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Received: 16 December 2020 Accepted: 4 January 2021
DOI: 10.1002/cpp.2553
RESEARCHARTICLE
Therapeutic interventions in in-person and remote
psychotherapy: Survey with psychotherapists and patients
experiencing in-person and remote psychotherapy during
COVID-19
1 2 2 2
ThomasProbst | Barbara Haid | WolfgangSchimböck | AndreaReisinger |
2 3 2
MarionGasser | Heidrun Eichberger-Heckmann | Peter Stippl |
1 1 1 1
AndreaJesser | Elke Humer | Nicole Korecka | Christoph Pieh
1Department for Psychotherapy and
Biopsychosocial Health, Danube University Abstract
Krems, Krems an der Donau, Austria Objective: First, to investigate how psychotherapists and patients experience the
2Austrian Federal Association for
Psychotherapy, Vienna, Austria change from in-person to remote psychotherapy or vice versa during COVID-19
3PROGES,Linz, Austria regarding the therapeutic interventions used. Second, to explore the influence of
therapeutic orientations on therapeutic interventions in in-person versus remote
Correspondence psychotherapy.
ThomasProbst, Department for
Psychotherapy and Biopsychosocial Health, Method: Psychotherapists (N = 217) from Austria were recruited, who in turn
DanubeUniversity Krems, Dr.-Karl-Dorrek- recruited their patients (N = 133). The therapeutic orientation of the therapists was
Straße 30, 3500 Krems an der Donau, Austria.
Email: thomas.probst@donau-uni.ac.at 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 interven-
tions: 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 interven-
tions (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.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
medium,provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
©2021TheAuthors.Clinical Psychology & Psychotherapy published by John Wiley & Sons Ltd..
Clin Psychol Psychother. 2021;1–13. wileyonlinelibrary.com/journal/cpp 1
2 PROBSTETAL.
KEYWORDS
COVID-19,interventions, psychotherapy
1 | INTRODUCTION
KeyPractitioner Messages
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 In times of COVID-19, psychotherapists and patients
et al., 2020). Previous studies showed that the treatment format for experience a change of the treatment format worldwide.
the provision of therapeutic interventions changed during COVID-19 This study examined in Austria how ‘real-world’ psycho-
with a reduction of in-person sessions and an increase of remote therapists and their patients, who experienced such a
sessions via telephone or Internet (e.g., Humer et al., 2020; Probst change of the format, rate various therapeutic interven-
et al., 2020). It has already been shown before COVID-19 that remote tions (measured with the MULTI-30) in in-person versus
therapeutic interventions are effective alternatives to the traditional remotepsychotherapy.
in-person treatment format (e.g., Carlbring et al., 2018; Castro Ratings for therapeutic interventions were higher for in-
et al., 2020). Yet, providers of therapeutic interventions usually report person than for remote psychotherapy.
that the remote treatment setting is not totally comparable to the in- Differences between therapeutic orientations in behav-
person setting (e.g., Connolly et al., 2020; Humer et al., 2020). With ioural and dialectical-behavioural interventions were not
regard to the comparability of remote and in-person treatment, most as consistent in remote psychotherapy as in in-person
of the previous studies focused either on the outcome (e.g., Carlbring therapy.
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 behavioural, interpersonal, person-centred, psychodynamic and
alliance even though telephone sessions were shorter. A randomized process-experiential). The original MULTI is rather long with 60 items
controlled trial allocated 80 clients to either in-person, audio-, or and a short version with 30 items has been developed (MULTI-30;
video-based psychotherapy and investigated client participation, Solomonov et al., 2019). The MULTI has been used in various interna-
client hostility, and therapist exploration as alliance variables (Day & tional psychotherapy studies. For example, it has been reported that
Schneider, 2002). While no differences in client hostility and therapist MULTI ratings on therapeutic interventions are influenced by the
exploration emerged, client participation was lowest in in-person applied therapeutic orientation (e.g., psychodynamic and behavioural)
psychotherapy (Day & Schneider, 2002). Recent studies comparing (King et al., 2020; McCarthy & Barber, 2009), that psychotherapists of
videoconference-based and in-person psychotherapy showed compa- a specific orientation integrate therapeutic interventions of other
rable outcome and alliance for both formats in individuals with panic orientations similar to their own (Solomonov et al., 2016) and that
disorder and agoraphobia (Bouchard et al., 2020) and better alliance the use of certain therapeutic interventions/their combination is
for videoconference in individuals with generalized anxiety disorder associated with patient progress (Boswell et al., 2010; Fisher
(Watts et al., 2020). et al., 2020).
The alliance is considered a common factor, that is, a factor rele- To expand this previous research, the following two research
vant in all psychosocial treatments (other common factors include questions were addressed in the current study in patients and thera-
positive expectations, a healing setting, rationale for symptoms) (for pists, who experienced a change of the treatment format (in-person
details on common factors, see Laska et al., 2014; Mulder et al., 2017; to remote and/or remote to in-person) during their psychotherapy in
Wampold, 2015). In contrast, specific factors are factors that are times of COVID-19.
specific for specific psychosocial treatments, for example, cognitive
restructuring in cognitive therapy. Although there has been a contro- Research question 1: Do therapists and/or patients rate the thera-
versial debate whether common factors or specific factors are more peutic interventions measured with the
important in psychosocial treatments, current research does not MULTI-30 as differently typical for in-person
support either any common factor or any specific factor to be an vs. remote psychotherapy? As we found that
empirically validated working mechanism (Cuijpers et al., 2019). remote psychotherapy is not totally compara-
One reliable and valid instrument capturing the heterogeneity of ble to in-person psychotherapy for psycho-
therapeutic interventions is the ‘Multitheoretical List of Therapeutic therapists in a previous study (Humer
Interventions’ (MULTI-60; McCarthy & Barber, 2009). The MULTI-60 et al., 2020), we hypothesized that therapeutic
assesses common factors and specific factors belonging to various interventions differ between in-person and
specific psychosocial treatments (behavioural, cognitive, dialectical- remotepsychotherapy.
PROBSTETAL. 3
Research question 2: Does the therapeutic orientation of the thera- who experienced a change of the treatment format in times of
pist influence how therapists rate therapeutic COVID-19. The change could be from in-person to remote
interventions in in-person and/or remote psy- psychotherapy (in times of COVID-19 restrictions) and/or from
chotherapy? As previous studies showed asso- remote psychotherapy to in-person psychotherapy (when COVID-19
ciations between MULTI ratings and restrictions were lifted). Five therapists and six patients did not expe-
therapeutic orientations (King et al., 2020; rience a change of treatment format and were excluded from further
McCarthy & Barber, 2009), we hypothesized analyses so that the final sample for the present study comprised
that the therapeutic orientation influences how N=217therapistsandN=133patients.
therapists rate therapeutic interventions. The
previous studies focused on one treatment
format. Therefore, we had no specific hypothe- 2.2 | Study design
sis regarding the question of whether the
influence of the therapeutic orientation is the Two cross-sectional online surveys were set up with REDCap (Harris
same or different in in-person and remote et al., 2009, 2019), one for psychotherapists and one for patients. The
psychotherapy. therapists' and patients' surveys were open from 26 June 2020 until
3 September 2020. This time interval was after the first Austrian
COVID-19 lockdown, which went into force on the 16 March 2020
2 | METHODS during which homes were only allowed to be left for five specific rea-
sons and during which in-person psychotherapy decreased and
All participants gave electronic informed consent after reading the remote psychotherapy increased in Austria (Probst et al., 2020). This
data protection declaration. The methods were approved by the first curfew ended on 30th of April 2020.
Ethics Committee of the Danube University Krems, Austria. The survey for psychotherapists comprised 128 items in total
(including the MULTI-30 as well as other questions, such as free text
questions about content, intensity, alliance, and structure of remote
2.1 | Participants vs. in-person sessions). The psychotherapists received the link to the
online psychotherapist survey from the first author or the Austrian
Psychotherapists in Austria were recruited by the first author in coop- Federal Association for Psychotherapy. The items described in the
eration with the Austrian Federal Association for Psychotherapy. measures belowwereanalysedinthepresentstudy.
Therapists received the link to the online psychotherapist survey (see The survey for the patients consisted of 159 items (including the
below). In Austria, there are 23 accredited psychotherapy methods MULTI-30 as well as other questions, such as free text questions
(Heidegger, 2017), which can be classified into four orientations: aboutcontent,intensity,alliance, and structure of remote vs. in-person
Psychodynamic (25.9% of the therapists in Austria), humanistic sessions). The patients received the link to the online patient survey
(37.8% of the therapists in Austria), systemic (24.3% of the therapists from their psychotherapists, who in turn received this link from the
in Austria) and behavioural (12.0% of the therapists in Austria). The first author or the Austrian Federal Association for Psychotherapy.
behavioural orientation focus on behavioural and cognitive techniques The items described in the measures below were analysed in the
to change maladaptive behaviours or thoughts. Humanistic present study. To ensure anonymous data collection, the patients
psychotherapies focus on human development, individual needs, werenotmatchedtothetherapistsintheonlinesurvey.
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. 2.3 | Measures
The systemic orientation focuses rather on the interactions of groups
such as families, their dynamics and patterns. Only these four orienta- 2.3.1 | Multitheoretical List of Therapeutic
tions and not the 23 methods were examined for research question Interventions—30 items
2. To motivate the therapists to participate, continuing education
credit points were offered to them for their participation. In total, The Multitheoretical List of Therapeutic Interventions (MULTI-30;
N = 222 psychotherapists gave electronic informed consent and Solomonov et al., 2019) is a reliable and valid instrument to assess
completedthesurvey. various therapeutic interventions (common factors and specific
Patients were recruited by the participating psychotherapists. factors). It consists of 30 items measuring interventions on the
Thepsychotherapists provided the link to the online patient survey to following eight scales (some items belong to more than more scale):
their patients. In total, N = 139 patients gave electronic informed Psychodynamic (five items, example item: ‘The therapist made con-
consent and completed the survey. nections between the client's current situation and his/her past’.),
To be able to compare in-person and remote therapeutic inter- commonfactors(4items, example item: ‘The therapist worked to give
ventions, only those psychotherapists and patients were analysed the client hope or encouragement’.), person-centred (three items,
4 PROBSTETAL.
example item: ‘The therapist repeated back to the client (paraphrased) changes from in-person to remote psychotherapy occurred when
the meaning of what the client was saying’.), process-experiential COVID-19 restrictions were applied and changes from remote to
(four items, example item: ‘The therapist encouraged the client to in-person psychotherapy occurred when COVID-19 restrictions were
identify or label feelings that he/she had in or outside of the session’.), lifted.
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, exam- 2.4 | Statistics
ple item: ‘The therapist encouraged the client to explore explanations
for events or behaviors other than those that first came to the client's All statistical analyses were performed with SPSS26. Frequencies,
mind’.), behavioural (five items, example item: ‘The therapist encour- percentages, means (M) and standard deviations (SD) were calculated
aged the client to think about, view, or touch things that the client is to describe the sample. Differences between therapists of the four
afraid of’.), dialectical-behavioural (seven items, example item: ‘The therapeutic orientations in gender, age, and professional experience
therapist both accepted the client for who he/she is and encouraged were examined with chi-squared tests and analyses of variances
him/her to change’.). Each item is rated on a five-point Likert-scale (ANOVAs). These tests were performed two-tailed and the signifi-
(1–5) and the scales are built by averaging the answers given to the cance value was set to p < 0.05.
related items. There exist versions for patients, therapists and To investigate research question 1 on differences between the
observers. In the current study only the patient and therapist versions MULTI-30 scales between in-person and remote psychotherapy,
were applied. Cronbach's Alpha of the scales have been reported to t tests for dependent samples were calculated, that is, eight t tests
range between 0.76 and 0.91 for the patient version and between to compare the eight MULTI-30 scales between in-person and
0.76 and 0.93 for the therapist version (Solomonov et al., 2019). In remote psychotherapy in patients and eight further t tests to
the original instruction of the MULTI-30, patients and therapists are compare the eight MULTI-30 scales between in-person and remote
asked to rate how typical each item was for the last session. We psychotherapy in therapists. The t tests were performed two-tailed.
changed this introduction and asked how typical each item is for The significance value was p < 0.05, and we report
in-person / remote psychotherapy sessions. Thus, therapists and Bonferroni-corrected results with p < 0.003125 (p < 0.05/16 t
patients had to complete the MULTI-30 twice. First for remote tests). Cohen's d was calculated as effect size, which can be inter-
therapy, then for in-person psychotherapy. preted 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
2.3.2 | ICD-10-Symptom-Rating orientation of the therapist influences how therapists rate therapeutic
interventions in in-person and remote psychotherapy, eight mixed
The ICD-10-Symptom-Rating (ISR; Tritt et al., 2015) is a reliable and ANOVAs (one for each MULTI-30 scale) were performed. These
valid instrument to assess distress due to mental health problems. It ANOVAs included one within-subject factor (‘format’: in-person
consists of 29 items (rated on five-point Likert scale), which are used vs. remote) and one between-subject factor (‘orientation’: psychody-
to calculate one global score and five syndrome scores—depression namic, humanistic, systemic and behavioural). Significant main effects
(four items), anxiety (four items), obsessive–compulsive (three items), for ‘orientation’ were followed-up by Bonferroni-corrected post-hoc
somatoform(threeitems)andeating(threeitems). TheISR wasadmin- tests. To explain significant interaction effects for ‘format x orienta-
istered to the patients only in order to examine their mental health tion’, Bonferroni-corrected simple effects tests compared each pair of
distress. 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’
2.3.3 | Changeoftreatmentformat and interaction effects for ‘format x orientation’ with p < 0.00625
(p < 0.05/8 ANOVAs).
The change of treatment format was asked as follows. Psychothera-
pists had to state with how many of their patients there was a change
of the treatment format either from in-person to remote psychother- 3 | RESULTS
apy or from remote psychotherapy to in-person psychotherapy.
Patients had to click yes or no to the question of whether they 3.1 | Sampledescription
experienced a change of the treatment format either from in-person
to remote psychotherapy or from remote psychotherapy to in-person 3.1.1 | Psychotherapists
psychotherapy.
All digital treatment formats were considered as remote psycho- Of the N = 217 analysed therapists, 77.0% were female. The
therapy (telephone, internet, chats, E-mail, …). Both change options therapists were M = 50.66 (SD = 9.65) years old. Most of the
(in-person to remote and remote to in-person) were considered, since therapists were certified psychotherapists in Austria (91.2%) and
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