Practicing Online During COVID-19: Psychodynamic and Psychoanalytic Therapists’ Experiences

Abstract

During the Covid-19 pandemic, psychotherapists quickly transitioned to provide online therapy, while facing many challenges. This study aimed to explore psychodynamic and psychoanalytically oriented therapists’ (N = 1450) experiences with online therapy during the first weeks of the pandemic and two months later. Results showed that therapists had little pre-pandemic experience with providing online therapy and even less training in it, and that younger therapists reported more challenges in the transition to online therapy. During the first weeks of the pandemic, most therapists thought that online therapy was less effective than in-person therapy, and they reported a wide range of relational and technical challenges, feeling more tired, less confident and competent, and less connected and authentic in online sessions, compared to previous in-person sessions. At follow-up, therapists viewed online therapy as more comparable to in-person therapy; the majority felt connected and authentic as they had during the initial weeks of the pandemic, or more so, but were still as tired as before. The most challenging aspect of online therapy was distraction in sessions, which increased over time. This study demonstrates the professional adaptability of therapists and highlights the need for more training and professional support for clinicians providing remote psychotherapy.

Keywords

Covid-19 teletherapy survey therapy process challenge

The ongoing Covid-19 pandemic is not only a threat to physical health but also has a negative impact on mental health andwell-being due to worries about health, social stresses of living amid a global pandemic, social isolation, and associated financial problems (Brooks et al. 2020; Prout et al. 2020; Qiu et al. 2020). Psychological distress including anxiety, depression, and stress are elevated during the pandemic (for a meta-analysis, see Salari et al. 2020), which may indicate an unfolding public mental health crisis. In the following months and years, the demand for mental health services will undoubtedly increase, and it is essential that mental health providers are equipped to respond to this dire need (Pfefferbaum and North 2020).

With the social distancing efforts meant to stem the pandemic, psychotherapy, among other services, quickly transitioned to being offered remotely. Whereas in pre-pandemic times the promotion and delivery of online mental health services was hindered by various human and structural barriers (Békés, Grondin, and Bouchard 2020; Connolly et al. 2020), the public health necessity forced providers to overcome long-standing biases practically overnight. The imposed change to remote therapy can be seen as a silver lining of the Covid-19 crisis. It will change the field in the long run, with remote therapy becoming more commonplace than previously, providing more easily accessible support for more patients.

In the meantime, this sudden, involuntary transition to online therapy has been challenging for many therapists. The work of the psychotherapist is stressful (Briggs and Munley 2008; Nelson 2019) and tends to be emotionally taxing even in the best of times (Hayes, Gelso, and Hummel 2011). Therapists have been affected by the general stress of the global pandemic of Covid-19, like everyone else, while also needing to adapt to rapid changes in the profession and transitioning to providing therapy remotely.

Pre-pandemic studies showed that therapists had many concerns about online therapy; main concerns included the effectiveness of online therapy, ethical and confidentiality issues, and the ability to build a good working relationship online (see Connolly et al. 2020). Despite these concerns, evidence is accumulating from empirical studies that online sessions do not differ from in-person sessions in effectiveness (Backhaus et al. 2012; Simpson 2009) and that patients and therapists generally develop a good therapeutic alliance online (see, e.g., Simpson and Reid 2014).

In addition to these issues, psychodynamic therapists have raised concerns regarding the challenges online work presents to the analytic process and frame (see Scharff 2018). Given psychodynamic therapy’s strong focus on unconscious material, as well as in-session relational processes, a standard setting for the session and being able to perceive subtle nonverbal communications are of central importance in therapy; these key components of psychodynamic psychotherapy are often challenged in remote settings and can raise concerns among analytic therapists. For instance, many analysts have expressed worries that the lack of nonverbal cues lowers the therapist’s sensitivity to notice and respond to unconscious affect (Scharff 2010). In addition, the impact of remote therapy on transference and countertransference processes has been seen as problematic, as it may, for example, foster the development of an illusory, idealized image of the therapist (Roesler 2017). Further, the lack of psychical presence, thought to be crucial in providing a holding environment (Migone 2013), has been a concern, as it may create a sense of loss, or even be traumatizing, for both therapist and patient (Argentieri and Mehler 2003). On the other hand, Ehrlich (2019) has described the containing function of online therapy, in that it provides continuity of care. Others have pointed out that technology can become an unwelcome third in the therapeutic relationship (Russell 2018), taking a measure of control away from the therapist and promoting nonanalytic communication about the communications medium itself (e.g., the need to ask in a literal sense, “Are you still there?”). This may interfere with the analyst’s capacity for reverie (Brahnam 2017).

Despite these concerns, remote analysis, far from being a recent invention, is as old as psychoanalysis itself (Zeavin 2018). Mirkin (2011) pointed out that Freud drew a comparison between the psychoanalyst’s function and that of a telephone receiver. Moreover, Scharff (2012) reminds us that some psychoanalysts have been working remotely—first by telephone and later by video—all along. She traces publications in support of (and opposed to) distance analysis back to the 1950s. Before the pandemic, remote therapy was known to offer certain obvious advantages, including access to treatment when a patient is bedridden (Scharff 2012), traveling (Leffert 2003), or geographically distant from an appropriately trained therapist (Scharff 2016) or a therapist with whom they have an established relationship (Leffert 2003). These remote therapy formats have been reported to be useful when the therapist needs to be physically elsewhere (Abrahams 2018). Others have argued that remote therapy can offer perhaps unexpected advantages to the therapy process, such as enhanced privacy for patients who live in small communities (Leffert 2003), liberation from patients’ self-consciousness about their appearance (Wooldridge 2017), or clinical insight and increased intimacy gained when therapist and patient can see into one another’s personal spaces (Chen et al. 2021). Besides these benefits to the general therapy process highlighted by psychoanalysts, the remote therapy format might have additional benefits specific to psychoanalytic processes. For example, Chen et al. (2021) have observed that with the distance inherent to screen-based therapy, some patients may feel reassured that their hostile or erotic feelings can be expressed without endangering the therapist or might show less defensiveness in their home environment. Even perceived drawbacks, such as equipment failures and discomfort with the online setting, can provide relevant material to be analyzed and discussed (Rossi and Ferro 2020).

Accumulating evidence from empirical studies suggests that remote therapy, such as online sessions via videoconferencing, do not differ from in-person sessions in effectiveness (Backhaus et al. 2012; Simpson 2009), and that patients and therapists generally develop a good therapeutic alliance online (see, e.g., Simpson and Reid, 2014; for a review and meta-analysis, see Norwood et al. 2018). Even before the pandemic, Ehrlich (2019) pointed out that “the rapidly expanding presence of technology in our everyday lives, and our growing reliance on it, suggests that the question for analysts should be how best to practice teleanalysis, not whether to” (p. 250).

In the context of this rich history of remote treatments in the field of psychotherapy and psychoanalysis and the reported areas of ambivalence and debate over time, the sudden transition to an entirely online therapy format during Covid has challenged the therapeutic work. Empirical studies conducted during the pandemic indeed show that the sudden switch to remote therapy caught many therapists unprepared and posed many challenges to them. In a mixed-methods study of 335 British psychotherapists with different theoretical orientations, McBeath, du Plock, and Bager-Charleson (2020) found that the most challenging aspects of online work via videoconferencing included reduced interpersonal cues, feelings of isolation and fatigue, and technical issues. Technological issues were also prominent in a qualitative study of 51 therapists in the Netherlands (Feijt et al. 2020).

Despite the challenges therapists have faced when transitioning to remote therapy, the experience of providing therapy remotely has been relatively positive. For example, Humer and colleagues (2020) reported that their surveyed psychotherapists (N = 1162) overall found the experience of providing online therapy via videoconferencing during the pandemic better than expected. Similarly, Steidtmann, McBride, and Mishkind (2020) also found among a small sample of mental health clinicians and administrative staff that 85% of respondents rated the experience of providing or supporting full-time telemental health was “somewhat better” or “much better than expected.” The literature based on the pandemic so far shows that therapists consider remote therapy effective (Feijt et al. 2020), and report that patients are comfortable with the process as well (McBeath, du Plock, and Bager-Charleson 2020). Patients also report many advantages of working online, such as flexibility and lack of travel time (Feijt et al. 2020). A majority of therapists indicated that they want to continue providing remote therapy in the future (Steidtmann, McBride, and Mishkind 2020) and that remote working would become an important part of their practice (McBeath, du Plock, and Bager-Charleson 2020). Relevant to our findings here, dynamic and analytic therapists appear to report relatively more positive perspectives on online therapy since Covid than therapists of other orientations (Cioffi et al. 2020; Humer et al. 2020).

Therapist characteristics that might be important to consider when examining the experience of the transition to online therapy include therapists’ age, training, and clinical experience. More seasoned, highly trained therapists are usually expected to be more confident and competent in their work, though this is not necessarily supported by empirical evidence on in-person therapy effectiveness (see, e.g., Goldberg et al. 2016). Because these same seasoned therapists are also expected to be less familiar with technology than their younger colleagues, therapist age might be a potentially important factor determining comfort with providing therapy online. The empirical literature on the direction of the effect of age is mixed. Some studies have found that younger male and female therapists hold more negative views of online therapy. For example, Cioffi and colleagues (2020) reported that among 507 therapists in Italy, younger age (< 35 years old) was associated with less positive views on online therapy; this study also found that therapists between age 36 and 45 reported the most positive opinion of online therapy. On the other hand, Korecka and colleagues (2020) did not find differences in attitudes toward remote therapy based on gender or age in a sample of 190 psychotherapists in Austria and Germany. Notably, regardless of their age, clinical experience, and gender, therapists with more experience treating people online via remote therapy tend to have more positive views of its effectiveness (Cioffi et al. 2020; Boldrini et al. 2020; Korecka et al. 2020).

Aims

This study expands the preliminary findings of a small sample of psychodynamic and psychoanalytic therapists (Békés et al. 2020) and aims to describe how psychodynamic and psychoanalytically oriented therapists experienced the transition to online therapy during the first weeks of the pandemic, as well as how they adapted two months later. These were retrospective reports of experience, taken at one time point, reflecting on pre-pandemic attitudes/experience/training and their experience during the first few weeks of the pandemic.

Although some therapists might have decided to use other methods to deliver psychotherapy, such as phone sessions, in the present study we specifically focused on online therapy via videoconferencing as an innovative technology with widespread implementation and simply refer to it as “online therapy.”

Although we conducted this survey at one time point during the pandemic, we were interested not only in the experience of therapy during the pandemic, but also in therapists’ retrospective reports of experiences of pre-pandemic attitudes/experience/training.

Our first aim was to examine therapists’ experiences providing online therapy during the first few weeks of the pandemic. Specifically, we investigated therapists’ preference for remote therapy formats, perception of online therapy’s effectiveness, and experience with fatigue and other challenges related to online sessions during the pandemic. Moreover, we were interested in experiences in-session, including tendencies to disclose personal information, the experience of the authenticity, connectedness, and quality of therapeutic relationship with their patients, and the subjective sense of competence and confidence while providing online therapy. We also wanted to examine how these online therapy experiences changed over the course of the first eight weeks of the pandemic, when therapists became more acclimated to the online format. Given the potential importance of therapist characteristics in how the transition to online therapy is perceived, we examined the role of therapists’ age, training, and gender in their adaptation to the online format over time.

Our second aim was to retrospectively examine psychodynamic and psychoanalytically oriented therapists’ pre-pandemic experiences with online therapy; specifically, we examined previous online therapy experiences and training, pre-pandemic attitudes toward online therapy’s effectiveness, and preparations for the transition to online therapy

Method

Procedures and Participants

This study reports on a large-scale online survey that assessed psychotherapists’ experiences and views about online therapy during the pandemic. Therapists who were seeing patients online during the first few weeks of the pandemic were recruited via professional email Listservs, social media, and individual contacts across the world, with a large majority in the United States. Licensed and trainee therapists were eligible to participate. Interested therapists were directed to an online survey platform providing study information and consent, followed by a questionnaire that took approximately fifteen minutes to complete. The study was approved by the Yeshiva University institutional review board.

Preliminary results from the first 190 survey responses (collected between March 25 and March 30, 2020), including responses from psychoanalytic therapists, have been published in a previous report (Békés et al. 2020), and a report on the total sample of therapists from all theoretical perspectives is presently under peer review (Békés et al. 2021).

Although the survey was completed by therapists from various therapeutic modalities, for the present study we focused specifically on the subsample of 1,450 therapists who identified as psychodynamic and psychoanalytic. The data for the present study were collected at two time points, at baseline between March 29 and June 21, 2020, shortly after a pandemic was declared by the World Health Organization, and at follow-up, between May 28 and August 9, 2020, approximately eight weeks later. Date of study enrollment was also recorded.

Survey Questions

Demographics and pre-pandemic professional experiences

We asked therapists to report their gender, country of residence, ethnicity, years of clinical experience since licensure, professional training background, and theoretical orientation. To assess the therapists’ usual professional context, we also assessed their pre-pandemic work setting, patient populations, and usual position of the patient in their in-person treatments (couch or chair). Moreover, we asked about their previous experience providing online therapy, previous training about how to provide it, their pre-pandemic view of its effectiveness, and preparations taken to prepare themselves and their patients for the transition to online therapy.

Preferences and views of online therapy

Therapists were asked about their preference for remote therapy format: “If given the choice, would you prefer to provide remote therapy online via videoconferencing or by phone?” Views about online therapy’s effectiveness in comparison to in-person therapy were assessed at baseline and at follow-up by the question: “How do you view online therapy now?” with a 5-point response option from 1 = definitely less effective than in-person therapy to 5 = definitely more effective than in-person therapy.

Tiredness

We also asked therapists at baseline and at follow-up how tired they felt after these online sessions in comparison to in-person sessions: “Compared to in-person sessions, doing therapy online made the therapist feel more/same/less tired than after in-person sessions.”

Challenges

Perceived challenges were also assessed at both time points by the question, “During the pandemic/now, what are the main challenges for you using online therapy?” Multiple responses were possible; for the list of challenges see Table 1. Based on factor-analytic findings in our previous paper, which included a larger sample of therapists with any type of theoretical orientation (Békés et al. 2021), we have collapsed the individual challenge items into the following categories: emotional connection (feeling connected with patients, reading emotions, expressing or feeling empathy), distraction during sessions (therapist or patient), patients’ privacy (private space, confidentiality), and therapists’ boundaries (professional space, boundary setting). Items regarding technical/internet problems and scheduling challenges did not load on any factors in the previous analysis and so are only listed individually in Table 2. Besides examining the endorsement of these individual challenges, we also calculated a sum score per therapist for the total number of challenges identified, ranging from 1 to 11.

Table 1.

Characteristics and pre-pandemic experiences of psychodynamic and psychoanalytic therapists (N = 1,450)

Demographics	n	%
Gender
Female	1,095	75.5
Male	432	23.6
Other	13	.9
Location
United States of America	1,112	76.3
Europe	158	10.9
Asia	87	6.7
Canada	71	4.9
South America	5	.3
Africa	4	.3
Ethnicity*
White	1,172	80.8
Asian or Asian Indian	143	9.9
Hispanic or Latino	39	278
Middle Eastern	27	1.9
Black or African American	9	.6
First Nations	6	.4
Native Hawaiian or Pacific Islander	5	.3
American Indian or Alaska Native	3	.2
Other	41	2.8
Clinical experience (years)
0–4	111	9.4
5–8	158	13.3
9–12	149	12.6
13–16	90	7.6
17+	677	57.1
Profession
Psychologist	746	51.4
Social worker	240	16.6
Medical doctor	189	13.0
Counsellor	160	11.0
Psychoanalyst	123	8.5
Psychotherapist	49	3.4
Marriage family therapist	21	1.4
Other (e.g., nurse practitioner)	11	.7
Work setting before the pandemic*
Private practice	1,223	84.3
Outpatient	251	17.3
Hospital	142	9.8
School/university	63	4.3
Phone/online	53	3.7
Other (e.g., residential facility, patient’s home)	20	1.3
Patient population*
Adults	1,396	96.3
Adolescents	645	44.5
Older adults	541	37.3
Children	363	25
Couples & Families	67	4.6
Theoretical orientation*
Psychodynamic	1,204	83.0
Psychoanalytic	831	57.3
Additional approach Integrative	441	30.4
Additional approach Humanistic	211	14.6
Additional approach Systemic	170	11.7
Additional approach CBT	235	16.2
Treatments
All patients face to face	502	55.9
Most patients face to face	250	27.8
Half my patients on the couch	108	12
Most patients on the couch	32	3.6
All patients on the couch	6	.7
Previous experience of providing online therapy
No, never	554	41.7
No, but I have experienced online therapy as patient	40	3
Yes, once or twice	146	11.0
Yes, but only after we met in-person first	383	28.8
Yes, I have several patients online	207	15.6
Previous training in providing online therapy
No	860	84.4
Yes	159	15.6
Pre-pandemic view of effectiveness of online therapy
Definitely less effective than in-person	396	38.1
Somewhat less effective than in-person	502	48.3
As effective as in-person	140	13.5
Somewhat more effective than in-person	0	0
Definitely more effective than in-person	1	.01
Therapist preparations of self for the transition to online therapy*
Spoke to colleagues	771	53.2
Read Listservs/forums	645	44.5
Read governmental guidelines	438	30.2
Spoke to supervisor	329	22.7
Attended trainings/webinars	329	22.7
Prepared consent forms	314	21.7
Read journal articles	280	19.3
Did not prepare	253	17.4
Therapist preparations of patients for the transition to online therapy*
Discussion first online session	798	55.0
Discussion before the switch	718	49.5
Provided technical support	360	24.8
Provided consent form	360	24.8
Provided information sheets	249	17.2
Canceled cancellation policy	186	12.8
Did not prepare	163	11.2
Already conducted sessions online	49	3.4
Reduced session fee	46	3.2

Note. Response categories are reported in order of prevalence in this sample; * multiple answers were possible per respondent.

Table 2.

Experiences of the transition to online therapy during the pandemic in the psychodynamic and psychoanalytic therapist sample

	First weeks of the pandemic (n = 1,450)		Follow-up 8 weeks later (n = 285)		Change over time
Experience of Online Therapy Item	n	%	n	%	Statistical test
If given the choice, therapists preferred. . .					F = 12.581**
Video conferencing sessions	676	69	152	70.3
Phone sessions	304	31	40	29.2
View of effectiveness of online therapy					t = –2.568*
Definitely less effective than in-person	124	11.9	22	9.1
Somewhat less effective	622	59.9	123	50.6
As effective as in-person	283	27.2	96	39.5
Somewhat more effective	0	0	2	.8
Definitely more effective than in-person	1	.01	0	0
Compared to in-person sessions, doing therapy online made the therapist feel					F = .000
More tired	711	70	134	53.4
As tired	238	23.4	74	29.5
Less tired	67	6.6	43	17.1
Current challenges using online therapy*					Asymp p
Technical / internet	854	58.9	193	67.7	.000
Patient finding suitable space	624	43.0	116	40.7	.093
Patient getting distracted	605	41.7	127	44.6	.134
Feel connected with patient	484	33.4	78	27.4	.108
Reading patients’ emotions	426	29.4	71	24.9	.048
Therapist getting distracted	417	28.8	96	33	.076
Maintaining professional boundaries	239	16.5	32	11.2	.003
Confidentiality concerns	208	14.3	25	33.7	.019
Feel/express empathy	189	13.0	35	12.3	.603
Therapist finding suitable space	180	12.4	33	11.6	1.00
Other (e.g., engagement, silence)	28	1.9	83	29.1	n/a
Increased likelihood of disclosure compared to in-person sessions pre-pandemic
No	512	39.6
Maybe, due to. . .	515	39.8
Definitely, due to. . .	267	20.6
Crisis situation led to loosening of professional boundaries	282	19.4
Compensating for lack of physical proximity	171	11.8
Providing sessions from home	161	11.1
Patients ask more about me	112	7.7
Supporting the patient (e.g., coping, normalizing)	77	5.3
Increased likelihood of disclosure compared to previous online sessions at start of pandemic
No			68	25.6
Maybe, due to			121	45.5
Definitely, due to. . .			77	28.9
The crisis situation led to loosening of professional boundaries			101	51
Compensating for lack of physical proximity			74	37.4
Providing sessions from home			40	20.2
Patients ask more about me			11	5.55
Compared to in-person sessions, the online relationship with patients felt. . .
More authentic	98	8.7
As authentic	738	65.8
Less authentic	285	25.4
Compared to previous online sessions at start of pandemic, the online relationship with patients felt. . .
More authentic			93	38.1
As authentic			138	56.6
Less authentic			13	5.3
Compared to in-person sessions, the online relationship with patients felt. . .
More connected	75	6.7
As connected	538	48.0
Less connected	508	45.3
Compared to previous online sessions at start of pandemic, the online relationship with patients felt. . .
More connected			88	36.2
As connected			144	59.3
Less connected			11	4.5
Compared to in-person sessions, the therapeutic alliance with patients felt. . .
Stronger	80	10.7
The same	489	65.6
Weaker	176	23.6
Compared to previous online sessions at start of pandemic, the therapeutic alliance with patients felt. . .
Stronger			93	38.3
The same			137	56.4
Weaker			13	5.3
Compared to in-person sessions, doing therapy online made the therapist feel. . .
More competent	27	2.7
As competent	661	65.1
Less competent	328	32.3
Compared to previous online sessions at start of pandemic, doing therapy online made the therapist feel. . .
More competent			115	47.3
As competent			114	46.9
Less competent			14	5.8
Compared to in-person sessions, doing therapy online made the therapist feel about professional skills
More confident	51	7.7
As confident	443	66.5
Less confident	172	25.8
Compared to previous online sessions at start of pandemic, doing therapy online made the therapist feel
More confident			84	34.6
As confident			143	58.8
Less confident			16	6.6

Note. Response categories are reported in order of prevalence in this sample; * multiple answers were possible per respondent.

p < .05; ** p < .01.

Disclosure

Potential changes in personal disclosure during the pandemic by the therapist were assessed by the question “Compared to in-person sessions pre-pandemic, have you disclosed more about your personal life in your online sessions?” Response options were no (1), maybe (2), definitely (3). Those who responded maybe or yes were then asked, “What led you disclose more?” with multiple response options. This question was repeated at follow-up, but in relation to previous online sessions at the start of the pandemic. “Compared to previous online sessions at the start of the pandemic did you disclose more about your personal life in your current online sessions?” Response options were no (1), maybe (2), and definitely (3).

In-session relational experiences

Relational experiences about authenticity, connectedness, and working alliance were assessed by three items, each with three response options: (1) “Compared to in-person sessions before the pandemic, in your online sessions, the relationship with most of your online patients feels more/as/less authentic than in-person sessions”; (2) “Compared to in-person sessions before the pandemic, in your online sessions, the relationship with most of your online patients feels more/as/less connected than in-person sessions”; (3) “Compared to in-person sessions before the pandemic, in your online sessions the therapeutic alliance feels stronger / the same / weaker.” These three questions about authenticity, connectedness, and the therapeutic alliance with online patients were repeated at follow-up, but then in comparison to previous online sessions at the start of the pandemic, rather than in comparison to in-person sessions.

In-session professional experiences

In-session experiences of professional competence and confidence were also assessed at baseline, in relation to in-person therapy pre-pandemic, and at follow-up, in relation to online therapy earlier in the pandemic. “Compared to in-person sessions / your previous online sessions at the beginning of the pandemic, doing online therapy sessions during the pandemic makes you feel more/as/less competent,” as well as by “Compared to in-person sessions / your previous online sessions at the beginning of the pandemic, doing online therapy sessions during the pandemic makes you feel more/as/less confident.”

Data Analysis

Survey responses were analyzed using IBM SPSS Statistics 25. Bivariate correlations and chi-square tests were conducted to examine the potential impact of therapist’s age, gender, clinical experience, online therapy training, previous online therapy experience, and days since the start of the study on the variables of experience providing online therapy. Paired-samples t tests were used to compare therapists’ experiences at the start of the pandemic with the follow-up responses collected eight weeks later. ANCOVAs were used to control for therapist variables that were significantly related to the transition to online therapy items at baseline. Paired-samples t tests were used for comparisons of frequencies of reported challenge categories over time, and McNemar tests were conducted for comparison of individual challenges.

Results

Therapist Characteristics

The sample of 1,450 therapists were mostly female (n = 1,095; 75.5%), from the United States (n = 1,112; 76.3%), and white (n = 1,172; 80.8%). Their average age was 52.92 (SD = 16.43), the majority with more than 17 years of clinical experience. Although professional training among the therapists varied, a majority were trained as psychologists (n = 746; 51.4%) or social workers (n = 240; 16.6%). Almost all therapists worked with adult patients (n = 1,396; 96.3%), though some worked also with demographic groups such as children and older adults. Patients were mostly seen face to face (n = 752; 83.7%), rather than on the couch. The participating therapists reported having a psychodynamic (n = 1,204; 83.0%) or psychoanalytic (n = 831; 57.3%) orientation, or identified with both (n = 585; 40.3%). Besides identifying as psychoanalytic and/or psychodynamic, more than half the therapists reported additional theoretical orientations, most commonly CBT or humanistic or integrative therapy. More detailed data about the study sample characteristics are presented in Table 1.

The Impact of Therapists’ Clinical Experience on Their Transition Experience

Only age, clinical experience, and the time variable (days since the first data collection point) were associated with responses at baseline. As expected, age and clinical experience were strongly correlated (r = .76, p < .001). Moreover, the time variable was also highly correlated (r = –.09, p < .001) with clinical experience; that is, more experienced therapists enrolled earlier in the study. Since including highly correlated covariates is statistically redundant and not recommended, we only included clinical experience in further analyses, as this variable was related to the same variables as age and the time variable, as well as to additional variables.

Therapists’ level of clinical experience was significantly related to several baseline variables of the transition to online therapy.¹ Therapists’ level of clinical experience was positively related to therapists’ sense of authenticity in their online sessions compared to in-person sessions (r = .08, p = .011), their level of connectedness with their online patients (r = .11, p < .001), and therapists’ tiredness (r = .18, p <.001), felt competence (r = .13, p < .001), and confidence (r = .16, p <.001). These positive correlations suggest that during the first weeks of the transition to online therapy, therapists with more clinical experience felt relatively more tired, but also more authentic and connected with their online patients, and more confident and competent about their work than those with less clinical experience.

Therapists with more clinical experience using phone therapy expressed a stronger preference for the online therapy format compared to phone therapy format (t = 3.97, p < .001). Less experienced therapists reported more challenges (r = –.21, p < .001) overall, and specifically more challenges with connectedness (r = –.15, p < .01), distraction (r = –.15, p < .05), and therapist boundaries (r = –.15, p < .05), but clinical experience was unrelated to patient privacy (r = –.07, p = .26).

Therapists’ Pre-Pandemic Professional Experiences

More than half of the therapists studied had never provided or had provided only one or two online sessions (n = 740; 55.7%), whereas fewer than half (n = 590; 44.4%) had provided sessions online at least once or twice. Most therapists had received no formal training in how to conduct online therapy (n = 860; 84.4%). Therapists had relatively negative pre-pandemic opinions about the effectiveness of online therapy, in that most thought it was definitely less effective (n = 396; 38.1%) or somewhat less so (n = 502; 48.3.1%) than in-person treatment. In preparation for the transition to online therapy, many therapists spoke to colleagues (n = 771; 53.2%) and read posts on Listservs and online forums (n = 645; 44.5%). Therapists prepared their patients for the transition to online therapy in various ways, but mainly by discussing it in the last in-person session (n = 718; 49.5%) and/or the first online session (n = 798; 55%).

Transition to Online Therapy during the First Weeks of the Pandemic

The responses on the individual items at baseline (during the first weeks of the pandemic) indicated that two-thirds of the therapists preferred online sessions via videoconferencing over phone sessions (n = 676; 69%), if given the choice. The majority of therapists perceived online therapy to be somewhat or definitely less effective than therapy provided in person at the beginning phase of the pandemic (n = 746; 71.8%). Although one-fourth of therapists (n = 283; 27.2%) thought that online therapy was as effective as in-person therapy, only one thought it was more effective. More than half of therapists reported that they had possibly or definitely disclosed more in these online sessions at the start of the pandemic than in their earlier in-person sessions (n = 782; 60.4%). Reasons for this increased level of disclosures varied among therapists; the majority felt that the pandemic crisis situation warranted a loosening of professional boundaries, whereas others reportedly compensated for the lack of physical proximity or disclosed more simply by providing sessions from home or because patients asked explicit questions.

During online sessions at the start of the pandemic the majority of therapists felt as authentic as during in-person sessions (n = 738; 65.8%), with a similar quality of working alliance (n = 538; 48%), and therapists felt as competent (n = 661; 65.1%) and as confident (n = 443; 66.5%) as in in-person sessions pre-pandemic. Although a near majority of therapists felt as connected with their patients as before (n = 538; 48%), almost half (n = 508; 45.3%) felt less connected with their online patients. Almost 70% of therapists reported feeling more tired after online sessions at the start of the pandemic than they did after in-person sessions pre-pandemic (n = 711; 49%).

Therapists reported a number of challenges with the transition to online therapy. The most frequently reported challenge was distraction (M = .16, SD = .32), followed by patient privacy (M = .14, SD = .27), connectedness (M = .12, SD = .26), and therapist boundaries (M = .07, SD = .20). For more detailed descriptions of the responses for individual items, see Table 2.

Comparisons of Experiences at the Start of the Pandemic and Eight Weeks Later

In subsequent pre-post change analyses that included baseline items significantly related to clinical experience, therapists’ clinical experience was assessed as a potential confounder, as a covariate in the ANCOVA. Within-person changes on variables unrelated to therapist age were assessed with paired-samples t tests.

A total of 285 psychodynamic or psychoanalytic therapists completed the survey at follow-up. There was no significant difference between the clinical experience of the therapists who completed only the first survey and those who also completed the follow-up survey eight weeks later. There was a significant increase in preference for online as opposed to phone therapy at baseline and follow-up, when controlling for clinical experience F(1, 167) = 8.750, p = .004, ηp2 = .05, and time since the start of the study F(1, 167) = 6.80, p < .01, ηp2 = .04. Views about the effectiveness of online therapy compared to in-person therapy significantly improved over time (t = –2.56, p =.011); that is, therapists reported more favorable (i.e., less negative) views of online therapy’s effectiveness compared to in-person therapy over time. Although half of participating therapists remained more tired than after in-person sessions, there was an overall tendency to feel less tired over time, but this change was no longer significant after controlling for therapist age, F(1, 241) = .000, p = .999.

Therapists who completed the follow-up survey eight weeks later reported, on average, fewer challenges regarding connectedness, patient privacy, and therapist boundaries, but this decrease was not statistically significant. The challenge of distraction, on the other hand, increased significantly (t = –2.97, p = .003). The number of challenges endorsed at the two time points also did not differ significantly (M = 3.61, SD = 2.01 and M = 3.46, SD = 1.85) endorsed challenges on average, respectively (t = 1.37, p = .171).

At follow-up eight weeks later, more than 70% of therapists thought they were more likely to disclose more information about themselves to their patients than they did in online sessions at the beginning of the pandemic, due mainly to the crisis situation and to make up for the lack of physical proximity with their patients. At follow-up eight weeks later, a majority felt that their therapeutic relationship with their patients was of similar or higher quality, as authentic or more so, and as connected or more so than in online sessions at the start of the pandemic. Therapists also felt equally or more competent and confident about providing therapy online over the course of the pandemic.

Discussion

Our aim was to examine psychodynamic and psychoanalytically oriented therapists’ experiences of the transition to online therapy during the Covid-19 pandemic over the first few months of the pandemic. Almost half of the therapists had at least some previous experience in providing online therapy, though very few had received training in online therapy. Therapists mainly relied on their professional network of colleagues, supervisors, and Listservs to prepare for the transition to online, and reported feeling more tired and less confident and competent in online sessions than in their usual in-person sessions. At the beginning of the pandemic, therapists perceived online therapy to be less effective than in-person treatment, but this shifted over the course of eight weeks, when therapists reported more favorable attitudes about the effect of online therapy, viewing it as just as effective as in-person therapy. Many therapists disclosed more about themselves in their online sessions than before and even more so eight weeks into the pandemic, as compared to the early weeks of the pandemic. Most therapists did not notice changes in the working alliance and authenticity with their patients and felt similarly confident and competent over the course of eight weeks. Almost half of therapists reported feeling less connected with patients online initially, though this improved over time. At the start of the pandemic, as well as at follow-up, therapists felt most challenged by being distracted during online sessions, which became even more challenging over time. Notably, therapists with less clinical experience endorsed more challenges with the therapy process and therapeutic relationship in online sessions than did their more experienced counterparts. Overall, between the two measurement points, therapists developed greater appreciation for the online therapy format and adjusted to the change in therapeutic relationship and their professional role.

Given that the involuntariness of using technological innovations is theorized to have a negative impact on users’ attitudes (Venkatesh, Thong, and Xu 2012), the relatively positive perspective on the online therapy process and outcomes among the study sample is remarkable. Although we have no pre-pandemic data specifically on psychoanalytic and psychodynamic therapists, in general therapists outside of crisis situations hold neutral or positive views of web-based interventions (Damianakis, Climans, and Marziali 2008; van der Vaart et al. 2014; Wangberg, Gammon, and Spitznogle 2007). Moreover, actual experience with providing online therapy has been shown to lead to more positive opinions about online therapy among providers (Connolly et al. 2020). This might in part be explained by the investment of therapists in their work, and the fact that humans tend to endorse the quality and effectiveness of the things they are choosing to do (i.e., choice supportive bias), even if we have been forced into it. In the current study, the more positive (or rather, less negative) views about the effectiveness of online therapy over the first few months of the pandemic support this claim among psychoanalytic and psychodynamic therapists, and it may also indicate that despite the forced and abrupt transition and the stress associated with the crisis situation, more seasoned therapists in particular had a reasonably good, or at least better than expected, experience with online therapy. We may speculate that even though initial concerns might have stopped therapists from engaging in it before, during the first months of everyday practice during the pandemic, therapists have found ways to address and overcome these concerns by adjusting their behavior or approach in sessions, finding ways to handle initially challenging aspects, and recognizing advantages of the online format (e.g., seeing patients in their home environment). For example, the fact that sessions are now conducted in the homes of both patient and therapist is a disruption of the traditional psychoanalytic frame, which may change the transference and countertransference; however, use of this new virtual space may also lead to a more egalitarian and authentic setting, and to a new type of emotional intimacy in sessions. Therapists (and their patients) have also found ways to address practical challenges, either by resolving them on a practical level, or using it as material for the sessions (e.g., a patient who prefers calls with the video turned off because he feels ashamed when seeing his image).

It is also noteworthy that senior therapists tended to prefer phone therapy to online therapy. This may be explained by the fact that phone, compared to video conferencing technology, has long been available for remote sessions, which means older therapists might be more accustomed to using it. Although they reported feeling more tired than their junior colleagues, they were also better able to create an authentic therapeutic relationship whereby they felt connected with their online patients and felt competent and confident in their therapeutic skills. Of concern, younger therapists reported experiencing more challenges, especially with regard to feeling emotionally connected to patients, being distracted (therapist or patient) during sessions, and creating a professional space and boundaries. The increased self-disclosure reported by therapists at both time points may be explained by the increased connectedness with patients over the shared crisis situation during the pandemic, and also by a need for bridging the physical distance with patients. It is also possible that the online format reduces power and status differences: the patient does not have to go to someone else’s domain (the therapist’s office), there is no liminal space to take on a patient role during commuting and sitting in the waiting room, which may lead to a more egalitarian setting in online sessions. When both patient and therapist are in their own domain, it may call for more balanced contributions; hence the increased therapist self-disclosure. Whereas the usefulness of therapist self-disclosure has been a subject of debate in psychoanalytic and psychodynamic circles, there is some evidence that patients in high distress especially benefit from therapist self-disclosure in psychodynamic therapy (Alfi-Yogev et al. 2020). Given the high-stress circumstances of the pandemic, it is possible that the increased self-disclosure was similarly helpful for patients. Based on these relatively positive experiences of providing online therapy during the pandemic, psychodynamic and psychoanalytic therapists are often choosing to offer therapy sessions online, even after social restrictions have been lifted, in order to provide easier access to patients in rural and remote areas, or to those who are housebound; to continue treatment with patients who have moved away; to reduce travel cost and time (Simpson 2009); or simply to make therapy more convenient for patient and therapist.

Interestingly, despite long-standing resistance to providing therapy online among psychodynamic and analytically oriented therapists, almost half of our sample had already provided remote sessions at least once or twice, even though few had formal training in how to adapt their approach to the online format. This supports previous notions that despite some wariness, in practice many psychoanalytic/psychodynamic therapists have long been using remote sessions (Scharff 2012). Given that online therapy seems here to stay, analytic therapists might take advantage of this momentum and attend training and seek supervision on the specifics of the online format—how it affects therapeutic boundaries, self-disclosure, intimacy, the holding environment, transference processes, and so on—as well as on handling technical glitches while keeping in mind their symbolic meaning (e.g., “Do you see me?” “Are you there?”). More generally, they can become more familiar with the literature on the process and outcome of online therapy, including understanding differences in the relational dynamic and alliance (see, e.g., Simpson and Reid 2014), and find ways to use remote sessions to achieve as much patient improvement as in in-person sessions (Backhaus et al. 2012; Simpson 2009).

Many of the variables examined in this study, including preparation of therapist and patient, building rapport, managing disclosure and professional boundaries, and in-session experiences of feeling tired, less confident and competent, less connected and authentic, might be usefully addressed in further training and peer support on providing online therapy. With more online therapy experience and understanding the specific dynamics that unfold in online sessions, as well as finding ways to recognize and respond to them, therapists may develop more favorable attitudes toward this therapy format (Aafjes–van Doorn, Békés, and Prout 2021), and it is possible that once the initial stress subsides and therapists gain experience and avail themselves of training, they will feel more at ease offering their patients the option of receiving therapy online. Given that attitudes and expectations regarding online therapies have shown to have an effect on the effectiveness of the treatment (Reese et al. 2016; Tonn et al. 2017), it is important for therapists to be supported in how best to provide online therapy to patients. Moreover, it is just as important to recognize that psychoanalytic and psychodynamic therapists, besides commonly shared concerns by therapists from other orientations, have additional complexities to consider when it comes to the online therapy format, such as transference, countertransference, resistance, and containment (see Scharff 2018), and addressing these questions is crucial if we are to keep up with the changing world and secure the advantages of online therapy. For example, the analytic process might be impacted by the changed transference-countertransference, as it might foster the development of an illusory, idealized image of the therapist (Roesler 2017). Also, the lack of nonverbal cues might dull the therapist’s sensitivity to unconscious affect (Scharff 2010), which might in itself make therapists feel less emotionally connected and more easily tired or bored in the therapeutic hour (Békés et al. 2021). In contrast, in therapeutic approaches that rely less on nonverbal information (e.g., CBT), the reliance on verbal communication and lack of physical presence might have been less troublesome.

A recent qualitative study among psychoanalysts (Békés, Aafjes–van Doorn, and Roberts 2021) suggests that the remote format allows patients to resist treatment by hiding both physically and emotionally, that is, by removing their video view, resisting engagement, remaining on a surface level of discussion, and going less deep. Therapists themselves also engaged differently, in that they reported being quicker to intervene, playing a more supportive and active role in sessions, being less challenging in their interventions, avoiding longer silences, disclosing more about themselves than in traditional in-person sessions, and being more likely to reduce the frequency of sessions. Moreover, the lack of physical presence can interfere with the therapist’s provision of a holding environment (Migone 2013). Patients in online psychodynamic therapy missed the “magic” of being in the physical presence of their therapists (Békés, Aafjes–van Doorn, and Roberts 2021). Maintaining a holding environment and staying emotionally attuned is especially challenging when distractions pop up on the patient’s or therapist’s screen or in their respective rooms. Similarly, therapists reported a wish to make their presence heard by saying things out loud, which might take away from the usual silences that facilitate the therapeutic work (Békés, Aafjes–van Doorn, and Roberts 2021). However, given the work on the symbolic level in psychodynamic therapies, these changes and challenges in remote sessions also offer an opportunity to analyze and understand their psychological meaning for both patient and therapist.

Limitations of the Study

Several limitations may be identified. First, the participant responses reported here reflect a convenience sample of therapists who were interested in completing the survey, and who were predominantly white, female, relatively seasoned, and in private practice, which might limit the generalizability of our findings. Moreover, the theoretical orientation of the therapists was based on self-reported identification, which might not necessarily reflect the therapists’ actual approach in sessions (Solomonov et al. 2016). Second, the survey responses we report were to single items that, though based on theory and clinical writings, were not part of standardized measures. The transition to online therapy, as well as the Covid-19 context, was unique, in that no standardized measures assessing the therapists’ experience existed. Future research would benefit from the development of standardized scales around the therapists’ attitudes toward online therapy, as well as the impact of Covid-19 on their professional role. Third, the analysis was quantitative in nature, and though it allowed us to report on the experience of a large sample of psychoanalytically oriented therapists, it did not provide contextual insights into the specific therapists’ circumstances. Future research designs may benefit from the inclusion of a qualitative approach and might be able to distinguish what part of the therapists’ experience resulted from the unique situation of Covid-19 and what part reflects online therapy more generally. Given the dearth of research on analytically oriented therapists providing online therapy pre-pandemic, it will be important to compare these Covid-related findings with therapists’ experiences of online therapy post-pandemic. Relatedly, the one-item variables were not normally distributed across all levels (i.e., some response categories were endorsed by only a few therapists), but were retained in the analyses and write-up of our findings, because these levels were deemed conceptually meaningful. Moreover, many items that were assessed at baseline (i.e., questions about tiredness, competency, confidence, therapeutic relationship) evaluated therapists’ perceptions of their online therapy sessions relative to in-person classes, whereas related items assessed at the eight-week follow-up referred to a comparison with previous online therapy sessions earlier in the pandemic. This means that these items could not be directly compared, but provided an indirect proxy of change over time. Fourth, in this study, therapists’ clinical experience was assessed as covariate, possibly influencing the experience of online therapy and change over time. Clinical experience² was highly correlated with age, but, admittedly, clinical experience is not the same as age. It is possible that older therapists might not have more clinical experience than younger therapists if they have changed careers or see fewer patients per week. Clinical experience is typically operationalized as a number of years, which in itself is a very rough estimate of one’s clinical experience, as therapists might see a different number of patients and might have different clinical roles in a wide range of settings, which might not result in clinical expertise per se. Lastly, the time frames of baseline and follow-up collection points overlap such that some therapists were already providing follow-up data while others were first providing baseline data. Even though we have controlled for time elapsed since the beginning of the data collection in the analyses, the retrospective reports of therapists in June 2020 about the experience of first moving their practice online in March 2020 may not be as reliable as the reports of those who participated in March or April.

Conclusion

All in all, these findings highlight the adaptiveness of psychodynamic and psychoanalytic psychotherapists in working in an online format within the context of the Covid-19 pandemic. Although most therapists did not use online therapy formats routinely before the pandemic, and experienced many challenges in the initial transition to online therapy, their experience with online therapy improved, and they also became more competent and confident over time. This study highlights the need to provide more training and professional peer support around the provision of psychoanalytic interventions remotely. The Covid-19 pandemic and its mental health consequences will affect many of us for a long time to come, which means that the demand for psychotherapy will likely remain high. It is hoped that analytic therapists can maintain this adaptive stance in the future, when remote therapy is no longer a necessary accommodation to a difficult situation but a welcome treatment option that increases accessibility to psychoanalytic work.

Footnotes

Katie Aafjes–van Doorn, Vera Békés, and Tracy A. Prout, Ferkauf Graduate School of Psychology, Yeshiva University. Leon Hoffman, New York Psychoanalytic Society and Institute. Acknowledgment: The data collection from Chinese therapists was supported by the China American Psychoanalytic Alliance.

Submitted for publication February 25, 2021; revised June, 29, 2021, October 13, 2021; accepted October 18, 2021.

ORCID iDs

Katie Aafjes–van Doorn

Vera Békés

Tracy A. Prout

1

For ease of reading these results, we transformed the scoring of the items so that higher scores reflect “more . . . than in in-person sessions” and lower scores reflect “less . . . than in in-person sessions.”

2

It is interesting that more experienced/older therapists were more comfortable with a technique which, for them, was novel. Was this finding a result of the greater adaptability and resilience of more experienced clinicians? If this is confirmed in future studies, it can contribute to the mixed findings about the impact of experience on outcome (see ).

References

Aafjes–van Doorn

Békés

Prout

T.A

. (2021). Grappling with our therapeutic relationship and professional self-doubt during COVID-19: Will we use video therapy again? Counselling Psychology Quarterly 34:473–484.

Abrahams

(2018). Review of The Digital Age on the Couch: Psychoanalytic Practice and New Media, by A. Lemma. British Journal of Psychotherapy 34:331–334.

Alfi-Yogev

Hasson-Ohayon

Lazarus

Ziv-Beiman

Atzil-Slonim

(2020). When to disclose and to whom? Examining within- and between-client moderators of therapist self disclosure-outcome associations in psychodynamic psychotherapy. Psychotherapy Research 31:921–931.

Argentieri

Mehler

J.A.

(2003). Telephone “analysis”: “Hello, who’s speaking?” Insight 12:17–19.

Backhaus

Agha

Maglione

M.L.

Repp

Ross

Zuest

Rice-Thorp

N.M.

Lohr

Thorp

S.R.

(2012). Videoconferencing psychotherapy: A systematic review. Psychological Services 9:111–131.

Békés

Aafjes–van Doorn

Luo

Prout

T.A.

Hoffman

(2021). Psychotherapists’ challenges with online therapy during Covid-19: Concerns about connectedness predict negative views on online therapy and its efficacy over time. Frontiers in Psychology 12:705699.

Békés

Aafjes–van Doorn

Prout

T.A.

Hoffman

(2020). Stretching the analytic frame: Analytic therapists’ experiences with remote therapy during Covid-19. Journal of the American Psychoanalytic Association 68:437–446.

Békés

Aafjes–van Doorn

Roberts

(2021). Therapists’ experiences with telepsychotherapy: A qualitative study. Unpublished manuscript.

Békés

Grondin

Bouchard

(2020). Barriers and facilitators to the integration of web-based interventions into routine care. Clinical Psychology: Science & Practice 27:e12335.

10.

Boldrini

Schiano Lomoriello

Del Corno

Lingiardi

Salcuni

(2020). Psychotherapy during Covid-19: How the clinical practice of Italian psychotherapists changed during the pandemic. Frontiers in Psychology 11:2716.

11.

Brahnam

(2017). Comparison of in-person and screen-based analysis using communication models: A first step toward the psychoanalysis of telecommunications and its noise. Psychoanalytic Perspectives 14:138–158.

12.

Briggs

D.B.

Munley

P.H.

(2008). Therapist stress, coping, career sustaining behavior and the working alliance. Psychological Reports 103:443–454.

13.

Brooks

S.K.

Webster

R.K.

Smith

L.E.

Woodland

Wessely

Greenberg

Rubin

G.J.

(2020). The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. The Lancet 395(10227): 912–920.

14.

Chen

C.K.

Nehrig

Wash

Schneider

J.A.

Ashkenazi

Cairo

Guyton

A.F.

Palfrey

(2021). When distance brings us closer: Leveraging tele-psychotherapy to build deeper connection. Counselling Psychology Quarterly 34:554–567.

15.

Cioffi

Cantone

Guerriera

Architravo

Mosca

L.L.

Sperandeo

Moretto

Longobardi

Alfano

Y.M.

Continisio

G.I.

Musii

Maldonato

N.M.

(2020). Satisfaction degree in the using of VideoConferencing Psychotherapy in a sample of Italian psychotherapists during Covid-19 emergency. 2020 11th IEEE International Conference on Cognitive Infocommunications (CogInfoCom), pp. 125–132.

16.

Connolly

S.L.

Miller

C.J.

Lindsay

J.A.

Bauer

M.S.

(2020). A systematic review of providers’ attitudes toward telemental health via videoconferencing. Clinical Psychology: Science & Practice 27:e12311.

17.

Damianakis

Climans

Marziali

(2008). Social workers’ experiences of virtual psychotherapeutic caregivers groups for Alzheimer’s, Parkinson’s, stroke, frontotemporal dementia, and traumatic brain injury. Social Work with Groups 31:99–116.

18.

Ehrlich

L.T.

(2019). Teleanalysis: Slippery slope or rich opportunity? Journal of the American Psychoanalytic Association 67:249–279.

19.

Feijt

de Kort

Bongers

Bierbooms

Westerink

IJsselsteijn

(2020). Mental health care goes online: Practitioners’ experiences of providing mental health care during the C-19 pandemic. Cyberpsychology, Behavior, & Social Networking 23:860–864.

20.

Goldberg

S.B.

Rousmaniere

Miller

S.D.

Whipple

Nielsen

S.L.

Hoyt

W.T.

Wampold

B.E.

(2016). Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting. Journal of Counseling Psychology 63:1–11.

21.

Hayes

J.A.

Gelso

C.J.

Hummel

A.M.

(2011). Managing countertransference. Psychotherapy 48:88–97.

22.

Humer

Pieh

Kuska

Barke

Doering

B.K.

Grossmann

Trnka

Meier

Kascakova

Tavel

Probst

(2020). Provision of psychotherapy during the Covid-19 pandemic among Czech, German and Slovak psychotherapists. International Journal of Environmental Research & Public Health 17(13):4811.

23.

Korecka

Rabenstein

Pieh

Stippl

Barke

Doering

B.K.

Grossmann

Humer

Probst

(2020). Psychotherapy by telephone or internet in Austria and Germany: Which CBT psychotherapists rate it more comparable to face-to-face psychotherapy in personal contact and have more positive actual experiences compared to previous expectations? International Journal of Environmental Research & Public Health 17(21):7756.

24.

Leffert

(2003). Analysis and psychotherapy by telephone: Twenty years of clinical experience. Journal of the American Psychoanalytic Association 51:101–130.

25.

McBeath

A.G.

Plock

S. du

Bager-Charleson

(2020). The challenges and experiences of psychotherapists working remotely during the coronavirus pandemic. Counselling & Psychotherapy Research 20:394–405.

26.

Migone

(2013). Psychoanalysis on the internet: A discussion of its theoretical implications for both online and offline therapeutic technique. Psychoanalytic Psychology 30:281–299.

27.

Mirkin

(2011). Telephone analysis: Compromised treatment or an interesting opportunity? Psychoanalytic Quarterly 80:643–670.

28.

Nelson

R.S.

(2019). Improving therapist wellbeing and the role of resilience. Dissertation, University of Sheffield.

29.

Norwood

Moghaddam

N.G.

Malins

Sabin-Farrell

(2018). Working alliance and outcome effectiveness in videoconferencing psychotherapy: A systematic review and noninferiority meta-analysis. Clinical Psychology & Psychotherapy 25:797–808.

30.

Pfefferbaum

North

C.S.

(2020). Mental health and the Covid-19 pandemic. New England Journal of Medicine 383:510–512.

31.

Prout

T.A.

Zilcha-Mano

Aafjes–van Doorn

Békés

Christman-Cohen

Whistler

Kui

Di Giuseppe

(2020). Identifying predictors of psychological distress during Covid-19: A machine learning approach. Frontiers in Psychology 11.

32.

Qiu

Shen

Zhao

Wang

Xie

(2020). A nationwide survey of psychological distress among Chinese people in the C-19 epidemic: Implications and policy recommendations. General Psychiatry 33(2).

33.

Reese

R.J.

Mecham

M.R.

Vasilj

Lengerich

A.J.

Brown

H.M.

Simpson

N.B.

Newsome

B.D.

(2016). The effects of telepsychology format on empathic accuracy and the therapeutic alliance: An analogue counselling session. Counselling & Psychotherapy Research 16:256–265.

34.

Roesler

(2017). Tele-analysis: The use of media technology in psychotherapy and its impact on the therapeutic relationship. Journal of Analytical Psychology 62:372–394.

35.

Rossi

R.S.

Ferro

(2020). Skype as a protected means to live a relationship. International Forum of Psychoanalysis 29:188–191.

36.

Russell

G.I.

(2018). Screen Relations: The Limits of Computer-Mediated Psychoanalysis and Psychotherapy. New York: Routledge.

37.

Salari

Hosseinian-Far

Jalali

Vaisi-Raygani

Rasoulpoor

Mohammadi

Rasoulpoor

Khaledi-Paveh

(2020). Prevalence of stress, anxiety, depression among the general population during the Covid-19 pandemic: A systematic review and meta-analysis. Globalization & Health 16:57.

38.

Sandell

Carlsson

Schubert

Broberg

Lazar

Blomberg

(2002). Varieties of therapeutic experience and their associations with patient outcome. European Psychotherapy 3:17–35.

39.

Scharff

D.E.

(2016). Psychoanalysis in China: An essay on the recent literature in English. Psychoanalytic Quarterly 85:1037–1067.

40.

Scharff

J.S.

(2010). Telephone analysis. International Journal of Psychoanalysis 91:989–992.

41.

Scharff

J.S.

(2012). Clinical issues in analyses over the telephone and the internet. International Journal of Psychoanalysis 93:81–95.

42.

Scharff

J.S.

ed. (2018). Psychoanalysis Online: Mental Health, Teletherapy, and Training. New York: Routledge.

43.

Simpson

(2009). Psychotherapy via videoconferencing: A review. British Journal of Guidance & Counselling 37:271–286.

44.

Simpson

Reid

C.L.

(2014). Therapeutic alliance in videoconferencing psychotherapy: A review. Australian Journal of Rural Health 22:280–299.

45.

Solomonov

Kuprian

Zilcha-Mano

Gorman

Barber

(2016). What do psychotherapy experts actually do in their sessions? An analysis of psychotherapy integration in prototypical demonstrations. Journal of Psychotherapy Integration 26:202–216.

46.

Steidtmann

McBride

Mishkind

M.C.

(2020). Experiences of mental health clinicians and staff in rapidly converting to full-time telemental health and work from home during the Covid-19 pandemic. Telemedicine & E-Health.

47.

Tonn

Reuter

S.C.

Kuchler

Reinke

Hinkelmann

Stöckigt

Siemoneit

Schulze

(2017). Development of a questionnaire to measure the attitudes of laypeople, physicians, and psychotherapists toward telemedicine in mental health. JMIR Mental Health 4(4):e39.

48.

van der Vaart

Witting

Riper

Kooistra

Bohlmeijer

E.T.

van Gemert-Pijnen

L.J

. (2014). Blending online therapy into regular face-to-face therapy for depression: Content, ratio and preconditions according to patients and therapists using a Delphi study. BMC Psychiatry 14:355.

49.

Venkatesh

Thong

J.Y.L.

(2012). Consumer acceptance and use of information technology: Extending the unified theory of acceptance and use of technology. Management Information Systems Quarterly 36:157–178.

50.

Wangberg

S.C.

Gammon

Spitznogle

(2007). In the eyes of the beholder: Exploring psychologists’ attitudes towards and use of e-therapy in Norway. CyberPsychology & Behavior 10:418–423.

51.

Wooldridge

(2017). Now I see you, now I don’t: Screen services, short stature, and the fear of being seen. Psychoanalytic Perspectives 14:193–205.

52.

Zeavin

(2018). The communication cure: Tele-therapy, 1890–2015. Dissertation, New York University.