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Lin, T., Stone, S. J., Heckman, T. G., & Anderson, T. (2021). Zoom-in to zone-out: Therapists report less therapeutic skill in telepsychology versus face-to-face therapy during the COVID-19 pandemic. Psychotherapy, 58, 449–459.

The COVID-19 pandemic has confronted psychotherapists with several challenges including rapidly switching their practice to using teletherapy (videoconferencing, phone, and other virtual media). The use of teletherapy in clinical work increased from 7.1% prior to the pandemic to 85.5% during the pandemic. And estimates suggest that at least one-third of clinical work will be performed by teletherapy post-pandemic. Over a third of psychologists reported that they lacked training in using teletherapy, and they believe that their skills in this domain are inadequate. Therapists have raised a number of concerns in past surveys including issues related to privacy, professional self-doubt, technological competence, challenges to the therapeutic relationship, and problems with implementing some interventions. In this survey of 440 therapists and trainees, Lin and colleagues were particularly interested in therapists’ perceptions of the impact of teletherapy relative to in person therapy on the therapeutic process and patient outcomes. Videoconferencing was the most frequently used modality by 73.56% of surveyed therapists. The survey asked if three broad areas of practice were affected by teletherapy compared to in person therapy. These areas included common therapeutic factors (level of therapist empathy, emotional expression, warmth, alliance bond), extra-therapeutic patient factors (the patient’s environment that impacted their ability to engage in homework or use prescribed resources), and perceived patient outcomes (therapist ratings of patient symptom reduction, satisfaction, clinical improvement). Therapists in the survey were representative of the population of therapists in the US, and 82% of them provided all their clinical work in recent months by teletherapy. Compared to in person therapy, therapists reported poorer skills related to common therapeutic factors (d = 0.86), somewhat greater impact of extra-therapeutic factors (d = 0.36), and perceived poorer patient outcomes (d = 0.68) in teletherapy. Therapists who were younger, preferred emotion-focused or relational therapies, and with no prior training reported a relatively greater decrease in therapeutic skills in teletherapy compared to in-person therapy.

Practice Implications

By far, most therapists believed that providing psychotherapy by virtual means reduced their capacity to use common therapeutic stances including empathy, warmth, and the therapeutic alliance. Some of this might be affected by the psychological distance caused by the virtual format and difficulties with reading body language and other non-verbal cues. Therapists perceived that patient outcomes suffered as a result. This was particularly true for younger therapists, possibly because of the impact of adopting the new modality on their professional self-confidence. Also, therapists who preferred experiential or interpersonally based therapies felt particularly challenged possibly because these therapies may be more reliant on emotional communication and discerning patient interpersonal behaviors. Training and support are needed for therapists and trainees to improve their confidence in providing teletherapy.

Finsrud, I., Nissen-Lie, H. A., Ulvenes, P., Melsom, L., Vrabel, K., & Wampold, B. (2022, September). Confidence in the therapist and confidence in the treatment predict symptomatic improvement week by week in therapy: A latent curve modeling approach. Journal of Counseling Psychology. Advance online publication.

In his classic book Persuasion and Healing, Jerome Frank suggested that all psychotherapies involve a trusting emotionally charged relationship with a sanctioned healer who has a good rationale for their interventions. The common factors approach to psychotherapy was born from this kind of thinking. Carl Rogers, for example, argued that to be effective therapists had to engage in unconditional positive regard, empathic understanding, and a genuine non-defensive stance. Contemporary therapeutic alliance theory emphasizes similar factors plus the patient’s expectation of benefit from therapy created through accepting the rationale for the therapy and agreement on the tasks and goals of therapy. From this research and theory, one can see that a patient’s confidence in the therapist and confidence in the treatment may be key common factors underlying effective therapies. Confidence in the therapist refers to a patient who believes that the therapist has the relational skills to help, and that the therapist is working in the patient’s best interest. Confidence in treatment refers to the patient’s belief that the rationale for treatment is meaningful, and that the treatment itself will remedy their problems. In this study, Finsrud and colleagues were interested in whether confidence in the therapist or treatment in one session predicted symptom reduction in the next session. Or was it the other way around – does symptom reduction increase a patient’s confidence? If the results showed the latter, then confidence is result of symptom improvement and so has little or no therapeutic value. The study had 587 adults receiving inpatient treatment for a variety of disorders and treated by psychotherapists of different orientations. Patients completed a measure of confidence in the therapist and treatment, and a scale of their depressive symptoms twice a week for an average of 12 weeks. The authors used sophisticated statistical modeling techniques to examine the effect of a patient’s preceding levels of confidence in therapist or treatment on the patient’s subsequent session symptoms, and vice versa. The researchers found that an increase in confidence in the therapist and confidence in the treatment predicted a decrease in symptoms in the next session. They also found that a reduction in symptoms predicted an increase in confidence in the therapist and in treatment in the next session.

Practice Implications

Patients’ confidence in the therapist and in the treatment both contribute to symptom reduction over and above early symptom change. In other words, the patient’s perception of the therapist as a person and their expectations that the treatment will be helpful are likely key factors that predict a reduction in symptoms. Therapists must have positive regard, genuineness, and empathy towards patients to facilitate the patients’ confidence in the therapist as a person. And therapists must provide a clear rationale for the treatment and develop a collaborative understanding with patients on how therapy will be done (agreement on the tasks) and what the desired outcomes will be (agreement on the goals).

Larsson, B. P., Broberg, A. G., & Kaldo, V. (2013). Do psychotherapists with different theoretical orientations stereotype or prejudge each other? Journal of Contemporary Psychotherapy, 1-10.

A remarkable difference between the field of psychotherapy and other health care or scientific areas is that psychotherapy is organized in different and somewhat competing theoretical orientations or schools. Leading thinkers of psychotherapy integration, have emphasized how this division presents an obstacle to integration and therefore to progress within the practice and science of psychotherapy. One of these obstacles could be persistent stereotypes that psychotherapists might have about other therapists who practice from a different theoretical orientation. Social psychologists have long known that people in one group (e.g., an in-group) may misjudge or stereotype people in other groups (e.g., out-groups). Stereotypes may be negative if members of an in-group hold a positive bias toward their in-group coupled with antagonism toward members of an out-group. Do psychotherapists stereotype other therapists who practice from a different theoretical orientation? A recent study by Larsson and colleagues addressed this question. They surveyed 416 therapists divided into four ‘pure’ self-reported schools: 161 psychodynamic therapists, 93 cognitive therapists, 95 behavioural therapists, and 67 integrative/eclectic therapists. Most were women (76%), mean age was in the mid 50s, mean experience was 5 to 10 years, and they represented a variety of disciplines including psychology, psychiatry, social work, and nursing. In the first section of the survey, therapists indicated what focus they deemed most important to their own psychotherapeutic work, including: (1) therapeutic relationship, (2) patient’s thoughts, (3) patient’s feelings, (4) patient’s behaviour, or (5) connection between the patient’s thoughts, feelings, and behaviors. Therapists then estimated how they thought psychotherapists from other orientations would rate each of these foci. In the second section of the survey, therapists completed scales about what they deemed were important aspects of psychodynamic, cognitive, behavioral, and eclectic/integrative therapy, respectively. Once again, they rated how they thought therapists from the other orientations would respond. Self-ratings of therapists within each orientation indicated the ‘true’ (i.e., prototypical) opinions of each orientation. The differences between ‘true’ opinions of the in-group versus the in-group’s ratings of therapists from other orientations (i.e. of the out-group) indicated the level of misjudgement or stereotyping. Of the 18 areas on which out-groups were rated, 11 were significantly misjudged by the in-group. Eclectic/integrative therapists were much less likely to stereotype therapists of cognitive or psychodynamic orientations, who were equally likely to stereotype others. The belief that one’s own orientation compared to others is better characterized as an applied science (a belief endorsed most often by cognitive therapists) was a statistically stronger predictor of stereotyping than orientation per se.

Practice Implications

Some researchers argue that different orientations are more similar in their practice of psychotherapy than theory would predict. Furthermore, research about common factors in psychotherapy suggests that these factors may be more important than techniques specific to a school of psychotherapy. However, as long as there are different therapeutic orientations there will likely remain a tendency among some psychotherapists to search for differences rather than to look for similarities between their own and other orientations. This may lead to stereotyping (i.e., an inaccurate opinion about therapists of other orientations), and perhaps negative stereotyping. Psychotherapists and researchers may want to keep in mind the tendency to stereotype clinicians from other orientations when talking to or about other psychotherapists. Such stereotyping is likely an impediment to good client care and research.

Author email: billy.larsson@psy.gu.se