Stretching the Analytic Frame: Analytic Therapists’ Experiences with Remote Therapy During COVID-19

Abstract

Remote therapy has been used by analytic therapists for quite some time, though many have been reluctant to use it regularly, out of concern that it might distort analytic frame and relational dynamics. Now the Covid-19 pandemic has forced therapists to make a sudden, across-the-board transition to remote therapy. This study reports on survey responses from 190 analytic therapists on their transition to online therapy via videoconferencing during the pandemic and their previous experience with remote therapy (the majority had such experience). During the pandemic they prepared themselves and their patients for the transition in a variety of ways. The majority of those surveyed reported feeling as confident and as competent in their online sessions as in their earlier in-person work. Moreover, despite technical and relational challenges, they remained as strong, emotionally connected, and authentic in their online therapy sessions as they were in person. These experiences during the pandemic led to more positive views of online therapy than they held before, but a majority still considered online therapy less effective than in-person sessions.

Keywords

analytic frame Covid-19 online therapy

Remote therapy (sessions via phone or online via videoconferencing) is not new to analytic therapists (see, e.g., Agar 2019; Brottman 2012; Ehrlich 2019; Trub and Magaldi 2017; Saul 1951), yet many analytic therapists have been reluctant to use it. Ethical and confidentiality issues, as well as concerns about the efficacy of online therapy, particularly concerns about whether a good working relationship can be established online, have been voiced across therapy modalities (see Connolly et al. 2020). Analytic therapists have raised additional concerns regarding the violation of analytic process and the analytic frame (see Scharff 2018). For instance, concerns have frequently been raised about the impact of remote therapy on the transference-countertransference process, for instance that it might foster the development of an illusory, idealized image of the therapist (Roesler 2017). Also, many analysts are worried that the lack of nonverbal cues dulls the therapist’s sensitivity to unconscious affect (Scharff 2010). Moreover, some are concerned that the lack of psychical presence might interfere with the therapist’s provision of a holding environment (Migone 2013) and may create a sense of loss, or even be traumatizing for both therapist and patient (Argentieri and Mehler 2003).

Despite these concerns, the global pandemic of Covid-19, and the social distancing guidelines promulgated in response, have forced many analytic therapists to suddenly transition to the practice of remote therapy. In this paper we report on responses from 190 self-identified psychoanalytically oriented therapists who completed an online survey covering their experiences with remote therapy pre-pandemic, and with the en masse transition to online therapy, shortly after Covid-19 was declared a pandemic by the World Health Organization.

Analytic Therapists Who Transitioned to Remote Therapy

For a detailed overview of the 190 analytic therapists who participated in the survey, see Table 1. Most were women from the U.S. who identified as white. They had an average age of 60.5 (SD = 15; range, 28–90) and an average of 17 years (SD = 5.03) of clinical experience. Most were trained as professional psychologists, medical doctors, or social workers, and most worked in private practice. All identified as psychoanalytically oriented, and though many also identified with other theoretical orientations, over half reported that they treated at least some patients on the couch.

Table 1.

Descriptive statistics of the 190 therapists

Demographics	n	%
Gender
Female	127	66.8
Male	63	33.2
Location
United States	178	93.7
Europe	7	3.6
Canada	5	2.6
Ethnicity*
White	177	93.4
Hispanic or Latino	7	3.7
Asian or Asian Indian	6	3.2
Middle Eastern	3	1.6
American Indian or Alaska Native	2	1.1
African American	2	1.1
Profession
Psychologist	83	43.6
Medical doctor	45	23.7
Social worker	32	16.8
Counsellor	10	5.3
Marriage Family Therapist	2	1.1
Other (e.g., psychoanalyst/psychotherapist)	18	9.5
Work setting before the pandemic*
Hospital	9	4.7
Outpatient	14	7.4
Private practice	172	90.5
Inpatient	3	1.6
Phone/online	11	5.8
Patient population*
Adults	189	99.5
Older adults	100	52.6
Adolescents	78	41.1
Children	50	26.3
Couples & Families	14	7.4
Theoretical orientation*
Psychoanalytic	190	100
Psychodynamic	136	71.6
Integrative	43	22.6
Humanistic	22	11.6
Systemic	22	11.6
CBT	11	5.8
Treatments
All patients face to face	89	46.9
Most patients face to face	60	31.6
Half my patients on the couch	35	18.4
Most patients on the couch	5	2.6
All patients on the couch	1	.5
Previous experience providing phone therapy
Yes	155	81
No	35	19
Previous experience providing online therapy
Yes	106	55.8
No	84	44.2
Previous training in providing phone therapy
No	171	90
Yes	19	10
Previous training in providing online therapy
No	172	90.5
Yes	18	9.5
If given the choice, therapists preferred . . .
Video conferencing sessions	126	66.3
Phone sessions	64	33.7

Note. Response categories are reported in order of prevalence in this sample; * = multiple answers were possible per respondent.

Before the pandemic, the majority of these therapists were seeing all or most of their patients face to face, sitting upright, rather than on the couch. A large proportion had experience providing sessions over the phone, and a few had had training in how to conduct phone sessions. Similarly, more than half had some experience with providing online therapy, and some had received training on how specifically to conduct online sessions. Before the pandemic, they conducted on average 23 sessions per week in person (SD = 10.58), three sessions (SD = 2.28) by phone, and one session (SD = 2.84) online via videoconferencing. Once the pandemic was declared, an average of seven (SD = 7.91) of the in-person sessions changed to sessions by phone, and 15 (SD = 10.33) to online sessions. If given the choice, the majority of therapists preferred doing therapy online rather than by phone.

The Transition

During the pandemic, most analytic therapists prepared for the transition to online therapy in some way, mainly by speaking to colleagues, reading posts on listservs or forums, and/or reading governmental guidelines. Besides preparing themselves, they also prepared their patients by discussing the transition in sessions before the switch and in early online sessions. The online sessions were conducted mostly from home or from the therapist’s regular office. By far the biggest challenge of the transition to online therapy was the technical aspect. Many therapists also reported experiencing difficulty connecting emotionally to the patient, reading the patient’s emotions, and maintaining professional boundaries. Half of all therapists also reported that their patients struggled to find a suitable space for the online sessions, and some had concerns about confidentiality. Many were worried about their patients’ being distracted during sessions and some also about getting distracted themselves. For a more detailed overview of the reported responses, see Table 2.

Table 2.

Therapists’ transition to online therapy during the pandemic (N = 190)

Item	n	%
Therapists prepared themselves for transition to online therapy
Yes	147	77.4
No	43	22.6
How did you prepare yourself for the transition to online therapy?*
Spoke to colleagues	97	51.1
Read posts on listservs/forums	85	44.7
Read governmental guidelines	60	31.6
Spoke to supervisor	39	20.5
Attended online trainings/webinars	38	20
Prepared consent forms	37	19.5
Read journal articles	36	18.9
Therapists prepared their patients for transition to online therapy
Yes	147	77.4
No	43	22.6
How did you prepare your patient for the transition to online therapy?*
Discussed during the first online sessions	123	64.7
Discussed it before the switch	117	61.6
Provided technical support	43	22.6
Changed cancellation policy	37	19.5
Provided consent form	36	18.9
Provided information sheets	17	8.9
Therapist conducted online sessions
At home	124	65.3
In their regular office	66	34.7
What are challenges right now using online therapy?*
Technical/internet problems	123	64.7
Difficult for patient to find suitable space	89	46.8
Risk of patient getting distracted	85	44.7
Difficulty feeling connected with patient	56	29.5
Difficulty reading patients’ emotions	52	27.4
Risk of therapist getting distracted	50	26.3
Difficulty keeping professional boundaries	44	23.2
Confidentiality concerns	31	16.3

Note. Response categories are reported in order of prevalence in this sample; * = multiple answers were possible per respondent.

Many of these therapists (n = 126; 66.3%) thought they had possibly disclosed more to their patients in the online sessions than in the in-person sessions before the pandemic, and thought that the crisis situation had led to a loosening of their boundaries (n = 77; 40.5%) or that they had tried to compensate for the lack of physical presence (n = 49; 25.8%). When asked about how they thought their patients perceived online therapy, most therapists reported a positive (n = 101; 53.2%) or neutral (n = 55; 28.9%) patient experience, with only 34 reporting a somewhat negative online therapy experience for their patients (25.8%).

Comparison with In-Person Therapy

Many therapists reported that the relationship with most of their online patients during the pandemic felt as authentic as in the earlier in-person sessions (n = 122; 64.2%), and half of the sample felt as emotionally connected (n = 88; 46.3%). However, the other half of our sample reported lower levels of online connection (n = 78; 41.1%), and some also experienced lower levels of authenticity online (n = 42; 22.1%). Most therapists reported that the therapeutic relationship with most of their online patients during the pandemic felt as strong as in the earlier in-person sessions (n = 122; 64.2%), though many felt more tired in online than in in-person sessions (n = 143; 75.3%).

The transition to online therapy did not appear to impact most therapists’ sense of competence and confidence. Most felt as competent (n = 125; 65.8%) and as confident in their skills (n = 133; 70%) as before, though a large minority reported lower levels of competence (n = 60; 31.6%) and lower confidence in their skills (n = 48; 25.3%) in online therapy.

Most therapists indicated that before the pandemic they viewed online therapy as definitely (n = 67; 35.3%) or somewhat (n = 97; 51.1%) less effective than in-person sessions. Only 14 percent (n = 26) viewed it as equally effective. Since these therapists’ experience with online therapy during the pandemic, their opinions have become somewhat more positive. Very few now see online therapy as “definitely less effective” (n = 20; 10.5%), most see it as “somewhat less effective” (n = 119; 62.6%), and 25.3% (n = 48) now view online therapy as equally effective. Age was not related to previous (r = .12, p = n.s.) or current(r = .12, p = n.s.) views on the effectiveness of online therapy. Moreover, clinical experience was also unrelated to previous (r = .09, p = n.s.) or current (r = .04, p = n.s.) views on online therapy’s effectiveness. However, younger age was associated with more reported challenges with online therapy, such as difficulties feeling and expressing empathy(r = −.17, p < .05), feeling connected with the patient (r = −.26, p < .001), finding a suitable place for the session for both therapist (r = −.25, p < .001) and patient (r = −.22, p < .01), and both the therapist (r = −.31, p < .001) and patient (r = −.39, p < .001) getting distracted during the session. Age was unrelated to perceived technical challenges.

Previous experience with online therapy and previous training in online therapy were associated with more positive views of online therapy before the pandemic (r = .28, p < .001 and r = .24, p < .001, respectively), even after controlling for age, but neither made a difference in views during the pandemic. Among the strategies used to prepare for the transition, only speaking to colleagues (r = .19, p < .01) and reading posts on listservs and forums (r = .16, p < .05) were associated with more positive views about online therapy during the pandemic.

Discussion

Our survey results of 190 analytic therapists show that despite concerns regarding the analytic process, the majority of our sample already had experience with phone and/or videoconferencing sessions before the pandemic. Analytic therapists took several steps to prepare for the transition to online therapy and to prepare their patients as well. Despite the technical and relational challenges, during their online therapy sessions many felt that the therapeutic relationship with their patients remained as strong, connected, and authentic as in the in-person sessions, and most felt as confident and competent professionally as before. Notably, half of the therapists reported lower levels of connection with their online patients, and a small proportion felt less competent and confident using this new format for the sessions. Age, as in some previous studies (e.g., Perle et al. 2013), was found to be unrelated to views on online therapy, though therapists who struggled with more challenges regarding the transition to online therapy tended to be younger. This is possibly related to the home situation of younger therapists, who often have family responsibilities they need to balance while providing therapy from home. For example, for therapists taking care of young children at home, it might be challenging to find a private space to work and have the mental capacity to focus on and empathize with patients. More research about the experiences of analytic therapists of different ages during the pandemic is needed.

The online therapy experience during the pandemic resulted in a more positive view regarding its effectiveness, although many still viewed in-person sessions as more effective. Overall, the findings indicate that even within the context of long-standing concerns within the field, as well of a sense of rapid transition and uncertainty during the pandemic, many reported a positive therapeutic experience and a more favorable view toward online therapy in general.

It is likely that once the Covid-19 crisis has passed, there will remain a demand for psychoanalytic sessions provided by phone or videoconferencing, due to patients’ frequent travel and the increasing use of technology in recent times. In response to these societal changes, analytic therapists will likely have to adapt the ways in which they are delivering therapy (Scharff 2018). Our findings suggest that this might not be as detrimental as sometimes thought, as analytic therapists and their patients are likely to have had relatively positive therapeutic experiences and might have a more positive mindset toward remote therapy going forward. These positive experiences are in line with those reported by psychotherapists from other theoretical orientations (e.g., Aafjes–van Doorn and Békés 2020; Aafjes–van Doorn et al. 2020; Békés and Aafjes–van Doorn 2020). All in all, these findings highlight the need to provide more training and professional peer support around the provision of psychoanalytic interventions remotely so that analytic therapists can provide treatment in a variety of formats with confidence and competence.

Footnotes

ORCID iDs

Vera Békés

Tracy A. Prout

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