Therapeutic encounters at the onset of the COVID-19 pandemic: psychodynamic therapists’ experiences of transition to remote psychotherapy

Abstract

The COVID-19 pandemic crippled many parts of society as it spread throughout the world beginning in early 2020. Overnight, whole societies were forced to change their way of life, because of social distancing and lockdowns. For therapists, the pandemic meant that in-person sessions were no longer possible and many switched to different forms of synchronous remote communication by telephone, online audio or video link. The aim of this study was to explore psychodynamic therapists’ experiences over time of forced transitions to telepsychotherapy. Five therapists were interviewed at the beginning of the pandemic and at a one-year follow-up. The data were analysed by applying thematic analysis with a phenomenological approach. Initially, the therapists struggled with technical and safety issues. The loss of the therapy room and of access to non-verbal nuances contributed to impaired contact with the patients and more superficial conversations. The therapists experienced that the very nature of psychodynamic psychotherapy was affected, even if telepsychotherapy could give some new opportunities. One year later many of the difficulties remained, but the therapists developed better coping strategies and were back to the therapy focus. One implication of this study is that telepsychotherapy needs to be integrated into psychotherapy training and supervision.

Keywords:

• pandemic
• telepsychotherapy
• therapeutic relationship
• therapeutic technique
• qualitative methods

Introduction

Traditionally, psychoanalytic psychotherapists have preferred that their sessions take place with the patient and the therapist present in the same room (face-to-face or the patient lying on the couch). Such a classical setting has been intended to facilitate observing, understanding and interpreting the patient-therapist here-and-now interaction and how both of the participants cope with the therapeutic boundaries (Migone, 2013). The COVID-19 pandemic dramatically altered the possibilities for therapeutic encounters ‘in the real world’ and many patient-therapist dyads had to switch to telepsychotherapy (different forms of synchronous remote communication via telephone, online audio or video link). In Sweden, in March 2020, the Public Health Agency recommended people should work from home when possible using remote communication technology. Accordingly, most therapists in private practice and in public care switched to remote psychotherapy. However, an initial lack of equipment could create difficulties and result in treatment interruptions in some cases. Some clinics continued in-person treatments using face masks, which were not widely available at the beginning.

The use of the telephone as a technical aid in psychoanalysis has been discussed since the 1950s (Saul, 1951) and the use of videoconferencing in group therapy was introduced in the 1960s (Wittson et al., 1961). Carlino (2011) argued for the evolution of psychoanalytic theory and practice and predicted that in the digital era tele-analysis will be the treatment of choice for many people. According to him, the main difference between the classical setting and tele-analysis is the concrete presence of two people in a room. Migone (2013) compared psychoanalysis on the couch and on the Internet, and concluded that online therapy is simply a different therapy. For other analysts, the main concerns in remote analysis are the vicissitudes of the embodied transference-countertransference, i.e., the ways embodied affective experiences are implicitly communicated to each other (Isaacs Russell, 2015; Lemma, 2017).

Internet-based psychotherapy, also known as e-therapy or online therapy (Smoktunowicz et al., 2020), is nowadays a well-established form of conducting different forms of psychotherapeutic treatments (Andersson et al., 2019; Foroushani et al., 2011; Lindqvist et al., 2020). Most of the relevant literature focuses on experiences of therapies that started and were designed as online treatments, or on comparison between customary setting and remote therapy. A systematic review of 65 studies with different therapeutic orientations and diverse patient groups (Backhaus et al., 2012) found that most patients and therapists were satisfied with receiving and providing videoconferencing psychotherapy and had similar outcomes to face-to-face therapy. Accordingly, a systematic review of 27 studies of videoconferencing therapies for anxiety disorders (Berryhill et al., 2019) found promising results for video delivered treatments. None of the seven studies directly comparing video and face-to-face therapy found differences in outcome. On the other hand, an interview study of cognitive behavioural therapists (Bengtsson et al., 2015) showed that they viewed the traditional face-to-face setting as a stronger experience than Internet-based CBT (more focused, easier to adapt to the client, more reinforcing, more demanding, and bringing more focus to the therapist) and as more easily promoting a working alliance. A study of 94 psychodynamic therapists treating Chinese students over videoconferencing (Gordon et al., 2016) showed that the therapists regarded this treatment modality as a valuable way of offering therapy to underserved and remote patients. Therapists rating the effectiveness of videoconferencing as low and those rating it as high differed regarding specific psychodynamic variables, such as exploring mental life, working through relational problems, working with resistance transference and countertransference, and privacy concerns.

Using communication technology is generally seen to have many benefits when it comes to providing therapy. On a practical level, telepsychotherapy can cut travel time and enable the provision of therapy to faraway locations and developing countries. On the other hand, telepsychotherapy deprives both participants of the direct physical presence in the here-and-now of the therapy setting and implies for the patient a loss of the transitional space and time on the way to and from the therapist’s office.

In order to inform psychotherapists about experiences of telepsychotherapy shortly after the World Health Organization (WHO) declared the COVID-19 outbreak a pandemic, Poletti et al. (2021) reviewed the most recent experimental evidence about telepsychotherapy. The 18 included studies showed that, despite scepticism among the general public and therapists, telepsychotherapy is a feasible option for treating common mental-health disorders, such as anxiety, depression and posttraumatic stress disorder. Similarly to in-person therapy, better outcomes were associated with a higher number of sessions and responsive management of patients’ expectations. Technical difficulties and unfamiliarity with online communication could negatively affect the effectiveness of telepsychotherapy.

However, the question remains about the patients’ and the therapists’ experiences of forced transitions from the therapist’s office to distant work. Békés and Aafjes-van Doorn (2020) collected survey data from 145 therapists from North America and Europe on the short-term effects of transitions to online therapy. About half of the included therapists had no previous experience of online therapy. Most of the therapists had a somewhat positive attitude toward providing therapy online. Cognitive behavioural therapists were more positive to online therapy than psychodynamic therapists. Furthermore, previous experience of online therapy was associated with a more positive attitude. A survey among 108 Portuguese psychologists (Dores et al., 2020) explored the use of information and communication technologies in psychological counselling before and during the COVID-19 lockdown. The greatest challenge for the therapists during the lockdown was the loss of non-verbal communication, privacy issues, establishing and maintaining the therapeutic relationship, and session interruptions.

Restricted channels for implicit communication might be especially challenging for psychoanalytically oriented therapists (Brahnam, 2017; Isaacs Russell, 2015; Lemma, 2017; Roesler, 2017). Several of the distinguishing features of psychodynamic therapy, identified by Blagys and Hilsenroth (2000; cf. Shedler, 2010), such as focus on affects and emotion expression, on interpersonal relations, and on the therapeutic relationship, as well as exploration of avoidance of disturbing thoughts and feelings, might be influenced in a salient way in remote setting, whereas other features, such as identification of repetitive patterns and themes, recognition of past prototypes, and exploration of wishes, dreams, and fantasies, might be less affected.

The research on transitions from in-person psychotherapy to telepsychotherapy is still in its infancy. At the same time the COVID-19 pandemic created a sort of ‘natural experimental situation’ for studies of experiences of shifts from psychotherapy ‘in the real life’ to digital communication technologies. In this context, studies of psychodynamic therapies are underrepresented, even if the challenges of transitions might be more essential within the psychoanalytical theoretical and clinical framework, focusing on understanding and interpreting what is going on in the here-and-now of the therapeutic setting.

The aim of the present qualitative, explorative study is to ‘give voice’ to and ‘make sense’ (Larkin et al., 2006) of psychodynamic therapists’ early experiences of forced transitions to telepsychotherapy after the outbreak of the COVID-19 pandemic. How do the transitions to remote therapeutic encounters and the use of communication technologies affect the therapeutic relationship, the therapy process and the therapists themselves, as viewed from the therapists’ perspective?

Method

Participants

In order to find a defined group of respondents that could give a comprehensive account of how forced transitions to telepsychotherapy had affected them and their work, we applied convenience sampling. Inclusion criteria were having training and a licence in psychodynamic psychotherapy, and working with patients in face-to-face settings, but switching to remote therapy due to the CORONA-19 pandemic.

The study was advertised in Swedish Facebook groups for psychodynamically trained psychologists and for licensed psychotherapists in order to recruit participants as quickly as possible in the early phase of the pandemic. Potential responders were asked to contact the first author (KA) via email or telephone. The first five individuals that met the criteria for participation were included after signing the informed consent form. This number of participants was regarded as sufficient for the phenomenologically inspired thematic analysis with focus on both group themes and individual differences (see below). The study was approved by the Swedish Ethical Review Authority (registration number 2020–06819 and 2021–01188).

The participating therapists (two women and three men in their 40s to 60s) had long experience of clinical work with patients and had been licensed for one to 18 years. All of them were in private practice and one was also publicly employed. None of them had previous experience of conducting remote therapy; however one therapist had had some telephone sessions prior to the pandemic and another one had experience of video sessions on rare occasions. Three of the therapists were continuing to work from their consulting rooms and two of them worked mostly from their homes.

Researchers

The interviews with therapists and the data analysis were conducted by the first author (KA), who, at the time of the study, was a student in an advanced psychotherapy training programme (psychodynamic orientation), as part of her diploma thesis. She was also a journalist, used to interviewing people, eliciting their own experiences and bracketing her potential pre-set hypotheses. The second author (CvB), a female PhD, senior university lecturer, licensed psychologist and psychotherapist, was involved in the planning of this study, preparing the interview protocol, and conducting continuous audits of data analysis. In her clinical work she had early experiences of transitions to remote therapy and of changes in the therapeutic alliance. The third author (DF), a male post-doc researcher, and the fourth author (AW), a male senior researcher and psychoanalyst, contributed to the interpretation and presentation of the results. DF did not do any clinical work when the study was ongoing and did not have any theoretical preconceptions. AW had long experience in remote psychoanalytic psychotherapy and supervision and was interested in exploring how different patients and therapists react to transitions to and from remote therapy. All the authors participated in writing and revising the manuscript.

None of the researchers had any relationship to the participants. In accordance with the phenomenological approach to reflexivity (Mortari, 2015), the researchers strived for introspective self-examination, paying attention to the evolving comprehension of the participants’ subjective experiences, and to the influence of the researcher’s background and presumptions.

Interviews

The semi-structured interviews followed a guide that included some background questions and indicated the focal areas of interest. The respondents were asked about their professional training and current work situation. This was followed by open-ended questions about both positive and negative experiences of patient work in a traditional setting and using communication technology; more specific non-verbal aspects of the online work, such as expressions of transference and countertransference; different nuances of silence; and how ruptures in the remote communication influenced the therapeutic work. Furthermore, the responders were asked if the duration of psychotherapy was affected, if the patient responded differently to the therapist’s interventions, and about the use of communication technology. Finally, the therapists were asked how they were affected, both physically and mentally, by the use of online communication, as compared to physical encounters. The interviews were carried out from June to August 2020, i.e., three to five months after WHO’s declaration of the COVID-19 pandemic (11 March 2020), two of them face-to-face, a further two via Zoom and one by telephone, and lasted 45–55 minutes.

About one year later, the responders were contacted again for a short follow-up interview including the following questions: What has changed during this year? What has become easier and what has become more difficult? Did you discover new aspects? What have you learned? Four of these interviews were conducted by telephone and one via Zoom. All interviews were audio-recorded and transcribed verbatim.

Exploratory qualitative analysis

The verbatim interview transcripts were analysed by the first author, applying inductive and experiential thematic analysis (TA; Braun & Clarke, 2006, 2013). This analytical method aims to identify themes and patterns of meaning starting in an unprejudiced way from the participants’ utterances and focusing on how the participants experience and make sense of their world. Qualitative analysis followed the steps described by Braun and Clarke (2006, 2013): (1) transcription of interviews, (2) becoming familiar with the data, (3) generating preliminary codes capturing the content, (4) searching for patterns and recurring themes in the preliminary codes across interviews, (5) reviewing themes, (6) defining and labelling themes, and (7) writing-up the report. This procedure included continuously taking notes on ideas of emerging themes and their interactions, as well as ongoing constant comparative analysis, shifting focus between the parts and the whole and comparing new findings with the already formulated understanding (Breakwell et al., 2012). Furthermore, the analysis was inspired by interpretative phenomenological analysis (IPA; Larkin et al., 2006; Smith et al., 2009), focusing both on the common experiences of the participants and on each individual’s specific experiences in depth, in order to identify and interpret the various facets of the phenomenon in question. The data analysis, formulation of themes and choice of examples and quotations were audited by the second author. As a further validity check, all quotations included in the report were reviewed and approved by the responders.

Results

The qualitative analysis based on the first round of interviews yielded six overarching themes, representing distinct aspects of the therapists’ experiences of transition from conventional psychotherapy to remote psychotherapy. Below, we present the therapists’ views of negative, hindering, and positive, facilitating effects of this transition. Each theme is illustrated with at least one personal account followed by direct quotes. When referring to a particular account, the therapists are presented using their alias.

Safety concerns and technical issues instead of therapeutic focus

All five therapists described how changed conditions and restrictions at the onset of the COVID-19 pandemic forced them to shift to remote sessions, and all of them were clearly affected by the transition. The therapists said that the changes took place quickly and without sufficient opportunity for preparation. Besides the changed therapy setting the therapists worried whether the communication technology would work, and whether they had done enough to ensure the patient’s confidentiality, as required by the regulations.

Martin had tried to look into laws, rules and secrecy: ‘but it has been quite a jungle.’ He was puzzled a great deal, ‘since you hear different things from colleagues and organizations.’ Although patient safety was important, Martin believed that there might be ‘a little hysteria around it indeed.’ Nevertheless, he thought that time had had a positive effect: ‘Everything new creates a lot of uncertainty but finally I come down feeling safe and we will see what happens.’ Yet, some worries remained: ‘can the National Board of Health and Welfare give me warnings [for not protecting patient confidentiality when working online] … when you read up you don’t get a clear picture.’

Sara described concerns about confidentiality as well as the realisation that remote work was more difficult, requiring a completely different approach: ‘I was probably quite scared the first few times I had to try it.’ Carl shared the experience that initially the focus was on getting the technology in order: ‘This happened so fast for us; all of a sudden we just had to find a computer and “the next session is via video link’”. David also reported initial concern about the technical solutions, but fairly quickly he had the products needed.

Partly negative expectations about technology came true: ‘I have missed seeing the patient in the room, but in many cases, it has worked beyond expectations, I think’ [Carl]. Anne had negative expectations from the beginning, and these remained: ‘There was a focus on technology and no thoughts on therapeutic method and the theoretical. Just go ahead and be creative.’ According to Anne, the video sessions had a more short-term focus and pedagogical approach. Even though Anne was interested in digital psychotherapy, she was disappointed that the shift was never talked through, and now there was nowhere to discuss what had happened. The technical problems had diminished over time, but were not fully remedied because the video calls also depended on the patient’s technical equipment.

Exiled therapy frame

The therapists experienced that the therapy room itself became exiled. The therapist had to follow the patient to a room of the patient’s choice. Therapists observed that the therapeutic meeting for the patient sometimes became only one among many digital work meetings: ‘You just click for the next meeting and it happens to be me there, instead of a workmate’ [Carl]. One therapist discovered that the patient was busy on social media while communicating with the therapist. The transitory space and time on the way to and from the therapist’s office disappeared, according to the therapists. The therapists described both positive and negative aspects of the changed power balance when the therapist was invited to the patient’s place rather than the opposite. Carl saw it as an opportunity to observe how patients managed their self-boundaries: for example ensuring they were alone in the room or letting the family come into the kitchen and greet the therapist. According to Sara she saw too much of the patient’s private life, such as books, documents or family members in the background. Martin said he would interrupt the session if other people appeared on screen: ‘I can’t stop the patient from choosing the room, but we need to talk about it. We share the power and the goal to make the best of it.’ David underlined that the changed power balance had some positive aspects, but when the patient was unable to take the responsibility needed, the therapist had ‘to do all the work,’ which made the therapist tired and might evoke a feeling of not being capable enough. Anne stressed the necessity of being flexible when entering the patient’s home, and she concluded that you could not expect the same therapeutic process and had the same view of ‘boundary crossing’.

Lost depth of conversations

The therapists generally experienced that the therapeutic exchanges in various ways became more superficial when using communication technology. All of them tried to put words to something indefinable that was missing. Remote therapy was ‘therapy light’, ‘artificial’, impeding the flow, rendering it more difficult to grasp what was going on and to be present with the patient, but also putting a damper on the therapist’s commitment, feelings and courage. It was more difficult to rely on transference and countertransference reactions, and other parameters must be used to understand the therapeutic interaction, leading to a more concrete level of exchanges. Carl was ‘not as touched when the patient starts crying.’ Sara ‘had to listen in a completely different way’ and instead of asking ‘what is going on between us just now’ she could say ‘now I see that you … ’ Anne said that it was more difficult to see the patient’s facial expressions and establish a rapport, which made it hard to be emotionally confronting and evoked guilt feelings and a sense of having abandoned the patient. The therapists expressed worries about not knowing how far they could go in their interventions, not being able ‘to read’ the patient’s reactions or to address what was going on. Martin had discovered that the more superficial and remote contact could be helpful for some patients. Especially patients with high anxiety levels might profit from ‘a safer home environment … they can shut down the computer if it becomes too much.’

The lost therapy room

All therapists experienced the loss of the shared therapy room as a disadvantage for themselves, the patient, or both. At their own office they could feel more confident of doing good work. Sara felt it was easier for her ‘to listen with the evenly-suspended attention’ and empathised with what the patient talked about when they were in the same room. The therapists described their office as a safe and protected place for the patients to share their stories and feelings, and to maintain the focus: ‘There is nothing here that disturbs their attention, neither inwards nor outwards … it is more difficult to talk about the violence being where the violence takes place’ [David]. David emphasised that the patients’ stories have their place in the therapist’s office and not in their private homes.

According to the therapists, the physical meeting in the shelter of the therapy room was an essential part of the therapy process: ‘I can get closer to the human being, closer to the core. I can talk about things as they are … the pain spots, to resolve issues, heal and relieve in a completely different way’ [Anne]. According to Carl, all therapeutic instruments were stronger in the office and it was easier to observe the unconscious communication. The loss of the shared physical space contributed to the therapists’ experience of weakened working alliance, less courage to challenge the patient, more doubt in one’s own judgements. Martin could get tired of digital calls, as it was ‘difficult to feel the same emotional investment in the contact via the computer screen’. Accordingly, Martin did not take on new patients without having first met them in person: ‘there’s something about being in the same room with someone else. There’s so much information in it.’ Lacking the stability of the therapy room, therapists stressed other ways of safeguarding therapeutic boundaries, such as maintaining the structure and fixed times of sessions, and keeping the focus on their work.

Loss of non-verbal nuances

Generally, the therapists experienced that access to nuances in non-verbal communication – an important part of the therapy process – was lost and mourned. Sara felt that ‘the beautiful part of psychodynamic therapy’ was lost in remote contact. When the opportunity to observe and interpret non-verbal material was limited, the focus shifted to concrete and practical treatment goals, and this evoked Sara’s performance anxiety and a feeling that she had to deliver something. Anne felt that, lacking access to non-verbal cues, the communication became more theoretical and superficial. Anne became more affirmative, active, supportive, less confrontational, and talked more. Most therapists described their attempts to compensate for the loss by being more focused and attentive, which might result in a special form of tiredness, for example Anne’s muscle pain.

According to the therapists, many indicators of transference and countertransference were lost in remote communication. It was more difficult for the therapists to be silent and wait, to create space for reflection, and to endure, understand and interpret patients’ silence: ‘Silence is also full of stuff’ [David]. Carl felt less ‘used’ by the patients: ‘I don’t get as many projections and suchlike on me.’ It could be a relief, because the workload then felt lighter. At the same time, it could be ‘refreshing’ to receive projections as these represent working materials. Sara said that the patients’ stuff could not be projected in the same way, nor yet returned in a digested form by the therapist. The non-verbal communication was not eliminated, but often needed to be put into words, according to the therapists’ experiences. Carl said that his tearful eyes could not be seen by the patient, which meant the reaction must be verbally communicated instead. Martin thought that the translation into words had been less difficult than might have been expected. He asked the patient to be observant for bodily reactions and other non-verbal cues the therapist could not see on the screen as one way to compensate for the loss of nuances: ‘It’s perfectly possible to say: Do you notice that you are avoiding the screen now? … What is going on here between us that makes that happen?’

New opportunities

All therapists brought up disparate positive aspects of the digital format. They could see benefits and new opportunities for some of their patients. Therapy had become more available independently of where the patients lived or their physical health. The familiarity among younger patients with online communication also made therapy with them easier. This could also be seen as a disadvantage, as patients did not invest as much in the therapy process as before. There was also a risk that people were becoming more easy-going and too lazy to come to the therapist’s office. The therapists could think that their patients were more satisfied with the remote contact than the therapists. The patients seemed to feel understood and confirmed, even though the therapist would prefer to be able to give more: ‘this is our desire, for sure. The patient may be contented’ [Sara]. For their part, the therapists expressed some degree of reluctant acceptance of remote therapy, gradually getting more used to the new format, and thus experienced the disadvantages as less problematic with time. David ‘was training’ and it was easier now. Carl remained sceptical, but said that the remote format was not as bad as he might have imagined: ‘It might be OK with time.’ Anne believed that you had to accept the reality: ‘Just go ahead! Be creative. Do your best. What are your options?’ Martin felt it had got better after overcoming his initial resistance, even if he had to make it clear to himself why he was acting as he did with each patient when working online.

One year later …

At the follow-up one year later all the therapists were still partly teleworking. The communication technology was still brought up, but the therapists did not react as strongly to technical problems. They had partly overcome them in different ways. ‘It was scary at first; like becoming a beginner again’ [Sara]. Martin adhered strongly to the therapeutic frames and found that it worked very well: ‘I ask the same questions to the patient anyway and we focus on the same things … I don’t think that the focus in the conversation, the content, has changed.’ David became less strict: ‘you have to let go a little of the frames.’ The therapists stated that they had developed new strategies that had enriched them as therapists and made most of them more positive about remote therapy.

The loss of the physical presence was still marked and all therapists still preferred in-person sessions, as they were more of a safe haven for the patient and gave more opportunities to deepen the contact. But with that being said, the therapists found online meetings work well and better than previously. They thought that remote therapy might sometimes be justified due to external circumstances. They had become more relaxed with teleworking over time and were confident that it was possible to find new paths with the patients. The change of the room to a place chosen by the patient was less problematic. Therapists and patients had found new locations, defined and approved by both. For example, David was working actively on defining the room together with the patient, talking about where they were and what it meant.

The therapists continued to experience online meetings as more superficial. The conversations had become less nuanced and more practical, sometimes faster and livelier, and the non-verbal communication was still problematic. Silence felt uncomfortable, transference and countertransference were more difficult to use, as were confrontations. David was using more of the relational part of the psychodynamic theory. Carl was a little more cautious in sessions and the consequence was a slightly lighter therapy: ‘It is not as easy to confront or make different interventions.’ Therapy in the physical room and online therapy were almost seen like two different products. Sara said that she had practised and expanded her ability to create and detect feelings in the digital space. Anne bridged the lack of in-person contact by talking more, being more active and informative when it came to affect theory, relational theory and trauma theory. She put into words the patient’s facial expressions in a different way than before, using expressions such as: ‘I see that you … ’ In consequence, her patients reflected more between sessions. According to Martin the screen in itself had not changed the interplay; the technology was highlighted if it worked poorly, but otherwise he was still asking the same questions and had the same focus in the sessions.

The challenges perceived by the therapists were smaller or less threatening than before, and the good experiences were now described with more emphasis. However, the difficulties could vary with different patients. Martin found it more difficult to work online with patients who tended to keep a lot of distance. On the other hand, online communication could be an advantage for those who had difficulties calming down and who felt safer with a remote contact. Nevertheless, remote therapy could provide better availability for patients, for people living far away and for those who, for psychological reasons, were better off if they could choose the place for remote sessions themselves. Remote therapy also gave more power to the patient, which could also be used psychotherapeutically. The negative aspect for the therapists could be uncertainty when it came to psychodynamic therapeutic technique and interventions, and fatigue due to the fact that they needed to be more alert and focused. But overall, practice and exposure had given them a more positive attitude. Remote therapy was not the same as real life therapy, but it was good enough, and it had helped them to develop as therapists owing to the challenges they had had to overcome. As expressed by Sara: ‘We have been forced to go into the future, fast forward into the future as psychodynamic therapists … I see myself as a much more multifaceted therapist today.’

Discussion

The aim of this study was to explore psychodynamic therapists’ experiences of forced transitions to telepsychotherapy. The qualitative analysis of the therapists’ accounts revealed that the core aspect of their experiences was a deep feeling of several types of loss, even if telepsychotherapy could give some new opportunities. Initially, the therapists struggled with technical and safety aspects at the expense of therapy focus. They felt that the therapy frame became exiled and they experienced that the loss of the therapy room and of access to non-verbal nuances resulted in lost depth in the dialogue and impaired contact with the patients. One year later, many of the difficulties remained, but the therapists had developed better coping strategies and seemed to be back to the therapy focus.

Our main finding was that the therapists experienced a thorough change in the patient-therapist communication and the very nature of psychodynamic psychotherapy after transition from in-person to remote sessions. All but one therapist experienced the conversations as more superficial and more matter-of-fact than in the therapy room. This was due to the more limited access to non-verbal communication when they only saw the patient’s face, and limitations in the ability to see small gestures and changes in facial expressions, as well as technical problems, such as lagging transmission. All therapists experienced the loss of the therapy room as a disadvantage. They could experience a kind of stress leading to accelerated communication and shortened moments of silence. They also described a certain fatigue when trying to concentrate harder in order to compensate for what was lacking; they could blame themselves and feel insufficient as therapists.

However, the five therapists differed in the ways they perceived the disadvantages. For some, remote psychotherapy was just another treatment modality (cf. Migone, 2013), for others it had limitations and required adaptations (cf. Poletti et al., 2021). One therapist [Anne] was more negative than the others concerning the chances of giving meaningful digital therapy. Another one [Martin] was convinced that the psychodynamic therapy setting could be partly transferred to an online format with some adjustments. This therapist had found ways of safeguarding the therapy borders in the new format.

The therapists’ early experiences of the transition to remote working without any preparation bore the stamp of an unforeseen and wide ‘catastrophic change.’ Furthermore, the therapists and their patients shared the same reality, uncertainties, and fears, the ‘shared trauma’ of pandemic (Escardó, 2021; Nuttman-Shwartz & Shaul, 2021). In particular at the beginning of the sudden and forced change to remote sessions, the therapists’ focus shifted from the therapeutic process to the issues of communication technology. All therapists described feelings of loneliness and lack of knowledge in the transition when trying to resolve technical and legal matters, but also in the online sessions themselves, and they could feel abandoned and anxious. They also conveyed a sense of isolation from colleagues and professional organisations during a time of crisis and uncertainty. According to the therapists, most problems in the early phase of transition had been at least partly resolved by the one-year follow-up (Anne becoming much more positive). In the meantime, guidelines and recommendations for the practice of telepsychotherapy and policies concerning it have been developed. For example, the American Psychoanalytic Association established the Covid-19 Advisory Team (Isaacs Russell, 2021). The Project Group on eHealth of the European Federation of Psychologists’ Associations (Van Daele et al., 2020) compiled recommendations for psychotherapists.

The nature of the therapeutic relationship was thoroughly discussed by the therapists. The power balance shifted somewhat when the patient chose the room and to a certain extent the setting. Patients thus had an increased responsibility to safeguard the therapeutic setting against external disturbances, which not all patients managed to do. The therapists described how, soon after the transition, they started to learn how to work while being deprived of a safe therapeutic setting by partially giving up, or the opposite, strictly holding on to the boundaries. According to Lemma (2017), the online setting in itself is a rupture of working alliance; therefore it is of great importance that the therapeutic frames are redefined in accordance with the new situation. The exiled therapy frames in our study might be a result of the frames not being renegotiated.

All therapists described their approach as more cautious with their patients, and they felt that as therapists they did not function as well as when working in-person. The therapists felt they were less important to the patient, and the patients did not do their part as much when working online. When the travel time disappeared, the patients did not give themselves space for preparation and after-thoughts, squeezing in online therapy sessions between several digital work meetings, or not being fully present. The use of communication technology removed the transitional space and time between the therapy setting and the outer reality, creating ruptures in the rituals surrounding therapy sessions. Taken together, these factors contributed to more superficial therapeutic interactions. However, the patients’ power to choose the room gave the therapists an opportunity to visit patients’ homes, which some of them appreciated and others experienced as too intrusive (cf., Essig & Isaacs Russell, 2021). While the therapists had access to their patients’ private space, the patients no longer had access to the consulting rooms, as noted by Isaacs Russell (2021), whereas the therapists could work from their private homes. Previously, Reeves (2015) described in a similar way difficulties in protecting the therapeutic space when working online. When the patient enters the physical, unchanging therapy room, the patient is expecting certain rituals and processes to take place there. In the digital space, on the other hand, the space is not fixed, thus the same mental processes are not set in motion. Reeves also noticed that the transitional time and space between everyday life and therapy session shrinks to a few seconds, the patient losing the opportunity for preparation and after-work.

In various ways, the therapists experienced that something elusive was missing in the therapeutic interactions. Their initial descriptions bore signs of not having been fully verbalised yet, as if they were still processing this new experience. They clearly experienced the effects of trying to compensate for whatever was missing – fatigue, not letting silences be present, focusing on concrete matters. Possibly, their own inner dialogue was also more superficial, giving them less inspiration and depth. Likewise, Brahnam (2017) emphasised the attenuation and distortion of non-verbal channels of unconscious communication in screen-based analysis, shrinking both the patient’s and the therapist’s access to their states of reverie. Roesler (2017) refers to Bollas (2015) critical remark that digital media produce superficiality in culture and society, and he describes the flattening as ‘channel reduction’: the channels for communication are lost or reduced in technological communication. This can have an enormous effect on the interactional relationship. The lacking non-verbal communication experienced by the therapists in the present study is one such reduced channel, resulting in a loss of significant nuances. Lemma’s term for this is ‘disembodied relating’ (Lemma, 2015, p. 571). When communication technology works, the lacking channels can be remedied by ‘telepresence’, the illusion of being in an external shareable world (Essig & Isaacs Russell, 2021; Isaacs Russell, 2021; Lombard & Ditton, 2006).

Noticeably, the therapists in our study struggled in the areas of affects, interpersonal experiences, therapeutic relationship, and unconscious wishes, fears, and ideas. These are also four of the seven distinguishing features of the psychodynamic clinical practice, found by Blagys and Hilsenroth (2000) when comparing the process and technique of short‐term psychodynamic‐interpersonal psychotherapy with that of manualised CBT. Most therapists in our study felt that they had limited access to their therapeutic instruments, deeply rooted in the psychoanalytical tradition. Work with resistance and transference-countertransference, confrontive interventions, and insight into the patient’s inner world became more difficult, particularly due to the restricted channels for implicit communication in the absence of two bodies in the same room (cf. Brahnam, 2017; Nebbiosi & Federici, 2021; Roesler, 2017). Even if we are still embodied when the interaction is mediated, the therapists are deprived of the full range of embodied countertransference as a pathway to the patient’s unconscious communication (Lemma, 2015, 2017).

On the other hand, some patients could open up more in remote contact. As noted by Lemma (2015), it is easier to feel totally in control in cyberspace. The patients’ ability to turn off the camera or even the session is also a part of the power shift. This, as well as the physical separation and the screen between the therapist’s and the patient’s body, makes it possible to shut off overwhelming shame in a way that might lead to faster emotional development in therapy (Leibert et al., 2006). Furthermore, technology mediated therapeutic relating can offer security for traumatised patients and people that cannot depend on others (Isaacs Russell, 2021; Roesler, 2017). The depth of the therapeutic work, physical proximity in the same room, mental presence, and treatment effectiveness are not necessarily connected. One conclusion from a study of psychodynamic therapists treating Chinese students over the Internet (Gordon et al., 2016) was that the patients seemed to value the therapist’s warmth, wisdom, empathy, and skilfulness as more important than in-person contact. Could the shared physical space be more important to therapists than to patients? The therapists in our study experienced loss of a sense of security when unable to meet their patients in the therapy room. Possibly, the therapists’ sense of security gives them more courage to be confrontive when needed, silent when needed, and to make use of their therapeutic expertise. Accordingly, the therapist who was less worried about the transition to telepsychotherapy was also the one who most stressed the importance of maintaining the psychodynamic framework, focusing on boundaries and transference work.

Whether the negative experiences of the therapists were part of the learning process of a new therapy format, rather than signs of lasting drawbacks with remote therapy, is a relevant question. All new things take time to learn. Indeed, one year later, safety concerns and the focus on technology were no longer in the foreground in the therapists’ experiences and all of them, in different ways, were back to the therapy focus. Most of them described becoming more flexible and developing new strategies, which had helped them to be more comfortable while working online. They compensated for the limited non-verbal communication and lost nuances by being more pedagogical and matter-of-fact, but also by developing new ways of listening, focusing on cues accessible in the online communication (facial expressions, avoiding screen, etc.), and inviting the patient to look at what was going on in the online exchanges. All therapists made some adjustments to the remote work and all of them felt that they were still conducting psychodynamic psychotherapy. As observed by Moshtagh (2020), listening in a psychoanalytic way is still possible online as long as both parties are willing to listen, hear and be heard emotionally. Summarising experiences of more than one year of remote working during the pandemic, Isaacs Russell (2021) noticed different creative ways that clinicians found to compensate for differences between in-person and remote therapy. According to her, the clinical value of remote therapy rests on the therapists’ balancing a shared illusion of ‘telepresence’ and a reflective stance to the differences between ‘telepresence’ and bodily co-presence. It is an open question how the therapists cope with this balance in the long term and what the differences are between therapists who are more or less able to keep this dynamic balance. Furthermore, we still do not know how the use of communication technology influences the treatment duration.

Accordingly, there is a necessity for further clinical reflection and research on the patient-therapist dynamic during transitions to remote therapy – and back to the office. Similarities and differences between in-person and remote psychotherapy with different patients have to be included in psychotherapy training and supervision. An important topic for future research and for training is which psychodynamic principles need to be adjusted to the remote work, and how this is best done. The therapists in the present study noticed that different patients reacted differently to the transition, for some of them this facilitated, and for others obstructed the therapeutic work – and this is another area for further research. As therapists we also can learn much from studies of the patients’ experiences of transitions. There seems to be a general expectation of more hybrid forms of treatment and training in the post-pandemic era. Thus, there is a need for continuing research on how such changes affect the very nature of psychoanalytically oriented psychotherapy.

The strengths of this study include the in-depth focus on the lived experiences of therapists affected by the forced transition to remote therapy, taking into account both overarching themes and individual differences. Furthermore, the interviews captured the early phase of this change and the follow-up elucidated the long-term adjustments. However, a limitation of this study is the low number of participants. Thus, some essential facets of these experiences might have been overlooked. Nevertheless, the small sample included a wide range of clinical experiences. Recruiting therapists from Facebook groups might have led to a sample that was more used to social media and digital solutions than other therapists. The convenience sampling might also mean that the therapists who chose to participate were more interested in the issue of remote therapies than others. The study focused exclusively on psychodynamic therapists. The results cannot be generalised to therapists with other orientations. Furthermore, Sweden is a country that has not been exposed to such extensive lockdowns as occurred in many other countries.

Acknowledgements

We thank the therapists who generously shared their time and their experiences with us.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Board of Human Science, Stockholm University, with one-year strategic grant for innovative research initiatives, registration number SU FV-5.1.2-3314 -20.