**1. Introduction**

The outbreak of the COVID-19 pandemic necessitated a sharp modification in the psychotherapeutic treatment format [1]. To contain the spread of the SARS-CoV-2 coronavirus, restrictive measures such as restrictions on outdoor activities, quarantine and social distancing were implemented. Psychotherapists and patients alike were faced with the challenge of adapting to a new, virtual setting within a very short time [2,3]. The number of patients treated psychotherapeutically via telephone or the internet increased sharply. During the first curfew in 2020, the number of patients treated via telephone on average per week in Austria increased by 979% and via the internet by 1561% (both *p* < 0.001) [4]. Study results confirmed that the infectious disease COVID-19 has a clear impact on the practice of psychotherapy in Austria [3].

In Austria, psychotherapy via digital media was not considered lege artis until that time [5] and was also not covered by health funds. The legal regulations changed with

**Citation:** Stadler, M.; Jesser, A.; Humer, E.; Haid, B.; Stippl, P.; Schimböck, W.; Maaß, E.; Schwanzar, H.; Leithner, D.; Pieh, C.; et al. Remote Psychotherapy during the COVID-19 Pandemic: A Mixed-Methods Study on the Changes Experienced by Austrian Psychotherapists. *Life* **2023**, *13*, 360. https://doi.org/10.3390/life13020360

Academic Editor: Daniele Giansanti

Received: 28 December 2022 Revised: 23 January 2023 Accepted: 25 January 2023 Published: 29 January 2023

**Copyright:** © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

the outbreak of the COVID-19 pandemic and the associated need to restrict socio-physical contact [6]. This is not the least since study results indicate that psychotherapy via the internet can be regarded as equally effective to psychotherapy in face-to-face contact [7,8]. There seems to be no significant difference in effectiveness between the treatment modes of face-to-face setting, real-time video conferencing and telephone [9]. Psychotherapy via videoconferencing has already been described as promising and tends to be equivalent in patients with anxiety disorders [10]. In a study by Bouchard et al. [11] involving 71 patients with panic disorder and agoraphobia, a very strong therapeutic alliance was demonstrated in video conferencing, which did not differ from treatments in face-to-face settings. Similarly, research findings suggest the effectiveness of treatment via telephone for depressive symptoms [12–15]. Moreover, dropout rates might be lower for telephone therapies than for treatments in face-to-face settings [16].

While there was still a general skepticism among therapists towards psychotherapy at a distance before the COVID-19 pandemic, despite the positive results of efficacy research [17,18], this attitude has since changed due to experiences gained during the first months of the pandemic [19,20]. While the digital treatment setting did not play a substantial role in healthcare before COVID-19, the outbreak of the COVID-19 pandemic also pushed former skeptics to work at a distance [21]; it seems that quite often, the experiences made in the process have led to a re-evaluation of remote psychotherapy [20]. At the same time, treatment at a distance is not considered by therapists to be fully comparable to the face-to-face setting [19].

In the remote setting, the therapeutic alliance between patients and therapists was described by therapists as impaired, for example, due to the loss of the physical exchange or the lack of various sensory impressions, and was experienced as more superficial and businesslike. Moreover, therapists were confronted with technical challenges and securityrelated issues regarding the safeguarding of confidentiality in the online setting [22]. Furthermore, therapists, psychologists, and social workers also expressed concerns about building and maintaining the therapeutic alliance [23]. Therapists seem to perceive greater differences between treatment settings in face-to-face contact and at a distance than patients [24]. Moreover, therapists' satisfaction with psychotherapy via videoconferencing seems to be related to their level of professional maturity and experience, as older therapists with previous experience in the video-based setting have a more positive attitude towards remote psychotherapy [25]. Furthermore, study results indicate that therapeutic interventions also differ between settings, and interventions of different psychotherapeutic orientations are more distinct in face-to-face contact than in remote psychotherapy [26].
