We conducted an international survey to better understand both the negative and positive reactions of distance treatment during the pandemic. We received 1,490 survey responses from practitioners from 56 regions and countries who remotely treated patients psychoanalytically during the beginning months of the Covid-19 pandemic. Eighty-nine percent of the practitioners agreed or strongly agreed that distance treatment is valuable when the patient is house-bound or when travel would be difficult or impractical. They also expected to treat about 47% of their patients via teletherapy in the future. A minority group (17%) with mainly negative opinions does not feel that distance analytic treatment is effective with exploring mental life. Those with mainly negative opinions had more difficulty with the technology, had little value for teletherapy even for the patient who is homebound or when travel would be impractical, and considered bodily presence as very important to outcome. The majority of respondents who have mainly positive opinions feel that they can work effectively with transference, resistance and relational problems in distance analytic treatment.
Distance psychoanalytic treatment, Teleanalysis, Teletherapy, Online treatment
Distance psychotherapy has been around for a long time. As far back as 1951, psychoanalyst Leon Saul wrote, "...one wonders if the idea of using modern technology in the form of the telephone as an adjunct to psychoanalytic technique will be met with horrified resistance, or whether most analysts are already far ahead of this in their thinking and anticipate experimenting with televisual communication if and when this becomes practicable" (p. 287).
Saul  was right about the future use of technology and the resistance to it as well. Until recently, only a minority of therapists offered distance treatment until forced to do so because of the COVID-19 pandemic. Many psychotherapists had no choice but to offer teletherapy in order to provide ongoing treatment with existing patients and to accommodate patients who needed to begin treatment. Just before the pandemic, Pierce, Perrin & McDonald  found that only 21% of psychologists (N = 1,791) reported using teletherapy within their practice. A survey of 3,038 doctoral psychologists at the beginning of the COVID-19 pandemic (response rate of 13.6%) reported that prior to the COVID-19 crisis, only 29% reported using any form of teletherapy. However, after the onset of the crisis, 83% of respondents reported using it almost exclusively .
Patients have been largely accepting of telepsychotherapy. It is certainly more convenient, saving time, with no commute stress and cost. Many patients feel more comfortable in their own environment. Wenhua Yan (Ren, Sze, Yan, Shu, Xie & Gordon)  wrote that the informality of the online psychoanalytic psychotherapy and the opportunity of being in their own space could actually encourage some patients to be more open and willing to express themselves.
Aafjes-van Doorn, et al.  reported that very few therapists thought that their patients experienced video therapy negatively (7%); the vast majority of therapists perceived the patients' experience as either positive (64%) or neutral (28%). Sammons, VandenBos & Martin  found about 90% of respondents reported that a majority of their patients were neutral about the use of teletherapy. Gordon & Lan  surveyed 90 graduates of a distance psychoanalytic training program, most of whom had local treatment before having distance psychoanalytic treatment. The graduates had a median of 3 days a week treatment. The graduates highly rated the effectiveness of their own psychoanalytic therapy over videoconferencing (VCON). The mean score on the rating of effectiveness of participants' own therapy over VCON (0 = lowest rating; 6 = highest rating), was 4.73, (SD = 0.97).
Many psychoanalysts have found distance work valuable. Gibbs  interviewed six psychoanalysts that focused on the seven central themes relative to the use of distance technology: The psychoanalytic frame, the working alliance, interpretations, free association, transference and counter transference, ethical concerns, and overall effectiveness. Gibbs found that the majority of psychoanalysts, when considering these themes, felt that distance technology was highly useful and highly therapeutic.
However, large surveys indicate that psychoanalytic practitioners feel that distance treatment is inferior to in office work. Békés, et al. (2020)  surveyed 190 analytic therapists on their transition to online therapy via videoconferencing during the pandemic and their previous experience with remote therapy and found that a majority still considered online therapy less effective than in-person sessions. Gordon, Wang, & Tune  studied the opinions of 163 psychoanalytic therapists in the China American Psychoanalytic Alliance, a distance psychoanalytic training program. The therapists felt that with distance treatment, the issues of symptom reduction, exploring mental life, working with transference, working though relational problems, working with resistances, privacy concerns, and countertransference issues were all rated in the range of "slightly less effective" than in-office treatment (All the ratings went from 1 = much less effective, 2 = less effective, 3 = slightly less effective, 4 = no difference (from in-person treatment), 5 = slightly more effective, 6 = more effective, and 7 = much more effective). Gordon, Tune & Wang  found that the mean ratings of "slightly less effective" in their previous study was actually a combination of two very different groups: 40% felt distance treatment was clearly "less effective" and 60% felt that it was "similar to in-office work". Nevertheless, low-raters and higher-raters of effectiveness both agree that treatment over VCON is valuable since it offers quality treatment to under-served or remote patients, and it is valuable when the patient is house-bound or when travel would be impractical.
Research has shown favorable results with distance psychotherapy. The results of an outcome analysis of three different deliveries of psychotherapy- face to-face, real-time videoconference (VCON), and 2-way audio found no significant differences among treatment groups . Irvine, et al.  reviewed 15 studies that used telephone and face-to-face psychotherapy. These studies found little difference between them in terms of therapeutic alliance, disclosure, empathy, attentiveness or participation. Poletti, et al.  reviewed the evidence of the effectiveness of teletherapy from 18 recent studies. They wrote that with the COVID-19 outbreak, teletherapy was imposed on most practitioners. Their results showed that, despite some therapists' and the public's skepticism, teletherapy can be used effectively to treat common mental-health disorders such as anxiety, depression and post-traumatic distress. They found that a higher number of sessions and the proper management of patients' expectations seemed to be associated with better outcomes. Watts, et al.  studied 115 participants suffering from generalized anxiety disorder (GAD), 50 of whom were randomly assigned to therapy by videoconference and 65 of whom were randomly assigned to conventional psychotherapy. Each client and their psychotherapist completed the Working Alliance Inventory every 2 sessions. Clients showed a stronger working alliance in the VCON psychotherapy than in conventional psychotherapy. Filgueiras & Stults-Kolehmainen  surveyed 360 Brazilians at the start of the COVID-19 quarantine and 1 month later. They found that the use of telepsychotherapy predicted lower levels of depression and anxiety. Lindegaard, Berg & Andersson  conducted a systematic review and meta-analysis of randomized controlled trials of the efficacy of internet-delivered psychodynamic therapy (IPDT). They concluded that, "IPDT is a promising treatment alternative, especially for depression".
Despite the favorable research on the effectiveness of distance psychotherapy, many psychoanalytic practitioners have been reluctant to use it as compared to practitioners who favor other theoretical orientations. Perle, et al.  in their survey of 717 therapists found that Cognitive-behavioral and systems psychologists were significantly more accepting of teletherapy than were psychodynamic/analytic or existential therapists. And more recently, Békés & Aafjes-van Doorn  found that CBT therapists had a more positive attitude towards online therapy compared to psychodynamic psychotherapists.
Experience and comfort with Internet and telecommunications technology appear to be a factor in the use of teletherapy. Aafjes-van Doorn, et al.  reported that therapists with more online therapy experience reported lower levels of self-doubt and anxiety. Those who experienced strong online relationships during the pandemic, or thought their patients viewed it positively, tended to be more accepting of video therapy. Several studies have found that the perceived effectiveness of telepsychotherapy [13,18] and teleanalysis  increases with more use and more comfort with the technology.
Wang, Gordon & Snyder  compared psychoanalytically trained Chinese practitioners who received their treatment and training online, with a group of U.S. psychoanalytic practitioners matched for age. They found that the Chinese practitioners had more positive opinions about teletherapy during the pandemic and had more positive opinions about the effectiveness of teletherapy in working with transference, relational issues and resistance. Since the Chinese practitioners were all treated and trained online, and it is likely that they were more prepared to do distance psychoanalytic psychotherapy during the pandemic than the U.S. psychoanalytic practitioners.
There are therapists and patients that feel that without an embodied presence in an office, there can be no real psychoanalytic therapy. There is an affective reaction to being in a treater's presence that might matter more to certain personalities than to others. These affects might influence the degree of comfort with distance treatment, but we have no data yet as to whether these emotions will influence the outcome of treatment. Moshtagh's  response to this concern is that "Being spatially distant poses no contradictions for psychoanalysis, as long as both parties-patient and analyst, supervisee and supervisor, candidate and instructor-are willing to listen, hear, and be heard emotionally".
Our review of the literature on the shift to teletherapy by psychoanalytic practitioners indicated some conclusions as well as gaps in our understanding. The patients are largely more satisfied with the change to teletherapy than the practitioners. There is support that distance treatment is effective. However, psychoanalytic practitioners tend not to be as enthusiastic as practitioners from other theoretical orientations. Is their negativity due to the discomfort with the technology, or lack of embodied presence in the treatment or other factors? We need to try to better understand this attitude, since it can affect the quality and availability of services.
1. We predicted along with the increased use of teletherapy during the pandemic, that psychoanalytic practitioners would expect to significantly increase their use of distance treatment as a regular option in their practices in the future. We also expect positive attitudes toward teletherapy to correlate with: The comfort with internet technology, that a therapeutic relationship need not to be embodied in an office, belief that mental life can be explored with distance treatment, and the value of offering distance treatment when travel for the patient would be difficult or impractical.
2. Our review of the literature suggests that while psychoanalytic practitioners as a whole tend to not be as enthusiastic about teletherapy as compared to practitioners from other theoretical orientations, we believe that this finding is more based on a highly opinionated sub-group within psychoanalytic therapists. This sub-group is very much against distance psychoanalytic treatment. We predict that when we divide the responses to the question "How do you feel about teletherapy now?" (during the pandemic) into two groups "mainly negative" and "mainly positive," the "mainly negative" group will state that they have more difficulty with using the technology, rate the treatment as less effective in dealing with transference; relational issues; resistance; consider less bodily presence more of a problem; have less value for using teletherapy for the homebound than the "mainly positive" group.
Our methodology employs a large international sample of the opinions of psychoanalytic practitioners collected in the early phase of the pandemic, between May 14 and June 8th 2020. We wanted to give practitioners a few months to experience the change from mainly embodied, in-office treatment to mainly on-line treatment before we began to collect our data. We used populations of convenience from email lists and listservs from the: China American Psychoanalytic Alliance (CAPA); International Psychotherapy Institute; Society for Psychoanalysis and Psychoanalytic Psychology of the American Psychological Association, and the American Psychoanalytic Association. We emailed a link to our Survey Monkey questionnaire and included the following notice: "Please help us with our research: Telepsychotherapy During the 2020 Pandemic. We are considerate of your time, so we kept the survey to less than 4 minutes. If you have recently psychoanalytically treated a patient by telepsychotherapy (i.e., phone, videoconferencing) click on this link:..."
We received 1,490 completed surveys, from 56 regions and countries: United States (59%), then China (11%), Europe (8%), United Kingdom (4%), Latin America (4%), Canada (3%), and Australia/New Zealand region (2%), Indian Subcontinent (1%), South Africa (1%) and other (7%). Most of the respondents identified as female (68%; male 31%; not listed and prefer not to answer, 1.5%). The mean age range was 50-59 for the whole sample, with over-all 65% of the sample within the 40-69 age range. Distribution across professions: Psychologists (46%), counselors (21%), social workers (15%), psychiatrists (12%). Psychoanalytic/psychodynamic was by far the most reported primary theoretical orientation (79%). Other orientations include CBT (9%), Humanistic/Existential (6%), Family Systems (2%) and other (4%). No surveys were excluded from our data analysis. All responses were anonymous. Gender and age did not significantly interact with any of the other variables. To correct for the large sample size, we only reported significant levels p < 0.001 and r greater than 0.40. The Washington Baltimore Center for Psychoanalysis Institutional Review Board gave full approval to conduct this study.
We used Survey Monkey which estimated that the average time to take the survey was about 4 minutes. We worked to make the survey short to increase compliance, and to be more easily read for those whom English is a second language. We used ad hoc scales with face validity to assess the specific issues related to the use of telepsychotherapy in the context of the Covid-19 pandemic. The first few questions were for demographic data. We asked about the use of telepsychotherapy before and during the pandemic and how much the respondents might use teletherapy in the future. We asked how problematic video conferencing was for them. Then we asked about specific psychodynamic issues such as working with transference, relational problems, and resistance. We know that there are more therapeutic issues, but we found from previous research that the responses to many of these psychodynamic factors are highly correlated with each other . The issue however of bodily presence is the one that is most strongly debated. We asked, "How much does less shared bodily presence affect the outcome of teletherapy?" We found from previous research that one of the highest rated reasons for having remote sessions was when the patient is house-bound or when travel would be difficult or impractical . We wanted to assess any differential responding to this largely agreed upon indication.
Our hypotheses were supported in that practitioners not only greatly increased their use of teletherapy during the pandemic, but additionally, practitioners significantly expected to increase their use of teletherapy as a regular part in their practices into the future. We also found that positive attitudes toward teletherapy to correlate with: The comfort with internet technology (VCON), that a therapeutic relationship need not to be embodied in an office, belief that mental life can be explored with distance treatment, and the value of offering distance treatment when travel for the patient would be difficult.
1. We asked, "What percentage of your patients did you see via teletherapy before the pandemic?" We found that before the pandemic, practitioners saw 20% of their patients with teletherapy.
2. We asked, "What percentage of your patients do you see by teletherapy now?" The practitioners responded that they saw 86% of their patients with teletherapy in the early phase of the pandemic, (change: t = -71.80, p < 0.00001, Cohen's d = 2.68).
3. In response to the question, "How much might you use teletherapy in the future?" practitioners stated that they expected to see about 47% of their patients via teletherapy in the future.
4. Practitioners were asked how much they agree with: "Teletherapy is valuable when the patient is house-bound or when travel would be difficult or impractical" (1 = Strongly disagree, 5 = Strongly Agree). Eighty-nine percent of the practitioners agreed or strongly agreed that teletherapy is valuable when the patient is house-bound or when travel would be difficult or impractical.
The ease of use of the technology ("How problematic has the use of videoconferencing been with your patients?" (1 = A great deal of problems, 100 = Not problematic) was highly correlated with the following ratings:
1. "What do you think about using teletherapy now? (1 = Mainly negative, 5 = Mainly positive) (r = 0.52, p < 0.0001);
2. "How much might you use teletherapy in the future?" (1 = Not at all, 5 = A great deal) (r = 0.41, p < 0.0001);
3. "How effective is teletherapy compared to in-office treatment with respect to working with transference?" (1 = Not effective, 5 = Similar results to in-office) (r = 0.51, p < 0.0001);
4. "How effective is teletherapy compared to in-office treatment in working with relational problems?"(1 = Not effective, 5 = Similar results to in-office) (r = 0.52, p < 0.0001);
5. "How effective is teletherapy compared to in-office treatment in working with resistance?" (1 = Not effective, 5 = Similar results to in-office) (r = 0.50, p < 0.0001);
6. "How much does less shared bodily presence affect the outcome of teletherapy?" (1 = Extremely detrimental, 5 = Similar results to in-office) (r = 0.52, p < 0.0001).
Our second hypothesis was supported. As predicted, the group who were most negative toward teletherapy reported more difficulty with internet technology (VCON), more valued the necessity of a physical presence for treatment, believed that mental life is poorly explored with distance treatment, and had less value for distance treatment for the patient who is house bound or for whom travel is impractical.
To test this, we divided practitioners into two groups (leaving out the "Mixed" opinion group N = 500) based on their responses to the question "What do you think about using teletherapy now?" There were 248 practitioners who during the early phase of the pandemic still felt "mainly negative" about teletherapy, and 733 practitioners who during the early phase of the pandemic felt "mainly positive" about teletherapy.
1. We found that the "mainly negative" group responded to the question, "How problematic has the use of videoconferencing been with your patients?" (1 = A great deal of problems, 100 = Not problematic) (M = 36.0, SD = 17.83) as compared to the "mainly positive" group (M = 75.65, SD = 23.57, p < 0.00001, Cohen's d = 2.04).
2. The "mainly negative" group rated the question "How effective is teletherapy compared to in-office treatment with respect to working with transference?" (1 = ineffective, 5 = similar results to in-office) M = 1.96, SD = 0.47) as compared to the "mainly positive" group (M = 3.9, SD = 0.85, p < 0.00001, Cohen's d = 3.30).
3. The "mainly negative' group responded to the question "How effective is teletherapy compared to in-office treatment in working with relational problems? (M = 1.95, SD = 0.51 as compared to the "mainly positive" group M = 3.9, SD = 0.88, p < 0.00001, Cohen's d = 3.20).
4. The "mainly negative" group responded to the question "How effective is teletherapy compared to in-office treatment in working with resistance?" (M = 1.92, SD = 0.46 vs. "mainly positive" M = 3.7, SD = 0.93, p < 0.00001, Cohen's d = 2.95) (see Table 1).
Table 1: Attitudes of practitioners who during the pandemic felt "mainly negative" about teletherapy (n = 248) and those who felt ‘mainly positive" about teletherapy (n = 733) in exploring mental life. View Table 1
5. The "mainly negative" attitude group responded to the question "How much does less shared bodily presence affect the outcome of teletherapy?" (1= Extremely detrimental, 5 = Similar Results to In-office) (M = 1.17, SD = 0.51 vs. "mainly positive" attitude group M = 3.45, SD = 0.86, p < 0.00001, Cohen's d = 3.67).
6. The "mainly negative" attitude group responded to the question "Teletherapy is valuable when the patient is house-bound or when travel would be difficult or impractical" (1 = strongly disagree, 5 = Strongly Agree) (M = 3.87, SD = 0.53 vs. "mainly positive" attitude group M = 4.4, SD = 1.08, p < 0.00001, Cohen's d = 0.76).
Prior research on the use of teletherapy for psychoanalytic treatments shows mixed opinions about effectiveness. The research was unclear as to why psychoanalytic practitioners were more negative about teletherapy than other theoretical orientations. The Covid-19 pandemic brought about a crisis where the problems that psychoanalytic practitioners had with distance treatment were no longer just a theoretical issue. Practitioners needed to help people with teletherapy. We wanted to better understand the opinions about teletherapy as applied to psychoanalytic treatment.
The Covid-19 pandemic was an international crisis, so unlike previous research, we wanted a multicultural perspective on the psychoanalytic use of teletherapy. Our survey consisted of 1,490 responses from practitioners from 56 regions and countries who remotely treated patients with psychoanalysis or psychoanalytic psychotherapy during the early phase of the shelter at home and physical distancing due to the COVID-19 pandemic. Unlike previous studies which had time consuming surveys, we kept our survey to about 4 minutes to encourage a higher rate of response. Also, we wanted it quick and easily understood, since for many of our respondents English was a second language. We found that consistent with previous research, practitioners reported from seeing an average of 20% of their patients on-line before the pandemic to 86% during the pandemic. Not previously explored, we found that the practitioners expected to increase their use of teletherapy as a regular part in their practices in the future to seeing almost half their patients on-line. This figure may be an underestimate, since the data was collected during the early phase of the pandemic when many practitioners were still just learning how to use Internet technology for distance treatment.
Eighty-nine percent of practitioners agreed or strongly agreed that teletherapy is valuable when the patient is house-bound or when travel would be difficult or impractical, although those who were negative about teletherapy were less likely to use distance treatment even under those circumstances. The expected use of teletherapy in the future was highly correlated with the ease of use of videoconferencing technology, the less concern about the lack of bodily presence, and the belief that one can work with transference, relational problems, and resistance with distance treatment.
Previous research on distance treatment usually treated psychoanalytic practitioners as a unimodal group. However, Gordon, Tune & Wang  found that there is a very distinct group of practitioners who are strongly opposed to distance psychoanalytic treatment. We believe that averaged ratings of opinions do not always give a clear picture of psychoanalytic practitioners' attitudes toward distance treatment. We felt that a data analysis should be broken into two groups- as we did in this study. We divided practitioners into those who during the pandemic still felt "mainly negative" about teletherapy and those who felt ‘mainly positive" about teletherapy. The mainly negative attitude group stated that they had much more difficulty using internet technology than the mainly positive attitude group. The negative group did not believe that teletherapy could be effective in dealing with transference, relational issues and resistance. The group that rated teletherapy mainly positive believed that teletherapy was practically similar to in-office work in dealing with transference, relational issues and resistance. The mainly negative opinion group considered the absence of bodily presence in teletherapy more of a problem than the positive group.
We believe that previous research findings that psychoanalytic practitioners generally have more negative attitudes towards teletherapy than those of other theoretical orientations are not correct. We found that most psychoanalytic practitioners consider teletherapy valuable and effective, and that there is small group that is strongly against doing psychoanalytic treatment on-line.
Limitations of this study are that it was based on populations of convenience, who volunteered to take the survey. We consider that this may be the only ethical methodology for conducting such research. We do not have any reason to suspect that the volunteer nature of the sample would significantly skew the results. Both those who had negative attitudes as well as those who had positive attitudes toward teletherapy participated in the study. We were not able to compute the exact response rate, since we used different email lists and listserv announcements from various organizations. However, our findings are very similar to other surveys on the same topic [2,3,5,8,17]. Also, pre-pandemic attitudes were not assessed and so findings speak primarily to respondent appraisals of their attitudes at the time of the survey. Finally, we did not partial out our independent variable of "psychoanalytic practitioners" into sub-groups of theoretical orientations or levels of training. We wanted to assess the over-all opinions of world-wide psychoanalytic practitioners about distance treatment during the pandemic.
In the future, it would be interesting to research if there are theoretical, training or trait differences (dependency, loneliness, etc.) that are involved in the feelings that practitioners have about teletherapy. Patients may feel positive about teletherapy for its convenience and the comfort of being in their own environment. However, practitioners during the pandemic have been put into long days of a lonely situation with many screen relationships. Some of these practitioners may not be in touch with how much they might feel the loss of the embodied gratification and may externalize that it is the patient who suffers the loss with teletherapy.
Also, future research may want to explore the impact of the countries' different healthcare systems and how they finance teletherapy. Moreover, it would be interesting to explore a subgroup analysis of attitudes between psychodynamic practitioners and compare them to those of other theoretical orientations.
Over-all, our findings suggest that much of the negative reaction to teletherapy is based on the practitioners' difficulties with technology, and their beliefs about what constitutes a therapeutic relationship. With experience, favorability increases, as evidenced by our finding that therapists plan to increase their use of teletherapy in the future after the pandemic. Further research is needed to test if this pans out. There is also a need for research on the unconscious meaning of being in the presence of the therapist and the patient. With teletherapy comes the greater availability of treatment across communities and countries, but also new problems. Are there attachment issues and personality traits that are particularly sensitive to the lack of a physical presence of the other? Does the overuse of screen time treatment contribute to therapists' isolation? These are yet to be studied. Jill S Scharff  made suggestions for self-care with the frequent use of on-line work and offered practical advice for making the necessary adjustments to provide competent, ethical teleanalysis and teletherapy. This sort of education about the use of on-line psychoanalytic treatment is essential for all analysts, analytic candidates and psychodynamic practitioners.
In this paper, the following terms are used interchangeably: "distance treatment," "teletherapy," "telepsychotherapy," "teleanalysis," "remote therapy," and "on-line therapy. "We would like to thank for their assistance in data collection: Tiffany Bryant, Xiubing Wang, Fu Xiaoyu, Wendy Cuiqin, Anna Innes, and Caroline Sehon. We also appreciate the feedback on our survey questions by: John Auerbach, Jacques P. Barber, Barbara Milrod, Paolo Migone, and Anthony F. Tasso. And thanks to Robert F. Bornstein and Kunhae Lee for help with the revision.