key: cord-0807349-8ljeiddn authors: Wang, Xiubing; Gordon, Robert M.; Snyder, Elise W. title: Comparing Chinese and US practitioners' attitudes towards teletherapy during the COVID‐19 pandemic date: 2020-10-27 journal: Asia Pac Psychiatry DOI: 10.1111/appy.12440 sha: 098161a4652aa5fb84f3b3ce43551f3ae0fa9304 doc_id: 807349 cord_uid: 8ljeiddn INTRODUCTION: The China American Psychoanalytic Alliance (CAPA) has been offering psychoanalytic psychotherapy training and treatment to Chinese mental health professionals entirely over the Internet since 2006. When the COVID‐19 pandemic began, most practitioners worldwide had to turn to teletherapy. US psychoanalytic practitioners were more negative towards teletherapy than those from other theoretical orientations. We predicted that CAPA practitioners as compared to US psychoanalytic practitioners would be more prepared for teletherapy services during the pandemic, since they their training and treatment had been on‐line. METHOD: We compared survey results from 164 CAPA practitioners with 165 US psychoanalytic practitioners (matched for age) who had recently psychoanalytically treated a patient on‐line. CAPA participants were recruited from CAPA email lists and the US sample were recruited from the Society for Psychoanalysis and Psychoanalytic Psychology of the American Psychological Association, the American Psychoanalytic Association and International Psychotherapy Institute. RESULTS: CAPA practitioners as compared to US psychoanalytic practitioners had more positive opinions about teletherapy before the pandemic; 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. The CAPA practitioners were more prepared to do psychoanalytic psychotherapy during the pandemic than the US psychoanalytic practitioners. DISCUSSION: Xiubing Wang discusses these findings in terms of her own experience as a CAPA graduate and treater before, during and after the COVID‐19 pandemic in China. The COVID-19 pandemic forced psychotherapists to go on-line. Sammons, VandenBos, and Martin (2020) surveyed 3038 doctoral psychologists at the beginning of the COVID-19 pandemic. Prior to the COVID-19 crisis, only 29% reported using any form of telepsychology, but after the onset of the crisis, 83% of respondents reported using it almost exclusively. Poletti et al. (2020) reviewed the evidence of the effectiveness of telepsychotherapy from 18 recent articles. Their results showed that, despite the skepticism of some therapists and some the public, telepsychotherapy is a trustworthy option that can be used effectively to treat common mental-health disorders. In this paper, the terms "psychoanalytic" and "psychodynamic" are used interchangeably. Also used interchangeably are the terms "distance treatment," "teletherapy," "telepsychotherapy," "tele-analysis," "remote therapy," and "on-line therapy." They also found that low familiarity with videoconferencing and technical issues might reduce the effectiveness of telepsychotherapy. Despite the favorable research on the effectiveness of distance psychotherapy, psychoanalytic practitioners have been reluctant to use it as compared to practitioners who favor other theoretical orientations. Perle et al. (2013) in their survey of 717 therapists found that cognitive-behavioral and systems psychologists were significantly more accepting of teletherapy interventions than were psychodynamic/analytic or existential therapists. Bekes and Aafjes-van Doorn (2020) surveyed 145 psychotherapists during the pandemic and also found that CBT therapists had a more positive attitude towards online therapy compared to psychodynamic psychotherapists. (Snyder, 2020) . Two studies from the point of view of the providers and the point of view of the consumers, evaluated the effectiveness of CAPA's program. Gordon, Wang, and Tune (2015) studied the expert opinions of 130 teachers, 152 supervisors and 163 psychoanalytic therapists in CAPA and found good support for distance training and treatment. CAPA strongly recommends, just as is the case in the psychotherapy training programs of the affiliates of the American Psychoanalytic Association, that students undertake personal treatment (Fishkin, 2020) . Gordon and Lan (2017) surveyed 90 CAPA graduates, most of whom had local treatment before having distance psychoanalytic treatment. The graduate/patients had a median of three average days a week in their own treatment. The graduates highly rated the effectiveness of their own psychoanalytic therapy over VCON. The graduates/patients felt that the therapist variables (warmth, wisdom, empathy, and skillfulness) were much more important in the effectiveness of their treatment than whether the treatment was in-office or with VCON, or because of any issues related to cultural differences. In our research, we wanted to test the hypothesis that the CAPA practitioners as compared to US psychoanalytic practitioners would be more prepared for psychoanalytic teletherapy services during the pandemic, since their training and treatment was on-line. "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 (ie, phone, videoconferencing) click on this link…." We received 877 surveys from US residents and 164 surveys from Chinese residents. In order to compare the US and Chinese samples we matched the US sample to the age of the Chinese sample so that they both had the same age distribution (χ 2 [3] = .003, P = 1.00). The modal age for the US sample was 60-69. This brought the US sample to N = 165. The modal age range for both samples after the adjusted US sample was age 30-39 (see Table 1 ). Most of the respondents identified as female (US: 71% female, 27% male, 2% other; China: 73% female and 26% male, 1% other). In our recruitment notice we asked for practitioners who "had recently psychoanalytically treated a patient by telepsychotherapy." In our survey, we also asked for primary theoretical orientation, since some practitioners might treat patients psychoanalytically, although they might have another primary theoretical orientation. Psychoanalytic/ psychodynamic was by far the most reported primary theoretical orientation (US 75%, China 97%). All responses were anonymous. The Washington Baltimore Center for Psychoanalysis Institutional Review Board gave full approval to conduct this study. Our on-line survey asked about the use of teletherapy before and during the pandemic. Also, we asked about the effectiveness of specific psychodynamic issues such as working with transference, relational problems, and resistance on-line. We know that there are more issues, but we found from previous research that the responses to many of these psychodynamic factors are highly correlated with each other (Gordon et al., 2015 It is interesting to note the very large differences in attitudes between the CAPA practitioners and the US psychoanalytic practitioners when it comes to teletherapy both before and during the COVID-19 crisis. It is also very interesting that the US sample changed little in their opinion about teletherapy despite the need for it. In comparison, the CAPA practitioners increased their value of teletherapy during the COVID-19 crisis. (See Table 2 ). Additionally our hypotheses were supported in that CAPA practitioners as compared to US psychoanalytic practitioners had more positive opinions about the effectiveness of teletherapy in working with transference, relational issues and resistance. (See Table 3 ). Our results found that CAPA practitioners as compared to US psycho- 3. Had more positive opinions about the effectiveness of teletherapy in working with transference, relational issues and resistance. The CAPA practitioners were more prepared to do psychoanalytic psychotherapy during the pandemic than the US psychoanalytic practitioners. This might be a result from CAPA practitioners having or having had their treatment on-line and treating more of their own patients on-line before the pandemic than the US practitioners. Prior research has shown that low familiarity with videoconferencing and technical issues may reduce the effectiveness of telepsychotherapy. The study was based on a survey of populations of convenience, which may be the only ethical methodology for conducting such research, but it has sources of bias. Sources of bias include the volunteer nature of the survey. There may also be cultural differences as well. CAPA trained practitioners were more experienced with distance treatment before the pandemic. But also, Confucian based cultures such as China are more likely to value and follow expert opinion than the US culture that is more individualistic and rebellious in their thinking (Littrell, 2006) . Dealing with the COVID-19 pandemic was a matter of following the expert advice. In the following narrative excerpt, Xiubing Wang will additionally offer an account as a full-time therapist in Shenzhen, China: Patients are not guests in your office when conducting online therapy (Campbell, 2020) . When you are the invited guest into the personal space of your patient, you are now viewing the patients' furnishings, artwork, children and pets that may intrude. Your face would be on the laptop of your patient's computer, and they can see their own face. All this should be considered as a different experience than in-office work. All these reactions are valuable for analysis and exploration. Note: Scales are rated from 1-5 (5 is highest score); χ 2 for 1 P < .0001; for 2 and 3 P = .02. Psychotherapists' attitudes towards online therapy during the COVID-19 pandemic CAPA supervision. Psychoanalytic Inquiry Distance psychoanalysis and psychotherapy in China Comparing psychodynamic teaching, supervision and psychotherapy over video-conferencing technology with Chinese students Assessing distance training: How well does it produce psychoanalytic psychotherapists? Psychodynamic Psychiatry Learning styles of students in and from Confucian cultures Attitudes toward psychological telehealth: Current and future clinical psychologists' opinions of internet-based interventions Telepsychotherapy: A leaflet for psychotherapists in the age of COVID-19. A review of the evidence Psychological practice and the COVID-19 crisis: A rapid response survey The history of CAPA How to cite this article Comparing Chinese and US practitioners' attitudes towards teletherapy during the COVID-19 pandemic We would like to thank for their assistance in helping to distribute our survey: Tiffany Bryant, Fu Xiaoyu, Wendy Cuiqin, Anna Innes, and Caroline Sehon. There were no conflicts of interest involved with this research. Data sharing is not applicable to this article as no new data were created or analyzed in this study.