficiency of therapy less than patients did. Despite the generally favourable attitudes towards the recordings, just under half of the patients felt that they had experienced obstacles to listening to their recordings, the most common reasons being poor quality recordings and a lack of privacy to listen to them.
With regards to the centre using the recordings for therapist peer supervision purposes, both patients and therapists generally had favourable attitudes towards this. The majority of patients were happy about their use in this way, and were confident that they would have been used in a professional manner. Only a small minority of patients were worried about and felt uneasy about this. None of the therapists were worried about this but, perhaps surprisingly, therapists felt considerably more uneasy about this than patients, which may be due to feeling evaluated in peer supervision.
There is little empirical research concerning the use of recordings in therapy. However, there has been some clinical and theoretical discussion. Macaskill (Reference Macaskill1996) suggested that recording therapy sessions overcomes the numerous difficulties associated with patients' memory for sessions. The results support this. Given that therapy sessions are often distressing for patients, recordings may give patients the opportunity to assimilate knowledge or aid learning after the therapy session has ended, when emotional distress has decreased. This supports Macaskill's (Reference Macaskill1996) assertion that recordings also give patients the opportunity to consider key therapeutic points at their own pace. Harvey, Clark, Ehlers and Rapee (Reference Harvey, Clark, Ehlers and Rapee2000) argued that recordings could challenge the distorted self-perception of patients. Although the authors were specifically considering video-recording patients with social anxiety, the current results suggest that patients of varying anxiety disorders believe that recordings (both auditory and visual) help provide this objectivity.
Alpert (Reference Alpert1996) argued that patients can watch videotapes with significant others, which may promote others' understanding of the patient's difficulties. In the present study, therapists but not patients generated this as an advantage of recordings. A third of therapists thought that patients typically did this, compared to only one patient who reported doing this. Given that significant others can unknowingly maintain a patient's anxiety (i.e. through facilitating avoidance and safety-seeking behaviours), it may be useful for services to find ways of encouraging the patient to consider sharing their recordings with significant others.
In terms of therapist supervision, Alpert (Reference Alpert1996) suggested that therapists can benefit from watching videotapes of therapy sessions, to allow them to note material to return to and observe missed opportunities, errors and things that went well. Alpert (Reference Alpert1996) also argued that videotaping can be a powerful resource for supervision and training. Therapist peer supervision using recordings in this way is routine practice at the centre and it is clear that therapists and patients had positive attitudes towards this use of session recording. Both patients and therapists believed that recordings could increase the efficiency of therapy. This is consistent with Perr (Reference Perr1985), who previously argued that recording psychotherapy sessions and asking patients to listen to these between sessions can shorten the time of therapy.
Alpert (Reference Alpert1996) suggested that recording therapy sessions can create anxiety in both therapists and patients, leading therapists to indicate that the “protection” of their patients is a factor in not offering to record sessions. There was some evidence of such therapist attitudes in the current results, despite the study taking place where recording of sessions for patient use is routine. Therapists rather than patients tended to express uneasiness regarding recordings being used for therapist peer supervision purposes. Overall, the results of the present research are consistent with research carried out in physical health settings (e.g. oncology), which suggests that patients have positive attitudes towards recordings and listen to them if they are provided (e.g. McHugh et al., Reference McHugh, Lewis, Ford, Newlands, Rustin, Coombes, Smith, O'Reilly and Fallowfield1995; Ong et al., Reference Ong, Visser, Lammes, Van Der Velden, Kuenen and de Haes2000).
The present results only reflect patients' attitudes at the end of therapy. A comparison between before and after therapy would be interesting. This would explore whether such positive attitudes develop as a result of experiencing recording or whether they reflect previous attitudes. Experimental studies could also be conducted to explore the utility of recordings more reliably. This might involve investigating whether memory for the session and learning/assimilation of information is actually improved by the use of recordings. Likewise, whether psychological distress impedes patients' processing of information or memory for the therapy session and whether recordings improve this.
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