**4. Discussion**

This study aimed to survey the changes experienced by Austrian psychotherapists when switching from face-to-face to remote psychotherapy in the first year of the COVID-19 pandemic.

An important finding of the analysis is that neither therapeutic orientation nor years of professional experience had any influence on perceived changes when switching from face-to-face to remote psychotherapy or vice versa during the pandemic. This raises the assumption that differences between therapeutic orientations are sometimes given too much weight. As has already been shown in research on psychotherapy outcomes, different therapeutic orientations are similarly effective, and differences in effectiveness are due to factors other than therapeutic orientation [35,36].

This study further showed that working from home, especially the elimination of travel time to and from the office, allowed the surveyed therapists more flexibility in time management. This result is reflected in other studies [37–39]. Therapists with younger children, in particular, benefited from the greater flexibility. On the other hand, the elimination of time spent traveling also led to a loss of mental space for patients for reflective discussion before and after the session. This was also observed by Ahlström et al. [22]. In particular, the male therapists in our study reported missing the office as a therapeutic space. This could be because women found working from home more convenient, especially due to childcare responsibilities, and therefore did not miss face-to-face practice as much. In fact, another Austrian study showed that male psychotherapists treated more patients on average in face-to-face contact than female psychotherapists during the COVID-19 pandemic, which suggests that they continued working from their office or returned to their offices more rapidly [40].

Challenges mentioned by many respondents were the occurrence of technical problems and a reduced perception of sensory impressions. Technical problems were also

reported in other studies from the same period [41,42]. As also noted by Jesser et al. [43] and Eichenberg et al. [44], therapists tried to compensate for the lack of non-verbal communication by focusing on other channels of perception. The respondents described this as exhausting and tiring, a finding that was also echoed by other authors [21,39,43]. The lack of a non-verbal level affected the therapeutic process. Respondents had difficulties in fine-tuning, found it harder to empathize, changed interventions and/or felt that an element of diagnostics was missing. Bayles et al. [45] argue that the quality of information is diminished in that therapeutic action is based on implicit and procedural non-verbal communication and that non-verbal information transmitted by the body in the setting at a distance is limited. Roesler [46] describes non-verbal information as essential in the process of mutual understanding. The loss or distortion of non-verbal elements has an impact on the patient's emotional security [46]. The accompanying lack of affective nuance can emotionally weaken the therapist's experience of working with the patient [41]. Respondents in our study also described a sense of loss of control in the remote setting. While they were able to choose their own space, they had no control over where their patients were or under what conditions they were attending. For many patients, finding an undisturbed space for confidential communication proved to be a challenge. This was also found by other authors [41,42,47]. The remote setting could also challenge patients to take more responsibility for themselves, which could be beneficial for patients with more moderate disorders. Simpson et al. [48], for example, described the "democratizing effect" of remote therapies, which enable patients to become more active in their own "territory". Furthermore, Jesser et al. [43] worked out that in a setting at a distance, successes can also be experienced more independently of the therapist.

In many cases, psychotherapy via video conferencing also offered our respondents insight into the patient's private environment and thus provided interesting additional information. Similarly, Jesser et al. [43] and Simpson et al. [48] described these insights as a unique opportunity to get a first-hand picture of the patients' life circumstances described in the sessions. Respondents did, however, describe the distraction caused by other people or animals in the household as a challenge, a finding that is also consistent with findings from other studies [42]. Furthermore, there is the challenge of separating private and professional life, as Liberati et al. [49] and Shklarski et al. [50] also noted. A study by Békés et al. [51] concluded that therapists who faced more challenges when switching to the digital setting tended to be younger. This could be related to family responsibilities. Therapists with young children face challenges in creating a space where they have the opportunity to engage with their patients in a focused and empathetic way. However, we found no evidence in our study that therapist age had an impact on perceived challenges of the remote setting, or on other observed changes related to the remote setting.

Respondents in our study, and female therapists in particular, mentioned the difficulties as well as the advantages of remote psychotherapy for certain diagnoses and patient groups. The observation that women seem to be more thoughtful about the difficulties and advantages of remote therapy for different patient groups and how to navigate this new setting could be attributed to women being more reflective and communicative in the study or in general [52]. Indeed, women provided, on average, 57% longer comments on free text questions vs. men. Respondents indicated that remote therapy, especially the setting via telephone, had proved helpful for patients with anxiety disorders. This finding is consistent with that of Jesser et al. [43], where respondents described that patients seemed more confident in remote treatment from their homes. Evidence from the research suggested the effectiveness of remote therapies for depression and/or anxiety disorders [10,12–15,53]. For the first time, according to our respondents, it was also possible for patients to address traumatic events in the setting at a distance. The remote treatment helped the patients to distance themselves from the events; furthermore, the setting was experienced as less fraught with feelings of shame. Previous study results already indicated the effectiveness of treating post-traumatic stress disorder (PTSD) in a distance setting [54,55] and described it as a viable alternative compared to the face-to-face setting [56]. By contrast, other respon-

dents in our study considered the remote treatment of traumatized patients to be more difficult, as it did not enable patients to be supported as well, e.g., in the case of dissociative disorders. Other evidence from research can also be found for this [43,57]. In this context, we might need to consider that the COVID-19 pandemic itself and its associated constraints constituted a traumatic experience for some people. From the literature, we know that people were disposed of different resources protecting them against the traumatic experience of the pandemic. Killgore et al. [58] found that resilience was higher among people who, for example, maintained more social relationships, engaged in outdoor activities, and exercised more. Further research could examine whether patients experienced psychotherapy as helpful in coping with the pandemic and how patients with more or less resilience benefited differently from remote psychotherapies.

It was more difficult for our surveyed therapists to provide psychotherapeutic treatment for children in the setting at a distance. They could only accompany during play without actively participating or intervening. This is consistent with other research findings, which already pointed out that significant elements (e.g., creative opportunities) are lost or cannot be used in the remote treatment of children [50,59]. Instead, therapists focused more on their patients' verbal communication, facial expressions, and tone of voice [60]. The ambiguity of the findings highlights the need for further research. How can the respective therapeutic methods be adapted to the remote treatment format [6], and are there possible contraindications for certain diagnoses or patient groups?

Our results suggest a higher variability in the duration and frequency of sessions in remote therapy. This would suggest that, in addition to psychotherapeutic work, crisis intervention and counseling settings have been given more space in the respondents' range of activities. Further research would be needed to determine to what extent the changed settings could be used for genuine therapeutic work or whether the focus of the work had shifted.

A significant issue indicated by our research is the abandonment or restriction of the use of therapeutic interventions in distance therapy. This was also observed by Cantone et al. [61]. Notermans et al. [62] found that interventions that intend to activate intense or aversive feelings are avoided in the setting of remote therapy. Probst et al. [26] also concluded that therapeutic interventions are considered more typical for face-to-face psychotherapy than for psychotherapy at a distance. This could be explained by the fact that in training, the use of therapeutic interventions has so far been taught exclusively in the context of face-to-face psychotherapy [26]. Further research is needed to determine whether genuine interventions can be adapted for remote therapy. Therapists may have been uncertain about using certain interventions in the remote setting due to a lack of experience. This could be counteracted by offering training on remote treatment that is rooted in education and training contexts.

We noticed a great ambivalence in our respondents' answers regarding the relational experiences and intensity experienced in the remote sessions. The continuation of therapy during the period of restrictions on outdoor activities was described by respondents as having a confidence-building and relationship-strengthening effect. Female therapists, in particular, described a strengthening of relationships. Arguing from a sociological perspective, this finding could be explained by women taking on more nurturing roles in society [63]. Research has shown that women shouldered much of the increased demands of housework and childcare during the pandemic [64]. It could be hypothesized that women are also more likely to take a nurturing role in therapy. Indeed, psychotherapy research has shown that female psychotherapists are more loyal, more optimistic, and less critical than their male colleagues and also more able to put their own person in the background [65]. While male therapists tend to use more confrontational techniques, female therapists intervene more empathically [66]. As a result, women may also be more likely to perceive the gratitude of their patients, which was particularly important during the pandemic. Huscsava et al. [42] and Bouchard et al. [11] also came to the conclusion that therapeutic relationships were strengthened by the continuation of psychotherapy in a remote setting

during the pandemic. One narrative review already published in 2014 was able to show that for patients, the therapeutic relationship in psychotherapy via videoconferencing does not differ from the face-to-face setting [67]. Stoll et al. [68] also rated the therapeutic relationship in the online setting as equal or even better compared to the face-to-face setting. Some of the respondents also perceived a high or higher intensity. Emotions were expressed more openly; furthermore, difficult or embarrassing topics could be addressed more easily. A study by Stefan et al. [21] already provided indications that patients can open up more easily about embarrassing topics over the telephone. It seems that this effect is not limited to psychotherapy via telephone, as patients also felt more confident and less intimidated to talk openly about their emotional state and problems in the setting of videoconferencing [67]. In this context, Russell [69] pointed to the disinhibitory effect in online settings, which leads to some patients opening up more emotionally in video conferencing or telephone settings. Furthermore, Roesler [46] described the intensification effect, which often occurs in the context of virtual interaction. In this situation, information that is only transmitted in a restricted way is completed through the use of fantasy in an imaginative process that also includes the processes of projection and transference [46].

On the other hand, some respondents described a decrease in the intensity of the therapeutic sessions in the setting of distance therapy. Other authors also reported that the therapeutic work became more superficial in terms of content [20,22,42] and that the topics were increasingly oriented toward the patients' everyday life [42]. Some of the respondents also perceived less closeness in the psychotherapeutic relationship in remote therapy and/or experienced the establishment of a sustainable psychotherapeutic relationship as challenging. Psychotherapists interviewed in the study by Stefan et al. [21] also described the therapeutic relationship as more superficial. The respondents in our study also reported limited possibilities of being able to emotionally support the patient in the setting at a distance. Therapists, according to Germain et al. [70], may feel that they can only support their patients in a limited way (e.g., because they cannot offer a handkerchief). Huscsava et al. [42] concluded that therapists feel more insecure in the event of a crisis due to limited options for taking action.

The hypothesis put forward by Roesler [46] is that using technological means to interact psychotherapeutically leads to a fundamental change in interpersonal encounters, the intrinsic rules and consequences of which are still not understood sufficiently well. Given the ambivalence and ambiguity of the empirical findings found in various studies [43,51], it is clear that further research and, in particular, observational studies are needed to better understand interaction in the remote setting, especially in the absence of pandemic conditions.

There are several limitations to this study. Firstly, it is a non-randomized study with some confounding factors that might influence the results (e.g., experiences of telepsychotherapy mainly relate to the time during the COVID-19 restrictions). Secondly, the cross-sectional design did not allow for obtaining therapists' experiences session by session, which in turn could lead to recall bias in the retrospective assessment of the change experienced when making the switch to remote therapy. Thirdly, only psychotherapists who had entered a valid email address in the Austrian list of psychotherapists were reached. Fourth, the survey was conducted online, which could lead to the higher participation of therapists with a higher preference for psychotherapy via videoconferencing. Fifth, it may not be possible to generalize the results to other countries since e-mental health services already have a long tradition in other countries, and therapists' attitudes and experiences may therefore differ. Finally, it would be interesting to investigate possible changes in therapists' attitudes toward the setting at a distance over time.

#### **5. Conclusions**

As a result of the COVID-19 pandemic, the forced and abrupt change in psychotherapeutic treatment format from face-to-face settings to remote psychotherapy faced psychotherapists with unique and complex challenges [50]. Our study showed that remote psychotherapy can be an option to ensure continuity in case of a crisis. Furthermore, the

setting offers spatial and temporal flexibility, which means that appointments can be offered more quickly in case of the need for a higher frequency of sessions or in case of crises. Our study indicates that for some disorders (e.g., anxiety disorders), treatment at a distance does have benefits. Further clinical studies are needed to identify how these patients benefit from distance treatment.

At the same time, it was found that the change of setting led to feelings of insecurity on the part of the therapists and that the range of therapeutic interventions was not fully utilized. This underscores the relevance of further research on how the therapeutic methodology can be adapted to the remote setting and for which patients there might be a contraindication. Because remote treatment has not been included in the process of professionalization so far, we see a need to expand the training and further education offered to therapists accordingly. At any rate, the pandemic situation has shown that to fulfill the duty of care toward patients, new ways are needed to ensure psychotherapeutic care [48]. Treatment at a distance could constitute an alternative to counteract the already existing underprovision of psychotherapeutic care in Austria.

**Author Contributions:** Conceptualization, T.P.; methodology, T.P., A.J. and E.H.; formal analysis, A.J., M.S. and E.H.; investigation, T.P.; data curation, T.P.; writing—original draft preparation, A.J. and M.S.; writing—review and editing, E.H., B.H., P.S., W.S., E.M., H.S., D.L., C.P. and T.P.; visualization, A.J.; supervision, A.J. and T.P.; project administration, T.P. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** The study was conducted following the Declaration of Helsinki and approved by the Ethics Committee and the data protection officer of the University for Continuing Education Krems (EK GZ 27/2018-202).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** The raw data supporting the conclusions of this article will be made available by the authors upon reasonable request after signing a confidentiality agreement.

**Acknowledgments:** Open Access Funding by the University for Continuing Education Krems.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


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