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Videoconferencing Psychotherapy During the Pandemic: Exceptional Times With Enduring Effects?

Authors:

Abstract

With the advent of COVID-19, a sudden, unexpected, and forced shift has been produced in the field of psychotherapy. Worldwide, many therapists closed their offices and started to deliver psychotherapy online through a screen. Although different media started to be incorporated, videoconferencing is undoubtedly the most common way in which therapists are doing therapy these days. This is catalyzing a rapid change in the practice of psychotherapy with probable lasting effects and deserves to be carefully reflected upon. Therefore, in this paper our aim is to outline the main challenges for a medium that may have arrived to stay. In that sense, we review the literature to describe the state-of-the-art regarding the main aspects of videoconferencing psychotherapy as well as to suggest possible avenues for future research and practice.
Frontiers in Psychology | www.frontiersin.org 1 February 2021 | Volume 12 | Article 589536
PERSPECTIVE
published: 19 February 2021
doi: 10.3389/fpsyg.2021.589536
Edited by:
Moshe Bensimon,
Bar-Ilan University, Israel
Reviewed by:
Keren Gueta,
Bar-Ilan University, Israel
Meyran Boniel-Nissim,
Kinneret College, Israel
*Correspondence:
Javier Fernández-Álvarez
javferalvarez@gmail.com
Specialty section:
This article was submitted to
Psychology for Clinical Settings,
a section of the journal
Frontiers in Psychology
Received: 30 July 2020
Accepted: 12 January 2021
Published: 19 February 2021
Citation:
Fernández-Álvarez J and
Fernández-Álvarez H (2021)
Videoconferencing Psychotherapy
During the Pandemic: Exceptional
Times With Enduring Effects?
Front. Psychol. 12:589536.
doi: 10.3389/fpsyg.2021.589536
Videoconferencing Psychotherapy
During the Pandemic: Exceptional
Times With Enduring Effects?
JavierFernández-Álvarez
1,2* and HéctorFernández-Álvarez
3
1 Department of Basic Psychology, Clinical and Psychobiology, Jaume I University, Castellón de la Plana, Spain, 2 Asociación
Aiglé, Valencia, Spain, 3 Fundación Aiglé, Buenos Aires, Argentina
With the advent of COVID-19, a sudden, unexpected, and forced shift has been produced
in the eld of psychotherapy. Worldwide, many therapists closed their ofces and started
to deliver psychotherapy online through a screen. Although different media started to
beincorporated, videoconferencing is undoubtedly the most common way in which
therapists are doing therapy these days. This is catalyzing a rapid change in the practice
of psychotherapy with probable lasting effects and deserves to becarefully reected upon.
Therefore, in this paper our aim is to outline the main challenges for a medium that may
have arrived to stay. In that sense, wereview the literature to describe the state-of-the-art
regarding the main aspects of videoconferencing psychotherapy as well as to suggest
possible avenues for future research and practice.
Keywords: COVID-19, psychotherapy, psychotherapists, telehealth, videoconferencing psychotherapy, telemental
health, e-mental health
INTRODUCTION
Although no consensus exists among experts regarding what comprises Internet-delivered
interventions (Smoktunowicz et al., 2020), there is no doubt that they have gained a central
role in the clinical psychology realm. A large body of evidence supports the incorporation of
dierent technologies, with dierent media and degrees of human support (Andersson et al.,
2019). Even psychotherapy, which has historically involved an in-person shared space, has
slowly but gradually incorporated more and more use of technologies. Fundamentally, the
application of videoconferences in routine practice has been progressive and is mainly explained
by practical reasons, such as geographical barriers, treatment-seeking stigma, or exibility in
scheduling sessions (Nickelson, 1998; Backhaus et al., 2012). Research on the remote delivery
of therapy has increased along with this increasing use, and accordingly, a large body of
evidence has been produced during the last two decades showing the ecacy of delivering
psychotherapy through videoconference, even with comparable results to in-person therapy
(Varker et al., 2018; Batastini et al., 2020). However, its application in routine practice has
not been widespread, with almost all therapists having no experience.
With the advent of the coronavirus disease (COVID-19), a sudden, unexpected, and forced
shi has been produced. Worldwide, many therapists closed their oces and started to deliver
psychotherapy online. e use of technology became the only way in many countries to provide
psychotherapy, and an overnight transition from in-oce to online practice occurred. Given that
videoconferencing constitutes a similar way of delivering therapy to traditional in-person
psychotherapy, it has been rapidly incorporated (Sammons et al., 2020; Wind et al., 2020).
Fernández-Álvarez and Fernández-Álvarez Videoconferencing Psychotherapy in Times of COVID-19
Frontiers in Psychology | www.frontiersin.org 2 February 2021 | Volume 12 | Article 589536
Although this massive dissemination is positive since millions
of people could potentially benet from these treatments, a
series of questions remain unanswered. In this paper, weaim
to outline the main challenges for a modality that may have
arrived to stay.
ISSUES IN WORKING WITH
VIDEOCONFERENCING
General Therapeutic Targets
e use of videoconferencing psychotherapy (VCP) does not
change the needs of patients and thus the general therapeutic
goals. Patients’ specic demands may have changed due to
the pandemic, but their suering will still be centered around
their diculties with the two main components of dysfunction:
self-dysfunction and interpersonal dysfunction (Hopwood etal.,
2013). Besides, it is important to focus the work on the two
dimensions in which the psychophysiological functioning of
the organism is deployed: behavior and experience.
Demanding scenarios such as lockdown or uncertainty about
the aermath of the pandemic constitute stressors that may
particularly aect people who already had maladaptive strategies
for coping with reality. In many cases, the context merits
exacerbated dysfunctional reactions regarding our mental health.
However, it is key to keep in mind that although the context
operates as a fundamental variable in peoples’ lives, the core
aspects regarding the ways of organizing experience are
personality and its components, such as schemas, attachment
styles, regulatory capacities, and interpersonal functioning,
among others (Livesley, 2012).
It is necessary to think outside the box and not just consider
the dangers and negative aspects of the pandemic. e current
context obliges us to live under constant threat, and therefore,
the situation reminds us that we are fragile beings (Won g,
2020). Implementing VCP, in particular due to a forced situation
like COVID-19, may be an opportunity to work on issues
that otherwise would not have been possible to address. e
presence of a dicult situation may facilitate the setting of
new goals. at is, this context may also foster the promotion
of positive changes such as meaning in life as an important
therapeutic target (Hill etal., 2017). Meaning in life has proven
to be a very powerful way of regulating emotions as well as
promoting positive psychology principles that, far from focusing
on the positive as a superuous thing, considers existential
sorrow to be a way to nd freedom (Wong, 2011). e
unexpected consequences of the pandemic foster a discussion
that is more important than ever: What should we pursue in
life? Are we living according to our values?
Therapeutic Alliance
ere are substantial dierences between in-person psychotherapy
and VCP that may have an impact on how the therapeutic
alliance is developed. For instance, in VCP, both patients and
therapists have the possibility of having feedback from their
own cameras. Certain patients and therapists (e.g., narcissistic
or socially anxious individuals) may pay too much attention to
their own behavior, and this may be detrimental to therapeutic
communication (Payne et al., 2020). Moreover, in-person
psychotherapy uses a physical shared space, entailing the
immediacy of the sensory experience and thus an undoubtedly
qualitatively dierent exchange. e most evident dierence
between in-person psychotherapy and VCP is the potential
technical diculties that may arise during the latter. As explained
by Markowitz (2020), an unstable connection, a frozen screen,
delayed audio or poor lighting are some of the diculties that
may impair engagement in therapy. Additionally, as described
by ompson-de Benoit and Kramer (2020), direct eye contact,
tone of voice, the ability to have an open posture, body movements,
synchrony, and attunement are some of the communicative
channels that may behampered in VCP. at is, the paralinguistic,
non-verbal and prosodic aspects of communication may
be aected. Principles that ground embodied cognition enable
one to grasp how physicality is key for information processing,
involving bodily aspects that may not betransferable to remote
modalities (Caramazza etal., 2014). A stooped posture, a shaking
leg or a clenched st are invisible in VCP. at relevant information
is missed in VCP both for therapists and patients.
Not taking into account these dierences that exist between
modalities may aect the development of the therapeutic process
and, consequently, result in early dropouts. Other ruptures in
remote psychotherapy may be exacerbated due to the
aforementioned technical problems or disappointment with the
restricted possibilities that this modality permits. Identifying
both confrontational and withdrawal ruptures and implementing
techniques to resolve them is crucial, and there are initial
suggestions regarding how to deal with this issue in VCP
(Dolev-Amit et al., 2020).
Beyond the conceptual debate around the establishment of
therapeutic alliance in VCP, a growing body of evidence shows
that it can be established, presumably with comparable results
to in-person psychotherapy (Simpson and Reid, 2014; Norwood
et al., 2018; Lopez et al., 2019). e results of these studies
converge on the conclusion that a therapeutic alliance can
be successfully formed in VCP. Indeed, Lopez et al. (2019)
conclude that VCP “…is a viable modality with the potential to
improve access to care with a low impact on therapeutic alliance.”
e authors suggest that the therapeutic alliance is not particularly
aected, and therefore, it does not hinder any therapeutic progress.
Although therapeutic alliance can be well established in VCP, it
is premature to conclude that it is equal to in-person psychotherapy.
Undoubtedly, the therapeutic alliance constitutes a core
element in all psychological treatments (Flückiger et al., 2018).
Indeed, the therapeutic alliance may beconceived as a moderator
or an active mechanism of change (Zilcha-Mano, 2017; Baier
etal., 2020). e longstanding tradition of therapeutic alliance
research in in-person psychotherapy has produced several lines
of research that have provided profound insight into how it
is deployed (Norcross and Lambert, 2019). However, there is
little research thus far on the role of the therapeutic alliance
in treatment in VCP research compared to in-person
psychotherapy. One topic it would be relevant to conduct
research on in VCP research is the reciprocal dependency
Fernández-Álvarez and Fernández-Álvarez Videoconferencing Psychotherapy in Times of COVID-19
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between the therapeutic alliance and symptomatology, as there
is mounting evidence in research on in-person treatment, which
suggests that the formation of a strong therapeutic alliance
precedes symptomatic change (Zilcha-Mano etal., 2014; Zilcha-
Mano, 2017). For now, there are only a few examples of VCP
research on this issue, without the same complexity as research
on in-person psychotherapy (Bouchard et al., 2020).
From a neurobiological point of view, the attachment bond
is usually associated with the 9-amino-acid cyclic neuropeptide
oxytocin (Schneiderman et al., 2014), which in turn is a
marker of the therapeutic alliance and alliance ruptures
(Zilcha-Mano et al., 2018, 2020). Additionally, based on the
Polyvagal eory (Porges, 2007), there is research showing
that higher in-session heart rate variability (specically the
high-frequency power) facilitates the establishment of
therapeutic alliance, and this predicts symptomatic improvement
(Blanck et al., 2019). It will be important to demonstrate
that these associations occur in remote modalities as well.
Should research beconducted on these more nuanced aspects,
it would not be surprising to nd that dierences between
in-person and remote psychotherapy emerge concerning the
quality of the therapeutic relationship.
ere is a great dierence regarding the establishment of
the therapeutic alliance between treatments that begun with
an in-person modality and transitioned to VCP and treatments
that were delivered remotely from the beginning. In treatments
that make a transition to VCP, it is important to consider the
necessity of making a new contract (Inchausti et al., 2020).
Beyond the bond, the classical conceptualization of the therapeutic
alliance entails objectives and tasks. Even though the bond
may be very strong, the tasks and specic goals previously
agreed upon should beclosely examined to determine whether
it is necessary to introduce changes given the new circumstances.
Concerning specic objectives, there may be some nuances,
but overall, they are also transferable from in-person to VCP.
e greatest dierence between in-person and VCP may lie
in the tasks. Due to either the modality or the context, the
usual tasks cannot be conducted. Commonly used techniques
in in-person psychotherapy may need a process of adaptation
to be implemented in VCP. An illustrative example is the
delivery of tele-chairwork (Pugh et al., 2020).
On a positive note, it has been found that VCP can promote
more disinhibition and openness due to the possibility of producing
a sense of safety and a more neutral power balance. At the
beginning of treatment, this neutral disposition in the bond
can foster greater disclosure among patients who have certain
interpersonal patterns (e.g., submissive patients) and may benet
from a less confrontational relationship (Simpson et al., 2020).
Adapting the Interventions to the Patients’
Preferences, Characteristics, and Clinical
Problems
Evidence-based practice in psychology entails the integration
of best available research, clinical expertise, and patient
preferences and values (APA Presidential Task Force, 2006).
Taking into account the preferences and values permits to
adapt the treatment to each individual. Cultural sensitivity
emerges more than ever as an essential aspect to consider,
given that there are substantial dierences depending on a
range of factors for the practice of VCP during critical times
such as the current COVID-19 pandemic. erefore, it is
relevant to tailor the treatment according to the following aspects:
Clinical variables such as psychopathological
severity
It is still very important to assess suicide risk, in particular in
the context of disasters like COVID-19in which suicide rates are
expected to increase (Gunnell et al., 2020). It is crucial to adopt
emergency measures if suicidal thoughts or attempts are detected
(Gilmore and Ward-Ciesielski, 2019; Jobes etal., 2020). For serious
mental illness as well as for particular clinical groups that may
be hindered from working properly through videoconferencing,
specic guidelines should be elaborated and followed.
ere are certain clinical situations that may be more
challenging than others. For instance, dealing with a person
with a severe eating disorder entails obtaining session weights
or having family meals, which demands specic solutions for
working remotely (Matheson etal., 2020). Likewise, the procedure
for conducting exposure therapy may be drastically changed.
An exposure task for social anxiety disorder in remote
psychotherapy can be adapted by including unknown people
in a videoconference call (OxCADAT, n.d.). Numerous papers
have been published for treating clinical conditions via remote
therapy, including obsessive compulsive disorder (McKay etal.,
2020), bipolar disorders (De Siqueira et al., 2020), suicide
(Mcginn etal., 2019), psychosis (DeLuca et al., 2020; Hasson-
Ohayon and Lysaker, 2020), post-traumatic stress disorder
(Aaes-van Doorn etal., 2020b; Fina etal., 2020), sleep disorders
(Arnedt et al., 2020), among others.
Sociodemographic variables
e socioeconomic background or digital literacy should
be particularly taken into consideration before starting a VCP
treatment (Nelson et al., 2017; Markowitz et al., 2020). at
means that the therapist needs to design the specic goals
and tasks in accordance with the patients characteristics, needs,
and preferences. is is particularly true given that, worldwide,
people who suer the most are vulnerable and underserved
populations (Frankham et al., 2020). e present situation
involving the presence of the COVID-19 pandemic is not
exceptional in this regard. Socioeconomically excluded people
or people at high risk such as elderly people are logically
those who potentially would need more help under these
circumstances, but paradoxically also have less access to
psychotherapy, including to VCP.
Acceptance and attitudes toward technology
Although it was thought that patients were resistant to VCP
in its early days, research shows that overall patients have a
positive attitude toward VCP (Trondsen etal., 2014; Bleyel etal.,
2020). Hence, it is essential to consider the experience of the
patients with technology as well as with previous psychological
Fernández-Álvarez and Fernández-Álvarez Videoconferencing Psychotherapy in Times of COVID-19
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treatments and, accordingly, to determine the extent to which
the patients consider that such a treatment may be benecial
for them. Patients’ resistance may be explored and potentially
coped with motivational interviewing strategies (Walker etal., 2020).
Adapting the Interventions to Different
Modalities and Settings
VCP was rst delivered fundamentally in individual formats,
for adults and in private practice. Recently, as a consequence
of the need for rapidly adapting practice to remote delivery,
VCP has extended to all formats (family, couple, and group
therapy formats), populations (children, adolescents and elder
people) and settings (e.g., hospitals, university counseling centers,
community clinics, prisons).
Family therapy is particularly necessary for certain clinical
situations (Amorin-Woods et al., 2020), such as those that
aected younger people and adolescents (Burgoyne and Cohn,
2020). An illustrative example is the work with patients having
an eating disorder (Matheson et al., 2020) or cases involving
child maltreatment (Racine et al., 2020). Couple therapy has
been in increasing demand recently, due to the signicant rise
of conicts that emerge as a consequence of the adverse
aermath of connement and the pandemic (Lebow, 2020;
Sahebi, 2020; Stanley and Markman, 2020).
A variety of circumstances aect the usual functioning of
group therapy, but the preliminary evidence suggests that ecacy
has been similar to that observed previously (Marmarosh etal.,
2020). ere is also evidence that group VCP allows for the
development of cohesion to a similar extent as in in-person
group psychotherapy (Gentry et al., 2018; Lopez et al., 2020).
Among the barriers, the participation of several patients in
VCP may reduce the communication uency of the group
and hinder the usual dynamics (Weinberg and Rolnick, 2019).
Working with groups necessarily increases the number of
interactions and, accordingly, the complexity of any system
such as therapeutic groups (Aureli and Schino, 2019). If,
normally, group therapists have to have a higher degree of
attentional exibility and more diverse intervention procedures
than individual therapists in VCP, this is particularly relevant.
The Person of the Therapist
ere are still a lot of unknown aspects, but it is an undoubted
global phenomenon that VCP became an essential tool regardless
of therapists’ therapeutic orientation, the clinical conditions, and
even the therapists’ previous experience with technology (Humer
etal., 2020b; Sammons etal., 2020). Besides, several studies (e.g.,
Békés and Aaes-van Doorn, 2020; Humer et al., 2020a; Jurcik
etal., 2020) have demonstrated that since the massive incorporation
of videoconferencing, therapists’ attitudes toward it have improved.
Psychotherapists would greatly benet from developing a
self-reective attitude during the whole process of therapeutic
alliance building in remote psychotherapy as well as other aspects
that may hamper (and potentiate) the therapeutic work. Under
these exceptional circumstances occurring during the COVID-19
pandemic, people and therapists all over the world are not the
exception, had their routines disrupted and their sense of
wellbeing challenged. For the rst time, many therapists may
be overwhelmed by the same complaints and problems as their
patients (Hasson-Ohayon and Lysaker, 2020). Besides, in many
cases, the caseload of patients has been reduced, impacting
their income (Sammons et al., 2020). Moreover, therapists are
not particularly prepared for this kind of modality, and therefore,
initial evidence suggests that therapists nd it more wearying
to do VCP, probably as a consequence of the aforementioned
reduced channels of communication (Homann et al., 2020).
Likewise, therapists inexperienced with VCP have higher levels
of self-doubt and anxiety and feel less competent and condent
about their professional skills (Aaes-van Doorn et al., 2020a).
It has been demonstrated that the adoption of VCP depends
a great deal on the attitudes of the providers, including
psychotherapists. In a systematic review of 38 studies, it has been
found that previous experience with VCP is highly related to having
positive attitudes toward it. Besides, therapists’ satisfaction levels
with VCP are overall high throughout the studies, although the
samples do not represent all psychotherapists (Connolly etal., 2020).
All these aspects necessarily entail an unusual professional
and emotional impact. Indeed, ample evidence has recently
emerged showing that in COVID-19 times, health professionals
are prone to suer, not only due to the same stresses as
everyone else but also due to the necessity of responding to
the contextual demands of working in the health care system
in such an unusually stressful time (Braquehais et al., 2020).
However, mental health professionals working remotely may
also have a great burden. Hence, self-care practices that
psychotherapists can adopt are essential (Homan, 2020).
Supervision and Training
Fortunately, in recent years, online supervision has become
practiced and studied more oen, leading to a set of
recommendations regarding how to best implement it
(Rousmaniere et al., 2014). Just like the work with patients,
videoconferencing supervision is more exible in terms of
scheduling meetings, which can beespecially important in critical
situations. e potential diculties that may arise in
videoconferencing supervision can be counteracted with a clear
framework at the time of development of the supervisory alliance.
In that sense, it is relevant to consider possible variations in
the alliance, which is a matter of importance just as between
patients and therapists (Watkins, 2014). e principles that govern
group therapy should also be applied to group supervision. Both
peer and traditional supervision could be taken as a rst step
toward the training process of psychotherapists doing VCP.
According to trainees receiving online supervision, it is a
valuable component for the training process (Bernhard and
Camins, 2020). Indeed, online supervision may serve as a
rst step toward the establishment of structured training
programs. Actually, given the massive dissemination of VCP,
it is urgent that psychotherapists be trained to incorporate
VCP eciently into their routine practice. So far, there are
a few existing studies of VCP training programs (Colbow,
2013; McCord et al., 2015; Dopp et al., 2017; Perle, 2020),
and despite the undoubted attention that has been recently
given to the topic due to the onset of the pandemic, there
Fernández-Álvarez and Fernández-Álvarez Videoconferencing Psychotherapy in Times of COVID-19
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is still a dearth of systematic knowledge regarding VCP training
(Hames et al., 2020). Until now, it seems a mere intuitive
transition from traditional in-person training.
Training programs should be based on the evidence-based
principles that have been shown to enhance therapeutic eects,
such as deliberate practice (Prado-Abril et al., 2018). e
valuable progress that has been made in in-person psychotherapy
should be applied to VCP. In this sense, it is important to
avoid disseminating manualized treatments and instead train
therapists in general principles of change (Castonguay and
Beutler, 2006; Castonguay etal., 2019; Goldfried, 2019; Boswell
etal., 2020). It is important to avoid incurring the infructuous
dispute between specic therapeutic schools and focus the
eorts on achieving therapeutic competence (Cooper et al.,
2019). ere were already examples of VCP guidelines even
before the outbreak of the pandemic (Yellowlees et al., 2010;
Turvey et al., 2013; McCord et al., 2020; Smith et al., 2020),
but it is expected that the mounting evidence that is being
produced and disseminated due to the pandemic will yield
valuable insights regarding how best to practice VCP.
Ethical Considerations
ese days, ethical considerations are usually reduced to the
privacy dimension. at includes informed consent from patients
doing VCP, the security of the platforms, and the guarantee
that any stored data will betreated according to data protection
regulations, among other aspects. However, ethical issues also
include accounting for the safety of the patients, competence
of the therapists, legal issues regarding the regulation of the
practice, consultants’ autonomy, and commercial contracts (in
particular for liberal and third parties’ professionals), among
other issues (Lustgarten and Elhai, 2018; Stoll et al., 2020a,b).
CONCLUDING REMARKS
Certainly, remote human interaction will increase in the coming
years. is has already been happening for at least a decade.
Yet, the outbreak of the pandemic has notably accelerated this
process. Psychotherapy will denitely not be the exception to
the rule, and therefore, it is crucial to outline how the eld will
be transformed in the near and long term. Most probably, the
implementation of VCP psychotherapy will increase in the next
few years (Norcross etal., 2013), and this will happen in a context
of the decline in the consumption of psychotherapy (Gaudiano
and Miller, 2013). erefore, we should guarantee the highest
standards to dierentiate psychotherapy from pseudoscientic
disciplines and to demonstrate the value of incorporating
psychotherapy into the ever-growing pharmacological treatments.
While it may be true that preliminary research comparing
in-person therapy to VCP yields comparable results in terms
of ecacy, it would be inaccurate to conclude that both
approaches have similar empirical support. Despite presenting
promising results, VCP is only in its beginning as a research
eld. us, research and training are key for the advancement
of VCP, and this scenario should be taken as an opportunity
to foster also the advancement of the eld of psychotherapy.
Real world implementation of evidence-based principles would
mean strengthening the active collaboration between researchers
and practitioners, redounding to the proliferation of practice
research networks in which the practice is evidence based and
the evidence is practice based. at would mean a reciprocal
enrichment both for practitioners and researchers (Castonguay
et al., 2015). However, this context undoubtedly facilitates the
possibility of improving the attitudes of therapists and consultants
toward VCP and by extension toward other technological tools
(Wind etal., 2020). Accordingly, a brighter future can beexpected
if more collaborative research in naturalistic settings occurs.
On a relative but dierent note, it is important to reect
on the role that VCP will have in the future of psychotherapy.
at is, for many psychotherapists, the use of remote modalities
constitutes a suboptimal resource that is necessary in order
to continue their work. However, many stakeholders consider
this an ecient way of increasing the prevalence of mental
health treatment. Although many therapists may indeed prefer
this modality, and for a range of mild conditions, it is proving
to be equally ecacious, the possibilities of in-person therapy
seem to still be superior.
Indeed, there are stakeholders that are advocating for the
incorporation of completely self-applied online interventions
with minimal contact. In fact, the evidence is conclusive
regarding the usefulness of low-intensity treatments mainly
through Internet interventions to improve access to treatment
of common mental disorders (Andersson et al., 2019). In that
sense, it is timely to review the paper by Barlow (2004) in
which he dierentiated psychological treatments from
psychotherapy. Briey put, for public concerns and to diminish
the massive clinical manifestations related to mental health,
all evidence-based psychological treatments may be of
importance, including brief protocolized procedures. However,
psychotherapy is only one of the possible psychological treatments
and most oen diers from other psychological treatments in
the sense that the main objective is not only symptomatic
reduction but also the reorganization of the personal system
and the improvement of the quality of life. is situation is
helping to distinguish the respective value of “psychological
treatments” as an umbrella term for many dierent psychosocial
interventions and “psychotherapy” as a more specic
non-manualized practice for dealing with the complexity of
experience and behavior. Our stance is that both should coexist
and even in blended treatments could be simultaneously
harnessed in the same situation. Accordingly, it is essential to
acknowledge that there are nuances that psychotherapy permits,
and at least for now, the optimal way of delivering psychotherapy
is in a shared physical space. However, VCP will denitely
be expanded and hopefully integrated as a modality through
which complex psychotherapeutic interventions can bedelivered.
AUTHOR CONTRIBUTIONS
JF-Á draed the manuscript and HF-Á provided critical
revisions. Both authors reviewed and edited the nal version
of the manuscript.
Fernández-Álvarez and Fernández-Álvarez Videoconferencing Psychotherapy in Times of COVID-19
Frontiers in Psychology | www.frontiersin.org 6 February 2021 | Volume 12 | Article 589536
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Conflict of Interest: e authors declare that the research was conducted in
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... internet, telephone applications and virtual reality), is on the rise [2][3][4][5][6]. COVID-19 accelerated this trend [7]. However, a scoping review about the efficacy and clinical utility of telepsychology in DBT is lacking. ...
... We did not find RCTs that tested the hypothesis that online or blended DBT is superior or at least equally effective as standard, face-to-face DBT. At the same time, we observe a steady increase of online or blended care in clinical practice, with the coronavirus pandemic as a catalyst [7,26,27]. ...
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Background Telepsychology is increasingly being implemented in mental health care. We conducted a scoping review on the best available research evidence regarding availability, efficacy and clinical utility of telepsychology in DBT. The review was performed using PRISMA-ScR guidelines. Our aim was to help DBT-therapists make empirically supported decisions about the use of telepsychology during and after the current pandemic and to anticipate the changing digital needs of patients and clinicians. Methods A search was conducted in PubMed, Embase, PsycARTICLES and Web of Science. Search terms for telepsychology were included and combined with search terms that relate to DBT. Results Our search and selection procedures resulted in 41 articles containing information on phone consultation, smartphone applications, internet delivered skills training, videoconferencing, virtual reality and computer- or video-assisted interventions in DBT. Conclusions The majority of research about telepsychology in DBT has focused on the treatment mode of between-session contact. However, more trials using sophisticated empirical methodologies are needed. Quantitative data on the efficacy and utility of online and blended alternatives to standard (i.e. face-to-face) individual therapy, skills training and therapist consultation team were scarce. The studies that we found were designed to evaluate feasibility and usability. A permanent shift to videoconferencing or online training is therefore not warranted as long as face-to-face is an option. In all, there is an urgent need to compare standard DBT to online or blended DBT. Smartphone apps and virtual reality (VR) are experienced as an acceptable facilitator in access and implantation of DBT skills. In addition, we have to move forward on telepsychology applications by consulting our patients, younger peers and experts in adjacent fields if we want DBT to remain effective and relevant in the digital age.
... Despite this limitation, for clinicians not only in Scotland, but worldwide, videoconferencing became the norm for knowledge sharing, and cross-sectoral engagement. [20][21][22][23] The digitized mode of communication facilitated access to the breadth of information globally, transcending boundaries of space, place, and even time thus helping to enhance quality of patient care and thereby enabling better health outcomes for some excluded groups. ...
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Response to COVID-19 has both intentionally and unintentionally progressed the digitization of health and community care, which can be viewed as a human rights issue considering that access to health and community care is a human right. In this article, we reviewed two cases of digitization of health and community care during the pandemic; one in Scotland, United Kingdom and another in British Columbia, Canada. An integrated analysis revealed that digitization of health and community care has intended positive and unintended negative consequences. Based on the analysis, we suggest five areas of improvement for equity in care: building on the momentum of technology advantages; education and digital literacy; information management and security; development of policy and regulatory frameworks; and the future of digital health and community care. This article sheds light on how health practitioners and leaders can work to enhance equity in care experiences amid the changing digital landscape.
... Due to the COVID-19 pandemic, clinicians have resorted to video teleconferencing (VTC) to deliver treatments (Fernández-Álvarez & Fernández-Álvarez, 2021). Past research ...
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The COVID-19 pandemic has necessitated the use of video-teleconferencing (VTC) for psychological treatments but VTC effectiveness studies are sparse. We examined treatment outcomes for a modified Buried in Treasures (BIT) group program for hoarding disorder (HD) delivered via VTC. Participants were 10 individuals with HD. Hoarding severity was evaluated at pre, mid, post, and six-month follow-up. Results showed significant decrease in hoarding symptoms over time (with an average decrease of 32%). The dropout rate was low (9%) and 30% of participants were fully recovered at follow-up. These results support the adaptation of in-person BIT for HD into a VTC format.
... Services provisions have also changed due to social distancing, quarantines, lockdowns, and employment layoffs [54]. These changes have had an especially significant impact on the provision of continuous mental health services [55]. As a result, mental healthcare providers had to quickly change their standard of care provision and adapt to the new reality [54] in order to provide continuous and effective mental health treatment with minimal disruptions [56]. ...
... While telehealth can include various media platforms and phone systems, videoconferencing (e.g., Zoom, Doxy.me) was the most widely utilized medium (Fernández-Álvarez & Fernández-Álvarez, 2021;Smoktunowicz et al., 2020). Changes in insurance coverage of telehealth opened the door to service continuity but presented challenges to therapists who were less comfortable with the technology associated with telehealth. ...
Article
Psychotherapists in private practice provide services to an ever-growing client population. The 2020 novel Corona Virus (COVID-19) pandemic was a catalyst for emerging and exasperated mental health concerns among the U.S. population. The result was an increase in demand for services and private practitioners stepping up to meet this growing need. Little is known about the psychotherapists who embark on independent practice and less is known about the nuances of practicing during a global pandemic. The aim of this review was to exhaust the literature on private practice psychotherapy and the practice of psychotherapy during COVID-19, synthesize the findings, report on themes in the literature, and provide recommendations for future lines of inquiry. Themes from this review included the impact of COVID-19 on public mental health, telemental health, private practice shifts, and private practice careers.
Article
Aim: A large body of evidence demonstrates the importance of the family environment in the developmental trajectory of mental illness in young people. Caregiver communication skills training represents a potential model for influencing the outcomes of adolescents and young adults struggling with emerging mental health and behavioural difficulties. The aim of the current study is to describe the development of a telehealth group training intervention for caregivers of adolescents and young adults, and to report the results of a pilot feasibility‐effectiveness study that took place in 2020–2021. Methods: The “School of Hard Talks” intervention consisted of 8 h of training in communication skills consistent with motivational interviewing techniques. All pilot study participants were assigned to receive the intervention. Outcomes of interest were family conflict, caregiver stress, caregiver self‐efficacy and expressed emotion (EE). Participants were assessed three times: prior to the intervention, after the intervention and 12 weeks later. Results: A total of 62 participants enrolled in the study, of whom 49 completed the intervention. Large, significant improvements were observed over time in all four domains of interest. Qualitative feedback from parents was very positive and added context to quantitative observations. Conclusions: The School of Hard Talks was a feasible and effective intervention targeting both caregiver wellbeing as well as important mechanisms of risk for youth psychopathology, namely family conflict and EE. Further research involving a larger sample and a control condition are needed to confirm these findings.
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Videoconferencing psychotherapy (VCT) is an effective treatment option. Yet, it is unclear whether a similar therapeutic alliance as in conventional face‐to‐face psychotherapy (F2F) can be achieved, since previous studies yielded mixed results. Furthermore, surveys about the attitudes towards VCT amongst patients have been missing until now. The current study gathered opinions from patients and psychotherapists about the perceived comparability of VCT and F2F regarding contextual factors and treatment characteristics, focusing on therapeutic alliance and empathy. An online survey amongst patients (N = 189) and practitioners (N = 57) taking part in cognitive behavioural therapy was conducted after the first lockdown in Germany due to the COVID‐19 pandemic and a resulting transition from F2F to VCT for most participants. While patients experienced therapeutic alliance and empathy as comparable, psychotherapists indicated advantages of F2F. Both groups indicated advantages of F2F for the therapy contents and expressed advantages of VCT for flexibility regarding location and time. More than half of the participants expressed a preference for a combination of analogue and digital therapy. The perceived disadvantages of VCT can be addressed, for example, with training programmes for psychotherapists targeting communication in VCT and adapting established psychotherapy methods to a digital format to further improve VCT.
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Purpose of review In the context of an ongoing, highly uncertain pandemic, disaster mental health measures can increase community capacity for resilience and well-being, support formal mental health treatment, and help address the risk for mental health reactions in high-stress occupations. The purpose of this review is to summarize the literature on disaster mental health interventions that have been helpful both prior to and during the pandemic in a broad range of applications, including for use with high-stress occupations in an effort to mitigate risk for post-traumatic stress disorder (PTSD) and other mental health sequelae. Recent findings Evidence-based and evidence-informed disaster mental health interventions, frameworks, and treatments have been studied in pilot studies, non-randomized trials, and randomized clinical trials prior to and in the context of the current COVID-19 pandemic. The studies have demonstrated feasibility and acceptability of these modalities and improved perceived support, as well as significant reductions in distress, and mental health symptoms such as depression, anxiety, and PTSD. Summary A disaster mental health approach to the COVID-19 pandemic can generate opportunities for prevention and support at multiple levels with timely interventions tailored for different concerns, cultures, and available resources.
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Zusammenfassung Hintergrund Durch die im Zuge des Ausbruchs der „coronavirus disease 2019“ (COVID-19) im März 2020 erlassenen Kontaktverbote haben Psychotherapeuten deutlich mehr und die meisten von ihnen erstmalig Videobehandlungen (VB) angeboten. Bisher gibt es nur wenig Forschung dazu, wie Therapeuten die VB während der Pandemie erlebt haben, und es liegen keine Studien vor, die mögliche verfahrensspezifische Besonderheiten betrachten. Ziel Es soll analysiert werden, welche subjektiven Erfahrungen Therapeuten unterschiedlicher Richtlinienverfahren mit der Durchführung von VB in Zeiten der COVID-19-Pandemie gemacht haben und welche Vor- und Nachteile sie erlebten. Methoden Es handelt sich um eine „Mixed-methods“-Studie mit einer querschnittlichen Onlineerhebung. Neben quantitativen Daten wurden anhand von 7 offenen Fragen die subjektiven Erfahrungen der Therapeuten mit der Durchführung von VB erhoben und mithilfe der qualitativen Inhaltsanalyse ausgewertet. Die identifizierten Kategorien wurden einer Häufigkeitsanalyse unterzogen. Angaben von 174 ärztlichen oder psychologischen Psychotherapeuten gingen in die Auswertung ein. Ergebnisse Besonders häufig genannte Vorteile waren die örtliche und zeitliche Flexibilität, die Kontinuität des Kontaktes in Pandemiezeiten und die Vermeidung des Infektionsrisikos. Der meistbenannte Nachteil war, dass Sinneseindrücke, Mimik, Gestik, Blickkontakt und nonverbale Kommunikation fehlen. Die meisten, aber nicht alle Patienten nahmen VB gut an. Technische Probleme erschwerten die Umsetzung. Schlussfolgerungen Für viele Therapeuten blieb VB eine „Notlösung“, die nicht auf Dauer angelegt sei. Allerdings könnte VB über die Pandemiezeit hinaus helfen, Versorgungsprobleme (z. B. Unterversorgung auf dem Land) zu lösen. Die Ergebnisse der Studie leisten einen wichtigen Beitrag dazu, Chancen und Risiken der VB für die psychotherapeutische Versorgung abzuwägen sowie mögliche Gefahren und Schwierigkeiten im Auge zu behalten.
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Objective: The coronavirus disease (COVID-19) threatened not only people's physical health but also every aspect of their psychological well-being: from their struggle to avoid contracting the disease, to their coping with the disruption of the normal course of their lives, to the trauma they endured when the virus took the lives of those they loved. The objective of this article is to consider the group-level processes that sustain people's physical and psychological well-being during COVID-19. Method: Applying group dynamic and group therapy theory and research, we explore why COVID-19 spread so rapidly. We also explore how people cope with prolonged social isolation, distress, and social inequities, as well as how people deal with the psychological trauma of the disease, which includes heightened levels of depression, anxiety, substance abuse, and complicated bereavement. Results: Researchers and theorists suggest that human beings are fundamentally social, and the need to gather with others is extremely important, especially during times of distress. The need to belong as well as the importance of reducing loneliness during uncertain times often encourages people to connect, despite recommendations to remain socially distant. Conclusions: Group treatment options developed by group psychotherapists are effective at reducing depression, anxiety, complicated grief, and stress. We conclude by examining the growing impact of online groups and the many ways that these groups help people improve their psychological well-being during the COVID-19 crisis.
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The arrival of the coronavirus (COVID-19) pandemic has confronted us with a global and unprecedented challenge of community-wide psychological distress alongside reduced access to therapeutic services in the traditional face-to-face format, due to the need to self-isolate. This previously unimagineable set of circumstances provides a unique opportunity, and indeed an imperative, for videotherapy to fulfil its potential in addressing mental health and well-being needs from a distance. Historically, the uptake of videotherapy has been hindered by psychotherapist expectations of inferior therapeutic alliance and outcomes, in spite of considerable research evidence to the contrary. Research suggests that videotherapy provides a powerful pathway for clients to experience enhanced opportunities for self-expression, connection and intimacy. This more neutral therapeutic 'space' provides clients with multifarious opportunities for self-awareness, creative experience and collaboration, with potentially a greater sense of agency over their own experience. This paper explores ways in which videotherapy can lead to a revitalisation of the concept of the therapeutic relationship, in order to meet the challenges associated with COVID-19. A number of specific considerations for videotherapy adaptations and etiquette in the midst of COVID-19 are described.
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The 2020 COVID-19 pandemic has abruptly overwhelmed normal life. Beyond the fear and fatality of the virus itself comes a likely wave of psychiatric disorders. Simultaneously, social distancing has changed overnight how psychiatrists and other mental health professionals must treat patients. Telepsychotherapy, until now a promising but niche treatment, has suddenly become treatment as usual. This article briefly reviews the limited clinical evidence supporting different modes of telepsychotherapy, then focuses on how remote therapy affects clinicians and their patients.
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The unprecedented changes in our society because of COVID-19 and the fourth industrial revolution (4IR) shows that our healthcare system and the medical approach to psychotherapy can no longer meet the mental health needs of society. This paper first described the negative impact of COVID-19 and 4IR on our mental health. Then, following a brief critique of the medical model, this paper proposes that the future of psychotherapy needs to be based on the more inclusive and integrative framework of existential positive psychology (PP 2.0), which emphasizes flourishing through suffering. Finally, the paper emphasizes Viktor Frankl’s cure and Wong’s integrative meaning therapy. It concludes that integrative meaning therapy represents the future of psychotherapy, because it is situated in the area of interactions of at least three traditions: Clinical psychology, existential psychology, and positive psychology. This integrative model is holistic, recognising humans as bio-psycho-social-spiritual beings and considers several theoretical perspectives in both diagnosis and treatment.
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Background In the context of the COVID-19 pandemic, legislations are being modified around the world to allow patients to receive mental health services through telehealth. Unfortunately, there are no large clinical trial available to reliably document the efficacy of delivering videoconferencing psychotherapy (VCP) for people with panic disorder and agoraphobia (PDA) and whether basic psychotherapeutic processes are altered.Methods This 2-arm intent-to-treat non-inferiority study reports on a clinical trial on VCP and documents how therapeutic working alliance and motivation toward psychotherapy are associated to treatment outcome. We hypothesized that VCP would not be inferior to standard face-to-face (FF) cognitive behavior therapy for PDA. No specific hypothesis was stated to address working alliance and treatment mechanisms. VCP was compared to a gold-standard psychotherapy treatment for PDA, which was delivered either in person or in videoconference, with a strict tolerance criterion of about 2 points on the primary outcome measure. Seventy one adult patients were recruited. Measures of working alliance were collected after the first, fifth, and last session. Motivation toward therapy at pre-treatment and working alliance after the fifth therapy session were used as predictors of treatment outcome and compared with change in dysfunctional beliefs toward bodily sensations.ResultsPanic disorder, agoraphobia, fear of sensations and depressed mood all showed significant improvements and large effect-sizes from pre to post-treatment. Gains were maintained at follow-up. No significant differences were found between VCP and FF, and effect sizes were trivial for three of the four outcome measures. Non-inferiority tests confirmed that VCP was no less effective than FF therapy on the primary outcome measure and two of the three secondary outcome measures. Working alliance was very strong in VCP and did not statistically differ from FF. Working alliance and motivation did not predict treatment outcome, which was significantly predicted by the reduction in dysfunctional beliefs. The strength of the therapeutic bond was correlated with change in dysfunctional beliefs.Conclusion Mental health professionals can use VCP to provide services to patients with PDA. Building and maintaining a sound working alliance should not be a source concern. Practical recommendations are formulated.ISRCTN Trial Registration NumberISRCTN76456442.
Article
Objective: Recent years have seen a significant and rapid increase in the provision of tele-therapies. Chairwork methods such as empty-chair dialogues and role-play represent a “common” category of therapeutic interventions which are utilized in many psychotherapeutic approaches. However, guidelines for facilitating chairwork in tele-therapy are currently lacking. The aim of this study was to survey expert providers regarding how chairwork is best provided in internet-delivered psychotherapy. Method: Forty one experts were recruited from a range of therapeutic backgrounds including cognitive behaviour therapy, compassion focused therapy, emotion focused therapy, psychodrama, schema therapy, and voice dialogue. Participants completed a brief questionnaire survey exploring the delivery of tele-chairwork. Responses were analysed using thematic analysis. Results: Five themes were identified: (i) divided opinion; (ii) convergence between therapy and home; (iii) disconnection and depth; (iv) practical impediments and benefits; and (v) revising and re-visioning chairwork. Overall, results indicate that chairwork can be successfully incorporated into tele-therapy, but requires adaption and special considerations. Discussion: Despite challenges, tele-chairwork appears to be a feasible method of psychotherapeutic intervention. Preliminary guidelines for initiating, facilitating, and concluding tele-chairwork are presented, alongside future directions for research.
Article
The unprecedented effects and duration of the COVID-19 crisis are likely to elevate the population's level of anxiety due to psychological stress, economic hardship, and social isolation. This effect may be especially potent for individuals with preexisting mental health conditions, such as posttraumatic stress disorder (PTSD). Prolonged Exposure (PE) therapy is a highly effective treatment for PTSD across trauma-exposed populations, and has been implemented effectively via telehealth. Nevertheless, PE implementation via telehealth may require specific adaptations during the COVID-19 crisis due to public health mandates calling for sheltering in place and physical distancing. This paper discusses strategies for implementing PE for PTSD during the COVID-19 pandemic, which may also be applied to other situations in which physical distancing must be considered.
Article
Background The current situation around the COVID-19 pandemic and the measures necessary to fight it are creating challenges for psychotherapists, who usually treat patients face-to-face with personal contact. The pandemic is accelerating the use of remote psychotherapy (ie, psychotherapy provided via telephone or the internet). However, some psychotherapists have expressed reservations regarding remote psychotherapy. As psychotherapists are the individuals who determine the frequency of use of remote psychotherapy, the potential of enabling mental health care during the COVID-19 pandemic in line with the protective measures to fight COVID-19 can be realized only if psychotherapists are willing to use remote psychotherapy. Objective This study aimed to investigate the experiences of psychotherapists with remote psychotherapy in the first weeks of the COVID-19 lockdown in Austria (between March 24 and April 1, 2020). Methods Austrian psychotherapists were invited to take part in a web-based survey. The therapeutic orientations of the psychotherapists (behavioral, humanistic, psychodynamic, or systemic), their rating of the comparability of remote psychotherapy (web- or telephone-based) with face-to-face psychotherapy involving personal contact, and potential discrepancies between their actual experiences and previous expectations with remote psychotherapy were assessed. Data from 1162 psychotherapists practicing before and during the COVID-19 lockdown were analyzed. ResultsPsychotherapy conducted via telephone or the internet was reported to not be totally comparable to psychotherapy with personal contact (P
Article
The use of videoconferencing technologies (VCT) is on the rise given its potential to close the gap between mental health care need and availability. Yet, little is known about the effectiveness of these services compared to those delivered in-person. A series of meta-analyses were conducted using 57 empirical studies (43 examining intervention outcomes; 14 examining assessment reliability) published over the past two decades that included a variety of populations and clinical settings. Using conventional and HLM3 meta-analytical approaches, VCT consistently produced treatment effects that were largely equivalent to in-person delivered interventions across 281 individual outcomes and 4336 clients, with female clients and those treated in medical facilities tending to respond more favorably to VCT than in-person. Results of an HLM3 model suggested assessments conducted using VCT did not appear to lead to differential decisions compared to those conducted in-person across 83 individual outcomes and 332 clients/examinees. Although aggregate findings support the use of VCT as a viable alternative to in-person service delivery of mental healthcare, several limitations in the current literature base were revealed. Most concerning was the relatively limited number of randomized controlled trials and the inconsistent (and often incomplete) reporting of methodological features and results. Recommendations for reporting the findings of telemental health research are provided.
Article
The alliance-outcome relationship has been consistently linked to positive treatment outcomes irrespective of psychotherapy modality. However, beyond its general links to favorable treatment outcomes, it is less clear whether the alliance is a specific mediator of change and thus a possible mechanism underlying psychotherapy response. This systematic review evaluated research examining the alliance as a potential mediator of symptom change, reviewing study characteristics of 37 relevant articles examining the alliance-outcome relationship and the extent to which these studies met recommended criteria for mechanistic research. Alliance mediated therapeutic outcomes in 70.3% of the studies. We observed significant heterogeneity across studies in terms of methodology, including timing of alliance assessment, study design, constructs used in mediation models, and analytic approaches. Building on recent methodological advancements, we propose directions for future research examining the putative mediational role of alliance, such as greater uniformity in and attention to study design and statistical methodology. This review highlights the importance of alliance in therapeutic change and discusses how adhering to requirements for process research will improve our ability to more precisely estimate how and to what extent alliance drives therapeutic change.