Psychotherapy During COVID-19: How the Clinical Practice of Italian Psychotherapists Changed During the Pandemic

Abstract

Aims: Italy was one of the first countries to be significantly affected by the coronavirus disease 2019 (COVID-19) pandemic, determining a unique scenario for Italian psychotherapists to consider changing the modality in which they deliver treatment. The present study aimed at studying which factors related to psychotherapists and their clinical practice had a major role in predicting two main outcomes: (1) the rate of interrupted treatments during lockdown and (2) psychotherapists’ satisfaction with the telepsychotherapy modality.
Methods: An online survey was administered to licensed psychotherapists (n = 306), who worked mainly as private practitioners, between April 5 and May 10, 2020 (i.e., the peak of the pandemic in Italy).
Results: Psychotherapists reported that 42.1% (SD = 28.9) of their treatments had been interrupted, suggesting that Italy faced an important undersupply of psychotherapy during the lockdown. Using the Akaike information criterion (AIC) model selection, we identified three predictors of the rate of interrupted treatments: (1) psychotherapists’ lack of experience with telepsychotherapy prior to the lockdown, (2) their theoretical orientation (with cognitive behavioral psychotherapists reporting a higher rate of interrupted treatments), and (3) patients’ lack of privacy at home, as reported to the psychotherapists. Furthermore, we found four predictors of psychotherapists’ satisfaction with the telepsychotherapy modality: (1) the rate of interrupted treatments, (2) psychotherapists’ previous experience with telepsychotherapy, (3) their beliefs about the compatibility of telepsychotherapy with their theoretical orientation, and (4) their use of a video-conferencing modality, rather than telephone.
Conclusion: The following recommendations can help policy makers, professional associations, and practitioners in promoting the continuity of psychotherapy treatments during the COVID-19 outbreak and in future emergencies: (i) disseminating training programs for practitioners on telepsychotherapy, (ii) supporting patients to pragmatically access a private space at home, (iii) encouraging practitioners to use video-conferencing (instead of telephone) to deliver remote therapy, and (iv) increasing the acceptance of telepsychotherapy among both clinicians and the general public.

Full text

Frontiers in Psychology | www.frontiersin.org 1 October 2020 | Volume 11 | Article 591170
ORIGINAL RESEARCH
published: 21 October 2020
doi: 10.3389/fpsyg.2020.591170
Edited by:
Sally Wai Chi Chan,
The University of Newcastle, Australia
Reviewed by:
Adam O. Horvath,
Simon Fraser University, Canada
Serena Giunta,
University of Palermo, Italy
*Correspondence:
Arianna Schiano Lomoriello
arianna.schianolomoriello@unipd.it
Specialty section:
This article was submitted to
Psychology for Clinical Settings,
a section of the journal
Frontiers in Psychology
Received: 03 August 2020
Accepted: 16 September 2020
Published: 21 October 2020
Citation:
Boldrini T, Schiano Lomoriello A,
Del Corno F, Lingiardi V and
Salcuni S (2020) Psychotherapy
During COVID-19: How the Clinical
Practice of Italian Psychotherapists
Changed During the Pandemic.
Front. Psychol. 11:591170.
doi: 10.3389/fpsyg.2020.591170
Psychotherapy During COVID-19:
How the Clinical Practice of Italian
Psychotherapists Changed During
the Pandemic
TommasoBoldrini
1, AriannaSchianoLomoriello
1,2*, FrancoDelCorno
3, VittorioLingiardi
4
and SilviaSalcuni
1
1 Department of Developmental Psychology and Socialization, University of Padova, Padova, Italy, 2 Department of Cognitive System,
Denmark Technical University (DTU), Copenhagen, Denmark, 3 Association for Research in Clinical Psychology (ARP), Milan, Italy,
4 Department of Dynamic and Clinic Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
Aims: Italy was one of the rst countries to besignicantly affected by the coronavirus
disease 2019 (COVID-19) pandemic, determining a unique scenario for Italian psychotherapists
to consider changing the modality in which they deliver treatment. The present study aimed
at studying which factors related to psychotherapists and their clinical practice had a major
role in predicting two main outcomes: (1) the rate of interrupted treatments during lockdown
and (2) psychotherapists’ satisfaction with the telepsychotherapy modality.
Methods: An online survey was administered to licensed psychotherapists (n= 306),
who worked mainly as private practitioners, between April 5 and May 10, 2020 (i.e., the
peak of the pandemic in Italy).
Results: Psychotherapists reported that 42.1% (SD=28.9) of their treatments had been
interrupted, suggesting that Italy faced an important undersupply of psychotherapy during
the lockdown. Using the Akaike information criterion (AIC) model selection, weidentied
three predictors of the rate of interrupted treatments: (1) psychotherapists’ lack of experience
with telepsychotherapy prior to the lockdown, (2) their theoretical orientation (with cognitive
behavioral psychotherapists reporting a higher rate of interrupted treatments), and (3)
patients’ lack of privacy at home, as reported to the psychotherapists. Furthermore, wefound
four predictors of psychotherapists’ satisfaction with the telepsychotherapy modality:
(1) the rate of interrupted treatments, (2) psychotherapists’ previous experience with
telepsychotherapy, (3) their beliefs about the compatibility of telepsychotherapy with their
theoretical orientation, and (4) their use of a video-conferencing modality, rather than telephone.
Conclusion: The following recommendations can help policy makers, professional
associations, and practitioners in promoting the continuity of psychotherapy treatments
during the COVID-19 outbreak and in future emergencies: (i) disseminating training
programs for practitioners on telepsychotherapy, (ii) supporting patients to pragmatically
access a private space at home, (iii) encouraging practitioners to use video-conferencing
(instead of telephone) to deliver remote therapy, and (iv) increasing the acceptance of
telepsychotherapy among both clinicians and the general public.
Keywords: telepsychotherapy, COVID-19, public health, remote psychotherapy, psychotherapy

Boldrini et al. Psychotherapy in Italy During COVID-19
Frontiers in Psychology | www.frontiersin.org 2 October 2020 | Volume 11 | Article 591170
INTRODUCTION
Italy was one of the rst countries to be severely aected by
the coronavirus disease 2019 (COVID-19). Beginning on February
23, 2020, the Italian government took strong actions to restrict
residents’ freedom, aimed at reducing the contagion. e most
severe of these restrictions was the imposition of a nationwide
lockdown in early March. is lockdown caused unprecedented
changes in daily personal and professional activities, forcing
Italian residents to avoid unnecessary face-to-face interactions
and social gatherings, as well as limiting their movement to
the strictly necessary.
Along with other healthcare treatments, psychotherapy was
not subject to the full government restrictions, with the exception
of general precautions (i.e., as outlined in the Italian Ministerial
Decree of March 8, 2020). However, while it remained possible
to maintain in-person psychotherapy sessions, doing so was
practically challenged in private clinics and public health systems,
considering that face-to-face meetings could increase the risk
of infection for both therapists and patients; thus, the National
Council of Psychologists CNOP) explicitly invited psychologists
and psychotherapists, as far as possible, to provide their
professional services via digital devices to guarantee the
continuation of previously active therapeutic treatments and
to ensure the mental health support for diseases linked to
pandemic and quarantine. Guidance and regulation for
telepsychology in Italy was provided in a document on
recommendations for telepsychology [National Council of
Psychologists (CNOP), 2017], which did not forbid any online
psychological practices, and provided specic guidelines regarding
deontological norms, informed consent, privacy and correct
identication of users, and emergency situations management
(i.e., recommending therapist to obtain emergency numbers
and contact details of places oering support that are close
by the place where a patient logs in or telephones). e natural
consequence of this extraordinary situation was that a primary
element of psychotherapy – the setting – was subject to renewed
reection. Specically, the crossroad at which psychotherapists
found themselves was dened by a choice between using
telepsychotherapy – which oered the possibility of continuing
therapy – or temporarily interrupting treatment.
At this historical time, the continuity of care for psychological
treatment is pivotal. A recent study by Brooks et al. (2020)
documented an increase in mental health disorders due to
the COVID-19 pandemic, including self-reported symptoms
of anxiety and depression (16–28%), and stress (8%), frequently
in association with a sleep disorder (Rajkumar, 2020).1 Evidence
suggests that telepsychotherapy could represent a safe and
1
A growing body of literature found out the potential consequences of the
COVID-19 pandemic scenario also in people with pre-existing mental health
disorders (e.g., Moreno et al., 2020). For example, people with anxiety-related
or mood disorders resulted in being significantly affected than others, reporting
greater fear about the danger of contamination, socioeconomic consequences,
xeno-phobia, and traumatic stress symptoms (Asmundson et al., 2020). Similarly,
individuals at high clinical risk for psychosis may be prone to exacerbate
psychological distress (DeLuca et al., 2020), as a result of heightened stress
sensitivity and comorbid mental health problems (Boldrini et al., 2019).
ecacious alternative to physical treatment during the pandemic
(Swartz, 2020; Wind etal., 2020). Poletti etal. (2020) reviewed
the results of 18 empirical studies in which psychotherapy
was provided via synchronous web technology. Interestingly,
the authors reported that telepsychotherapy was substantially
equivalent to face-to-face psychotherapy in its ecacy for
treating common mental health disorders (Poletti etal., 2020).
In particular, research has found telepsychotherapy to beeective
in treating anxiety (Catarino et al., 2018), depressive (Egede
etal., 2015; Catarino etal., 2018), and posttraumatic symptoms
(Wierwille et al., 2016). Of note, patients who attend
telepsychotherapy treatments report similar perceived quality
of life, satisfaction, and treatment credibility as those enrolled
in face-to-face psychotherapy (Egede et al., 2015).
Conversely, despite the evidence for its eectiveness, negative
attitudes about telepsychotherapy are prevalent (see also Varker
et al., 2018). Survey studies have reported that approximately
half of all respondent psychotherapists perceive telepsychotherapy
as less eective than face-to-face psychotherapy (Gordon etal.,
2015, 2016; Schulze et al., 2018). Indeed, there are ethical
arguments against the seamless implementation of online therapy,
including (1) privacy, condentiality, and security issues, (2)
therapist competence and need for special training, (3)
communication issues specic to technology, (4) research gaps,
and (5) emergency issues (Stoll et al., 2020).
Moreover, patients have been found to express a low
willingness to use telepsychotherapy (Apolinário-Hagen et al.,
2017; Hantsoo etal., 2017), especially when they have already
experienced face-to-face psychotherapy (Hantsoo et al., 2017).
General skepticism toward telepsychotherapy is also present
and is particularly strong among practitioners. In a sample of
1,791 US psychotherapists, nearly 80% reported that they did
not use telepsychotherapy within their own practice (Pierce
et al., 2019). Overall, learning curves in the adoption of new
e-mental health technologies by both patients and psychologists
have progressed far more slowly than initially expected, thus
tallying with the estimate that it takes, on average, 16 years
for a healthcare innovation to be implemented (Rogers etal.,
2017). However, this prevision has been dramatically disproved
by the COVID-19 lockdown, which has led to signicant and
swi changes in clinical practice. is, in turn, has given rise
to a unique opportunity to study the consequences of a sudden,
large-scale, massive setting transition towards telepsychotherapy.
As Italy was one of the rst countries to experience forced
changes in clinical activities due to the COVID-19 pandemic,
the aim of the present investigation was to provide a picture
of the scenario and to delineate which factors played a pivotal
role in promoting better telepsychotherapy interventions at this
time. In doing so, the investigation sought to generate knowledge
to guide other countries struggling with the pandemic. For
this purpose, we focused on two outcomes: (1) the rate of
interrupted treatments (i.e., failure in the implementation
of telepsychotherapy treatments) and (2) psychotherapists’
satisfaction with the telepsychotherapy modality. In particular,
we collected information related to the psychotherapists (e.g.,
sociodemographic characteristics, theoretical orientation, and
treatment modality), their clinical practice (e.g., their selected

Boldrini et al. Psychotherapy in Italy During COVID-19
Frontiers in Psychology | www.frontiersin.org 3 October 2020 | Volume 11 | Article 591170
modality for delivering remote psychotherapy sessions, previous
experience with telepsychotherapy), and their general beliefs
about telepsychotherapy (e.g., their perception of the compatibility
of their theoretical orientation to the online modality), as these
factors were thought to play a role in determining the
selected outcomes.
MATERIALS AND METHODS
Study Design
An online survey designed in Qualtrics was administered to
licensed psychotherapists in Italy, using snowball sampling
techniques. Data were collected from April 5 to May 10, 2020 –
during the peak of the pandemic in Italy, approximately 5weeks
from the beginning of the lockdown and just before the second
phase of restrictions easement (e.g., to allow access to church
services, weddings, salon services, and short-term hospitality
without boarding).
Participation in the research was voluntary, and no incentives
were provided. All participants provided informed consent by
agreeing to the data protection declaration prior to starting
the survey. e principles outlined in the Declaration of Helsinki
were followed, ensuring anonymous participation through the
administration of the informed consent format of the ethics
committee of the University of Padua (GDPR EU 2016, pd. 196/03).
Description of Study Participants
A sample of 308 psychotherapists [84% female; mean age=45.1
(SD=10.2)] completed the survey. e geographical provenance
of the respondents was pretty homogeneous (Northern
Italy = 37%, Central Italy = 35%, Southern Italy = 28%).
Participants had been registered psychotherapists in Italy for
mean = 12.9 (SD = 8.5) years, and they typically (i.e., before
the COVID-19 lockdown) treated an average of 21.8 patients
(SD = 16.3) per month. eir psychotherapeutic orientations
were as follows: psychodynamic (60.8%), cognitive behavioral
(16.1%), systemic (8.6%), humanistic (11.7%), and integrated
(2.27%). Individual psychotherapy was the preferred treatment
modality of 49.1% of the clinicians; 32% saw mostly families
and couples; and the rest (18%) specialized in group therapy.
e enrolled psychotherapists performed their work mainly as
private practitioners (58.4%), with most of the rest (32%)
working in hospitals or mental health services in addition to
private practice (see also Figure 1). Finally, the majority of
the enrolled psychotherapists, under ordinary circumstances
(i.e., before the COVID-19 lockdown), received clinical
supervision: 38% received one supervision session per month,
36.3% received two to four sessions per month, and 5.34%
received more than four sessions each month. e remaining
psychotherapists (20.3%) received no supervisions. Information
about the therapists’ clinical practice is summarized in Figure1.
Measures
e survey comprised 45 items in total, and it took respondents
approximately 8min to complete. Given the aim of the present
study, we analyzed only a portion of all the items of the
survey. In addition to collecting sociodemographic characteristics
and information about the psychotherapists’ working practices
(as reported above), the survey also asked respondents to report
the proportion of their interrupted treatments since the
COVID-19 lockdown, as well as the relative proportions of
their patients whom they currently treated face-to-face, via
telephone, and via video-conferencing. Respondents were also
asked to rate their personal beliefs about telepsychotherapy,
in terms of its compatibility with their therapeutic orientation,
and their personal satisfaction with it. Additional items evaluated
respondents’ previous experience with video psychotherapy and
if their patients reported a lack of access to private space
at home.
Statistical Analysis
In the following analyses, weadopted a model selection strategy
based on the Akaike information criterion (AIC; Wagenmakers
and Farrell, 2004). e AIC (Akaike, 1973) is a powerful metric
derived from information theory that identies the relative
quality of each model within a set of candidate models
A
BC
FIGURE1 | The respective plots depict (A) the number of patients in
treatment during the month prior to lockdown as a function of
psychotherapists’ work settings (i.e., independent practices, hospitals, public
mental health, and housing services) and patient orientation (i.e., family and
couples, individual, and group); (B) psychotherapists’ theoretical orientations
[i.e., psychodynamic, cognitive behavioral therapy (CBT), and “other”]; and
(C) the proportion of patients in treatment in the month prior to lockdown, as
a function of clinicians’ theoretical orientation (i.e., psychodynamic, CBT, and
“other”) and patient orientation (i.e., family and couples, individual, and group).

Boldrini et al. Psychotherapy in Italy During COVID-19
Frontiers in Psychology | www.frontiersin.org 4 October 2020 | Volume 11 | Article 591170
(i.e., the lower the AIC, the higher the model quality, aer
controlling for model complexity).
Each full model was compared with simpler versions by
removing predictors until an intercept-only model was reached.
Aer identifying the best model (with the lowest AIC),
weregressed participants’ responses on the same set of regressors.
Signicant eects were explored with post hoc pairwise contrast
using the Wald test, corrected for multiple comparisons using
the false discovery rate (Benjamini and Hochberg, 1995).
e analyses were performed using the soware R (2.13)
with the lm function from the car package (Fox and Weisberg, 2019).
RESULTS
Changes in the Provision of Psychotherapy
During the COVID-19 Lockdown
With respect to psychotherapists’ changes in clinical practice
during the COVID-19 lockdown, respondents reported that
42.1% (SD = 28.9) of their psychotherapy treatments were
interrupted during the lockdown.2 e remainder of their
treatments was primarily delivered via online video [63.7%
(SD = 38.3)] or telephone [29.1% (SD = 25.3)]. Only 7.2%
(SD = 15.1) of their treatments were delivered face-to-face,
while taking precautionary measures (e.g., wearing masks
and gloves).
Predictors of a Higher Rate of Interrupted
Treatments
e rate of interrupted treatments was estimated via a linear
model. Data were t to one model, which included respondents’
therapeutic modality (individual vs. couples and families vs.
groups), theoretical orientation [psychodynamic vs. cognitive
behavioral therapy (CBT) vs. “other”], clinical experience (in
years), previous experience with telepsychotherapy (frequent
vs. rare vs. none), beliefs about the compatibility of
telepsychotherapy with their own theoretical orientation (yes
vs. no), and frequency of supervisions received before the
outbreak (none vs. once vs. one to four vs. more than four
per month), as well as patient’s reported lack of privacy at
home (yes vs. no) as predictive variables, as well as the
interactions between these variables.3
Model comparisons showed that the best model for explaining
the data observed for the rate of interrupted treatments included
clinicians’ previous experience with telepsychotherapy, clinicians’
2
erapists were asked to consider the all number of patients treated before
the lockdown and to report (on dierent sliders, which could vary between
0 and 100%) the percentages of (i) interrupted treatments, (ii) treatments
currently delivered by video call, (iii) by telephone, and (vi) face-to-face. us,
all the distributions reported in Changes in the Provision of Psychotherapy
During the COVID-19 Lockdown should be interpreted as the means and
standard deviations of the percentages reported by enrolled therapists to the
number of patients treated before the lockdown.
3
e full model for the rate of interrupted treatments was as follows:
rate ~ theoretical orientation × clinical experience × experience with
online × theoretical compatibility × supervision + patient’s privacy (in
Wilkinson notation).
theoretical orientation, and patient’s reported lack of privacy
at home as predictive variables (AIC=2,656.3, logL=−1,320.12,
ΔAIC = 35.02).4
We regressed participants’ responses to these sets of regressors
and found a signicant dierence predicted by clinicians’
previous experience with telepsychotherapy (b = −11.53,
SE = 3.47, p = 0.001), suggesting that the rate of interrupted
treatments was signicantly lower when psychotherapists reported
having frequently used telepsychotherapy prior to the COVID-19
outbreak (μ = 22.3; SD = 21.75); the opposite was true when
psychotherapists reported having never used this modality
(μ = 50.50; SD = 29.94). Notably, a signicant dierence was
also present for psychotherapists who reported having used
this modality rarely (μ = 39.54; SD = 26.40), compared to
those who reported either frequent or no previous experience
with telepsychotherapy. Furthermore, the model showed a
signicant dierence depending on respondents’ theoretical
orientation (b = −12.04, SE = 4.75, p = 0.01), whereby those
with a psychodynamic approach reported a lower rate of
interrupted treatments (μ = 39.82; SD = 28.86), compared to
those practicing CBT (μ = 48.6; SD = 31.11). However, this
dierence was not signicant with those characterized as having
an “other” clinical orientation. Finally, we found a signicant
eect of patients’ reported lack of privacy at home (b= 10.37,
SE = 3.77, p = 0.006), suggesting that psychotherapists with
patients lacking private space at home (μ= 48.31; SD = 31.45)
experienced a signicantly higher rate of interrupted treatments
compared to those who did not report the same issue (μ=39.86;
SD = 27.74; Figure 2 and Supplementary Table S1).
Predictors of Therapists’ Satisfaction With
Telepsychotherapy
Participants’ satisfaction was estimated via a generalized linear
eect binomial model because the outcome variable (yes vs.
no) was dichotomous. Data were t in a model that included
respondents’ theoretical orientation (psychodynamic vs. CBT
vs. other), clinical experience (in years), previous experience
with telepsychotherapy (frequent vs. rare vs. none), beliefs
about the compatibility of telepsychotherapy with their own
theoretical orientation (yes vs. no), rate of interrupted treatments,
dropped clinical supervisions (none vs. half vs. more than the
half vs. all), use of the telephone, use of video-conferencing,
and therapeutic modality (individual vs. couples and families
vs. groups) as predictive variables, as well as the interactions
between these variables.5
Model comparison showed that the model that best explained
the data observed for perceived satisfaction included the
rate of interrupted treatments, previous experience with
4
e ∆AIC was computed as the dierence in AIC between the best ranked
model and the null model, representing the dierence in quality between
the models.
5
The full model for satisfaction was as follows: satisfaction ~ theoretical
orientation + experience with online + theoretical compatibility + rate of
interrupted treatments+dropped of supervision+ telephone modality× clinical
experience + video call modality × clinical experience + therapeutic modality
(in Wilkinson notation).

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Frontiers in Psychology | www.frontiersin.org 5 October 2020 | Volume 11 | Article 591170
telepsychotherapy, theoretical compatibility, and use of video-
conferencing as predictive variables (AIC = 305.5,
logL = −146.618, ΔAIC = 2,386.01).
We regressed participants’ responses to these sets of regressors
and found a signicant dierence in satisfaction determined
by psychotherapists’ rate of interrupted treatments (b = −0.01,
SE = 0.005, p = 0.02), whereby the more satisfaction they
declared, the less dropout they reported. We also found a
signicant eect of previous experience with telepsychotherapy
(b=2.43, SE= 1.05, p = 0.02), indicating that psychotherapists
who reported having frequently used telepsychotherapy prior
to the COVID-19 lockdown had signicantly higher satisfaction
(μ = 0.97; SD = 0.16) than those who reported having never
used this modality (μ=59.35; SD=29.94). Notably, a signicant
dierence was also found for psychotherapists who reported
having rarely used this modality (μ=0.51; SD=0.50), compared
to those who had either frequent or no previous experience
with telepsychotherapy. Furthermore, the model showed a
signicant eect of theoretical compatibility (b=1.62, SE=0.38,
p<0.001), suggesting that psychotherapists who perceived their
theoretical orientation as compatible with the telepsychotherapy
modality (μ = 0.69; SD= 0.46) were more satised than those
who perceived their orientation as incompatible (μ = 0.26;
SD = 0.44). e model also revealed a signicant eect of the
number of video-conference calls (b=0.01, SE=0.004, p=0.01),
showing that the more psychotherapists provided sessions via
video-conferencing, the more satisfaction they reported (Figure3;
Supplementary Table S2).
DISCUSSION
e present study aimed at identifying the most signicant
factors in delivering psychotherapy during the COVID-19
lockdown in Italy. In this vein, we sought to both describe
the situation for psychotherapy during the peak of the
pandemic in Italy and provide guidance for countries still
facing (or likely to face) a similar situation as that
experienced in Italy.
e rst outcome of the present study considered the rate
of interrupted treatments (as reported by psychotherapists),
suggesting the degree of failure in implementing
telepsychotherapy. Psychotherapists reported that 42.1% of their
treatments had been interrupted, suggesting that, during the
COVID-19 lockdown, there was an important undersupply of
psychotherapy. ese data are even more surprising, because
the majority of participants worked exclusively (58.4%) or
mainly (32%) as private practitioner, so they could potentially
quickly rethink their clinical practice without having to conform
to the slower reorganization that impacted on public mental
health services and hospitals. A similar reduction in
psychotherapy was observed in Austria, where a decline in
face-to-face sessions was compensated by a reported increase
in telepsychotherapy in the early weeks of the COVID-19
lockdown – even though the increase was not sucient to
cover the full proportion of interrupted treatments (Probst
et al., 2020). On the contrary, a survey study conducted in
the Czech Republic, Germany, and Slovakia did not observe
psychotherapy dropout during the pandemic (Humer et al.,
2020). Notably, the present study was conducted during the
peak of the pandemic, aer the Italian government imposed
strong limitations on personal movement; in contrast, no
curfews existed in the aforementioned survey study at the
time of data collection (Humer et al., 2020). is mismatch
in the study conditions substantially limits our ability to
compare ndings.
e present analyses focused on identifying the predictive
factors of treatment interruption, emphasizing that both
therapists and patients play a role in this outcome. In particular,
the model of best t suggested that psychotherapists’ lack of
experience with telepsychotherapy prior to the lockdown was
an essential factor in predicting the rate of interrupted
treatments. It is reasonable to assume that a lack of experience
with telepsychotherapy may have threatened clinicians’
professional self-condence (Poletti et al., 2020). Further, a
lack of familiarity with using technology to provide video-
conferencing psychotherapy (present in 43.8% of our sample)
could have represented a barrier to providing remote treatment,
ABC
FIGURE2 | The plots depict the parameters selected as the best predictors of the rate of interrupted treatments. In particular, they represent differences between
(A) theoretical orientations (i.e., psychodynamic, CBT, and “other”); (B) psychotherapists’ use of telepsychotherapy prior to the lockdown (i.e., none, rare, and
frequent); and (C) patients’ lack of privacy at home, as reported to psychotherapists (i.e., yes, no).

Boldrini et al. Psychotherapy in Italy During COVID-19
Frontiers in Psychology | www.frontiersin.org 6 October 2020 | Volume 11 | Article 591170
as suggested by previous research (Rössler etal., 2011; Cipolletta
et al., 2017; Etzelmueller et al., 2018). is nding is
corroborated by evidence that therapists who have received
specic training in delivering telepsychotherapy are more likely
to adopt this treatment modality (Pierce et al., 2020). Given
that COVID-19 may impact nearly everyone in the world,
the need for psychological support is fundamental (Duan
and Zhu, 2020). us, the dissemination of training programs
on telepsychotherapy and video-conferencing technology by
professional associations may be crucial for countries aected
by the pandemic, in order to prevent an undersupply of
psychotherapy treatment.
A secondary relevant aspect shown in our analyses related
to patients. Although the information we obtained on patients’
conditions was derived from psychotherapists, the data suggested
that patients’ reported lack of private space at home presented
a signicant barrier to the implementation of telepsychotherapy.
According to this nding, the continuation of therapeutic work
may require therapists to pragmatically discuss with their
patients the incidental diculties in achieving an intimate,
reassuring, and safeguarded setting in which to participate in
telepsychotherapy sessions.
Moreover, we found a signicant eect of theoretical
orientation on the rate of interrupted treatments, with
psychodynamic therapists reporting a lower rate than CBT
therapists. is result is unexpected, since previous studies
have found CBT clinicians to be more accepting of telehealth
interventions than psychodynamic therapists (e.g., Perle et al.,
2012), and similar evidence is deducible from the higher number
of studies on CBT delivered remotely (e.g., Egede et al., 2015;
Zerwas etal., 2017; Catarino etal., 2018; Etzelmueller etal., 2018).
e second focus of the present investigation was
psychotherapists’ satisfaction with telepsychotherapy. As
expected, the rate of interrupted treatments represented a
negative predictor, as it implied a withdrawal of therapists’
professional duties and consequent nancial damage. Importantly,
among the two dierent modalities for delivering remote
sessions (i.e., telephone vs. video-conferencing), only the video-
conferencing modality predicted therapists’ satisfaction,
suggesting that – although telephonic communication may
provide a fast and easy method of providing remote care –
whenever possible, therapists should choose video-conferencing
technology over the telephone. Indeed, previous studies have
reported the ecacy of this modality, explaining that it enables
psychotherapists and patients in separate locations to see each
other and interact in real time (i.e., “synchronously”; see
Fletcher et al., 2018; Norwood et al., 2018, for reviews). is
nding is also supported by experimental studies showing that
the perceived distance between two interacting individuals
modulates the empathic reaction between them (Schiano
Lomoriello et al., 2018), which is a key ingredient of all
psychotherapeutic interventions.6
Finally, therapists’ attitudes and beliefs about telepsychotherapy
played a signicant role in qualitatively shaping their experiences
of online sessions. In particular, we found that therapists who
considered the online modality as incompatible with their
theoretical orientation reported less satisfaction. Overall, there
are no valid reasons to believe that a specic therapeutic
orientation is more or less suitable for telepsychotherapy (Varker
et al., 2018; Poletti et al., 2020). In fact, preliminary research
has pointed to the ecacy of both CBT and diverse
psychotherapeutic approaches, as delivered over an online
modality (e.g., Dennis et al., 2020). Moreover, as brilliantly
discussed by Swartz (2020), strategies for supporting patients
during the COVID-19 pandemic can be found in virtually all
psychotherapeutic disciplines. In this vein, therapists’ reluctance
6
As pointed out by Racine et al. (2020), another therapeutic concern is the
assessment of patients’ emotional states via telematic modality, especially about
dissociation. Dissociative symptoms, which are challenging to assess even in
natural therapeutic circumstances (e.g., Fagioli et al., 2015), could be more
challenging to be identied using a video call, and barely impossible to identify
via telephone.
AB
CD
FIGURE3 | The plots depict the parameters selected as the best predictors of differences in psychotherapists’ satisfaction with telepsychotherapy. In particular,
the respective plots represent the variation in perceived satisfaction according to (A) the rate of interrupted treatments; (B) the use of video-conferencing to deliver
sessions; (C) psychotherapists’ use of telepsychotherapy prior to the lockdown (i.e., none, rare, and frequent); and (D) psychotherapists’ beliefs about the
compatibility of telepsychotherapy with their theoretical orientation (i.e., yes, no).

Boldrini et al. Psychotherapy in Italy During COVID-19
Frontiers in Psychology | www.frontiersin.org 7 October 2020 | Volume 11 | Article 591170
to use technology for psychotherapy may berelated to uninformed
attitudes, rather than fundamental issues relating to this modality
(Van Daele etal., 2020). National and international institutions
hold the responsibility for increasing the acceptance of
telepsychotherapy among both clinicians and the general public,
especially in the current context, given that a surge in the
demand for mental health resources is expected in the months
following isolation (Gao et al., 2020).
Surprisingly, we did not nd any eect of psychotherapists’
clinical experience in predicting either the rate of interrupted
treatments or therapists’ satisfaction with the online treatment
modality. We hypothesize that, given the high correlation
between psychotherapists’ age and clinical experience in our
sample, this lack of evidence could represent a compensatory
eect of the sample characteristics. Indeed, previous studies
on psychotherapy treatments delivered via video-conferencing
have shown that psychotherapists’ familiarity with Internet
technology promotes patients’ compliance by limiting technical
diculties (e.g., brief interruptions or breakdowns in online
communications; Etzelmueller et al., 2018) and that older age
is associated with a lower dropout rate and better clinical
outcomes (Catarino et al., 2018). In other words, younger
therapists may encounter fewer technological barriers when
delivering online sessions, whereas older therapists may benet
from their greater clinical experience, which allows them to
better manage their patients during this potentially destabilizing
transition in setting.
It is necessary to recognize the limitations of the present
study. Notably, the enrolled psychotherapists performed their
work mainly as private practitioners; thus, the generalizability
of the present results should be limited to the changes in
psychotherapy activities in the private practice. A further
limitation relates to the cross-sectional design. Multiple
measurement points in a longitudinal design would have the
advantage of monitoring the provision of psychotherapy in
Italy as the government restrictions eased. It should also benoted
that the snowball technique used for recruitment may have
produced a biased sample (e.g., the higher proportion of
psychodynamic therapists may have been due to the therapeutic
orientation of the authors). Finally, the study only analyzed
psychotherapists’ self-reports, and no objective data (e.g., health
insurance information) were considered.
To conclude, Tab le  1 reports key messages that can provide
insight for countries struggling with the pandemic and oer
specic guidance for policy makers, mental health institutions,
professional organizations, and psychotherapists in promoting
the continuity of psychotherapy treatment during the COVID-19
outbreak and in future pandemics.
DATA AVAILABILITY STATEMENT
e raw data supporting the conclusions of this article will
be made available by the authors, without undue reservation.
ETHICS STATEMENT
e studies involving human participants were reviewed and
approved by Ethics committee of the University of Padua. e
patients/participants provided their written informed consent
to participate in this study.
AUTHOR CONTRIBUTIONS
TB and AS developed the survey and wrote the rst dra of
the manuscript. AS analyzed the data. SS conceived the research
study and contributed to the development of the survey. SS,
VL, and FC contributed to the interpretation of the results
and critically reviewed the nal dra of the manuscript. All
authors contributed to the article and approved the
submitted version.
ACKNOWLEDGMENTS
We would like to thank all of the psychotherapists who
patiently responded to our survey during this critical and
frightening time.
SUPPLEMENTARY MATERIAL
e Supplementary Material for this article can befound online
at: https://www.frontiersin.org/articles/10.3389/fpsyg.2020.591170/
full#supplementary-material
TABLE1 | Key message for practitioners.
During the peak of the lockdown in Italy, 42.1% of psychotherapy treatments
were interrupted.
The following points are the factors weobserved to limit the implementation of
telepsychotherapy, followed by suggestions to help countries that are affected
by the pandemic:
I. Therapists’ lack of experience with telepsychotherapy.
 Disseminate training programs on telepsychotherapy.
II. Patient’s lack of a private space to access telepsychotherapy
sessions.
 Help and support patients to pragmatically access a private space.
III. Not using video-conferencing to administer telepsychotherapy
(video-conferencing was the only remote modality found to predict
therapists’ higher satisfaction).
 Therapists should use video-conferencing to deliver remote therapy,
where possible.
IV. Therapists’ consideration of teletherapy as compatible with their
theoretical orientation (those who did not report less satisfaction).
 Relevant associations should seek to increase the acceptance of
telepsychotherapy among both clinicians and the general public.

Boldrini et al. Psychotherapy in Italy During COVID-19
Frontiers in Psychology | www.frontiersin.org 8 October 2020 | Volume 11 | Article 591170
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Conflict of Interest: e authors declare that the research was conducted in
the absence of any commercial or nancial relationships that could beconstrued
as a potential conict of interest.
Copyright © 2020 Boldrini, Schiano Lomoriello, Del Corno, Lingiardi and Salcuni.
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