3.2.3. Difficulties

*N* = 74 (34.1%) respondents addressed the difficulties encountered in remote psychotherapies. Figure 4 illustrates the subcategories.

*N* = 14 (6.5%) mentioned having worked remotely only with patients who had been in therapy for some time. First consultations were described as difficult. In particular, establishing a holding psychotherapeutic relationship was mentioned as a challenge. *Noncommittal* (respondent 79), *businesslike* (respondent 151), and *insecure* (respondent 208) were adjectives therapists used to describe their experience.

Other *n* = 37 (17.1%) respondents described difficulties in upholding the therapeutic setting. The temporal frame was an issue for some. Therapists reported they had to contact patients more often, for example, to remind them of sessions. For other respondents, the focus was on the therapeutic space. They expressed a sense of losing control in the remote setting. As respondent 193 expressed, *"The setting was eroding".* Although it was possible for therapists to choose the room in which they located themselves, it was not possible to exert any influence on the spatial conditions at the patients' homes. Disturbances by family members were mentioned very frequently as well as *"undignified conditions"* (respondent 178), e.g., in case patients had to attend a session from their bathroom or from behind a paravan. Patients had to take care of adequate conditions "on their side" themselves, which required more self-responsibility. Therapists also described it as difficult not having any influence on the technical connection or on how patients participated in the session, e.g., lying in bed, eating, etc.

Finally, we generated the category "difficulties or benefits for certain diagnoses and patient groups", which was addressed by *n* = 40 (18.4%) respondents. Not only difficulties but also benefits were subsumed under this category. Several respondents mentioned difficulties with remote psychotherapies for patients with structural deficits who needed a lot of stabilization. There appears to be little consensus and very contradictory statements regarding the different types of mental disorders. For anxiety disorders and schizophrenia spectrum disorders, staying in one's own room was described as building confidence and reducing anxiety by some respondents. Other respondents found it more difficult to treat these patients remotely. Some respondents also saw advantages in treating traumatized patients in a remote setting. They described that patients were able to address traumatic events for the first time in the remote setting, as it helped them to distance themselves from the event and reduced feelings of shame. Not being seen during their account had a disinhibiting effect. Other respondents experienced working with traumatized patients as more difficult in the remote setting because patients could not be supported so well, for example, when dissociating. As respondent 151 put it:

*"Traumatic experiences were addressed. But for me as a therapist, the patient in tears on the phone is an experience that I do not wish to repeat. I had a strong feeling that I could not fulfill my responsibility as a therapist. Even without touching the patient in such situations, I am convinced that my physical presence alone and my staying present are important for the patient. Also, the thought came to my mind: what do I do when he/she throws down the phone and—yes, what does he/she do? jumps out of the window, runs into the street without looking left or right..."*

Another patient group that was mentioned several times was the group of children and adolescents. Therapists found it more difficult to work remotely with children, as the remote setting made it more difficult to engage in playing and relied a lot on verbal communication. There were more positive observations regarding remote psychotherapy with adolescents. It was noted that remote formats are familiar to young people and are therefore a good way to get in touch.

Among the experienced difficulties of remote psychotherapy, gender differences became visible for the subcategory "difficulties or benefits for certain diagnosis and patient groups", with female psychotherapists reporting more often respective experiences (21%)

than male psychotherapists (8%; χ<sup>2</sup> (1) = 4.383; *p* = 0.036). For the remaining two categories, no differences were observed with respect to gender (*p* ≥ 0.144).

#### 3.2.4. Modifications of the Setting

*N* = 134 (61.8%) respondents made statements regarding how they dealt with changes in the setting and how they adapted to the new situation. Subcategories are shown in Figure 5.

The subcategory "handling the new setting", mentioned by *n* = 72 (33.2%) respondents, describes statements from respondents about how the move to remote psychotherapy initially caused a sense of uncertainty among therapists and among patients. For the most part, respondents described continuing to hold sessions from their practice rooms. This was felt to help separate work from private life, maintain a professional attitude, and provide continuity for patients in the form of a familiar space.

*"The beginning was structured by me, when I started the Zoom call and let the (waiting) person in. It was important to me to maintain continuity and stability in the sense that I told and showed the patients that I was sitting in the usual armchair in the practice room. Their familiar space thus continued to exist, only they were not spatially there, I was connected to them via telephone or Zoom".* (respondent 78)

Alternatively, some therapists switched to their home office. In this case, the background visible on the screen was arranged in such a way as to create a professional context (e.g., removal of personal items and pictures, covering glass doors to other living spaces, etc.). In addition, respondents explained that it was important for them to convey a sense of security to the patients. This also included establishing the new setting, e.g., discussing from where patients participated in the session and whether undisturbed communication was possible in this environment, how to handle the software and deal with technical failures, how data protection regulations were complied with, who could provide help in the event of a crisis and who could also be reached by the therapist, etc. Respondents mentioned how they had to be more demanding that patients ensure adequate setting conditions "on their side" or adhere to setting conditions, such as starting times. As respondent 85 stated: *"Discussing "rules of conduct" in advance is important (e.g., pat. not just hanging up, closing laptop)"*.

In a few cases, respondents described that patients went for a walk during the session because they could not establish an undisturbed atmosphere at home. Respondents also discussed the possible advantages and disadvantages of remote psychotherapy with patients and inquired about patient expectations. Some therapists also mentioned new rituals they introduced for beginning and ending a session via videoconferencing or on the phone.

Another subcategory mentioned by *n* = 44 (20.3%) respondents concerns changes in the frequency and duration of sessions. Some respondents explicitly mentioned not changing anything about the structure of the sessions (day of the week, time, duration). However, another part of the respondents reported more frequent or less frequent, more irregular or more regular and shorter sessions. In addition to videoconferencing and telephone sessions, some therapists also communicated with patients in writing (text messaging, email, chat).

A very large subcategory mentioned by *n* = 77 (35.5%) respondents concerns the use of therapeutic interventions. The majority of respondents described having to forgo many interventions in the remote setting. In particular, interactive interventions (e.g., role-playing, constellation work, etc.), body-based interventions (demonstrations, movement, EMDR, hypnotic trances, autogenous states of relaxation), art therapy interventions (visualizations, sand play, sculptures, etc.), therapeutic play in work with children, animal-assisted interventions, and work with objects or with guided affective imagery were mentioned. In contrast, other interventions were used more frequently, such as the assignment of homework. The therapeutic conversation also gained importance in remote psychotherapy, as much of the content was addressed verbally. Some respondents described that interventions were more difficult to apply but could be adapted for the remote setting. For example, some body-based interventions could be delivered in an adapted form, such as autogenic states of relaxation or hypnotic trances, as could interactive interventions, such as role-playing and

guided affective imagery. Some respondents reported using handouts, exercise sheets, and audio that they gave to patients to take home. The overall impression was that respondents used interventions primarily in a stabilizing or resource-strengthening way and focused on techniques that activated cognition. In contrast, they worked in a less confrontational, less regression-promoting, and less emotion-activating manner. Trauma-specific interventions were also used with caution.

Handling the new setting was mentioned by more female (38%) than male (18%) psychotherapists (χ<sup>2</sup> (1) = 6.752; *p* = 0.009). For the other two subcategories, no differences were observed between male and female therapists (*p* ≥ 0.714).

#### 3.2.5. Lack of Physical Presence

*N* = 146 (67.3%) respondents named categories related to the absence of physical presence. The subcategories are displayed in Figure 6.

*N* = 21 (9.7%) respondents noted that the office was lacking as both a physical and an intrapsychic space in remote psychotherapies. They observed that patients missed the time in the office away from their usual contexts. Also missing was the journey to and from the office as a mental space for reflective engagement with what patients wanted to talk about or had worked through in the session. Sessions took place more *"in-between"* (respondent 65). As one respondent put it: *"Patients reported that it is unusual when the journey home can no longer be experienced and one is back in "real" life from one second to the next. Processing what was discussed suffers".* (respondent 30) Therapists also missed rituals that had shaped the therapeutic encounter in the office, such as inviting patients in, shaking hands, offering a drink or passing a handkerchief.

A majority (*n* = 118 (54.4%)) of respondents made mention of impaired sensory perception in remote psychotherapies. They referred to the perception of nonverbal communication signals and body language, such as facial expressions, gestures, posture, movements, ideomotor activity, and breathing. They also reported altered acoustics, lack of smell, and eye contact. It was mentioned that it became more difficult to gather diagnostic information, to emotionally tune in to the patient, and to assess the effect of interventions. Respondent 94 commented, *"The distance made it more difficult to perceive, to sense, to observe".* The difficulty of assessing the atmosphere was mentioned in particular. The assessment of silence was mentioned several times in this context, as here by respondent 59:

*"A young woman wanted to stay in contact via telephone—in this case it was difficult, especially for me, to assess her reactions without having an image (silence—is she thinking about what has been said or is she crying quietly??? Difficult to assess; asking was disruptive in the process)"*

In addition, body-oriented psychotherapists pointed out the lack of (inter-)bodily perception. Respondent 53 described that *"physical encounters support the process of emotional processing. Traumatic experiences can be better processed through therapeutic physical proximity".*

*N* = 65 (30%) respondents reported how they tried to replace missing sensory perceptions by focusing on existing sensory channels. They attached particular importance to attentive listening, the perception of speech melody, tonality and subtleties in speech (formulations, choice of language and words, pauses, speaking pace, volume, etc.). Respondent 179 noted, *"the lack of physical presence focused my attention on listening and the words used and was just as intense".* Other respondents remembered how an imaginary image of the patient was formed during telephone contact. Therapists also observed that they used their voice and speech more consciously to stay in contact with their patients. In the case of video conferencing, respondents described how they paid close attention to what was visible on the screen. Respondent 73 observed, *"only a section of the patient is visible, but you focus on details that are otherwise not present to this extent".* Respondent 54 recounted:

*"The "large format" of the upper half of the body during video chat, with the visibility of subtle changes in facial expressions, had its own "physical" presence for me. When I was on the phone and the patient's voice was close to my head, I also experienced a special*
