The transition to online psychotherapy during the pandemic: a qualitative study on patients’ perspectives

Abstract

The coronavirus disease 2019 (COVID-19) pandemic has substantially increased online psychotherapies due to the impossibility of participating in vis-à-vis settings. In the last years, research about online therapy has been quickly growing. However, until now, few studies investigated patients’ perspective about the transition to online psychotherapy and, specifically, no qualitative research in group therapy has been done on this topic. This study aimed to explore the experience of 51 patients (39 group patients and 12 from individual psychotherapies) who continued psychotherapy in the online setting during the COVID-19 outbreak. A structured online questionnaire with open answers investigated the following topics: setting online, effectiveness, psychotherapy relationship, specific dynamics of online psychotherapy. Patients’ answers were analysed by means of Consensual Qualitative Research, modified version (CQRM), an inductive method that allows analysing a large sample and relatively brief written answers. The results show the impact of shift to online platforms on patients and explore how easy or difficult it is for them to adapt to therapeutic processes are in online therapy (vs in-person therapy), by highlighting potential barriers and resources to practice implementation. Participants’ responses have been arranged into three main domains: setting online, content/effectiveness of online therapy and therapeutic relationship. A fourth domain, specific for online group therapy, collected responses referred to the changes perceived regarding the group dynamics. From the patient’s perspective, online therapy is effective and satisfying. Patients perceived a positive quality of therapeutic relationship in online setting, whereas produced more controversial judgments concerned the changes due to the online setting. Finally, patients in group therapy gave more attention and importance in showing and seeing private personal spaces than the ones in individual therapy.

Introduction

It is known that the coronavirus disease 2019 (COVID-19) pandemic, which started spreading in Italy in December 2019, provoked several global detrimental consequences and critical mutations in political, economic, sanitary and psychosocial dimensions of private and public life. Italy was the first European country severely hit by COVID-19. As a consequence, the Italian population showed immediate negative psychological effects of the pandemic and the quarantine (Marazziti, Pozza, Di Giuseppe, & Conversano, 2020).

Psychological consequences of COVID-19 pandemic arose from the COVID-19 outbreak resulting in feelings related to contagion and mortality, uncertainty, fear, and symptomatology characterized by anxiety and psychological distress, post-traumatic stress (PTS) (Rajkumar, 2020; Wang et al., 2020; Asmundson & Taylor, 2020; Taylor et al., 2020). In this sense, the threatening condition represented by the COVID-19 pandemic tends to aggravate baseline levels of fear and anxiety in at least three ways, as conceptualised by Markowitz et al. (2021): i) by inducing congruous fears of contagion; ii) by revolutionising the sheltered structure and rhythm of the patient’s and therapist’s work and life planning; and iii) through physical distancing, which stretches attachment bonds and challenges people with isolation and the risk of loss of social support.

Discussing the psychological consequences of the pandemic, it is also necessary to consider the impact of the confinement measures implied in lockdown and quarantine, which resulted to have long-lasting consequences on mental health (Gullo, Misci, Teti, Liuzzi, & Chiara, 2020). The primary stressor imposed by home confinement can be attributed to isolation and the consequent loss of social and physical contact. Isolation arises from briefand long-term effects, like depression and prolonged avoidance behaviours related to the perception of stigmatisation, often continuing for some time after quarantine, even after containment of the outbreak (Brooks et al., 2020; Di Blasi et al., 2021).

The containment measures were relatively effective in the acute phase, but the current post emergency phase is the key challenge for healthcare systems, as it addresses the long-term psychosocial consequences (Marazziti et al., 2020; Zhou et al., 2020).

The sudden and deep changes caused by the COVID- 19 pandemic included mental health and psychotherapy since during the lockdown, face-to-face activities were interrupted, and psychotherapies started to be provided via digital devices (Xiang et al., 2020). In other words, social distancing suddenly forced to change how mental health professionals and patients interact within the treatment setting (Markowitz et al., 2021).

Although online psychotherapy was already practised before the COVID-19 outbreak for reasons like geographical barriers (Barak, Klein, & Proudfoot, 2009; Cook & Doyle, 2002; Roesler, 2017), with the rise of confinement measures linked to the COVID-19 pandemic, online psychotherapy became a necessity largely known and used by mental health professionals (Beaunoyer, Dupéré, & Guitton, 2020; Markowitz et al., 2021).

Since loneliness resulted positively related to psychological symptoms (Faustino, Vasco, Delgado, Farinha- Fernandes, Guerreiro, 2020), online psychotherapy had a crucial role in reducing the effects of isolation in a challenging moment for mental health. In fact, online psychotherapy represented an important resource for both clinicians and patients, giving them the possibility to continue psychological treatments that otherwise would have been interrupted or at least temporarily suspended (Zhou et al., 2020; Simpson, Richardson, Pietrabissa, Castelnuovo, & Reid, 2021).

Research has already focused on online psychotherapy before the outbreak of the COVID-19 pandemic, substantially proving its efficacy (Hilty et al., 2013; Carlbring, Andersson, Cuijpers, Riper, & Hedman-Lagerlöf, 2018) and confirming the importance of clinical constructs like therapeutic alliance (Rees & Stone, 2005; Cook & Doyle, 2002; Norwood, Moghaddam, Malins & Sabin-Farrell, 2018). As expected, the increase of requests for psychological support due to the worsening of psychological symptoms related to the pandemic (Markowitz et al., 2021), led to a growth of studies in this topic, mainly focused on individual psychotherapies (Weinberg, 2021). Confirming previous evidence, psychotherapy provided via digital devices seems to be a good alternative to traditional psychotherapy in treating common mental health disorders (Poletti et al., 2021). It also seems to be well accepted and satisfying with high levels of alliance both patient- and therapist-rated (Simpson & Reid, 2014; Simpson et al., 2021).

In this regard, literature about online psychotherapy before and after COVID-19 focuses on work alliance (Cook & Doyle, 2002; Rees & Stone, 2005; Norwood, Moghaddam, Malins & Sabin-Farrell, 2018; Simpson & Reid, 2014; Simpson et al., 2021; Sperandeo et al., 2021) and highlights the prevalent therapeutic resources and limitations of the psychotherapy online setting. In particular, online psychotherapy may offer new ways to form strong relationships with different kind of patients (Kocsis & Yellowlees, 2018), and it led psychotherapy to become more feasible, flexible, and cheaper (Puspitasari et al., 2021; Stoll, Müller, & Trachsel, 2020). Despite the advantages, research highlighted some significant issues with privacy, confidentiality, and security, as well as communication difficulties due to technical problems (Stoll et al., 2020; Lamb, Pachana, & Dissanayaka, 2019). The major evidence showed that the therapeutic opportunities offered by online psychotherapy have to deal with three main aspects: i) boundaries of setting and a ‘safe’ therapeutic space (Simpson, et al., 2021); ii) presence and commitment to the therapeutic relationship (Weinberg, 2021; Markowitz et al., 2021); and iii) inequalities of digitalization (Beaunoyer, Dupéré, & Guitton, 2020; Giansanti & Veltro, 2021). These problems may be related to high patients’ drop-out percentages (Boldrini, Schiano Lomoriello, Del Corno, Lingiardi, & Salcuni, 2020).

According to recent literature, both therapists and patients seemed to have suffered the abrupt transition from one mode to another. For example, patients reported some experiences of anxiety linked to the unplanned transition to online psychotherapy (Knight, 2020), while many therapists perceived it as great challenge, describing the need for adequate online training programs (Shklarski, Abrams, & Bakst, 2021). Also, several studies evidenced that some theoretical orientations could fit better with online mode than others (Boldrini et al., 2020; Stoll et al. 2020; Probst et al., 2021). It can be assumed that the therapists’ need for research and clinical attention could be the reason why current research focused primarily on therapists’ point of view (Naik, Manjunatha, Kumar, Math, & Moirangthem, 2020), maybe leaving apart the patient’s experience, the real users of psychotherapy.

Furthermore, to our knowledge, little attention was specifically given to group online psychotherapy, in which the absence of body-to-body interaction between members and members to therapist in the group may be considered a great obstacle. According to Weinberg (2020; 2021), there are a lot of specific challenges raised by the transition to online group psychotherapy. In a recent paper (Gullo et al., 2022), found that group therapists reported high difficulties in managing relationships in the online session and these difficulties may represent a barrier to enacting group therapeutic factors and predicted the therapist’s perception of the online group effectiveness. Working online, therapists were able to observe only a limited number of non-verbal cues such as facial expressions or eye gaze, but missing cues about posture, leg movements, this kind of ‘disembodied environment’ may significantly affect the group experience and the interplay among group participants. In addition, group therapists may feel they are losing their presence and commitment in the online mode and, last but not least, both therapists and patients may feel distracted during the online session (Weinberg, 2020; Weinberg, 2021).

Therefore, the aim of our study is to give voice to the patients who experienced the transition to online psychotherapy during the lockdown, including patients of both individual and group psychotherapies. This study tried to collect their specific thoughts and attitudes, trying to monitor this crucial change, employing a qualitative design, considering it the most well-fitting research approach to explore their unique experiences, feelings, and emotions.

Materials and methods

Participants

Eleven group and individual psychotherapists were invited by the research team to forward the survey link to three of their patients. The questionnaire was administered online using Google Forms platform, from 12^th June to 2^nd September 2020. A total of 51 participants (39 group patients and 12 from individual psychotherapies) accepted to participate in the online survey (34% of the maximum sample size of 150 that we have expected for this study). The use of the online survey was discussed in the research team prior to the start of the project. There is currently a great deal of debate in the scientific community regarding the pros and cons of using online surveys. If on the one hand they allow data to be collected in a broad, easy, quick and organized way, allowing a great saving of resources, on the other hand the limits and distortions they can produce have been highlighted. In particular, the surveyed population cannot be described is not possible to verify the presence of bias in responders, thus the results of online surveys cannot be generalized and can therefore be misleading (Andrade, 2020). In our case, wanting to extend the survey to as many subjects as possible, we opted for an online survey. In this way, only by sending a link, we have simplified the collection procedure and guaranteed the maximum possible privacy for patients. Regarding individual psychotherapies (IP), the age of the participants ranged from 24 to 64 years old (M=35.25; SD=14.43). Most of the participants were female (58.33%), and the remaining 41.67% was male. 66.66% were single, 25% were married, and the remaining 8.34% lived with their partner. Most of the participants had a master’s degree (50%) while 33.33% had a bachelor’s degree and the remaining 16.67% was a PhD or was attending graduate school.

Patients from group psychotherapies (GP) had a mean age of 47.25 (SD=12.90) which ranged from 22 to 72. Most of them were female (61.54%) while the remaining 38.46% were male. Regarding marital status, 51.28% were single, 41.02% were married, 5.12% were divorced, and the remaining 2.58% lived with their partner. As far as educational level is concerned, 38.46 of the subjects had a high school diploma, 35.89% had a master’s degree, 15.38% was a PhD/was attending graduate school, 7.69% had a bachelor’s degree while the remaining 2.58% had a middle school diploma.

Procedure

Qualitative analyses were carried out based on the modified version of Consensual Qualitative Research (CQR-M; Hill, Thompson, & Williams 1997; Spangler, Liu, & Hill, 2012). This method aims to understand a phenomenon by observing the ways in which people construct and understand their experiences (Hill, 2015). The CQR was chosen because it is a systematic and rigorous qualitative method that allows to identify common themes that could be generalised to the larger population (Di Blasi et al., 2016).

The CQR and CQR-M approaches differ for some aspects. The CQR is used to code data from in depth interviews with eight to 15 participants, while the CQR-M is more appropriate for brief written narratives collected from a larger sample. A relevant difference between the two methods is that in the CQR-M data are placed directly into categories without a previous coding of the core ideas. Moreover, unlike the CQR, in the CQR-M response frequencies are determined in terms of proportions of each category. Both methods were based on a consensual process which enabled the integration of multiple perspectives. Indeed, this methodology makes the research team and consensus among team members the two pillars of the research process. In the presence of ambiguous data, including responses with multiple units of meaning, the authors solved the ambiguity through coming to a consensus about the participant’s intent, as required by the CQR-M manual (Spangler et al., 2012). The team of this research was formed by five members: two team members worked on structuring the questionnaire and discussing the results, three team members worked on data analysis according to the step-by-step methodology provided by the CQR-M. One of the three members who worked on data analysis had experience in conducting qualitative studies, and the other two received a training in CQR-M methodology. Data analysis was conducted firstly on group therapy data sample and secondly on individual psychotherapy data sample, always maintaining the analyses separated for the two groups of responses. According to the recommendations from Spangler et al. (2012), the research’s team wrote and discussed the biases. Some team members indicated their personal involvement with the issue such as a major bias, because two team’s members experienced the transition to the online psychotherapy as patients and others as psychotherapists. The team’s members, also, were expecting: i) to identify significant changes between the experience of online psychotherapy and the one in presence; ii) to identify differences concerning to the therapist’s way of conducting the online session; iii) to detect less satisfaction by patients in online therapy that of face-to-face.

Data collection

The survey questions

According to Spangler et al.’s (2012) recommendations, the questions were derived after identifying current gaps in the literature. The aim was to capture the complexity of the patients’ experience that continued psychotherapy in the online setting due to the inability to participate in therapies in-person during the period of restrictions due to the pandemic.

Thirteen open-ended questions for individual and fifteen for group’s patients, were built around five topic areas: setting online, effectiveness, psychotherapy relationship, conduction and group dynamics (the latter only for patients of groups). The first topic area includes five questions that aim to investigate the impact on patients regarding the change experienced in the online setting (‘What did you feel/think when your therapist asked you to start with the online mode?’; ‘How do you feel about showing part of your private space to your therapist?’; ‘How do you feel to see your therapist’s private space?’; ‘How do you feel to see other members’ private space?’; ‘Was it difficult for you to find a proper space to connect?’). The second topic area concerns the perception of the effectiveness of online psychotherapy (‘Did the online mode promote the emergence of new, different themes, undiscussed previously?’; ‘Was it difficult for you to face certain themes in the online mode?’; ‘Which ones are for you the most positive aspects of online psychotherapy?’; ‘Which ones are for you the most negative aspects of online psychotherapy?’). The third topic area comprises three questions concerning the changes perceived regarding the psychotherapy online relationship (‘Do you feel that the quality of the relationship with your therapist has changed during the online mode?’; ‘Do you feel that the quality of your relationship with other group members has changed during the online mode?’; ‘Do you think your representation of your therapist has changed during COVID-19 emergency?’). Finally, the fifth topic area, specific to groups’ patients, refers to the changes perceived regarding the conduction and the group dynamics (‘Have you noticed a difference in the therapist’s way of group conduction?’; ‘Do you feel that group dynamics - interactions between group members, modes of communication.. - are different compared to previous psychotherapy sessions?’).

Data analysis

CQR-M process. The process followed the recommendations suggested by Spangler and colleagues (2012). In first step preliminary domains directly from the survey questions were derived after collecting data. In the second step, two judges separately read an initial data set of answers to the survey’s questions, in order to identify the categories. In this way, a preliminary list of categories for each domain has been identified. Next, the entire research team (three judges) met to reach consensus on these categories that were then divided into smaller sets of labelled subcategories. Categories and subcategories changed greatly during the consensus process, and those that were too small were incorporated into larger categories. The research team met many times to compare the coding of the judges and debated on classifications that did not previously lead to consensus. Finally, response frequency was calculated using proportions. Two different database included answers of individual and group patients.

Results

Categories were identified based on participants’ responses to the questions asked through the questionnaire. Following, the most representative categories of each domain are discussed and supported by illustrative quotes.

Setting online

The first domain is aimed at understanding the patient’s perspective about the changes of setting perceived in the transition from in-person to online therapy. Specifically, the domain includes participants’ perceptions of changes in the setting in the online modality, identifying two key aspects: i) the emotional impact of the introduction of the new modality by the therapist; ii) the involvement in the other’s private space and the loss of the usual shared space. Through this domain, the responses regarding the feelings connected to having to show one’s personal space, to seeing the private space of the therapist and other members (if a group therapy is carried out), and the main difficulties related to the setting in online mode are examined. Four patients (0 group patients and 4 individual patients) had missing responses in this domain; the range of number of words in response boxes ranged between 1 and 52 and between 1 and 84 for group patients and individual patients, respectively. The complete list of categories and subcategories of this domain, and associated proportions is shown in Tables 1 and 2.

Concerning the category ‘introduction of the new mode’, participants reported that when switching from face-to-face therapy to online therapy, they experienced both positive (41% GP and 41% IP) and negative (51% GP and 50% IP) feelings. Among positive reactions, patients reported sense of reassurance (10% GP and 17% IP), trust (15% GP and 17% IP), and curiosity (15% GP and 8% IP). With regard to negative feelings, patients reported as prevalent sense of precariousness, scepticism (28% GP and 33% IP) and resignation (23% GP and 17% IP).

Regarding this topic, examples of response are the following:

Having been doing the therapy for years, I was confident my therapist would still be able to grant the appropriate setting;

I thought that unfortunately it would be the only alternative not to interrupt an important journey/path;

I was very sceptical and was afraid of not being able to use the platform.

Concerning the category ‘therapy involving private spaces’, several answers referred to the feeling about the personal background seen on the participant’s image, whereas others focused on feelings about seeing the therapist’s personal background. With respect this topic, quality of experience was rated as ‘indifferent’ (31% GP, 42% IP) or ‘comfortable’ in most of the responses. In line with these responses, one out of three IP patients (33%) perceived greater closeness and intimacy to their therapist in the online videoconference.

However, a small but not negligible portion of patients treated in group (28%) or in individual (8%) therapy reported feeling of ‘embarrassment’ or ‘discomfort’, responding with phrases like:

I was concerned that my background was showing meaningless items such as a door, and heater, etc.; I wondered what people thought of my background;

I talked about profound personal and intimate things and the fact of showing my environment didn’t bother me at all.

Patients reported interest or curiosity in observing private background of the therapist (38% GP; 17% IP), and a high percentage of patients in group (44%) reported their interest also for background of the others group members. In line with these results, patients perceived closeness and intimacy to their therapist in the online psychotherapy, and about 10% of those in group felt also greater intimacy with the other members of the group in meeting them in their private space.

Regarding these aspects, the following are illustrative examples:

A curiosity that it’s not fulfilled by what I could see in the screen. I would have liked to have the chance to explore more and i was quite happy when one of the group’s members was login in from another room;

Observing the private space of the others I could get further info from the other members of the group.

Finally, the domain ‘setting online’ includes questions about various kinds of difficulties experienced during the transition to online therapy. Here, the majority of the patients (67% GP; 53% IP) declared, that they did not encounter any difficulties, while the remaining (33% GP and 42% IP) stated they had difficulty with finding a comfortable place in their home that could guarantee adequate privacy.

Yes, I encountered difficulties due to poor connection, and the impossibility of having a secluded space where I could feel ‘not observed’ or ‘not heard’ at home. When the restrictions didn’t prevent it, I tried many options such as walking around the city and being connected via Zoom, looking for secluded alleys.

Contents and effectiveness of online therapy

The second domain is aimed at understanding the patient’s perspective about the effectiveness of online psychotherapy. Specifically, the domain includes participants’ perceptions about modification of the therapeutic process on two key aspects: i) the opportunity to work on new topics; and ii) aspects that might hamper the patient’s change. Two patients (1 group patient and 1 individual patient) had missing responses in this domain; the range of number of words in response boxes ranged between 1 and 71 and between 1 and 61 for group patients and individual patients, respectively. The complete list of categories and subcategories of this domain, and associated proportions is shown in Tables 3 and 4. Concerning the first category, the majority of participants (58% for IP and 46% for GP) affirmed that switching online did not lead to addressing new topics. Among those affirmed to have worked on new topics, themes reported by IP and GP patients were very different. The first declared that they faced ‘new hints of themes already discussed in face-to-face setting’ (17%) and that they worked on ‘new fantasies and memories of the past, evoked by doing therapy at home’ (25%); the latter reported to have discuss of health emergency issues (21%) and very intimate themes related to sexuality and past abuse experiences (33%).

Table 1.

Domain, Category, and Subcategory related to group patients.

Setting online	%*	n
Introduction of the new mode
1. Positive feelings	41	16
a. Reassurance	10.2	4
b. Trust	15.4	6
c. Curiosity	15.4	6
2. Negative feelings	51.3	20
a. Precariousness and scepticism	28.2	11
b. Resignation	23.1	9
3. Other/ I don’t remember/ Missing answer	7.7	3
Therapy involving private spaces
Feeling about showing the own personal space
1. Comfort	41	16
2. Indifference	30.8	12
3. Embarrassment or discomfort	28.2	11
Feeling about seeing therapist’s personal space
1. Interest or curiosity	38.5	15
2. Indifference or disinterest	30.8	12
3. Closeness or intimacy	17.9	7
4. Other	12.8	5
Feeling about seeing other members’ personal space
1. Indifference or disinterest	46.2	18
2. Interest or curiosity	43.9	17
3. Closeness or intimacy	10.3	4
Difficulties in finding a good place to connect at home
1. No difficulties at all: the choice considered privacy, comfort and connection	66.7	26
2. Privacy-related difficulties	33.3	13

*Approximate values.

Table 2.

Domain, Category, and Subcategory related to individual patients.

Setting online	%*	n
Introduction of the new mode
1. Positive feelings	41.7	5
d. Reassurance	16.7	2
e. Trust	16.7	2
f. Curiosity	8.3	1
2. Negative feelings	50	6
c. Precariousness and scepticism	33.3	4
d. Resignation	16.7	2
3. Other/ I don’t remember/ Missing answer	8.3	1
Therapy involving private spaces
Feeling about showing the own personal space
4. Comfort	41.7	5
5. Indifference	41.7	5
6. Embarrassment or discomfort	8.3	1
7. Other/ I don’t remember/ Missing answer	8.3	1
Feeling about seeing therapist’s personal space
1. Indifference or disinterest	33.3	4
2. Interest or curiosity	16.7	2
3. Closeness or intimacy	33.3	4
4. Other/ I don’t remember/ Missing answer	16.7	2
Difficulties in finding an adequate space for online therapy
1. No difficulties at all: I choose according to better space, privacy and connection quality	58.3	7
2. Privacy-related difficulties	41.7	5

*Approximate values.

Yes, we discussed more personal issues, for example the intimacy of a couple’s life;

Yes, for example, a member of the group was finally able to tell about the childhood abuse he suffered;

It was like I had freed myself because I felt protected by the screen;

The theme that emerged and to which we returned at different times is related to fear, the sense of imposition and anger related to the lockdown.

Regarding the category ‘difficulties in facing certain themes’, in both GP and IP samples the majority of participants perceived no particular difficulties. However, one out three in GP (33.3%) and one out of four in IP (25%) felt some obstacles in expressing emotionally relevant themes on the online mode. The following examples illustrate this phenomenon:

Yes, partially. For me it is difficult to talk at a distance about certain aspects regarding sexuality, and neighbours can hear;

I felt troubled when I had to talk about certain themes concerning my current relationship, or dreams and fantasies about a previous relationship, because I knew that my partner was in the next room.

As far as concerns the category ‘Negative aspects of online mode according to the patient’, most of participants (56% GP; 58% IP) claimed that a hindering aspect regarding that online psychotherapy modified is linked by ‘difficulties on communication and lack of corporeality’ and (for 18% GP and 17% IP of patients) by ‘missing shared physical space: lack of privacy and less freedom of expression’. GP patients reported also, in 23% of cases, the ‘lack of intimacy and emotional detachment’ as negative and not negligible aspect. Some examples:

The non-verbal is missing, the feeling that envelops you physically and that reminds you of how you are in a group, the feeling of sharing and belonging to a group because it is difficult to interpret the reactions of others sometimes;

The lack of crossing glances;

It is much easier to disconnect emotionally. Also the distractions and the possibility of ‘escaping’ from the virtual room are just a flick of the mouse away; More distraction, less intimacy and less chances to fully express yourself and understand each other, the communication is limited to the voice and not to the whole body;

In my opinion an obstruction was having to wait for all the other interventions because on the screen makes sense wait for the other to finish otherwise the conversation would result in being quite messy; Conversely when you are all in the same room is easier to intervene, interrupt or express yourself; I missed the journey, the preparation time, the mutual greetings and all the rituals. Once again, I missed all the aspects related to non-verbal communication, physical presence and even the arrangement of chairs in a circle.

Table 3.

Domain, Category, and Subcategory related to group patients.

Contents and effectiveness of online therapy	%*	n
New emerged topics
1. No new topics	46.2	18
2. New topics not related to the sanitary emergency (sexuality, intimacy, abuses...)	33.3	13
3. New topics strictly related to the sanitary emergency	20.5	8
Difficulties in facing certain themes
1. No difficulties perceived	66.7	26
2. Difficulties in expressing emotionally relevant themes in the online mode connected to devices and privacy	33.3	13
Negative aspects of online mode according to the patient
1. Communication issues and lack of corporeality	56.4	22
2. Lack of intimacy and emotional detachment	23.1	9
3. Missing shared physical space: lack of privacy and less freedom of expression	17.9	7
4. None	2.6	1

*Approximate values.

Table 4.

Domain, Category, and Subcategory related to individual patients.

Contents and effectiveness of online therapy	%*	n
New emerged topics
4. No new topics	58.3	7
5. New hints of themes already discussed in face-to-face setting	16.7	2
6. New fantasies and memories of the past evoked by doing therapy at home	25	3
Difficulties in facing certain themes
3. No difficulties perceived	75	9
4. Difficulties in expressing emotionally relevant themes in the online mode connected to devices and privacy	25	3
Negative aspects of online mode according to the patient
1. Communication issues, lack of corporeality: lack of intimacy and emotional detachment	58.3	7
2. Missing shared physical space: lack of privacy and less freedom of expression	16.7	2
3. Other/ I don’t remember/ Missing answer	25	3

*Approximate values.

Therapeutic relationship

The domain ‘therapeutic relationship’ aims to deepen the changes of the therapeutic relationship after the switch to online psychotherapy. In particular, the domain highlights patients’ perceptions of the therapist regarding both to: i) therapeutic alliance; and ii) the representation of the person of the therapist. Three patients (3 group patients and 0 individual patient) had missing responses in this domain; the range of number of words in response boxes ranged between 1 and 44 and between 1 and 40 for group patients and individual patients, respectively.

The complete list of categories and subcategories of this domain, and associated proportions is shown in Tables 5 and 6.

It is interesting to note that in both IP and GP a high portion of patients (46% GP; 50% IP) reported that switching to online produces changes in quality of relationship with the therapist; a third of IP patients (33%) evaluated as positive these changes since they ‘improved the quality of the therapeutic relationship’ because of less worries and more intimacy; while 17% of them felt that ‘quality worsened’ because of ‘emotional detachment and lack of corporeality’. One out of two patients in the GP group (50%) perceived as positive the change. The positives were attributed to the increased possibility of self-disclosure and of participate and expose themselves on the therapeutic work. Vice versa, 35,9% of GP patients judged as negative the change, perceiving the ‘emotional detachment, lack of corporeality, and communication difficulties’, which typically arise in the online group, as factors that obstacle the therapeutic work.

Table 5.

Domain, Category, and Subcategory related to group patients.

Therapeutic relationship	%*	n
Alliance: perceived quality of the relationship with the therapist
1. No changes perceived	51.3	20
2. Some changes perceived	46.1	18
a. Emotional detachment, lack of corporeality	35.9	14
b. More self-disclosure, less defences	10.2	4
3. Yes, without specifications	2.6	1
Alliance: perceived quality of the relationship with the group
1. No changes perceived	41	16
2. Some changes perceived	51.3	20
a. More self-disclosure, participation and exposure, less defences	17.9	7
b. Emotional detachment, lack of corporeality, communication difficulties	33.4	13
3. Other/invalid answer	7.7	3
Representation: perceived changes in patient’s representation of the therapist
1. No changes	64.1	25
2. Enriched representation of the therapist (more esteem, trust, intimacy and humanization)	28.2	11
3. Other/invalid answer	7.7	3

*Approximate values.

Table 6.

Domain, Category, and Subcategory related to individual patients.

Therapeutic relationship	%*	n
Alliance: perceived quality of the relationship with the therapist
1. No changes perceived	50	6
2. Improved quality: less worry more intimacy	33.3	4
3. Worsened quality: emotional detachment and lack of corporeality	16.7	2
Representation: differences perceived in the therapist between online and physical setting
1. No differences at all	50	6
2. Therapist perceived as hasty, emotionally detached, impatient	25	3
3. Therapist perceived as welcoming, talkative, familiar	16.7	2
4. Other/ I don’t remember/ Missing answer	8.3	1

*Approximate values.

The online mode allows you to lower some defences and this leads to new experiences that therefore indirectly modify the relationship with the therapists.

A specific issue they discussed regards the perception of changes in the alliance with other group members. Most of the participants felt some changes (51% GP). 33% of GP participants believe that this change has to do with an ‘emotional detachment, lack of corporeality, and communication difficulties’ and ‘more self-disclosure, participation and exposure, less defences’ (17.9% GP).

Yes. I feel less of the relationship, since you cannot see whoever observes the members of the group; Yes, the lack of interactions between the group members through the posture, voice and eyes contact somehow jeopardises the spontaneity and the therapeutic relationship is affected.

As far as concerns the representation of the person of the therapist only a minority of the patients reported changes in their perception of the therapist’s figure. The change assumed very different meaning in group and in individual therapy. In fact, 25% of the IP sample, feel the therapist more hasty, emotionally detached and impatient. Vice versa, 28% of GP patients reported an enriched representation of the therapist, with feelings of ‘esteem, trust, intimacy and humanization’. Only 16% of IP think that he/she was more talkative, familiar and welcoming.

Here some illustrative responses:

Yes, the esteem and respect for my therapist are more solid and it seems to me that we are going even deeper into the therapeutic work we are doing; Yes, in the online mode sometimes I felt her more detached.

Group leadership and interpersonal dynamics among members

As mentioned above, the last domain ‘group leadership and interpersonal dynamics among members’ refers only to GP participants. This domain collects participants’ evaluations of the changes they eventually observed in the online setting regarding group leadership (i.e. frequency of intervention or strategies of silence management) and interpersonal dynamics among members. None of the group patients had missing responses in this domain; the range of number of words in response boxes ranged between 1 and 52.

The complete list of categories and subcategories of this domain, and associated proportions is shown in Table 7.

Concerning the category ‘group leadership’, 59% of GP did not notice relevant differences between online and face-to-face mode. Conversely, others reported difficulties in communication related, for example, to the inability to reading non-verbal signs and to the increase of more distractions (15% GP). Yet others declared to have noticed interventions from the therapist that showed an increased ‘concern about group cohesion’ (15% GP).

Finally, the majority of participants (87.2%) reported also changes in interpersonal dynamics among members in the online setting (interaction between group members, communication modalities, etc.). Some of them (36%), for example, observed more communication problems, emotional detachment with the other members and less fluidity in interactions. Others, 18% of GP participants, attributed the change they perceived to technical issues (i.e. connection problems, the viewing of other members through smartphone or computer, the necessity to switch on the microphone for interventions).

The following responses illustrate these aspects:

The online session is more distracting for the therapist and I got the impression that he could not pick up on everyone’s ‘non-verbal’ signals; There are less silences compared to the face-to-face; Of course, the platform does not allow for real dialogue but only small personal monologues; Yes, since gestures and expressions were lacking, one had to rely only on words to make oneself understood, and this has sometimes made the listening process tiring.

Table 7.

Domain, Category, and Subcategory related to group patients.

Group leadership and interpersonal dynamics among members	%*	n
Group leadership
1. No differences at all	59	23
2. Difficulties in communication: reading non-verbal signs and more distractions	15.4	6
3. Concern about group cohesion	15.4	6
4. Some differences perceived (without specifications)	10.2	4
Interpersonal dynamics among members
1. No differences at all	12.8	5
2. Lack of corporeality, emotional detachment, communication issues	35.9	14
3. Technical and logistical aspects	17.9	7
4. Some differences perceived (without specifications)	33.4	13

*Approximate values.

Discussion

The present study aimed explore the impact of shift to online platforms on patients and the impact of the transition on their perceptions of how easy or difficult therapeutic processes are in online therapy (vs in-person therapy), by highlighting potential barriers and resources to practice implementation. To our knowledge, this is until now one of the few attempts to study the specificity of online therapy by analysing the patient’s experience (Gentry, Lapid, Clark, & Rummans, 2019), this study indeed provides relevant observations regarding the patients’ perspectives and sheds light on the experience of switching online in patients treated in individual therapy or participating in psychodynamic groups. Most of recent studies have indeed addressed these issues exploring the therapist’s perception since it has been recognized that online setting asks the therapist to rethink some aspects of his/her own practice (Bekés, Aafjes-van Doorn, Luo, Prout, & Hoffman, 2021). Moreover, prior research on individual therapies suggested that therapists and clients may have discrepant views of online therapy, and that therapists may find the process of therapy more challenging than do clients (Thomas et al., 2021). Changes in management of setting, sometimes referred also as loss of control (Smith & Gillon, 2021), difficulties in observing non-verbal communication, and a new way of conceptualizing their presence in the therapeutic space of the therapist are some of the issues most frequently reported in literature by therapists as challenging aspects that they had to deal with during the transition to online. However, it appears likewise important to explore the experience of patients in order to understand which aspects correspond to therapist’s perspective and which one are different.

The responses of the patients who agreed to participate at the survey were arranged into three main domains: i) setting online; ii) content/effectiveness of online therapy; and iii) therapeutic relationship. A fourth specific domain collected responses referred to interpersonal communication in online group therapy. These domains represent important elements of psychotherapy found in in-person individual and group therapy (Alldredge, Burlingame, Yang, Rosendhal, 2021; Burlingame, McClendon, & Yang, 2018; Johnson, Burlingame, Olsen, Davies, & Gleave, 2005).

Regarding the first domain (setting online), we can summarize patients’ experience affirming that there was a substantial mix of positive and negative feelings related to switching online. Of course, a part of the positive evaluations of the participants can be attributed to the sense of reassurance that they attributed to the possibility that the online guaranteed the maintenance of continuity of care during the pandemic. However, among positive reactions, patients reported also trust and curiosity as renewed aspect of their therapy, whereas negative feelings involve sense of precariousness, skepticism and resignation. Similar ambiguities were found in a study that explored eating disorders patients experience towards online care (Lewis, Elran- Barak, Grundman-Shem Tov, & Zubery 2021), whereas authors found that most of participants did not report adverse effect of online on quality of therapy, but they would not recommend online treatment to others, and would not choose to continue treatment online.

As expected, the experience of group patients has highlighted some interesting specificities related to the multi-personal sharing that the group setting introduces in the therapeutic process. In particular, patients treated in group have emphasized the aspects of showing and seeing private spaces; while for example this theme is scarcely present in IP participants. The prevalent feelings associated were embarrassment and discomfort, however a minority of GP patients also reported curiosity and greater sense of intimacy. These reactions evoke a wellknown theory (Yalom & Leszcz, 2005) that conceptualizes the group as a social space in which members play their interpersonal style in interactions with other members (Kivlighan et al., 2021) and perceive the group as an environment more exposed to social judgment (Goldberg & Hoyt, 2005). These results could have interesting clinical implications suggesting that some patients felt online setting as a less safe and comfortable place and therefore less suitable for revealing their internal world. In this regard, data in literature are inconsistent, for example some studies showed that specific diagnostic group had higher rates of dropout in online therapy than in presence (Fernandez et al., 2015), while other found that diagnosis did not impact outcome of online treatment (Swift & Greenberg, 2012) or capacity to adaptation to online therapy (Lewis et al., 2021). It would be important better understand in the future the role of patient’s psychopathology in this process. This in turn could incentivize the opportunity to adequately prepare patients to work in online group, since the majority of group therapists indicated that they did not provide clients with preparation specific to the online format (Gullo et al., 2021). More congruence in responses was found regarding the difficulties experienced during the transition to online therapy. The majority of patients converged in indicating difficulties on communication and lack of corporeality as the principal hindering aspect of the online setting. This not surprising result focused on one of the most debated issues raised using online setting (Rochlen, Zack, & Speyer, 2004). There is still inconsistent evidence about the ‘real’ effects of these aspects, but it is noteworthy that patient’s experience was in accordance with the major concern among therapists of being able to establish good connectedness with online patients in a disembodied virtual setting (Connolly, Miller, Lindsay, & Bauer, 2020; Garcia et al., 2021).

Noteworthy, a non-negligible portion of patients experienced the switch online as an opportunity to recap memories, fantasies and meanings already treated in therapy, and others, mainly in group therapy, reported the experience of deal new, or never expressed before, issues.

Responses regarding the third domain showed that patients perceived a positive quality of therapeutic relationship in online setting. Alliance with therapist was rated as improved by both group and individual patients, and these results were in line with prior research that showed the therapeutic alliance in videoconferencing therapy is strong and equivalent to that reported in face-to-face settings across a range of clinical populations (Gullo et al., 2021). Nevertheless, most of group patients felt as more problematic alliance with other members ascribing these difficulties to a lack of ‘real’ interactions. Weinberg (2020) has discussed this point arguing that when group participants sitting together, they create a certain dynamic which affects the meeting’s flow, the content and the participation; while when people are sitting in different rooms obviously different dynamics arise in which people may lose the ability to connect intimately and the strength of their relationship weakens. Consistent with this interpretation, almost all group patient reported perceiving a change in group interplay and dynamics, and most of them noticed change in the way therapist led the group. This latter result is in line with previous findings which showed that therapists claimed to have changed some aspects of their style and way of working with patients (Smith & Gillon, 2021, Gullo et al., 2022).

In sum, the results of the current study suggest that from the patient’s perspective online therapy is effective and satisfying, this appears to be confirmed for both individual and group setting. However, patients’ experience highlighted that many aspects of the treatment, aspect related to the setting and the therapeutic relationship, change in a relevant way in respect to the face-to-face therapy. Several elements of communication are quite unanimously considered to be more difficult in online. In group some of these difficulties seem even more exacerbated. We believe that one of the strengths is to have highlighted these aspects thanks to the qualitative analysis. The large number of recent studies on online therapy seem to confirm that it is for most patients an effective tool as much as face-to-face therapy. However, there is probably a minority of patients, easily negligible when we refer to average results that negatively experienced a long distance relationships. Given that online videoconferencing platforms entered mainstream usage with the COVID-19 pandemic and that many therapists are likely continuing to offer online therapy, further research is necessary to examine how to deal with challenges and opportunities due to videoconference delivery of care (Weinberg, 2020). Also, further studies are needed to examine how practitioners can more effectively treat patients that feel particular difficulties in online therapy format. The study has some limitations that should be considered when interpreting the results. Firstly, the choice of a questionnaire (with both open- and closed-ended questions), instead of an interview, to evaluate the subjective experience of transition to online therapy setting elicited shorter responses and so reduced the qualitative significance of some data. Surely a qualitative interview design would have allowed participants to express more widely and in detail their perspective and so it would have possibly provided broader and more significative data. Secondly, the low numbers and the disparity between the data coming from individual and group therapy made quantitative analyses inadequate and limited the comparison between the two modalities (GP vs IP). Thirdly, it was not possible to establish the correspondence between patient to their therapist and group. This limited the possibility of verifying any differences/ similarities in the responses provided by patients followed by the same therapist or in the same group. Finally, the lack of information on the characteristics of the treatments (e.g. length of treatment, professional background of therapist, etc.) and lack of information about the patients (diagnosis, clinical history, assumption of psychotropic medication, medical conditions, etc.) limits the possibility of interpreting the results and their extensibility, as these aspects can heavily impact the patient experience

Conclusions

The findings of this study show that patients perceive and describe their experience of online psychotherapy through several aspects, such as the ‘new’ setting, the relationship with the therapist and other members, the reflection about importance and effectiveness of online therapy.

One of the issues found in this study is that patients seem to have an overall positive view of online therapy despite perceiving some change. Regarding to what has changed there is greater variability, the patient’s subjectivity appears fundamental in perceiving a change and in attributing importance to it for one’s therapeutic work. Future studies may aim to identify what the characteristics of the patients that make them more sensitive to (or suffering from?) remote treatment.

The other important issue is that many of the aspects reported by the patients coincided, or were similar, to the topics raised by the therapists in the studies conducted so far. However, this result could be an allegiance effect (given the psychological training of the evaluators who did the qualitative analysis) and more studies are needed to confirm these hypotheses.