key: cord-1016822-5hi9htwm
authors: Probst, Thomas; Haid, Barbara; Schimböck, Wolfgang; Reisinger, Andrea; Gasser, Marion; Eichberger‐Heckmann, Heidrun; Stippl, Peter; Jesser, Andrea; Humer, Elke; Korecka, Nicole; Pieh, Christoph
title: Therapeutic interventions in in‐person and remote psychotherapy: Survey with psychotherapists and patients experiencing in‐person and remote psychotherapy during COVID‐19
date: 2021-01-15
journal: Clin Psychol Psychother
DOI: 10.1002/cpp.2553
sha: d6b7a29c9781750367e9d226cd8488cad04c0a75
doc_id: 1016822
cord_uid: 5hi9htwm

OBJECTIVE: First, to investigate how psychotherapists and patients experience the change from in‐person to remote psychotherapy or vice versa during COVID‐19 regarding the therapeutic interventions used. Second, to explore the influence of therapeutic orientations on therapeutic interventions in in‐person versus remote psychotherapy. METHOD: Psychotherapists (N = 217) from Austria were recruited, who in turn recruited their patients (N = 133). The therapeutic orientation of the therapists was psychodynamic (22.6%), humanistic (46.1%), systemic (20.7%) or behavioural (10.6%). All the data were collected remotely via online surveys. Therapists and patients completed two versions of the ‘Multitheoretical List of Therapeutic Interventions’ (MULTI‐30) (version 1: in‐person; version 2: remote) to investigate differences between in‐person and remote psychotherapy in the following therapeutic interventions: psychodynamic, common factors, person‐centred, process‐experiential, interpersonal, cognitive, behavioural and dialectical‐behavioural. RESULTS: Therapists rated all examined therapeutic interventions as more typical for in‐person than for remote psychotherapy. For patients, three therapeutic interventions (psychodynamic, process‐experiential, cognitive interventions) were more typical for in‐person than for remote psychotherapy after correcting for multiple testing. For two therapeutic interventions (behavioural, dialectical‐behavioural), differences between the four therapeutic orientations were more consistent for in‐person than for remote psychotherapy. CONCLUSIONS: Therapeutic interventions differed between in‐person and remote psychotherapy and differences between therapeutic orientations in behavioural‐oriented interventions become indistinct in remote psychotherapy.

completed two versions of the 'Multitheoretical List of Therapeutic Interventions' (MULTI-30) (version 1: in-person; version 2: remote) to investigate differences between in-person and remote psychotherapy in the following therapeutic interventions: psychodynamic, common factors, person-centred, process-experiential, interpersonal, cognitive, behavioural and dialectical-behavioural.

Results: Therapists rated all examined therapeutic interventions as more typical for in-person than for remote psychotherapy. For patients, three therapeutic interventions (psychodynamic, process-experiential, cognitive interventions) were more typical for in-person than for remote psychotherapy after correcting for multiple testing. For two therapeutic interventions (behavioural, dialectical-behavioural) , differences between the four therapeutic orientations were more consistent for in-person than for remote psychotherapy.

Conclusions: Therapeutic interventions differed between in-person and remote psychotherapy and differences between therapeutic orientations in behaviouraloriented interventions become indistinct in remote psychotherapy. The COVID-19 pandemic has been labelled as the 'black swan' for mental health care as well as a turning point for e-health (Wind et al., 2020) . Previous studies showed that the treatment format for the provision of therapeutic interventions changed during COVID-19 with a reduction of in-person sessions and an increase of remote sessions via telephone or Internet (e.g., Probst et al., 2020) . It has already been shown before COVID-19 that remote therapeutic interventions are effective alternatives to the traditional in-person treatment format (e.g., Carlbring et al., 2018; Castro et al., 2020) . Yet, providers of therapeutic interventions usually report that the remote treatment setting is not totally comparable to the inperson setting (e.g., Connolly et al., 2020; . With regard to the comparability of remote and in-person treatment, most of the previous studies focused either on the outcome (e.g., Carlbring et al., 2018; Castro et al., 2020) or the therapeutic alliance (e.g., Irvine et al., 2020; Norwood et al., 2018) . Irvine et al. (2020) recently reviewed interactional differences between telephone-based and in-person psychotherapy and found no substantial differences in the alliance even though telephone sessions were shorter. A randomized controlled trial allocated 80 clients to either in-person, audio-, or video-based psychotherapy and investigated client participation, client hostility, and therapist exploration as alliance variables (Day & Schneider, 2002) . While no differences in client hostility and therapist exploration emerged, client participation was lowest in in-person psychotherapy (Day & Schneider, 2002) . Recent studies comparing videoconference-based and in-person psychotherapy showed comparable outcome and alliance for both formats in individuals with panic disorder and agoraphobia and better alliance for videoconference in individuals with generalized anxiety disorder (Watts et al., 2020) .

The alliance is considered a common factor, that is, a factor relevant in all psychosocial treatments (other common factors include positive expectations, a healing setting, rationale for symptoms) (for details on common factors, see Laska et al., 2014; Mulder et al., 2017; Wampold, 2015) . In contrast, specific factors are factors that are specific for specific psychosocial treatments, for example, cognitive restructuring in cognitive therapy. Although there has been a controversial debate whether common factors or specific factors are more important in psychosocial treatments, current research does not support either any common factor or any specific factor to be an empirically validated working mechanism (Cuijpers et al., 2019) .

One reliable and valid instrument capturing the heterogeneity of therapeutic interventions is the 'Multitheoretical List of Therapeutic

Interventions' (MULTI-60; McCarthy & Barber, 2009 ). The MULTI-60 assesses common factors and specific factors belonging to various specific psychosocial treatments (behavioural, cognitive, dialectical-behavioural, interpersonal, person-centred, psychodynamic and process-experiential). The original MULTI is rather long with 60 items and a short version with 30 items has been developed (MULTI-30; Solomonov et al., 2019) . The MULTI has been used in various international psychotherapy studies. For example, it has been reported that MULTI ratings on therapeutic interventions are influenced by the applied therapeutic orientation (e.g., psychodynamic and behavioural) (King et al., 2020; McCarthy & Barber, 2009) , that psychotherapists of a specific orientation integrate therapeutic interventions of other orientations similar to their own (Solomonov et al., 2016) and that the use of certain therapeutic interventions/their combination is associated with patient progress (Boswell et al., 2010; Fisher et al., 2020) .

To expand this previous research, the following two research questions were addressed in the current study in patients and therapists, who experienced a change of the treatment format (in-person to remote and/or remote to in-person) during their psychotherapy in times of COVID-19.

Research question 1: Do therapists and/or patients rate the therapeutic interventions measured with the MULTI-30 as differently typical for in-person vs. remote psychotherapy? As we found that remote psychotherapy is not totally comparable to in-person psychotherapy for psychotherapists in a previous study , we hypothesized that therapeutic interventions differ between in-person and remote psychotherapy.

• In times of COVID-19, psychotherapists and patients experience a change of the treatment format worldwide.

• This study examined in Austria how 'real-world' psychotherapists and their patients, who experienced such a change of the format, rate various therapeutic interventions (measured with the MULTI-30) in in-person versus remote psychotherapy.

• Ratings for therapeutic interventions were higher for inperson than for remote psychotherapy.

• Differences between therapeutic orientations in behavioural and dialectical-behavioural interventions were not as consistent in remote psychotherapy as in in-person therapy.

Research question 2: Does the therapeutic orientation of the therapist influence how therapists rate therapeutic interventions in in-person and/or remote psychotherapy? As previous studies showed associations between MULTI ratings and therapeutic orientations (King et al., 2020;  McCarthy & Barber, 2009), we hypothesized that the therapeutic orientation influences how therapists rate therapeutic interventions. The previous studies focused on one treatment format. Therefore, we had no specific hypothesis regarding the question of whether the influence of the therapeutic orientation is the same or different in in-person and remote psychotherapy.

All participants gave electronic informed consent after reading the data protection declaration. The methods were approved by the Ethics Committee of the Danube University Krems, Austria.

Psychotherapists in Austria were recruited by the first author in cooperation with the Austrian Federal Association for Psychotherapy.

Therapists received the link to the online psychotherapist survey (see below). In Austria, there are 23 accredited psychotherapy methods (Heidegger, 2017) , which can be classified into four orientations: Psychodynamic (25.9% of the therapists in Austria), humanistic (37.8% of the therapists in Austria), systemic (24.3% of the therapists in Austria) and behavioural (12.0% of the therapists in Austria). The behavioural orientation focus on behavioural and cognitive techniques to change maladaptive behaviours or thoughts. Humanistic psychotherapies focus on human development, individual needs, and emphasize positive growth as well as subjective meaning.

Psychodynamic approaches focus on revealing or interpreting unconscious conflicts, which are thought to cause mental disorders.

The systemic orientation focuses rather on the interactions of groups such as families, their dynamics and patterns. Only these four orientations and not the 23 methods were examined for research question 2. To motivate the therapists to participate, continuing education credit points were offered to them for their participation. In total, N = 222 psychotherapists gave electronic informed consent and completed the survey.

Patients were recruited by the participating psychotherapists.

The psychotherapists provided the link to the online patient survey to their patients. In total, N = 139 patients gave electronic informed consent and completed the survey.

To be able to compare in-person and remote therapeutic interventions, only those psychotherapists and patients were analysed who experienced a change of the treatment format in times of COVID-19. The change could be from in-person to remote psychotherapy (in times of COVID-19 restrictions) and/or from remote psychotherapy to in-person psychotherapy (when COVID-19 restrictions were lifted). Five therapists and six patients did not experience a change of treatment format and were excluded from further analyses so that the final sample for the present study comprised N = 217 therapists and N = 133 patients.

Two cross-sectional online surveys were set up with REDCap (Harris et al., 2009 (Harris et al., , 2019 , one for psychotherapists and one for patients. The Psychodynamic (five items, example item: 'The therapist made connections between the client's current situation and his/her past'.), common factors (4 items, example item: 'The therapist worked to give the client hope or encouragement'.), person-centred (three items, example item: 'The therapist repeated back to the client (paraphrased)

the meaning of what the client was saying'.), process-experiential (four items, example item: 'The therapist encouraged the client to identify or label feelings that he/she had in or outside of the session'.), interpersonal (four items, example item: 'The therapist tried to help the client better understand how the client's problems were due to difficulties in his/her social relationships'.), cognitive (five items, example item: 'The therapist encouraged the client to explore explanations for events or behaviors other than those that first came to the client's mind'.), behavioural (five items, example item: 'The therapist encouraged the client to think about, view, or touch things that the client is afraid of'.), dialectical-behavioural (seven items, example item: 'The therapist both accepted the client for who he/she is and encouraged him/her to change'.). Each item is rated on a five-point Likert-scale

(1-5) and the scales are built by averaging the answers given to the related items. There exist versions for patients, therapists and observers. In the current study only the patient and therapist versions were applied. Cronbach's Alpha of the scales have been reported to range between 0.76 and 0.91 for the patient version and between 0.76 and 0.93 for the therapist version (Solomonov et al., 2019) . In the original instruction of the MULTI-30, patients and therapists are asked to rate how typical each item was for the last session. We changed this introduction and asked how typical each item is for in-person / remote psychotherapy sessions. Thus, therapists and patients had to complete the MULTI-30 twice. First for remote therapy, then for in-person psychotherapy.

The ICD-10-Symptom-Rating (ISR; Tritt et al., 2015) is a reliable and valid instrument to assess distress due to mental health problems. It consists of 29 items (rated on five-point Likert scale), which are used to calculate one global score and five syndrome scores-depression (four items), anxiety (four items), obsessive-compulsive (three items), somatoform (three items) and eating (three items). The ISR was administered to the patients only in order to examine their mental health distress.

The change of treatment format was asked as follows. Psychotherapists had to state with how many of their patients there was a change of the treatment format either from in-person to remote psychotherapy or from remote psychotherapy to in-person psychotherapy.

Patients had to click yes or no to the question of whether they experienced a change of the treatment format either from in-person to remote psychotherapy or from remote psychotherapy to in-person psychotherapy.

All digital treatment formats were considered as remote psychotherapy (telephone, internet, chats, E-mail, …). Both change options (in-person to remote and remote to in-person) were considered, since changes from in-person to remote psychotherapy occurred when COVID-19 restrictions were applied and changes from remote to in-person psychotherapy occurred when COVID-19 restrictions were lifted.

All statistical analyses were performed with SPSS26. Frequencies, percentages, means (M) and standard deviations (SD) were calculated to describe the sample. Differences between therapists of the four therapeutic orientations in gender, age, and professional experience were examined with chi-squared tests and analyses of variances (ANOVAs). These tests were performed two-tailed and the significance value was set to p < 0.05.

To investigate research question 1 on differences between the MULTI-30 scales between in-person and remote psychotherapy, t tests for dependent samples were calculated, that is, eight t tests to compare the eight MULTI-30 scales between in-person and remote psychotherapy in patients and eight further t tests to compare the eight MULTI-30 scales between in-person and remote psychotherapy in therapists. The t tests were performed two-tailed.

The significance value was p < 0.05, and we report Bonferroni-corrected results with p < 0.003125 (p < 0.05/16 t tests). Cohen's d was calculated as effect size, which can be interpreted as follows: small effect 0.2-0.5, medium effect 0.5-0.8 and large effect >0.8.

To examine research question 2, that is, whether the therapeutic orientation of the therapist influences how therapists rate therapeutic interventions in in-person and remote psychotherapy, eight mixed ANOVAs (one for each MULTI-30 scale) were performed. These ANOVAs included one within-subject factor ('format': in-person vs. remote) and one between-subject factor ('orientation': psychodynamic, humanistic, systemic and behavioural). Significant main effects for 'orientation' were followed-up by Bonferroni-corrected post-hoc tests. To explain significant interaction effects for 'format x orientation', Bonferroni-corrected simple effects tests compared each pair of therapeutic orientation for each treatment format. The ANOVAs were performed two-tailed. The significance value was p < 0.05, and we report Bonferroni-corrected results for main effects of 'orientation' and interaction effects for 'format x orientation' with p < 0.00625 (p < 0.05/8 ANOVAs). These values for the ISR syndrome scales indicate low syndrome distress (Tritt et al., 2015) .

3.2 | Results for research question 1 Table 2 shows the results of the 16 t tests. To summarize, therapists consistently gave higher ratings for all MULTI-30 scales for in-person than for remote psychotherapy and this was statistically significant even after correcting for multiple testing (p < 0.003125). Patients' ratings for therapeutic interventions did not differ that consistently between in-person and remote psychotherapy. Although, without

Bonferroni-correction, all MULTI-30 scales (except interpersonal therapy) were higher for in-person than for remote psychotherapy in the patients' perspective (p < 0.05), differences remained statistically significant only for psychodynamic interventions, process-experiential interventions, and cognitive interventions after correcting for multiple testing (p < 0.003125). Effect sizes were small for patients and mostly moderate for therapists. The results of the ANOVAs to address RQ 2 are summarized in Table 3 .

For four MULTI-30 scales (psychodynamic, person-centred, process-experiential, interpersonal), the therapeutic orientation of the therapist did not significantly (regardless of correcting for multiple testing, all p > .05) influence how therapists rate therapeutic interventions for in-person and remote psychotherapy (no significant main effect 'orientation' and no significant interaction effect 'format x orientation').

Across in-person and remote psychotherapy, the therapeutic orientation influenced the therapists' ratings on two MULTI-30 scales (common factors, cognitive) even after correcting for multiple testing with p < 0.00625 (significant main effect 'orientation' but no significant interaction effect 'format x orientation').

For common factors, post-hoc tests revealed that common factors were significantly more typical for systemic therapists than for psychodynamic and humanistic therapists. The therapeutic orientation influenced how therapists rated therapeutic interventions and this was different for in-person vs. remote treatment format for two MULTI-30 scales (behavioural, dialectical behavioural) even after correcting for multiple testing with p < 0.00625 (significant main effect 'orientation' and significant interaction effect 'format x orientation').

T A B L E 2 Comparisons between in-person and remote psychotherapy with regard to the MULTI-30 scales for patients and therapists (across all therapeutic orientations). For dialectical-behavioural intervention, simple effects tests to explain the interaction showed the following effects.

• For in-person format, dialectical-behavioural interventions were significantly more typical for behavioural therapists than for psychodynamic, humanistic, and systemic therapists. Moreover, dialectical behavioural interventions were significantly more typical for systemic than for humanistic and psychodynamic therapists. In addition, dialectical behavioural interventions were more typical for humanistic than for psychodynamic therapists. (Laska et al., 2014; Mulder et al., 2017; Wampold, 2015) , our result for differences between therapeutic approaches in common factors corresponds to another study, which found higher common factor use in cognitive-behavioural therapy than in supportive listening (King et al., 2020) . Again, regardless of the treatment format, there was no influence of the therapeutic orientation of the therapist on how therapists rated psychodynamic, person-centred, process-experiential and interpersonal interventions.

This is surprising, since, in relation to other therapeutic orientations, higher psychodynamic intervention scores would be expected for psychodynamic therapists and higher person-centred as well as process-experiential intervention scores could be expected for humanistic therapists. This might be explained by the previous finding that therapists of a specific orientation also integrate therapeutic interventions of other orientations (Solomonov et al., 2016) . This could explain the rather low syndrome scores on the ISR and limit the generalizability of the results. Another explanation for the rather low ISR syndrome scores is that the patients were already in treatment, on average almost 2 years, and the symptoms which were the cause for the psychotherapy had likely improved at the time of this study. Representativeness is further limited due to the overrepresentation of humanistic psychotherapists in our sample compared to the distribution of the therapeutic orientations in the official list of Austrian psychotherapists (46% vs. 38%). It should also be kept in mind that therapists could select exactly one therapeutic school in the online survey. Some therapists could have more than one therapeutic orientation (e.g., psychodynamic and humanistic) and results might differ when these therapists are grouped not only in one but multiple orientations. Future research should consider this and also engagement measures or even synchronicity to evaluate the differences in the dyadic dimension.

Despite these limitations, the study also has several strengths. can be tailored differently well to the requirements of remote psychotherapy (e.g., the largest differences between remote and in-session for therapists emerged for psychodynamic interventions).

To conclude, the results of the current study show that the examined therapeutic interventions are more typical for in-person than for remote psychotherapy, especially for therapists and less pronounced for patients. In addition, remote psychotherapy is associated with fewer differences between therapeutic orientations in behaviouraloriented interventions. Further qualitative research of the free text questions of the survey is ongoing and will reveal further insights.

Data regarding this study will not be shared, because clinical data were investigated and the data protection the participants signed included a statement that the data will not be shared.

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The authors would like to thank the participating therapists and patients.

All authors have no conflict of interest related to this paper. Some co-authors work for the 'Austrian Federal Association for Psychotherapy' (partner of the Danube University Krems for this research project) and are therefore interested in representing the Austrian psychotherapists well, but this did not influence the study or the results.

https://orcid.org/0000-0002-6113-2133Elke Humer https://orcid.org/0000-0001-9776-0353Nicole Korecka https://orcid.org/0000-0002-7723-9779