Videotaping is a key method for assessing competence in the psychotherapies (1). Electronic recording technology gives both supervisors and residents an exact account of what took place in therapy, and it eliminates recall gaps and bias. Videorecording may be especially useful in early training, when residents' observational skills are still developing. However, it may also be intrusive to patients and residents. We wanted to know how intrusive videorecording might feel to patients and what other factors might influence them to consent to videotaping. We attempted to answer this question by critically reviewing the literature pertinent to this subject.
We searched the literature using PubMed, PsycINFO, Google Scholar, and Web of Science. In PubMed, we used the MeSH terms attitude AND video recording and attitude AND TV for English-language publications from the mid-1950s through February 2009. For PsycINFO, we used the descriptors client attitudes AND videotape recorders OR videotapes OR closed circuit TV and limited the search to English-language and peer-reviewed journals. We looked at the references of the relevant articles using Web of Science.
We identified 35 relevant articles. Of these, 27 involved a study. One could not be retrieved despite searching Google Scholar and National Library of Medicine. Among the rest, 19 (73%) were conducted in general practice, three (11.5%) in psychiatry, one (4%) in psychology, two (7.7%) in neurology, and one (4%) in hospice. Seventeen of the studies were done between 1981 and 2000. The four mental health studies were done between 1961 and 1980. Several studies were done at teaching sites, including all four of the mental health studies. Sixteen study designs were cross-sectional, five were experimental, three were quasi-experimental, and two were qualitative. Of the mental health studies, two were qualitative, one experimental, and one cross-sectional.
We classified study outcomes by consent rate and factors, patients' feelings and behaviors, patient satisfaction, and patients' perception of doctors. Twenty-one studies examined consent rate; 10, consent factors; 13, patients' feelings and behaviors; 5, patient satisfaction; and 5, patients' perception of doctors. Within the mental health studies, one article looked at consent rate, four at feelings and behaviors, and two at patient satisfaction. None of the mental health studies examined consent factors or patients' perception of doctors.
Most patients consented to being videotaped, with a few exceptions. Bain and Mackay (2) reported a consent rate of 54%; however, participants' responses were speculative; no recording actually took place in the study. In Howe's study (3), the videotaping was presented to the participants as having solely a research purpose, and a research assistant, who did not have a close relationship with the patients, conducted the consenting process. Servant and Matheson (4) had an extremely low consent rate of 10%, mainly using an indirect consent process. Patients were introduced to the videotaping through letters handed out or left in the waiting area or through notices posted in the waiting area. Taking out these three studies, the mean consent rate among the general-practice studies was 89.7%, and 94.5% for neurology studies. The one hospice study had a consent rate of 100%. The only mental health study to look at consent rate was a qualitative study conducted by Barnes and Pilowsky (5), with the comment that "patients showed little, if any, reluctance to take part" (p 58).
No mental health studies looked at consent factors affecting patients. In the other studies, those who did not consent tended to be female and younger and to have a previous psychiatric history or psychological distress. Of the six studies that looked at consent factors, only two mentioned statistical analysis, and the one with N>1,000 showed statistical significance for all three factors. Patients were more likely to consent when asked by their doctors than by the receptionist. They were also more likely to consent when asked directly rather than indirectly and verbally rather than through written consent. None of the three studies looking at methods of consent mentioned statistical analysis.
Patients' Feelings and Behaviors
Most patients reported feeling comfortable being taped. One mental health study found that 92% of patients felt comfortable with the camera, and 51% felt relaxed during the interview (5). It should be noted that the patients in the study were being interviewed by a psychiatrist that they had never met before.
In terms of patients' awareness of the camera, the majority of them were not aware. One study in psychiatry, by Haggard and colleagues (6), looked at direct and indirect references made by the patient and therapist to the recording process in two different settings. Patients made more references in a research setting than in a private office.
Most of the patients also felt free to talk. Interestingly, only 45% of the participants in a psychology study by Gelso (7) felt free to talk, but, because of the small sample size, the difference from the control group was not statistically significant. In his study of psychiatry patients, Friedman and colleagues (8) reported that most patients "would not have said anything different" if they had not been taped.
Utility and Disposition of Videotaping
Three studies, one each in general practice, hospice, and psychiatry, revealed that most patients felt positive about videorecording knowing that it served an educational purpose. Almost none of the patients in three general-practice studies asked to have their tapes erased.
A limitation of this review is that possible articles were not found despite a thorough search. The literature was limited in that the studies, especially in mental health, were dated and scarce. Many studies lacked clear discussion of the sample and design, and most did not use statistical analysis where appropriate. Implications for practice are drawn from the general-practice literature because of the limited number of mental health studies available. Some recommendations for increasing consent rate are to build a relationship with patients before asking them for videotaping, to carefully explain the educational value and specific purpose behind the recording when asking, to tell patients that the majority of those who were taped felt comfortable during it, and to give patients the option to have their tapes erased after the intended use.
More research is needed in this area. One could look into the effects on consent rate by patient demographics, method of consent, diagnosis, type, duration of therapy, session contents, relationship with therapists, the utility and disposition of recordings, the effects of other modes of supervision on patients in comparison to videotaping, and the effects of videotaping on trainees and supervisors. The Health Insurance Portability and Accountability Act (HIPAA) and Institutional Review Boards may pose challenges to conducting research in mental health involving videorecording, but the return in improved education and quality of care will be well worth it.