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What are the Characteristics and Concerns
of High and Low Raters of Psychodynamic
Treatment to Chinese Students
Over VCON?1
Robert M. Gordon, Jane Tune, and
Xiubing Wang
Abstract
In an earlier study, Gordon and colleagues (2015), surveyed 176 therapists,
supervisors, and teachers in the China American Psychoanalytic Alliance (CAPA)
and found that the psychodynamic constructs hold up well when treating
Chinese patients over videoconferencing (VCON). Over-all, expert raters felt
that psychodynamic treatment over VCON was only slightly less effective than
in-person treatment. However, there were a small number of therapists who had
strong feelings against VCON treatment. In this study we asked what differenti-
ated low raters from higher raters of treatment effectiveness. This study focused
on the ninety-four therapists, who completed the survey questions on treatment
issues. As hypothesised, gender and profession (psychiatrists, psychologists,
social workers, and others) were not significantly related to how therapists rated
the effectiveness of treatment over VCON. Also as hypothesised, the number of
years doing therapy and number of years using VCON were also both not signif-
icantly related to how therapists rated the effectiveness of treatment over VCON.
As hypothesised, low effectiveness raters and higher raters significantly differed
on all the questions regarding specific psychodynamic variables over VCON:
symptom reduction, exploring mental life, working with transference, working
though relational problems, working with resistances, privacy concerns, and
countertransference (p< 0.001 for all these comparisons). Low raters felt that
exploring the mental life of the patient was most affected by VCON and working
on transference was least affected by VCON.
Nevertheless, low raters and higher raters of effectiveness generally agree
that treatment over VCON is valuable since it offers quality treatment to under-
served or remote patients, and it is valuable when the patient is house-bound
or travel would be impractical. The few who were most critical of treatment
over VCON were perhaps comparing it to the more familiar psychoanalytic
conditions rather than considering new ways to extend psychodynamic thought
and services.
Key words: online psychodynamic psychotherapy, China American
Psychoanalytic Alliance (CAPA), videoconferencing (VCON) treatment.
Psychoanalysis and Psychotherapy in China, Volume 2, 2016: pp. 86–96.
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Psychological treatment over the internet with videoconferencing (VCON)
extends services to many underserved populations around the world.
However, we know little about how VCON psychodynamic psychother-
apy differs from in-person (or embodied) psychodynamic psychotherapy.
Backhaus and colleagues (2012) looked at sixty-five studies of video-
conferencing psychotherapy (VCP). They found that VCP has been used in
a variety of therapeutic formats and with diverse populations, is generally
associated with good user satisfaction, and is found to have similar clinical
outcomes to traditional face-to-face psychotherapy.
However, it is possible that the more the treatment depends on a thera-
peutic relationship, as in the case of psychodynamic treatment, the more
there may be problems with online treatment. Bayles (2012) states that
Skype can be a productive asset to psychoanalytic treatment. However,
Bayles, is concerned that physical proximity is a factor in the psychoana-
lytic situation. She writes that technology could limit access to the kinds of
vital information that our sense modalities contribute to the analytic
process.
Sucala and colleagues (2012) reviewed the literature on “E-therapy” and
found of the 840 reviewed studies, only eleven (1.3%) investigated the
therapeutic relationship. Cognitive behaviour therapy with less emphasis
on the working alliance and more emphasis on technique with cognitive
learning as the goal, would seem to be a natural treatment for the internet.
Empirical studies support this. Johansson and colleagues (2013) report
studies showing no differences between internet-delivered cognitive
behavioural therapy and in-person cognitive behavioural therapy for mild
to moderate depression, anxiety disorders, and somatic problems.
Although psychoanalysis and psychodynamic treatment require more of
a therapeutic “presence” than other psychotherapies, there remains the
question of how much the internet filters the interpersonal psychodynamic
constructs.
Berle and colleagues (2015) administered a survey to fifty-five patients
asking them to rate their preferences for various forms of therapy delivery
including treatment over the internet. Not surprisingly, the results suggested
that patients overwhelmingly preferred individual face-to-face therapy.
Scharff (2013a) cited a study by the American Psychoanalytic Association
that found that 28% of analysts reported using the phone, 9% using Skype
for psychotherapy, and 4% using Skype for psychoanalysis. Scharff states
that online supervision and online analyses are part of the repertoire of
current practice; and, when used with care, the internet has the potential
to allow teaching and treatment to occur when it would otherwise be
impossible.
The issue of privacy with providing treatment online is another area of
debate. Churcher (2012) was concerned that in the virtual environment of
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cyberspace, we have less knowledge about our immediate physical and
social environment to make reliable judgments about whether a conversa-
tion is private. However, Scharff (2013a) replied that we need to work on
weighing the benefits against the risks with teleanalysis. She argues that
there will be fewer concerns when there is more discussion at our associa-
tion meetings, and more systematic research as to whether teleanalysis can
provide a secure setting and can meet the standard of being clinically
equally effective.
Skype and most other videoconferencing services offer privacy with the
use of varying degrees of encryption. HIPPA (Health Insurance Portability
and Accountability Act of 1996) compliance however, is another matter if
there is electronic billing for insurance. For example, Skype is not HIPPA
compliant since it does not notify clinicians when security breaches occur
and because it does not claim to be so. Other VCON services such as VSee
and Zoom are HIPPA compliant and do immediately report any breach of
personal health information.
Paolo (2013) feels that online therapy is simply a different form of
therapy than standard psychoanalysis. Dettbarn (2013) discussed Skype as
a third “secret sharer” in the analytic process. She wondered what feelings,
fantasies, and thoughts analyst and client entertain when they experience
each other over the internet. Dettbarn brought up questions about the
absence of spatial and physical proximity and the development of trust,
denial of the reality of separation and mourning, internet as a protec-
tion against the real dangers in a physical presence (violence, aggression,
sexual seduction), and if transference, resistance, and regression will seem
more magical.
The less sense of propinquity in treatment may be why, despite the effec-
tiveness of online treatment, there might be a higher drop out rate as com-
pared to in-person treatment as reported by King and colleagues (2014).
Caparrotta (2013) claims that digital technologies need to be embraced
responsibly and with an open mind by the psychoanalytic profession. This
seems to be occurring as indicated by three recent books on the topic,
Psychoanalysis Online: Mental Health, Teletherapy and Training, and
Psychoanalysis Online II, both edited by J. S. Scharff (2013b, 2015), and
Psychoanalysis in the Technoculture Era edited by Lemma & Caparrotta,
(2013). J. S. Scharff’s (2013b, 2015) books emerged from an international
workgroup of colleagues from the International Psychoanalytical
Association (IPA) and the International Institute for Psychoanalytic Training
(IIPT) studying the practice of psychoanalysis and psychotherapy con-
ducted on the telephone and over the internet.
Fishkin and colleagues (2011) reported on teaching and treatment
offered by the China American Psychoanalytic Alliance (CAPA), which
provides treatment, education, and supervision to Chinese mental health
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professionals over the internet. They discussed the success of the pro-
gramme and how the cultural issues as well as aspects of the transference
and countertransference are shaped by the virtual nature of the technol-
ogy. D. E. Scharff (2015) reported that another psychoanalytic distance
learning institute, the International Psychotherapy Institute has also had
great success in the use of videoconference technology.
Recently, in a special issue of the round robin newsletter entitled
“Working electronically”, Lynch (2015) expressed the concerns about
working online. Lynch wrote that he was involved with the Sino-American
Continual Training Project for Senior Psychodynamic Psychotherapists. He
wrote,
There are two obvious benefits of providing psychoanalytic therapy and
training in an online modality. First, this modality increases the availability of
psychoanalysis, psychotherapy, and training to potential patients and candi-
dates from remote areas. It also provides the opportunity for continuity for
those patients who otherwise are unable to come to an analyst’s office with
frequency due to long travel distances or to employment conditions.
Yet, Lynch had doubts that the standard analytic situation could be
carried out online since the analyst’s physical presence is held to be so
important.
In an effort to study if psychodynamic constructs (i.e., analysis of trans-
ference, resistances, defences, mental life, etc.) can be effectively con-
veyed online, Gordon and colleagues (2015) emailed 300 past and present
members of CAPA requesting that they respond to an online survey about
their experiences in teaching, supervising, and treating Chinese students
over VCON. The CAPA faculty is mainly English speaking Westerners,
mostly from the US. Of the 300 email requests, 176 took the online survey,
roughly a 59% response rate. The respondents were 65% female, 37%
were psychologists, 33% were social workers, and 22% were psychiatrists.
The teachers (n = 130) had an average of 18.35 years of experience (SD =
9.72), supervisors (n = 152) had an average of 18.63 years of experience
(SD = 10.21), and the therapists (n = 163) had an average of 23.84 years
of practicing psychoanalytic treatment (SD = 7.44). Seventy-nine per cent
(n = 175) stated that they have been using videoconferencing (VCON) for
three or more years for doing teaching, supervising, or treatment (M =
4.21, SD = 2.14). The results indicated that teaching, supervision, and
treatment were all rated in the range of “slightly less effective” than in-
person, with supervision rated significantly more effective than teaching
and treatment over VCON; when doing psychodynamic treatment over
VCON the issues of symptom reduction, exploring mental life, working on
transference, relational problems, resistance, privacy issues, countertrans-
ference, are all equally rated in the range of “slightly less effective” than
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in-person treatment; the highest significantly rated indications for treat-
ment over VCON are: “To offer high quality treatment to underserved or
remote patients” and “When patient is house-bound or travel would be
impractical”, and the highest significantly rated contraindication for treat-
ment over VCON was: “Patient needs close observation due to crisis or
decompensation”.
Since the CAPA mailing list included members of CAPA who dropped
out, this added more variance to the sample in that it included dissatisfied
experts.
We wish to know more about this group of therapists who did not think
that online treatment was effective. There were 42 out of 102 therapists
(41%) who rated treatment effectiveness either “1” or “2” (1 = much less
effective, 2 = less effective than in-person, on a 7 point scale). We wanted
to investigate their characteristics and concerns about psychodynamic
treatment of Chinese students over VCON.
We hypothesised that gender, profession (psychiatrists, psychologists,
social workers, others), years doing therapy, and number of years using
VCON would all not be significantly related to how therapists rated the
effectiveness of treatment over VCON.
However, we predicted that low raters would feel that the psycho-
dynamic constructs (i.e., symptom reduction, exploring mental life, work-
ing with transference, working though relational problems, working with
resistances, privacy concerns, and countertransference issues) would not
translate effectively over the internet as compared to in-person treatment.
However, we also hypothesised that the low raters and higher raters (i.e.,
scores 3 = slightly less effective, 4 = no difference than in-person, etc.)
would agree that there was value in VCON treatment in that it offers high
quality treatment to underserved or remote patients, and it is valuable
when the patient is house-bound or travel would be impractical.
METHOD
We recruited our expert participants from the email list of 300 past and
present China American Psychoanalytic Alliance (CAPA) teachers, supervi-
sors and therapists. The email notices stated that participation is voluntary
and anonymous. They were given a link to the online survey on Survey
Monkey where their responses to the questions were automatically stored
and exported to SPSS for analysis. We stated in the survey: “Answer only
the questions as they apply to your work with CAPA. There may be issues
with differences in education, language, and cultural between your CAPA
students/supervisees/patients and your in-person American students/super-
visees/patients. For the sake of this research, please assume ‘all other things
being equal’ though this is not easy to do.”
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The executive members of CAPA initially screened all the participants
for their expertise before they were allowed to offer their services to CAPA.
Additionally, the results indicating the many years of teaching, supervi-
sion, and treating, support our methodological assumption that this is a
survey of expert opinion.
For this current study, we specifically looked at only the responses of
CAPA therapists and only looked at the following questions regarding
demographic, profession, and experience:
1. gender
2. profession
3. years doing therapy
4. years using VCON
5. “How does videoconferencing compare to in-person treatment in
reducing symptoms?”
6. “How does videoconferencing compare to in-person treatment in
exploring the mental life of the patient?”
7. “How does videoconferencing compare to in-person treatment in
working on transference?”
8. “How does videoconferencing compare to in-person treatment in
working through relational problems?”
9. “How does videoconferencing compare to in-person treatment in
working with resistance?”
10. “How does videoconferencing compare to in-person treatment in
creating a sense of privacy?”
11. “How does videoconferencing compare to in-person treatment in
dealing with countertransference issues?” and the importance of these
treatment indications
12. “To offer high quality treatment to underserved or remote patients,”
13. “When patient is house-bound or travel would be impractical”
DEMOGRAPHICS
There were ninty-four CAPA therapists who completed the survey ques-
tions on treatment issues, of those fifty-five were female. Seventeen were
psychiatrists, forty-one were psychologists, twenty-seven were social
workers, and nine were other.
RESULTS
In order to avoid false positives due to the high number of comparisons
(13), we set the alpha level for significance at p< 0.001. We used ANOVA
with harmonic means to analyse the demographic variables, and with
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each of the questions, we used Levene’s Test for Equality of Variances
(with equal variances not assumed) and Paired T tests for our specific
hypotheses. Also to control for the wide differences in variances we
assigned a “1” for low scores (1–2) and a “2” for high scores (3–7).
We hypothesised that profession, gender, years working with VCON,
and treatment online would not be factors in the ratings. As hypothesised:
using ANOVA with harmonic means, profession (psychiatrist N = 17,
psychologist N = 41, social worker N = 27, other N = 9) (p= 0.20) and
gender (p= 0.11) were not significantly different in how therapists rated
the effectiveness of treatment over VCON.
As hypothesised: the number of years doing therapy (p= 0.27) and
number of years using VCON (p= 0.42) were also both not significantly
different in how therapists rated the effectiveness of treatment over VCON.
As hypothesised: low effectiveness raters and higher effectiveness
raters significantly differed on all the questions regarding psychodynamic
treatment over VCON: symptom reduction, exploring mental life, working
with transference, working though relational problems, working with resis-
tances, privacy concerns, and countertransference (p< 0.001, 2-tailed, for
all these comparisons).
Low effectiveness raters differed from the higher effectiveness raters in
all the questions on psychodynamic psychotherapy constructs (in order of
degree of mean differences) (1 = not effective, 2 = effective):
“How does videoconferencing compare to in-person treatment in explor-
ing the mental life of the patient?” mean difference = 0.86 (low n = 29, M
= 1.03, SD = 0.19; high n = 57, M = 1.90, SD = 0.31, p< 0.0001)
“How does videoconferencing compare to in-person treatment in reducing
symptoms?” mean difference = 0.79 (low n = 31, M = 1.10, SD = 0.30;
high n = 52, M = 1.89, SD = 0.32, p< 0.0001)
“How does videoconferencing compare to in-person treatment in dealing
with countertransference issues?” mean difference = 0.72 (low n = 24, M
= 1.08, SD = 0.28; high n = 62, M = 1.80, SD = 0.40, p< 0.0001)
“How does videoconferencing compare to in-person treatment in working
through relational problems?” mean difference = 0.67 (low n = 30, M =
1.17, SD = 0.38; high n = 56, M = 1.84, SD = 0.37, p< 0.0001)
“How does videoconferencing compare to in-person treatment in working
with resistance?” mean difference = 0.66 (low n = 36, M = 1.22, SD =
0.42; high n = 50, M = 1.90, SD = 0.33, p< 0.0001)
“How does videoconferencing compare to in-person treatment in creating
a sense of privacy?” mean difference = 0.64 (low n = 30, M = 1.20, SD =
0.41; high n = 55, M = 1.84, SD = 0.37, p< 0.0001)
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“How does videoconferencing compare to in-person treatment in working
on transference?” mean difference = 0.61 (low n = 34, M = 1.24, SD =
0.43; high n = 52, M = 1.85, SD = 0.36, p< 0.0001)
As hypothesised low raters and high raters did not significantly differ in
the indications for VCON:
“To offer high quality treatment to underserved or remote patients,” mean
difference = 0.01 (low n = 5, M = 1.60, SD = 0.55; high n = 79, M = 1.61,
SD = 0.49, p= 0.97)
“When patient is house-bound or travel would be impractical”, mean dif-
ference = 0.35 (low n = 7, M = 1.29, SD = 0.49; high n = 57, M = 1.64,
SD = 0.49, p= 0.11) (See Table 1).
Table 1. Low effectiveness raters vs. high effectiveness raters on the use of
therapy over VCON
Comparing VCON with Mean difference between high and low raters
in-person Tx
Exploring the mental life low n = 29, M = 1.03, SD = 0.19
of the patient high n = 57, M = 1.90, SD = 0.31, p< 0.0001
Reducing symptoms low n = 31, M = 1.10, SD = 0.30
high n = 52, M = 1.89, SD = 0.32, p< 0.0001
Dealing with low n = 24, M = 1.08, SD = 0.28
countertransference issues high n = 62, M = 1.80, SD = 0.40, p< 0.0001
Working through relational low n = 30, M = 1.17, SD = 0.38
problems high n = 56, M = 1.84, SD = 0.37, p< 0.0001
Working with resistance low n = 36, M = 1.22, SD = 0.42
high n = 50, M = 1.90, SD = 0.33, p< 0.0001
Sense of privacy low n = 30, M = 1.20, SD = 0.41
high n = 55, M = 1.84, SD = 0.37, p< 0.0001
Working on transference low n = 34, M = 1.24, SD = 0.43
high n = 52, M = 1.85, SD = 0.36, p< 0.0001
Offer treatment to underserved low n = 5, M = 1.60, SD = 0.55
or remote patients high n = 79, M = 1.61, SD = 0.49, p< = 0.97
Patient is house-bound or travel low n = 7, M = 1.29, SD = 0.49
would be impractical high n = 57, M = 1.64, SD = 0.49, p= 0.11
Most the therapists who use VCON for treating patients in China rate it high
on the psychodynamic variables. Low raters while differing with high raters
on the effectiveness of psychodynamic therapy over VCON as compared to
in-person, do not differ with high raters on the value of psychodynamic
therapy over VCON for treating underserved or remote patients, and when
the patient is house-bound or when travel would be impractical.
1 = not effective, 2 = effective.
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DISCUSSION
Gordon and colleagues (2015) found that 60% of CAPA therapists over-
all considered delivering psychodynamic psychotherapy with VCON
favourably. However, we wanted to explore the characteristics and con-
cerns of those few therapists who were most critical of psychodynamic
treatment over VCON. These results suggest that therapists who rate
psychodynamic psychotherapy over VCON low (i.e., “Much less effective
than in-person” and “Less effective than in-person”) than higher raters (i.e.,
“Slightly less effective,” “No difference,” “slightly more effective,” etc.)
believe that the psychodynamic constructions are not effectively translated
over VCON as compared to in-person treatment. The issues of symptom
reduction, exploring mental life, working with transference, working
though relational problems, working with resistances, privacy concerns,
and countertransference issues were all considered negatively affected by
online work. Low raters felt that exploring the mental life of the patient was
most affected by VCON and working on transference was least affected by
VCON.
Nevertheless, low raters of effectiveness and higher raters of effective-
ness agree on that treatment over VCON is valuable since it offers high
quality treatment to underserved or remote patients, and it is valuable
when the patient is house-bound or travel would be impractical.
Perhaps these low effectiveness raters were comparing VCON psycho-
dynamic treatment to more familiar psychoanalytic conditions rather than
considering new ways of extending psychodynamic thought and services.
Many of the CAPA therapists expressed the opinion that the problems
posed by using VCON were grist for the mill and interpretable. As one
respondent of the survey stated in a comment box, “Most of the problems
with teletherapy can be dealt with by interpretation and working through.”
Profession (i.e., psychiatrist, psychologist, social worker, other), gender,
years working with VCON, and years doing treatment were not factors in
the ratings.
The limitations of this study are that it is a survey of the opinions of
experts, and not a randomly controlled outcome study. We recommend
more empirical research in this area using a variety of methodologies. The
condition of the differences in culture and language were held constant:
that is both high and low rates were mainly English-speaking Westerners
treating CAPA English-speaking patients in China. Further research is
needed to see how much culture and language are factors in using VCON.
Gordon and Lan (in press) looked at this question with a sample of Chinese
patients. Our findings suggest that the Chinese patients feel that the thera-
pists’ qualities (warmth, wisdom, empathy, and skilfulness) are more
important than both issues of cultural difference and whether the treatment
was over the internet or in-person.
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NOTE
1. This research was approved by the IRB of the Washington Center of
Psychoanalysis.
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