key: cord-0935822-x2bgqiwz
authors: McKee, Grace B.; Pierce, Bradford S.; Tyler, Carmen M.; Perrin, Paul B.; Elliott, Timothy R.
title: The COVID‐19 Pandemic’s Influence on Family Systems Therapists’ Provision of Teletherapy
date: 2021-04-29
journal: Fam Process
DOI: 10.1111/famp.12665
sha: 0090b9887cc77064ada09b2974d55d0fe82f7a3b
doc_id: 935822
cord_uid: x2bgqiwz

The COVID‐19 pandemic has altered life globally like no other event in modern history, and psychological service changes to meet the resultant impacts on families have not been assessed in the empirical literature. The purpose of the current study was to examine whether family systems therapists increased their teletherapy use during the pandemic relative to prepandemic usage, and whether projected postpandemic rates would remain at the same level; further, environmental and demographic predictors of these changes were examined. In May 2020, a sample of 626 family systems therapists (58.6% women, 40.6% men; M = 57.4 years old; M years in practice = 25.5) completed a national online study assessing these variables. Results suggested that family systems therapists performed 7.92% of their clinical work using teletherapy before the pandemic and 88.17% during the pandemic. They also projected that they would perform 36.57% of their clinical work using teletherapy after the pandemic. Teletherapy uptake was unrelated to primary practice setting, provider age, gender, race/ethnicity, and practice location (urban/suburban vs. rural) but was higher for family systems therapists who reported increased supportive teletherapy policies and training in their practice setting. Organizational infrastructure and availability of training played an important role in influencing teletherapy uptake during the pandemic. Family systems therapists have a unique opportunity to deploy teletherapy modalities to meet the needs of families during the COVID‐19 pandemic, and infrastructure and training to do so may facilitate that work.

Pandemic proscriptions instigated a quick transition from traditional in-person therapy to teletherapy in the first quarter of 2020 (Sammons, VandenBos, & Martin, 2020) . Acceptability, efficiency, and effectiveness of teletherapy for the treatment of some of the most commonly occurring mental health conditions (e.g., depression, anxiety, and substance use) have been demonstrated repeatedly (e.g., Adler, Pritchett, Kauth, & Nadorff, 2014; Bennett, Ruggero, Sever, & Yanouri, 2020) . However, prepandemic teletherapy utilization comprised merely 7% of therapists' clinical practice and was predicted by their perceptions of its clinical value and how difficult it would be to use (Pierce, Perrin, & McDonald, 2020a) . In the COVID-19 milieu, the research on acceptability, efficacy, and efficiency of teletherapy has become more salient, and research performed during the pandemic found therapists were using teletherapy to provide more than 85% of their services (Pierce, Perrin, & McDonald, 2020b) . Barnwell (2019) asserted that since email, videoconferencing, and electronic medical records are already integrated in most practices, using teletherapy for provision of direct psychological services is a natural progression. Some have opined that the previously slow adoption of teletherapy was due to limited training (Cooper, Campbell, & Smucker Barnwell, 2019) , which may have been emphasized by the sudden demand for teletherapy. However, educational, research, and professional entities have heightened efforts to fill this gap by publishing best practice guidelines and handbooks for teletherapy provision and supervision (e.g., APA, 2020; Sahebi, 2020) .

While lack of training may have hindered earlier adoption of teletherapy, other likely barriers were federal regulations meant to protect patient privacy (e.g., HIPAA), Medicare and Medicaid reimbursement schedules (APA, 2014; United States Centers for Medicare & Medicaid Services, 2019), and other state and local laws governing the use of teletherapy. Many regulations have been relaxed during the pandemic to better accommodate telehealth (U.S. Department of Health & Human Services' Office for Civil Rights, 2020) . Practices with established teletherapy policies and procedures before the COVID-19 crisis were better equipped to make the transition to 100% teletherapy (Burgoyne & Cohn, 2020) . For example, teletherapy use for therapists in Veterans Affairs (VA) medical centers increased by a smaller margin (79) than the rise in usage for non-VA outpatient clinics (26x), largely due to early integration of telehealth in VA hospitals (Pierce et al., 2020b) .

As governments implemented measures to curtail the spread of the virus, families experienced major shifts in their usual routines (Pietromonaco, 2020) . Family systems www.FamilyProcess.org 2 / FAMILY PROCESS researchers have noted how these unique circumstances will provide insights into family adaptation to acute and chronic stressors (Brock & Laifer, 2020) . Enforced togetherness may have promoted interpersonal connectedness in some couples and families, while others have experienced increasing conflicts and anxiety with feelings of isolation, old arguments resurfacing, fear related to financial worries and the disease itself, and decreased privacy (G€ unther-Bel, Vilaregut, Carratala, Torras-Garat, & P erez-Testor, 2020) . In a 59-country study of the pandemic's effects on well-being, increases in verbal arguments or conflict with other adults in the home were the largest predictor, by far, of increased anxiety and depression as well as sleep problems . Moreover, there is evidence of increased domestic violence during the pandemic (Mahase, 2020) and qualitative research suggests that the pandemic may have exacerbated risk of intimate partner violence in relationships with a history of abuse (Lyons & Brewer, 2021) .

In fact, clinicians have noted marked advantages to teletherapy with couples and families such as improved access in areas with few mental health providers (Doss, Feinberg, Rothman, Roddy, & Comer, 2017) . Families with modified work and study hours have more flexibility because of the elimination of transportation concerns and arranging childcare for younger children (Fraenkel & Cho, 2020) . Teletherapy has also proven acceptable and effective in treating children and adolescents, as well as adults (Bennett et al., 2020) , an important consideration for family systems therapists. Another important benefit is the opportunity to decrease barriers to care for underserved populations (Cooper et al., 2019; Reed, Messler, Coombs, & Quevillon, 2014) . This is especially salient in the current health crisis, as racial/ethnic minority families are at greater-than-average risk of contracting COVID-19 and are experiencing more serious health effects (CDC, 2020a).

The current study focused on changes in teletherapy provision by family systems therapists as a function of the pandemic. Practice settings, institutional policies and training, and practitioner demographic characteristics and therapeutic approaches were examined to determine their potential influences on implementation of teletherapy. These variables were previously found to explain a substantial degree of variance in the use of teletherapy (Pierce, Perrin, Tyler, McKee, & Watson, 2020c) . There have been no known studies to date which have assessed how family systems therapists' usage of teletherapy has changed during the pandemic and what factors may have influenced those changes. It was hypothesized that utilization of teletherapy by family systems therapists would increase during the first few months of the pandemic when compared to prepandemic usage, and that postpandemic teletherapy rates of use would be projected to be higher than prepandemic but lower than during the pandemic. The current study represents a secondary analysis of a study of environmental and demographic predictors of therapists' use of teletherapy during the COVID-19 pandemic (Pierce et al., 2020c) .

Study procedures are more fully detailed in the manuscript for the original study (Pierce et al., 2020c) . The study was approved by the Virginia Commonwealth University Institutional Review Board. Invitations were emailed between May 11, 2020, and May 25, 2020, to 27,324 potential participants obtained from lists of psychologist newsgroups, social media groups, professional rosters, and directories from counseling centers and mental health clinics. This convenience sample of licensed psychologists was chosen Fam. Proc., Vol. x, xxxx, 2021 MCKEE, PIERCE, TYLER, PERRIN, & ELLIOTT / 3 because the co-author team was comprised of psychologists who, as a result, had access to professional psychologist directories.

Potential participants received a personalized email with a description of the study's purpose and an HTML link to the survey. Of these, 14.3% were returned as "undeliverable" and 15.8% of those delivered resulted in participants opening the survey; the overall completed response rate was 11.18%. Those who opened the link were provided a document describing the study, IRB compliance, investigator contact information, and an informed consent form. Eligible participants who consented to participate then answered questionnaire items assessing demographic information, practice characteristics, and use of teletherapy. The eligibility criteria to participate in the overall study were that respondents were (a) currently licensed to practice as a psychologist within the United States, (b) currently practicing as a psychologist by treating clients/patients, and (c) age 18 or older.

Among the 2,619 participants who completed the survey, a subset of 626 self-identified with a theoretical therapeutic approach as "family systems" and were thus included in the current analyses. Demographic and practice characteristics of the sample appear in Table S1 . Participants reported being 58.67 years old on average, with the majority (67.7%) identifying as women and 31.9% identifying as men. There were a greater number of therapists in this sample who identified as women in comparison to demographics reported by APA members, although the average age was similar (58.6% women, 40.6% men; M = 57.4 years old; APA, 2018). The average number of years in practice was 25.5, and most participants reported having an individual practice (58.0%) in a suburban (49.7%) or urban (41.4%) location.

Participants reported their current age, years in practice, gender, and race/ethnicity. They were also asked to indicate if their primary practice was located within a rural, suburban, or urban location, the type of setting (e.g., private practice, group practice, and VA medical center), the number of psychologists within their place of practice, their therapeutic orientation (Table S2) , and the treatment focus of their setting (e.g., ADHD, anxiety, depression, and obesity). For items assessing therapeutic orientation and setting treatment focus, respondents were asked to select all options that applied.

Actual teletherapy provision was assessed by asking participants, "What percentage of your patient treatment is provided using telepsychology?" where telepsychology was defined as "the use of real-time audio (e.g., telephone) and/or video conferencing technology to provide psychological services." Participants were instructed to provide answers based on three time points, (a) before the COVID-19 pandemic began in the United States on January 20, 2020, (b) during the COVID-19 pandemic in the United States, and (c) their anticipated use after the COVID-19 pandemic ends in the United States.

All descriptive statistics and analyses were conducted using IBM SPSS Statistics 26. First, a repeated-measures analysis of variance (ANOVA) was used to examine the effects of time on use of teletherapy. Time (three levels) was included as the sole predictor variable, with percentage of clinical work performed via teletherapy as the outcome variable.

www.FamilyProcess.org 4 / FAMILY PROCESS Second, four separate ANOVAs were conducted to test the effects of primary practice setting (the predictor variable) on the four outcome variables of percentage of clinical work performed via teletherapy prepandemic, during the pandemic, projected after the pandemic, and change from prepandemic to during the pandemic, respectively. For these ANOVAs, primary practice settings were excluded if they were selected by fewer than five participants, and those who chose the "other" practice setting were also excluded. Thus, for these ANOVAs only, participants in geriatric facilities, correctional facilities, rehabilitation centers, and residential treatment centers were excluded, as well as those who identified working in "other" practice settings.

Then, two multiple regression analyses were used to predict increases in use of teletherapy during the pandemic relative to before the pandemic. The first regression included predictors comprising participant demographic variables, changes in workplace policies regarding teletherapy provision, changes in workplace teletherapy training, and practice geographical area. Several predictor variables were dichotomized, including gender (1 = woman, 0 = man or transgender or nonbinary), race/ethnicity (1 = White/European American, 0 = racial/ethnic minority), and geographic area type (1 = rural, 0 = suburban/ urban). The second regression used workplace treatment foci as predictor variables.

The repeated-measures ANOVA showed that percentage of clinical work performed using teletherapy differed significantly by time, F(2,1250) = 2497.48, p < .001, partial eta squared = .80. Family systems therapists indicated that they performed 7.92% (SD = 15.71) of their clinical work using teletherapy before the pandemic, and 88.17% (SD = 25.79) during the pandemic. They also projected that they would perform 36.57% (SD = 27.59) of their clinical work using teletherapy after the pandemic. These changes demonstrate an over 11-fold increase in percentage use of teletherapy during the pandemic relative to use of teletherapy before the pandemic.

Before the pandemic, 42.5% of family systems therapists indicated that they did not provide any services via teletherapy, and an additional 39.1% reported providing <10% of their clinical work using teletherapy; moreover, only four individuals (0.6%) reported using teletherapy for all of their clinical work. In comparison, only 1.9% of family systems therapists reported that they did not use teletherapy for any clinical work during the pandemic, while 69.3% reported using teletherapy exclusively. Further, only 8.1% projected not using teletherapy for any clinical work after the pandemic had resolved, while 4.3% expected that they would use teletherapy exclusively for clinical work.

Before the pandemic, percentage use of teletherapy ranged from 3.54% (outpatient treatment facilities) to 9.44% (individual practices), while use during the pandemic ranged from 81.84% (school/university clinics) to 92.84% (group practices). After the pandemic, family systems therapists projected percentage use of teletherapy ranging from 29.47% (school/university clinics) to 44.17% (Veterans Affairs Medical Centers). Four one-way ANOVAs were conducted to compare the percentage of teletherapy use before, during, and after the pandemic, and change in percentage use by primary practice settings (Table 1) . None of these ANOVAs were significant, indicating that there were no statistically significant differences in percentage of teletherapy use and change in percentage use based on therapists' primary practice settings. 

Results from the first multiple regression (Table 2 ) indicated that the model predicted a statistically significant amount of change in teletherapy use during the pandemic relative to prepandemic use, F(6,619) = 7.79, p < .001, R 2 = .07. Interestingly, none of the demographic predictor variables (provider age, gender, race, and rural practice location) predicted uptake in teletherapy, ps > .05. However, changes in policies supporting teletherapy use, b = 1.72, SE = .63, p = .007, and increases in teletherapy training, b = 2.73, SE = .70, p < .001, were both associated with increased use of teletherapy. These results indicate that for each 1-unit increase in supportive policy changes, teletherapy use increased by 1.72% and increased by 2.73% for each 1-unit increase in teletherapy training changes.

Results from the second multiple regression (Table 3 ) also indicated that the model predicted a statistically significant amount of change in teletherapy use from prepandemic to during the pandemic, F(55,570) = 2.07, p < .001, R 2 = .17. Therapists whose primary practices treated relationship issues and women's issues reported the highest increases in teletherapy use during the pandemic relative to before the pandemic. Conversely, those Notes. ***p < .001. **p < .01.

www.FamilyProcess.org 6 / FAMILY PROCESS whose primary practices treated physical medicine and rehabilitation, antisocial personality disorder, traumatic brain injury, and family conflict reported the lowest increases in teletherapy uptake.

The current study is among the first to examine the effects of the COVID-19 pandemic on family systems therapists' clinical work delivered via teletherapy, as well as predictors of these changes. Results supported hypotheses that family systems therapists would report increased utilization of teletherapy during the first few months of the pandemic in comparison to prepandemic rates, and that projected postpandemic rates would be higher than prepandemic rates but lower than during the pandemic. Secondary analyses showed that teletherapy uptake was unrelated to primary practice setting, age, gender, race/ethnicity, and practice location (urban/suburban vs. rural), but was higher for family systems therapists who reported increased supportive teletherapy policies and training in their practice setting, suggesting that organizational infrastructure and availability of training played an important role in influencing teletherapy uptake during the pandemic.

Perhaps most notably, the current study demonstrates a dramatic, unprecedented shift in family systems therapists' provision of teletherapy, as rates increased substantially during the first few months of the pandemic. Therapists reported that they had performed 7.92% of their clinical work with teletherapy before the pandemic, and 81.6% noted that they had not used teletherapy at all or used teletherapy for <10% of their clinical work. These are similar to other prepandemic estimates that only about one-fifth of practicing psychologists provided clinical work via teletherapy (Pierce et al., 2020a) . In contrast, family systems therapists estimated performing 88.17% of clinical work using teletherapy by the third month of the pandemic, representing an over 11-fold increase relative to before the pandemic. Furthermore, participants predicted that they would perform 36.57% of clinical work using teletherapy after the pandemic had ended, which is a nearly fivefold increase relative to use before the pandemic. These results suggest that participants anticipated long-lasting changes in the provision of services via teletherapy even after pandemic-related concerns are addressed.

Results from the current study also highlight the efforts of family systems therapists to meet the needs of the general public in the context of the pandemic. This is not only important given the documentation of increased symptoms of anxiety and depression in individuals (e.g., Perrin et al., 2020; Twenge & Joiner, 2020) but is also highly relevant for families who have experienced unprecedented disruptions to home and work life, increased conflicts, and decreased family functioning (G€ unther-Bel et al., 2020) . Teletherapy allows family systems therapists to treat these difficulties while following social distancing mandates. Teletherapy also allows for increased access to care for individuals in rural areas (Nelson & Bui, 2010) and individuals in other underserved populations (Cooper et al., 2019; Reed et al., 2014) . It may also increase access for couples and families who would need to arrange transportation or childcare. Overall, no differences were found in percentage of teletherapy use and change in percentage use based on family systems therapists' primary practice settings. This suggests that therapists across multiple practice settings experienced similar abilities to introduce or increase teletherapy use during the pandemic. There were no significant differences by primary practice setting in family systems therapists' projected use of teletherapy after the pandemic, suggesting that changes in uptake were projected to occur on a wide scale. Interestingly, these results are inconsistent with prepandemic research indicating that therapists were more likely to use teletherapy if their primary practice setting was a VA Medical Center, individual private practice, or group practice (Pierce et al., 2020b) . It could be that family systems therapists in other settings (e.g., academic medical centers and schools/universities) did not experience the same barriers to teletherapy uptake as other therapists did before the pandemic. Additionally, although therapists in settings like VA Medical Centers may have benefited from the teletherapy and telemedicine infrastructure that was already in place (e.g., Caver et al., 2020) , it could be that other practice settings with fewer barriers to uptake (such as less complex infrastructure or more rapid administrative action) may have allowed them to transition more rapidly.

Teletherapy use was not significantly related to therapists' age, gender, race/ethnicity, and practice location. This is partially consistent with previous prepandemic findings (Pierce et al., 2020b ) that teletherapy use was not associated with age, gender, or race/ethnicity, although it was associated with rural practice location. However, this is inconsistent with findings from the original larger sample (Pierce et al., 2020c) , which demonstrated that therapists who identified as women and those in nonrural practice settings reported increased teletherapy use. These results suggest that teletherapy was consistently adopted by family systems therapists during the pandemic regardless of these demographic and practice characteristics. This is a somewhat surprising finding, as initial rates of COVID-19 cases tended to be higher in more densely populated states (CDC, 2020a), and rural providers have historically been less likely to provide teletherapy services (Pierce et al., 2020b) . This may indicate that demand for family systems therapists' teletherapy services increased consistently across multiple types of communities. Alternatively, it could be that in rural areas increased teletherapy availability in order to improve access to care for couples and families in urban and suburban areas.

Changes in policies supporting the use of teletherapy and increases in teletherapy training were both associated with increased use of teletherapy during the pandemic relative to before the pandemic, consistent with previous research (Pierce et al., 2020b (Pierce et al., , 2020c . Previously, perceived ease of teletherapy use was identified as a significant barrier or facilitator of uptake (Pierce et al., 2020a ); certainly, it seems possible that both policies and training could impact therapists' ability to easily and efficiently transition to teletherapy use. In addition to changes that were implemented on a national scale, such as privacy and security regulations (APA, 2014), these results highlight the important role that organizational support and training for teletherapy use has played in the rapid adoption of teletherapy among family systems therapists during the pandemic.

Lastly, the current study examined treatment foci that were associated with increased or decreased teletherapy use during the pandemic. Family systems therapists whose primary practices treated relationship issues and women's issues reported the highest www.FamilyProcess.org 8 / FAMILY PROCESS increases in teletherapy. This could indicate that therapists perceive that these therapeutic issues may be particularly amenable to being adapted to teletherapy. It could also be that family systems therapists experienced greater demands for teletherapy use with these issues during the pandemic, which would be consistent with reports of increased conflict in the home (G€ unther-Bel et al., 2020) and its impact on health Yuksel et al., 2021) . Patients seeking therapy for women's issues may also have higher need for teletherapy services, particularly as women tend to provide the bulk of childcare (Bianchi, Sayer, Milkie, & Robinson, 2012) , and teletherapy may have facilitated access to care for working parents while many schools and daycares were closed.

In contrast, physical medicine and rehabilitation, antisocial personality disorder, traumatic brain injury, and family conflict were associated with the lowest increases in teletherapy uptake. Physical medicine and rehabilitation as well as traumatic brain injury may be perceived by family systems therapists as less adaptable to teletherapy, possibly because of the need to coordinate psychotherapy with medical services like examinations or physical therapy, which are likely to be provided in-person. Yet, the benefits of homebased teletherapy interventions have been documented for some time in this literature, including patient groups such family caregivers of persons with traumatic spinal cord injuries (Elliott, Brossart, Berry, & Fine, 2008) , families of adolescents with traumatic brain injuries (Wade, Carey, & Wolfe, 2006) , and individuals with multiple sclerosis (Ehde et al., 2015) . Further, those who have severe physical impairments that require routine assistance with essential activities of daily living may be in relationships that are vulnerable to pressures, neglect, and abuse that may occur under times of duress, warranting clinical attention from the treating therapists. Therapists in these settings are aware of these clinical issues and presumably, of the research supporting the use of telehealth in working with these individuals in the home. The reasons, then, for the lower rate of teletherapy use among family systems therapists in these settings may merit further investigation.

Mental health providers may be reluctant to treat antisocial personality disorder via teletherapy because of perceived safety concerns, or because of a perception that treatment may not be easily adaptable to teletherapy. This may also be the case for family conflict: while family systems therapists may feel comfortable adapting couples therapy or therapy for relationship issues to teletherapy, conducting teletherapy with more than two patients at a time (as might occur with therapy for family conflict) might prove to be prohibitive, particularly if childcare or supervision is needed for other children in the home at the same time. This finding was consistent with a small qualitative study of mental healthcare providers in the Netherlands, who identified that family therapy, in addition to the treatment of psychotic symptoms, severe anxiety, trauma, or individuals in crisis, was less suited to online modalities (Feijt et al., 2020) . Family systems therapists may also feel reluctant to address family conflict via teletherapy because of safety issues, such as the duty to assess and report child abuse or suicidality in minor patients. There may also have been concerns on the part of therapists as to liability or licensure issues related to providing services to families whose members live in different states. Provider concerns related to family therapy via teletherapy and possible adaptations are discussed in recent commentary (Burgoyne & Cohn, 2020) .

The current study has a number of important limitations which should be taken into account. First, because of the observational design used, no causal inferences should be made about patterns relating to teletherapy use. It was not possible to determine whether differences existed between therapists who completed the survey and those who chose not to participate or did not complete the questionnaires. In the subset of data used in the Fam. Proc., Vol. x, xxxx, 2021 MCKEE, PIERCE, TYLER, PERRIN, & ELLIOTT / 9 current study, there were small numbers of family systems therapists practicing in geriatric facilities, correctional facilities, rehabilitation centers, and residential treatment centers. Therapists in these settings may also have had fewer opportunities to use teletherapy, as patients in these facilities often reside on site. Because of the small numbers of therapists in these settings, they were excluded from the analysis of primary practice setting, which could potentially obscure differences that might have been detectable with a larger sample.

The data in the current study were collected in May 2020 during the initial wave of the COVID-19 pandemic. Additional research is needed to determine whether these patterns of teletherapy use have persisted as social distancing practices in many states have continued throughout the first quarter of 2021. Teletherapy use by family systems therapists may have continued to increase even in excess of the percentage reported here, as many patients may have perceived that they could no longer wait to initiate therapy. This could also impact the projected use of teletherapy after the pandemic, as family systems therapists, their practice settings, and patients may be more amenable to teletherapy use in the future with increased use and familiarity/perceived ease of use while the pandemic continues. Relatedly, because many future policy changes (or lack of changes) regarding the practice of teletherapy are not yet known, such as changes to privacy or security regulations, therapists' predictions of postpandemic teletherapy use may change over time. Moreover, because participants in the current study were asked to project current use at some point in the future, in contrast to observed past time points (prepandemic and during the pandemic), there is likely to have been systematic error introduced in therapists' projections that did not exist for the two earlier time points.

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The authors report no conflict of interests related to the submission of this manuscript.

Since Dr. Perrin and Dr. McKee are employees of the U.S. Government and contributed to the manuscript "The COVID-19 Pandemic's Influence on Family Systems Therapists' Provision of Teletherapy" as part of their official duties, the work is not subject to U.S. copyright.

The contents of this manuscript do not represent the views of the U.S. Department of Veterans Affairs or the U.S. Government.

Additional Supporting Information may be found in the online version of this article: Table S1 . Summary of Participant Characteristics.