Efficacy and recommendations for the delivery of telehealth psychotherapy for people with personality disorder

Abstract

Objective

There are few studies on the efficacy and acceptability of psychotherapy conducted via telehealth technology for people with personality disorder. This study aims to examine clinician perspectives on virtual psychotherapy.

Method

Twenty multidisciplinary mental health clinicians (85% female, average age 42 years) with at least 2 years of experience in telehealth psychotherapy contributed quantitative and qualitative ratings of acceptability and efficacy of this modality.

Results

Likert scale ratings (1 = not, 5 = very) demonstrated high client acceptability (mean = 4.0), effectiveness (4.0) and high clinician acceptability (4.2) and sustainability (4.2). Three recommendations emerged from qualitative analysis: prioritising frame establishment, ensuring client safety online and maximising alliance-enhancing strategies.

Conclusions

This study, which collected quantitative and qualitative ratings of virtual psychotherapy, found that telehealth psychotherapy can be effective and acceptable for people with personality disorder. Strategies associated with success included strong governance, secure technology and careful attending to relationship management.

Personality disorders are a prevalent mental health disorder, with 7.8% of the global population estimated to meet criteria. ¹ Personality disorders are characterised by complex difficulties in both the interpersonal and intrapersonal lived experience. ² An estimated 40 to 50% of psychiatric patients have a diagnosable personality disorder. ³ Therefore, it is vital that mental health services consider effective, accessible and evidence-based psychotherapy treatment options.

Treatment guidelines for people with personality disorder recommend psychotherapy as a first line of treatment.^4,5 The global coronavirus pandemic (Covid-19; declared 11 March 2020-2023) required services to rapidly pivot to virtual platforms to allow continuity of care. Emerging research suggests that people with personality disorder presented to hospital more frequently during this time compared to other groups, ⁶ demonstrating the need for rapid community-based, accessible and effective interventions for this population.

One example rapid treatment option is the Project Air Strategy (2015) brief intervention clinic. ⁷ Grenyer and colleagues (2018) have previously reported benefits of this intervention with reduced re-admissions and inpatient bed days. ⁸ Further, Huxley and colleagues (2019) have reported on improved client outcomes including quality of life and reducing suicidal ideation. ⁹ Stepped models of care provide therapy options suited to the individuals acuity, presenting concerns, readiness and willingness to engage in treatment. ¹⁰ As a first step, brief and rapid follow up psychotherapy provides treatment at the time of acute distress, enabling diversion from emergency and acute services and the commencement of recovery-oriented psychotherapies. ¹¹

This study aimed to explore mental health clinicians’ perspectives on the virtual delivery of psychotherapy to people with personality disorder.

Methods

Participants

A total of 20 multidisciplinary mental health clinicians (85% female, average age 42 years) were recruited from a snowball sampling call out for volunteers. Participants needed to have at least 2 years experience in telehealth psychotherapy.

Clinician demographics are represented in Table 1. Most clinicians worked in metro services (70%) with the remaining working in rural and remote areas (30%). Clinicians worked across adult (45%), child and adolescent (25%), youth (12-25 years; 10%) or across all ages (20%).

Table 1.

Mental health clinician demographics (n = 20)

Mean age (SD; range)		42 (13.6; 24-67)
Sex	Female	17 (85%)
	Male	3 (15%)
Mean years working in current role (SD; range)		13.9 (10.87; 2-34)
Mean years of experience working with people with personality disorder (SD; range)		12.63 (9.42; 1-34)
Employment status	Full-time	14 (70%)
	Part-time or casual	6 (30%)
Profession	Psychologist	12 (60%)
	Mental health nurse	5 (25%)
	Occupational therapist	2 (10%)
	Social worker	1 (5%)

Psychotherapy

Clinicians provided written informed consent following Institutional Review Board approval. Psychotherapy was a structured one-month brief intervention. The publicly-available Project Air Strategy (2015) manual was utilised. ⁷

Procedure

Clinicians who consented to the research completed a survey and semi-structured interview. The survey included demographic and service-based questions, and brief ratings as described below. Interviews were conducted between November to December 2022, were audio recorded and transcribed verbatim.

Measures

Acceptability and perceived efficacy

Participants were asked about the acceptability of the virtual brief intervention from the perspective of the client and clinician on a Likert scale from 1 (not) to 5 (very). Participants were also asked how effective the virtual delivery of the brief intervention was from the perspective of the client from 1 (not) to 5 (very). Asking clinicians on their perspective of the clients’ experience has been used previously in the literature as a proxy-measurement of client acceptability. ¹² Finally, participants were asked how sustainable they thought telehealth psychotherapy was for the service from 1 (not) to 5 (very).

Semi-structured interview

Participants provided their insights into using telehealth modality for the brief intervention. Participants were asked questions on the acceptability, efficacy, sustainability, challenges and opportunities of telehealth psychotherapy and recommendations. The interviews were an average of 31 min duration (range = 12–54).

Statistical analysis

Quantitative data was analysed using descriptive statistics. Qualitative data was analysed using a Husserlian phenomenological approach. ¹³ Approximately 20% of the qualitative data was coded by two researchers, and discrepancies were discussed until consensus was reached. Inter-rater reliability was assessed on agreement of theme ratings, with Cohen’s kappa coefficient being K = 0.91, indicating a very strong level of agreement.

Results

Efficacy

Participants rated their client’s experience of virtual care as highly effective (M = 4.0, SD = 0.86; range = 3-5) and acceptable (M = 4.0; SD = 0.86; range = 3-5). Participants also reported that they felt the intervention was acceptable from their perspective as a psychotherapist (M = 4.2; SD = 0.77; range = 3–5). Further, participants reported that the intervention is sustainable (M = 4.2; SD = 0.77; range = 3–5).

Recommendations for delivery of virtual care

Thematic analysis of the qualitative data resulted in the identification of core themes. Table 2 provides examples of significant statements and formulated meanings, and Table 3 provides both general and specific recommendations elicited from the clinicians.

Table 2.

Selected examples of significant statements and formulated meanings regarding conducting psychotherapy in an online virtual environment

Sub-themes	Significant statement	Formulated meaning
Theme 1: The frame (what makes it work)
Equipment, connectivity and technology	‘Often the IT difficulties, the platforms, like really it sounds so dull and mundane, but the logistics of it can be quite difficult in terms of accessing the equipment, accessing rooms, resourcing is an issue… we had to give it additional clinical support… but if you orient people well enough and if you've got the additional support then we found that people managed pretty well’.	Mental health clinicians spoke about the importance of practical requirements to support telehealth psychotherapy, including equipment, resources and reliable Internet connectivity for both the clinician and client
	‘Internet connection was an issue because we cover remote areas… and some people just don't have Internet access or it's very unreliable. Sometimes our Internet access was unreliable too, and dropout depending on the time of day’.
Orientation and reminders	‘I think it was set up from the first appointment… this is what it’s going to be, it’s going to be an online therapy, it’s going to go for this many weeks, this is how it‘ll work. Most people when that’s kind of set up is what it is, will accept it and run with it’.	Mental health clinicians spoke about the importance of orienting the client to telehealth psychotherapy, including all aspects of connecting, sending reminders and engaging carers or parents in this process when needed
	‘So just sending a single link didn’t seem to work… so really proactively reminding people of appointments was a big part of it’.
Providing choice and flexibility	‘Most people can access a virtual platform, which is fantastic, without the challenges that sometimes coming in here directly poses for individuals. That's affordability, that's time, that's transport, that's illness, that's COVID, that's [wearing a] mask, all sorts of different things’.	Mental health clinicians highlighted the value of being able to offer flexible and accessible virtual care
Privacy and confidentiality	‘I think ethically it’s about confidentiality, who else can hear this, who else is in the room with them, because we can’t see, we don’t know, and so being conscious of that, that you’re not breaching confidentiality. Also being able to do good assessments because you don’t actually know who else might be in the house, and particularly where there’s been interpersonal violence or domestic violence situations, those sorts of things where that’s really hard to know’.	Mental health clinicians discussed the importance of considering privacy and confidentiality, including in the space they are connecting from, the space the client is connecting from and the shared virtual space
Managing boundaries and expectations	‘[Virtual sessions are] potentially not treated in the same way that you would face-to-face in terms of maybe clients don't feel the need to get dressed’.	Mental health clinicians discussed particular challenges in managing boundaries
	‘helping parents to understand the importance of that session rather than just kind of seeing it like all the other things a young person does online’.
Theme 2: The holding environment (what makes it safe)
Risk assessment, management and escalation procedures	‘you’d have access to your supervisor, there’s team leaders, so there are escalation procedures and guidelines in place for clinicians so that they don’t ever feel that they’re managing risk completely on their own… if people need to be brought in to the ED for a face-to-face assessment and for containment, that can happen, and that we have procedures in place for that to happen’.	Mental health clinicians described the need to develop and understand risk management policies adapted to telehealth, and how to access further supports when needed
Strong leadership support and governance	‘I think it probably needs that continued investment in making sure that people have the training, they have the resources, and the skills to do it. So, it probably means budget allocation to make sure that’s continuing’.	Mental health clinicians commented on the importance of senior endorsement and investment to ensure the sustainability
Training and resources	‘More training on… online simple things like screen sharing. And like sharing documents live. For example, it would've been really helpful to… type the safety plan up on a shared screen so the client can see it as well’.	Mental health clinicians discussed the importance for training and resources to support virtual brief intervention. This included training on the virtual platform, using therapeutic tools virtually and how to build rapport online
	‘I think there needs to be training for clinicians… [in] that ability to build a therapeutic relationship in the online space… I think having space to think about and plan how to do that would really help clinicians to actually establish that online’.
Theme 3: The therapeutic alliance (what makes it effective)
‘I think the strengths and limitations [to virtual brief intervention] are really secondary to you as a clinician and that ability to make that connection’.		Mental health clinicians discussed the challenges and importance of prioritising the therapeutic alliance which remained central to the effectiveness of telehealth psychotherapy
‘I think it was also working out ways to get them to take ownership of that session. Sometimes with clients I would get them to type out some goals for the session in the chat at the start so we would remember to go back to them, and there was a bit of that ownership of what they were working towards. So it didn’t just feel like a one-way screen that they can just look at, it felt like something they had to engage with’.

Table 3.

Recommendations for conducting virtual telehealth psychotherapy

Topic	Recommendations
Orientation	The initial orientation allows the clinician to begin to establish a clear and consistent frame
	• The initial orientation discussion can assess the suitability of clients for virtual mental health care, including whether they have access to the technology, private space and a stable Internet connection
	• Information on the technology being used to connect, any particular software that needs to be installed in advance of the appointment and a backup plan in case technology issues prevent connection
Setting expectations	Setting clear and consistent expectations can assist to manage any attachment insecurities, including reducing risk of disengagement, or idealisation and expectation of further access to the clinician
	• The initial orientation discussion can include information on the importance of finding a private, confidential and quiet place for the duration of the session. This may need to be repeated in subsequent sessions
	• Clinicians may benefit from orienting clients to establish their own virtual therapy ritual to prepare their space and mind prior to the session. Guidance in setting up the virtual therapeutic space may include
	· Thinking about goals for the session
	· Wearing appropriate attire
	· Sitting in a chair
	· Using a static video-camera
	· Ensuring clarity of lighting and sound
	· Using earphones with a microphone
	· Having water and tissues available if needed
	· Minimising distractions from other people, pets and technology (e.g. closing any applications that are open to prevent alerts, having an uncluttered environment and door closed.)
	• Offer support in problem solving issues (e.g. finding a private space for the duration of the sessions, suggest the use of virtual backgrounds and earphones to enhance privacy and access to equipment.)
	• Communicating risk escalation procedures should the client not connect or drop out
	• Highlight the goals of the psychotherapy intervention and how these will be managed in the virtual modality (e.g. rather than the sessions being a check-in or casual supportive interaction; need to focus on goals in the session and reviewing agreed between-session tasks)
Confidentiality	Assisting the client to consider the importance of confidentiality during their sessions can promote a sense of safety and further develop the therapeutic alliance
	• Assess the therapeutic space at the start of each session, and either problem solve locating a private space or reschedule the session if this is not possible
	• Clinicians may move their camera to show the client that the therapeutic room is private with the door closed, and may ask the client to do the same
	• Openly enquiring whether clients are connecting in a space where they feel comfortable to freely express themselves
	• Whilst clients may choose to have a support person with them during the virtual session, it may be useful to discuss this openly with the client to empower decision making regarding the opportunity for time alone with the clinician
	• Clients may not be aware of the emotional content in psychotherapy sessions at the outset, and therefore may need guidance from the clinician to prioritise confidentiality
	• Clinicians may need to guide the client to enhance confidentiality to ensure safe disclosure of sensitive concerns, such as domestic violence
Troubleshooting connection difficulties	Assisting clients to troubleshoot connectivity issues can facilitate a calmer and more goal-oriented initial engagement with the session
	• Clinicians may find it beneficial to guide the client on how to connect to the virtual platform during the initial orientation. This may include providing the option of testing the virtual platform together, or being available prior to the agreed appointment time to guide the client through connecting
	• The clinician may send a follow up email with step-by-step instructions or a video demonstrating how to connect, including troubleshooting tips
	• Clinicians may need to consider back up plans in the event that technology is unavailable or non-functional. This may include using the phone to connect with clients where necessary
	• Clinicians may benefit from checking in with clients regularly on any barriers or issues with virtual engagement
	• Clinicians may need to provide ongoing feedback to senior management should additional or replacement technological resources be required
	• Clinicians may benefit from the support of senior clinicians or software engineers to set up sessions prior to the appointment time whilst they are new to the system. Consider localised training to ensure all staff are confident in the use of the technology software
	• Clinicians may benefit from familiarising themselves with the organisational policies and procedures for virtual mental health care, including the security of the endorsed platform
	• Some virtual mental health care platforms allow clients to test their equipment prior to the appointment, which may assist their confidence in joining at the allocated session time
	• Should clients experience discomfort in seeing their own-camera view, clinicians may discuss the client’s reluctance to share their video during the virtual session, and troubleshoot ways for the client to only see the clinician on screen whilst still sharing their own video with the clinician
Enhancing safety	Understanding how to tolerate chronic risk to maintain the progress of therapy, and how to intervene when risk is acute, via the virtual modality
	• Strong service frameworks that support the assessment and management of risk via telehealth should be developed. Operational ‘business rules’ should incorporate localised risk management procedures that are supported by senior management. Opportunities for team-based decisions should be integrated into best-practice, including multidisciplinary team meetings, formal or informal supervision, so that risk management is shared
	• Where appropriate, some risk assessments may benefit from the collaborative input from parents and/or carers on any changes in behaviour, increased concern and clarification of safety plans
	• Chronic risk may be managed by asking for a parent and/or carer to be present in the home or available by phone at the time of the appointment. If the client is a young person, or where the client consents, some services may use text messages with carers to manage chronic risk. For instance, messaging the carer when the session has finished, and providing a telephone update at an agreed upon time after they have been able to check in with the client. This includes providing feedback to the carer regarding any risks, and any updates on the safety plan
	• Depending on the nature of the service, it can be useful to have identified pathways of alerting colleagues should an acute risk arise. This may include text messaging a colleague to call for an ambulance for your client whilst you remain on the phone or on the virtual platform of care
	• It can be useful to have discussions with the client and their carer around the assessment and management of risk at the outset of the therapy and at the start of each session, including the steps that will be taken if there is any concern
Enhancing attendance	Manage the risk of disengagement by focussing on building attachment security. Reminding the client of their appointment may allow them to feel held in the clinician’s mind
	• Sending a number of reminders (e.g. the day before and the morning of the appointment/an hour before) can increase attendance
	• It can be beneficial to do assertive follow up for missed appointments (after 5 min of non-attendance) rather than waiting until there is insufficient time remaining to complete the session either on the phone or virtually
	• If clients are reluctant to answer calls from unfamiliar numbers, phone calls may be preceded by a text message indicating that a clinician is about to call in regards to their referral/appointment
	• Engaging parents and/or carers may assist clients in remembering their appointment, setting up for their session and troubleshooting any connectivity issues
Enhancing engagement	Promote agency by maintaining a curious stance working on the assumption that the client has choices and can consider new perspectives
	• Asking clients to type their session goals into the chat function at the start of the session can increase engagement, sense of agency and client-ownership of the session. The clinician might also add some ideas, which together may form the agenda that can be referred to throughout the session
	• Therapeutic discussion may need to be more dyadic (i.e. ensuring there is frequent turn taking in discussion, rather than one person doing all the talking to ensure a good mutual balance and engagement of client and clinician in the work)
	• Utilising the opportunity to practice experiential exercises, use engaging resources (such as share screen for videos emphasising key points or skills) or prioritising rapport-building activities
	• Clinicians may benefit from spending time consolidating the session at the end, allowing time for reflection and encouraging the client to think about their immediate post-therapy activity (e.g. they may benefit from taking the time to write some of their immediate thoughts in a reflective journal, rather than move on to house or work-related activities immediately)
	• Resources can be shared during the session by sharing the screen. Where this is not possible, resources may be shared by emailing the client before or after the session
	• Clinicians may be able to encourage clients to adjust their environment to enhance the therapeutic value (e.g. making sure the space is private and comfortable, using nearby resources such as a blanket or pet)
	• Clinicians may be able to connect with parents or carers and encourage them to assist in protecting the space for the client to engage in their virtual session. This may include directing other family members away from the home-therapy room
	• Regularly asking for feedback about their experience of telehealth allows clients to practice expressing their preferences and promotes agency
Enhancing alliance	The working alliance is established on a foundation of shared goals and tasks, and the bond between the clinician and client. Defining and focussing the goals on the here-and-now is best-practice. Focussing on attunement with the client can facilitate an enhanced bond over the virtual platform
	• Clinicians may need to consider how to ‘hold’ clients in the virtual therapeutic space by creating a sense of safety and compassionate support. This may include consideration to their use of voice, pace, visible body language and expression to clearly portray empathy and understanding. This includes considering virtual eye contact, and if notes should be completed during or after session
	• The clinician may need to be particularly mindful of the increased possibility of misunderstandings and invalidation via telehealth (particularly when facial features, body posture or vocal tone is masked)
	• Clinicians may wish to alternate between looking at the client’s image on-screen to looking directly at the camera whilst talking. This may assist to balance between the need to observe the client’s facial expression and body language, with providing eye contact through the camera
	• Clinicians may find it useful to check in with the client more often when using telehealth
Senior support and governance	Strong senior support and governance is necessary to enhance clinician confidence in delivering virtual psychotherapy
	• Strong senior support and endorsement of telehealth approaches are essential for clinician confidence in utilising the modality
	• Organisations may wish to implement specific indices in the electronic medical record and reporting systems that capture the delivery of psychotherapy sessions, in either in-person or virtual modality, to monitor service utilisation, efficiencies and effectiveness
	• Organisations may wish to consider providing clear endorsement for platforms of telehealth with sufficient therapeutic capabilities
	• Organisations may need to consider the ongoing budget allocation for equipment, software, licencing and training for clinicians in using virtual platforms of care (both in terms of the technology, and in terms of the therapeutic adaptations required)
	• Organisations may need to incorporate formalised debrief or supervision sessions into the activity structure of virtual psychotherapy to prevent clinicians from feeling isolated. This may be particularly important for clinicians working remotely or in rural and remote areas

Theme 1: The frame – what makes it work

In addition to the usual frame considerations documented in the Project Air Strategy (2015) brief intervention manual, ⁷ participants reported that it is essential to orient the client to the specific requirements of psychotherapy delivered via telehealth. It was important to consider the physical location where the client was connecting (e.g. a confidential location free from distractions), where the clinician was connecting, and the shared virtual platform. Practical considerations, including choice of an endorsed platform with sufficient clinical features, enhanced the virtual therapy:

‘there were things we could do online that we might not have done as easily face-to-face, like sharing screens with resources and putting YouTube videos up and emailing resources before and after the session. Particularly the kind of [brief intervention] therapeutic fact sheets and handouts, we were able to do that in the online format, and I think that actually made it more effective for some’.

Theme 2: The holding environment – what makes it safe

Participants commented on the need to carefully consider telehealth risk assessment and management, including ensuring clear risk escalation procedures to support decision making. This also included strong senior endorsement to support the telehealth modality. Participants commented on the need for training in how to use the technology, and how to enhance clinical effectiveness via telehealth:

‘I think for me the biggest things that I think are important considerations in terms of personality disorders and the online space is just the therapeutic relationship and how you keep that attachment and accountability and get that person to really feel held by the clinician and team in the online space. I think finding a way to do that and teach that is really going to be the key to actually getting effective services for people with lived experience of personality disorder to be able to work online… Like, I think if we can do that, I think all the other stuff will fall into place’.

Theme 3 – The therapeutic alliance – what makes it effective

Participants spoke about solutions to overcoming alliance challenges via telehealth, including being more dyadic, focussing on attunement, being creative in enhancing engagement, inviting regular feedback and being mindful of the increased risk of misunderstanding and invalidation. There may be a need to work harder to ensure good communication, and also recognise the possibility of inadvertent disclosure (e.g. potential intrusion of other people). Participants also commented on the importance of maintaining therapeutic boundaries and guiding clients to set up their home-therapy space to maintain the therapeutic value of the intervention. Participants suggested that once engagement and rapport was established, the telehealth psychotherapy could be both effective and acceptable:

‘if we got the relationship and we got the engagement, the efficacy was there. If you had someone who was signed on, who was rearing to go, that was happy to do it, that we’d set it up, did the homework between sessions, then the efficacy was there’.

Discussion

The current study explored the efficacy, acceptability and recommendations of a brief psychotherapy intervention for people with personality disorder delivered via telehealth. Overall, clinicians reported that the virtual intervention was efficacious and acceptable. Qualitative analysis identified core themes centring around The Frame, The Holding Environment and The Therapeutic Alliance. Throughout these three core themes, participants discussed the challenges, opportunities and recommendations (see Table 3) for telehealth psychotherapy.

Our findings are consistent with previous reviews suggesting virtual technologies may be efficacious for people with lived experience of borderline personality disorder (BPD). ¹⁴ For example, a recent study found equitable outcomes when comparing telehealth to in-person treatment for BPD patients in a partial hospital setting. ¹⁵ Further, studies have found positive outcomes in delivering Dialectical Behaviour Therapy group programs online.^16,17 Our study provides further evidence to suggest that telehealth options in the treatment of people with personality disorder are efficacious and acceptable, including for brief community-based intervention during times of crisis.

Despite the benefits and ongoing high use of telehealth interventions, ¹⁸ this modality presents unique challenges for both the clinician and client. Our results echo previous reports of clinician anxiety in managing risk through telehealth. ¹⁹ Whilst the risk is often equitable to an in-person modality, the reduced sense of control in managing the therapeutic environment may heighten the need to support clinicians with clear guidance (see Table 3) and training.^12,18,19 Whilst the therapeutic content and best-practice clinical care is transferable across modality, it has been suggested that treatment programs for personality disorders need careful set up to ensure telehealth is successful, ¹⁷ and the opportunities of virtual care are maximised. This includes a particular focus on adapting to the unique engagement, privacy, confidentiality and safety needs of telehealth, ¹⁷ and the interpersonal challenges inherent in the treatment of personality disorder.

As reported by participants here, a working alliance is paramount in any therapeutic intervention. ²⁰ A systematic review of telehealth modality across a range of mental health conditions suggests that the working alliance may be equitable; however, there is a specific need to consider whether this translates to particular disorders (such as personality disorders) that pose unique challenges to the therapeutic relationship. ²¹ A recent study surveying psychologists working remotely demonstrated the changed experience of therapy with the loss of some boundaries, impacts on the working alliance and new opportunities for engagement. ¹⁹ It was also found that therapists may need to work harder to maintain the therapeutic boundaries of the intervention focused on clinical change, rather than allowing this to be a general ‘check in’ supportive-only approach. These previous findings were extended in the present study, where clinicians provided specific recommendations to enhance the telehealth working alliance for personality disorders and maintain the therapeutic value of the intervention.

Clinician recommendations generated by the current study (outlined in Table 3) detail therapeutic approaches to enhance engagement and efficacy of the telehealth modality. The key qualitative themes parallel the recommendations: the importance of establishing a collaborative frame, the need for a safe holding environment for both client and clinician and a focus on establishing the therapeutic alliance. The success of the modality appears to rest on the client and clinician working together to create a shared virtual space that is engaging and therapeutic. Clinicians may be pivotal in guiding the client to prepare a home-therapy space, both in physical location and psychological readiness. Encouraging the client to take ownership of the session by preparing goals, discussion priorities and desired outcomes enhances engagement in the virtual modality and fosters agency which is a key therapeutic focus in the treatment of people with personality disorders.

This study has a number of limitations. This study focussed on a structured one-month psychotherapy approach, although clinicians had experience in treatments of a longer duration meaning these recommendations are likely also suitable for longer-term therapy. Use of telehealth is often convenient for client and clinician, which may present a bias in inflating ratings of efficacy due to this preference. Whilst the study included a sufficient sample size for qualitative research, future studies may benefit from evaluating the perspectives of a larger sample, including responses from more males. In addition, future research would benefit from seeking direct feedback from clients and measuring comparable outcomes to assess the effectiveness and acceptability of telehealth psychotherapy from multiple perspectives and using a broader range of outcome measures.

Conclusion

The present study investigated the perspective of mental health clinicians delivering a brief virtual intervention to individuals with personality disorder. Psychotherapy delivered via telehealth was found to be both effective and acceptable. This model of care has the potential to increase the scope of practice by offering treatment for those with personality disorder living in remote places, or with other prohibitive barriers to standard face-to-face engagement. To ensure efficacy of this intervention, there is a fundamental need to consider appropriate resourcing, guidelines and senior support. When clinicians feel supported by the service, are provided opportunities to reflect on building rapport virtually, and are provided resources that are therapeutically oriented, they can safely provide accessible and effective psychotherapy via telehealth to people with personality disorder.