Online psychotherapy practice by psychodynamic therapists

Recebido em: 26/11/2019. Aprovado em: 18/4/2020. Publicado em: 21/01/2021. Abstract: Online psychotherapy was recognized by the Federal Council of Psychology Resolution n. 11/2018. With the official recognition of this practice, many professionals raised questions about its equivalence to face-to-face psychotherapy and the possible need of technical adaptations. Considering the lack of research on this theme, this study aimed to explore how psychodynamic/psychoanalytical psychotherapists perceive their own practice in online settings, including technical and relational aspects of the therapeutic process, in comparison to their experience in face-to-face treatments. This is a qualitative study with an exploratory approach. Eight psychologists responded to videoconference interviews. The interviews were audiotaped, fully transcribed, and analyzed by thematic analysis. Results were organized in two major themes (online psychotherapy practice and technique and psychodynamic process in online psychotherapy). Main results indicate online psychodynamic psychotherapy has many distinctive features (e.g. relying on quality of internet connection, fostering focal process, occurring in a more vulnerable setting, and eliciting a different pattern of communication) that require adaptation from therapist. Implication of findings to psychotherapy training and practice are discussed.

la experiencia en tratamientos cara a cara. Este es un estudio cualitativo con un enfoque exploratorio. Ocho psicólogos fueron entrevistados en videoconferencia. Las entrevistas fueron grabadas en audio y analizadas por análisis temático. Los resultados se organizaron en dos temas generales (práctica de psicoterapia online y técnica y proceso psicodinámico en psicoterapia online). Los principales resultados indican que una psicoterapia psicodinámica online tiene muchas características distintivas (por ejemplo, confiar en la calidad de conexión de Internet, promover un proceso focal, ocurrir en un ambiente más vulnerable, y provocar otro modo de comunicación) que exige la adaptación del terapeuta. Se discuten las implicaciones de los hallazgos para el entrenamiento y la práctica de psicoterapia. interpersonal relationships in many contexts (Ulkovski, Silva, & Ribeiro, 2017). The expansion of ICTs is not limited to informal activities, but also happens in formal services, such as education and psychotherapy. In the various segments of human activity, ICT promoted an increase in the speed of communication and new ways of interaction between people (Feijó, Silva & Benetti, 2018b;Ulkovski, Silva, & Ribeiro, 2017).
Psychotherapy is not an exception and was also affected by the dissemination of ICTs in many ways.
In this paper we focus on online psychotherapy, i.e., in psychotherapy delivered entirely online by video conference. We acknowledged that there are other forms of delivering online psychotherapy, for example, by internet phone, chat, and e-mail.
In literature, online therapy is also designated by other terms, like e-therapy, internet-based psychotherapy, and cybertherapy, among others.
The use of different nomenclatures can hinder the systematization of research on the theme (Amichai-Hamburger, et. al., 2014;Crestana, 2015). (2013) proposed the generic term telepsychology to designate different psychological services through
Although there are evidences that the online psychotherapy is effective, there is the need of more process-outcome research about psychotherapy by videoconference. Within psychodynamic approach, research about online practice is mandatory (Feijó, Fermann, Andretta, & Serralta, 2018). Furthermore, some studies suggested that ICTs can modify some of the psychodynamic techniques (Feijó, Silva, & Benetti, 2018b).
Online psychodynamic psychotherapy is controversial. Among psychodynamic-oriented therapists, there is a continuum of conceptions that varies from those that are pro online treatments to those who are against it, the latter based on the assumptions that psychodynamic process would not developed in this context and that interventions would be limited to support (Ehrlich, 2019). However, its noteworthy, that most of authors that recommend or not the practice of online psychodynamic therapy do so based on their own clinical experience, using clinical vignettes of their own cases, without any systematic measurement (Ehrlich, 2019). Therefore, this conclusion may denote a researcher bias, and not derived from a systematic observation of the real process of treatment (Serralta, Nunes, & Eizirik, 2011 Alliance is the collaborative aspect of therapeutic relationship. It is characterized by patient and therapist agreement on the objectives and tasks of the treatment, as well as their mutual bond of trust and attachment (Bordin, 1979).
The few studies conducted in Brazil about online psychotherapy suggest that alliance can be successfully developed in this kind of environment (Pieta, 2014;Prado & Meyer, 2006). This assumption is coherent with international meta-analysis (Flückiger, Del Re, Wampold, & Horvath, 2018) and systematic reviews (Berger, 2017;Sucala et al., 2012) results of equivalence between face-to-face and online treatments regarding alliance levels and alliance contribution to outcome.
However, there are still many unanswered questions about online therapeutic relationship, its theoretical foundations and technical management (Crestana, 2015;Feijó, 2017;Machado et al., 2016;Pieta, 2014). In fact, little is known about the qualitative aspects of online relationship; and there are many controversies, in literature, about whether alliance and other dynamic therapeutic processes would be the same. For example, although some (Carlino, 2011;Ehrlich, 2019) concluded that psychodynamic psychotherapeutic work is not negatively affected by remote relationship, Russel (2015) suggests that, because of the physical distance between the pair and the split created by the computer screen, aggressive and primitive content could not be fully expressed by the patient. Thus, treatment could turn out to be incomplete and/or inefficient. Clearly there is a need for more process and qualitative studies about how online psychodynamic work. Therefore, this study aims to explore how psychodynamic psychotherapists perceive their online clinical practice, including the technical and relational aspects of the therapeutic process, in comparison to their experience in face-to-face treatment.

Method Design
This is a qualitative study with an exploratory approach. This kind of study has the objective applying empirical research methods to a problem or event in order to make it clear and so to build hypothesis or expectations about it. Thus, it aims to access the phenomena under a new perspective (Gerhardt & Silveira, 2009).

Participants
Participants were recruited from psychodynamic psychotherapists registered in online psychotherapy platforms. Selection was by convenience (Creswell, 2010). The inclusion criteria were: to be a psychologist, to have at least two years of clinical experience, to be conducing one or more online psychotherapeutic treatments for at least two months. Four therapists who used other theoretical approaches or self-dominated eclectics were excluded. In order to reach the final number of participants, the data saturation criterion was used, that is, the interviews were closed when there were no new manifestations, either due to redundancy or repetition in the content of the interviews (Fontanella, Ricas, & Turato, 2008). Using this criteria, a total of eight professionals were accessed, five women and three men. Mean age was 39 years (dp=9.25 years).

Instruments
The instruments were (a) Sociodemographic and clinical experience questionnaire; (b) Semistructured interview with questions that aimed to investigate the clinical experience of the psychotherapists, their perceptions about the online psychotherapy process, including its technical and relationship aspects, in comparison to face-to-face practice. The participants were fully informed about the objectives and procedures of the study prior to agreement to participate. At all times, researchers were available to participants to solve their doubts and to give additional information.

Results and discussion
Participants had 12.5 years (DP=7.08 years) of clinical experience and worked at least for 1 year and 9 months on online settings (DP=1 year). At the time of interviews, each therapist had at least 5 online psychotherapy clients. Thematic analysis of interview transcriptions generated two categories.
These major themes and their subthemes are further described. Therapists' report on the lack of literature about online psychotherapy and of formal training is derived from the fact that most of literature on this subject is published in English (Feijó, 2017;Pires, 2015). Previously, other study had showed that Brazilian therapists are unprepared to conduct online psychodynamic psychotherapy (Feijó, Silva, & Benetti, 2018a). There is an urgent need to include this topic of study in all levels of clinical training, including psychology undergraduate and graduate courses and psychotherapy specific training courses. Lack of training can supposedly negatively impact on the quality of the offered attendance. To minimize these impacts, online psychotherapy process and process-outcome studies should be conducted in Brazil (Feijó, Fermann, et al., 2018), and their results translated into clinical guidelines.

Subtheme 1.2: Legal and ethical aspects
The interviewed psychotherapists mentioned that the Federal Council of Psychology (Conselho Federal de Psicologia) resolution that guides psychologists' online practice helped to stablish for whom these interventions are suitable (i.e, the target population) and contributed to give some simple guidance to clinicians.
We know that out there [abroad] people already deliver online therapy and I think the Federal Council of Psychology release was a big gain. We are now allowed to practice online therapy, a gain, many years ahead… And maybe now we will be able to work more freely, online, and with less paperwork ( there are systematic reviews suggesting good results with some groups of patients (Barak et al., 2008;Feijó, Fermann, et al., 2018;Machado et al., 2016;Rees & Maclaine, 2015). However, none of these reviews include Brazilian studies. Studies are needed to examine who does and who does not benefit from online psychotherapy.

Subtheme 1.3: Benefits and limitations
Interviewees' perspectives regarding online psychotherapy benefits and limitations are described in this category. Benefits include the possibility of therapists to relocate to other city, state or country, without having to discontinue attendance, being able to practice at home, as well as of seeing patients that live in other places or even in other counties. Also, therapists considered beneficial to patients to receive attendance at their own residence, having access to psychotherapy from almost anywhere, and being able to be assisted by a psychotherapist from their own country when living in another. "With online assistance I reach people that I can't reach with face-to-face therapy" (P6).  (Miclea, Miclea, Ciuca, & Budau, 2010;Pieta & Gomes, 2014;Proudfoot et al., 2011). For example, in some clinical situations the patient may feel safer to receive online attendance instead of face-to-face.
That is sometimes the case of patients with high levels of anxiety (Barak et al., 2008;Pieta & Gomes, 2014

7/11
[…] because of that I repeat, the technological device needs to be good, because suddenly the person [patient] is on his peak, having an insight and the internet connection is lost … then you are lost […] so, I repeat that your instruments need to be suited for that [ Although more studies are necessary, online psychotherapy is found effective for many clinical conditions. Anxiety disorders and depression are the conditions with more evidence (Ebert et al., 2018). The contraindication of online psychotherapy for patients with risk of suicide, patients with severe personality disorders and for those experiencing violence and/or suffering from rights violation is a common agreement in literature (Carlino, 2011;Nóbrega, 2015). It is noteworthy online interventions for many clinical conditions had never been studied. Therefore, some caution is mandatory. Psychotehrapy is not a panacea and online psychotherapy (as face-toface-psychotherapy) probably will not work for all in the same way, and could even be harmful in some conditions.

Theme 2: Technique and psychodynamic process in online psychotherapy
The theme "Technique and psychodynamic process in online psychotherapy" gather thematic units that refer to technical adaptations that need to be made in online psychotherapy, according to participants (Subtheme 2.1: Technical adaptations).
It also includes their evaluation of therapeutic process of change (Subtheme 2.2: Change process).

Subtheme 2.1: Technical adaptations
Respondents stated that online psychodynamic psychotherapy ends up being configured as a short-term and focal treatment. They also mentioned that, in comparison to face-to-face psychodynamic psychotherapy, in this modality the therapist has a much more active role and tend to use more body language "[…] The patient is very attentive to us; It seems that he/she wants everything of you, even my attitude changes a little more, I become more active than I usually am in my consulting room" (P2).
Literature reveals the existence of changes in technical aspects of psychotherapy when relationship is virtual (Carlino, 2011;Sfoggia et al., 2014). Siegmund and Lisboa (2015) study results suggested that in online therapy therapist may have an extra effort and use a wider range of interventions, both expressive and supportive, to be able to express themselves and communicate with patients.
To promote and to support the therapeutic alliance in psychoanalytic therapies, therapist's attitudes of empathetic and friendly listening, clarifying activity, as well as their synthetic and reflective functions are fundamental (Peres, 2009). It is worth noting that these therapeutic behaviors are also persecuted and sustained in online environment, according to the interviewed therapists. Respondents also expressed that, because of the limited nonverbal content, they felt the need to be more didactic and active with their remote patients. So, for example, they end up sitting very near to the camera, making more facial expressions and using more hands and body language than in face-to-face interactions.
Supposedly these changes in attitudes are needed to compensate the losses relationship may suffer when mediated by a computer screen.
By preventing communications difficulties derived from the virtual environment and accommodating themselves to the new setting, therapists can diminish the purposely negative impact that distance and less body information can exert on the therapeutic bond.
In general, participants perceived that their online patients engaged collaboratively in therapy as much as others do in face-to-face therapy.
Yet, they emphasize that the construction of the therapeutic relationship may be slower and arduous, demanding more work from the therapist. Many researchers state that in online psychotherapies therapeutic alliance can be successfully developed and maintained over the treatment (Flückiger et al., 2018;Pieta, 2014;Prado & Meyer, 2006;Sucala et al., 2012) From the psychanalytic perspective, the setting is a set of processes that organize, standardize and allow the therapeutic process (Zimerman, 2004). It is much more than simply the place, time and conditions were the sessions occurs, as it includes specific attitudes of therapist (e.g., continent function), as well as an interpersonal field (Baranger, Baranger, & Mom, 2002;Churcher, 2018). In this sense, it is important to keep it constant in order to provide a sense of continuity that facilitates therapeutic interactions. Since online psychotherapy can easily occur in any place with internet access, a special attention to setting establishment and continuity is recommended.

Subtheme 2.2: Change process
In the interviews, therapists discussed about how they identified change in online treatments. They reported observing the process of change through patient's narratives, just as they did in face-to-face sessions. Changes markers that were mentioned include signs that patients were becoming more able to overcome everyday difficulties, exhibit

Final considerations
This study explored how psychoanalytic/ psychodynamic oriented psychotherapists deliver online treatment and perceive the therapeutic process in this modality in terms of its technical and relational aspects. Results suggest that online psychotherapy fosters a dynamic process in many ways very similar to the process of face-to-face intervention. Therefore, this approach apparently is a secure alternative to face-to-face psychotherapy when patients do not otherwise have access to therapy, are living in other places and wish a therapist from their cultural background, among other situations or clinical conditions (e.g., social phobia). However, it is noteworthy that not every clinical condition that benefits from face-to-face psychotherapy benefits from remote treatments.
Although much more studies examining for whom online therapies work and for whom they do not, there is a consensus that psychological-minded patient's with reactive anxiety and depression symptoms are favored. On the other hand, online psychotherapy is contraindicated for many severe clinical situations, especially those involving risk.
In terms of therapist attitudes and techniques, apparently online psychodynamic psychotherapy demands much more afford of therapist to stablish a good-enough relationship. Bond and trust may develop slowly as this component of alliance probably depends of the development of a so-called virtual presence. For that to happen not only the internet connection have to be optimal, but a stable setting has to be developed. Since in online setting the relationship is not psychical but virtual, therapists (and probably patients) need to express themselves in a different manner in order to be fully understood, for example, using more facial and hands language.