Research project Transitions to telepsychotherapy, COVID-19 pandemic, personality orientation and attachment style
Transitions to telepsychotherapy, personality orientation and attachment style: Learning from COVID-19 pandemic and its effects on provision of psychotherapy.
Online therapy is a rapid growing trend, but for whom is it right and for whom not? The COVID-19 pandemic created a sort of natural experiment, an opportunity to study how patients and therapists deal with transitions to remote communication, how the transitions influence the therapeutic process, and which patients—under which circumstances—benefit more from face-to-face therapy or from telepsychotherapy.
The aim is to explore associations between different reactions to the transitions to telepsychotherapy and back to the office—and the patient’s personality orientation (focus on relatedness/intimacy or autonomy/performance), the patient’s attachment style (secure attachment vs attachment anxiety or attachment avoidance), the current phase of the therapeutic process, and how comfortable the therapist feels about the transitions.
Project description
Transitions to telepsychotherapy, personality orientation and attachment style: Learning from COVID-19 pandemic and its effects on provision of psychotherapy.
Objectives
The present research program is intended to explore, in a series of studies, for which patients the traditional setting with the patient and the therapist present in the same room is the treatment of choice, and for which patients treatment online might be more favorable.
Current State of Knowledge
American Psychological Association defined 2013 telepsychology as the provision of psychological services using telecommunication technologies. Internet-based psychotherapy, also known as e-therapy or online therapy, is nowadays a well-established form of conducting different forms of psychotherapeutic treatments. Most of the relevant literature focuses on experiences of therapies that started and were designed as online. An increasing number of recent publications focus on therapists’ experiences of transitioning from face-to-face to remote psychotherapy.
However, to our knowledge, the effects of transition to telepsychotherapy or in the opposite direction have not yet been systematically studied in relation to the patient personality orientation or attachment style.
Nevertheless, experiences from clinical practice and supervision at the onset and during the COVID-19 pandemic indicate that different patients reacted different to the transition. Some of them were lacking the direct in-session contact, physical presence at the same place, and the own time on the way to and from the therapist’s office, and found it difficult to maintain good enough therapeutic relationship online. Some others were relieved not to have to travel, not to sit in the same room, and they could “open up” more than previously in the ordinary psychotherapy setting.
Theoretical Starting Point
According to Blatt’s (2008) empirically supported theoretical “double helix” model, psychological development is a lifelong negotiation between two fundamental dimensions in human experiences: self-definition (an increasingly consolidated and realistic sense of self) and interpersonal relatedness (increased intimacy and interpersonal reciprocity). Psychological well-being involves both a meaningful identity and meaningful attachments, a balance between individuation and intimacy.
In contrast, different forms of psychopathology reflect an exaggerated and distorted preoccupation with one or the other of these developmental dimensions. The anaclitic configuration is connected with difficulties in close relationships, while the introjective configuration is connected with excessive demands for achievement and perfectionism.
In attachment theory, a parallel distinction is made between secure attachment and the two underlying dimensions of insecure attachment: attachment anxiety and attachment avoidance (Mikulincer & Shaver, 2007).
Empirical studies have demonstrated that patients with predominantly anaclitic and predominantly introjective personality configurations, as well as patients with secure and insecure attachment style, respond to different forms of therapeutic interventions, and show distinct patterns of change.
Furthermore, a considerable body of knowledge suggests that the therapists’ flexibility and capability to adjust their work to the patients’ needs and vulnerabilities might be decisive for the effects of temporal or more protracted transition from customary psychotherapy setting to telepsychotherapy and back to the office.
Method
The research focuses on short-term and long-term effects for patients and therapists of transitions to, and back from, telepsychotherapy in relation to non-diagnostic patient characteristics (personality orientation and attachment style). The project includes interview studies with patients and with psychotherapists, as well as a national-wide survey to Swedish psychotherapists, conducted in the intial phase of COVID-19 pandemic (step 1). Stage 2 studies patients‘ and therapists’ experiences of unprepared and forced transitions to remote therapy during the pandemic. In step 3, the focus is on experiences from transitions back to the therapist's office and from mixed hybrid models in diffetent therapeutic approaches, and on the importance of the intersection in time and space between therapy sessions and everyday life.
Patients are recruited via social media and therapists via professional associations.
The interview protocol aims at collecting narratives concerning positive and negative experiences of transitions to telepsychotherapy or in the opposite direction, how the transitions affect the patient–therapist relationship, the therapy process, and the therapeutic results.
The instruments inlude assessments of personality orientation, attachment style, therapeutic alliance, outcome, and measures of acceptance and use of technology.
The research program is approved by the Swedish Ethical Review Authority (2020-06819; 2021-01188; 2021-03728; 2021-06358-02; 2024-01716-02).
Significance
Even if there is nowadays extensive literature on psychotherapy designed for different forms of synchronous remote communication, the present research program is to our knowledge the first attempt to address the experiences and effects of transition from customary psychotherapy setting to telepsychotherapy and back to the office in relation to the patients’ personality orientation and attachment style.
The hypotheses examined are highly clinically and theoretically relevant. The main contribution of this program to the research field is the focus on how personality orientation and attachment style—in interaction—can be matched with the mode of delivering psychotherapy (in vivo or remote). This issue is especially important in the era of growing emphasis on online communication in mental care. The current COVID-19 pandemic created a kind of “natural experiment” for studying this issue.
Last but not least, the issue of who benefit from what in psychotherapy (“different strokes for different folks”) is of high clinical and theoretical relevance. The results might contribute to guiding clinicians in deciding whom to offer online or in-person psychotherapy when not all patients can be seen at the clinic.
Project members
Project managers
Camilla von Below
Assistant Professor
Björn Philips
Professor
Members
David Anders Forsström
Researcher
More about this project
Publications
Ahlström, K. & von Below, C. (2021). Psykodynamisk terapi i pandemin: Psykoterapeuters röster om övergången till digital terapi. Psykoterapi, 30(2), 6–9.
Ahlström, K., von Below, C., Forsström, D., & Werbart, A. (2022). Therapeutic encounters at the onset of the COVID-19 pandemic: Psychodynamic therapists’ experiences of transition to remote psychotherapy. Psychoanalytic Psychotherapy, 36(3), 256–274. doi:10.1080/02668734.2022.2058988 (Open access)
Erlandsson, A., Forsström, D., Rozental, A., & Werbart, A. (2022). Accessibility at what price? Therapists’ experiences of remote psychotherapy with children and adolescents during the COVID-19 pandemic. Journal of Infant, Child and Adolescent Psychotherapy, 21(4), 293–308. doi:10.1080/15289168.2022.2135935 (Open access)
Reatto, L., Werbart, A., Oasi, O., De Salve, F., Ierardi, E., Giordano, M., & Riva Crugnola, C. (2023). Understanding psychoanalytic work online and back to the couch in the wake of the COVID-19 pandemic: An investigation among Italian psychoanalysts. Frontiers in Psychology, 14, 1167582. doi:10.3389/fpsyg.2023.1167582 (Open access)
von Below, C., Bergsten, J., Midbris, T., Philips, B., & Werbart, A. (2023). It turned into something else: Patients’ long-term experiences of transitions to or from telepsychotherapy during the COVID-19 pandemic. Frontiers in Psychology, 14, 1142233. doi:10.3389/fpsyg.2023.1142233 (Open access)
Werbart, A., Byléhn, L., Jansson, T.M., & Philips, B. (2022). Loss of rituals, boundaries, and relationship: Patient experiences of transition to telepsychotherapy following the onset of COVID-19 pandemic. Frontiers in Psychology, 13, 835214. (Research Topic; “Highlights in Psychology for Clinical Settings: The Ascent of Digital Psychotherapy”) doi:10.3389/fpsyg.2022.835214 (Open access)
Werbart, A., Dominicus, E., Sheahan, L., & Philips, B. (2024). When the screen deepens the sense of connectedness: What therapists have found effective in successful cases of teletherapy. Counselling and Psychotherapy Research: Linking Research with Practice (Advance online publication) doi:10.1002/capr.12820. (Open access)
Werbart, A., & Forsström, D. (2024). New skills for distance regulation in remote psychotherapy: Therapists’ learnings from the COVID-19 pandemic. The Integrative Therapist, 10(1), 5–11.
Werbart, A., Jonsson, M., Jankowski, B., & Forsström, D. (2024). New skills for distance regulation: Therapists’ experiences of remote psychotherapy following the COVID-19 pandemic. Journal of Psychotherapy Integration, 34(1), 27–44. doi:10.1037/int0000310
Werbart, A., Rådberg, U., Holm, I., Forsström, D., & Berman, A. H. (2024). The meaning and feeling of the time and space between psychotherapy sessions and everyday life: Client experiences of transitions. Psychotherapy Research, 34(7), 899–912. doi:10.1080/10503307.2023.2274061 (Open access)
Theses
In addition, the research program has resulted in 17 theses on the psychology program, the master’s program and the psychotherapy program by 29 students at Stockholm, Uppsala, and Karlstad Universities, as well as several ongoing studies.
Linda Byléhn & Tuva Maja Jansson. (2021). Förlusten av ritualen, ramen och relationen. Patienters upplevelser av övergången till psykoterapi på distans under covid-19-pandemin: En studie utifrån personlighetsorientering och anknytningsstil. [The loss of ritual, frame and relationship. Patients' experiences of the transition to remote psychotherapy during the COVID-19 pandemic: A study based on personality orientation and attachment style.] Psychologist degree thesis, 30 credits, Department of Psychology, Stockholm University.
Katrin Ahlström (2021). Digitala psykodynamiska psykoterapisamtal: Psykodynamiska psykoterapeuters upplevelser av övergången till digitala samtal på grund av corona-pandemin. [Digital psychodynamic psychotherapy sessions: Psychodynamic psychotherapists' experiences of the transition to digital sessions due to the Corona pandemic.] Psychotherapist degree thesis, 15 credits, Department of Psychology, Stockholm University.
Erik Smedjegård & Sebastian Hedman Moe (2021). Distansterapi, ett hot eller en ny möjlighet för klientarbetet? Terapeuters erfarenheter och upplevelser av oförutsedda övergångar från traditionell psykoterapi till psykoterapi på distans. [Remote therapy, a threat or a new opportunity for client work? Therapists' experiences and perceptions of unforeseen transitions from traditional psychotherapy to remote psychotherapy.] Psychologist degree thesis, 30 credits, Department of Psychology, Uppsala University.
Michaela Jidemyr & Märta Kågström (2021). Hur klarar alliansen distansen? En enkätstudie om övergången till telepsykoterapi under covid-19 och dess påverkan på den terapeutiska alliansen utifrån patientens anknytningsstil och personlighetsorientering. [How does the alliance overcome the distance? A survey study on the transition to telepsychotherapy during COVID-19 and its impact on the therapeutic alliance from the point of view of the patient's attachment style and personality orientation.] Psychologist degree thesis, 30 credits, Department of Psychology, Uppsala University.
Anna Ollén Lindqvist (2021). Vilken betydelse har husdjur vid distansarbete för personer med olika anknytningsmönster? En intervjustudie. [What is the influence of pets on teleworking for people with different attachment patterns? An interview study]. Master thesis in psychology, 30 credits, Department of Psychology, Stockholm University.
Jenny Bergsten & Therése Midbris (2022). Det blev någonting annat: Patienters upplevelser av övergångar till och från telepsykoterapi under covid-19-pandemin: En långtidsuppföljning [It became something else: Patients' experiences of transitions to and from telepsychotherapy during the COVID-19 pandemic: A long-term follow-up.] Psychologist degree thesis, 30 credits, Department of Psychology, Stockholm University.
Anette Erlandsson (2022). Tillgänglighet till vilket pris? En studie av barn- och ungdomsterapeuters upplevelser av distansbehandlingar under covid-19 pandemin. [Accessibility at what cost? A study of child and adolescent therapists' experiences of remote treatments during the COVID-19 pandemic.] Psychotherapist degree thesis, 15 credits, Department of Psychology, Uppsala University.
Colleen Tintin Johansson (2022). Personal accounts of online therapy: An interview and survey study on patients’ experiences of psychological treatment online, attachment pattern and personality orientation. Master thesis in psychology, 30 credits, Department of Psychology, Stockholm University.
Martin Jonsson & Bartosz Jankowski (2022). Att optimera distans: Psykologers och psykoterapeuters erfarenheter av psykoterapi på distans under och efter covid-19 pandemin: En kvalitativ intervjustudie. [Optimising distance: Psychologists’ and psychotherapists’ experiences of remote psychotherapy during and after the COVID-19 pandemic: A qualitative interview study.] Psychologist degree thesis, 30 credits, Department of Social and Psychological Studies, Karlstad University.
Isabel Orihuela Swartling & Elin Hellström (2022). Terapeuters lärdomar från arbete med telepsykoterapi under COVID-19-pandemin: En intervjustudie. [Therapists' learnings from working with telepsychotherapy during the COVID-19 pandemic: An interview study.] Psychologist degree thesis, 30 credits, Department of Psychology, Stockholm University.
Isa Holm & Ulf Rådberg (2022). Övergångarna mellan terapi och vardag: En kvalitativ intervjustudie om hur klienter upplever och använder sig av utrymmet i tid och rum mellan terapisamtalet och vardagens sammanhang. [Transitions between therapy and everyday life: A qualitative interview study on how clients experience and use the gap in time and space between the therapy session and the context of everyday life.] Psychologist degree thesis, 30 credits, Department of Psychology, Uppsala University.
Eric Dominicus & Luke Sheahan (2023). När avståndet för närmare: Vad terapeuter upplevt verksamt i en teleterapi. [When distance brings closer: What therapists experienced as effective in a teletherapy.] Psychotherapist degree thesis, 15 credits, Department of Psychology, Stockholm University.
Kasper Below Blomkvist & Fabian Biström (2023). Att underlätta övergångar mellan terapi och vardag: En kvalitativ studie om hur terapeuter förhåller sig till patienternas övergångar i tid och rum mellan terapisamtal och vardag. [Facilitating transitions between therapy and everyday life: A qualitative study of how therapists address patients' transitions in time and space between therapy sessions and everyday life.] Psychologist degree thesis, 30 credits, Department of Psychology, Uppsala University.
Anna Bursell (2023). Psykologers lärdomar av att bedriva digital KBT vid depression: Tematisk analys. [Psychologists' learnings from conducting digital CBT for depression: Thematic analysis.] Psychologist degree thesis, 30 credits, HT 2023, Department of Psychology, Stockholm University.
Chanelle Ekner Nordbäck & Oskar Tapper (2023). Bygga upp, förbereda, ladda ur: KBT-patienters upplevelse av övergångar mellan terapi och vardag. [Building up, preparing, discharging: CBT patients' experience of transitions between therapy and everyday life]. Psychologist degree thesis, 30 credits, Department of Psychology, Uppsala University.
Imme Bijvoet Hellberg (2023). Den rumslösa terapin: En intervjustudie om terapeuters erfarenheter och lärdomar av distansterapier som inte har fungerat under COVID-19 pandemin. [The roomless therapy: An interview study on therapists' experiences and lessons learnt from distance therapies that have not worked during the COVID-19 pandemic.] Psychologist degree thesis, 30 credits, HT 2023, Department of Psychology, Stockholm University.
Oksana Johansson & Libertad Rodriguez Pimentel (2024). Att mötas trots distansen: Patienters positiva upplevelser av teleterapi. [Meeting despite the distance: Patients' positive experiences of teletherapy.] Psychotherapist degree thesis, 15 credits, Department of Psychology, Stockholm University.
Funding
The first step of the research program was awarded by the Board of Human Science, Stockholm University, with one-year strategic grant for innovative research initiatives. Stages two and three are funded by grants from the American Psychoanalytic Association and the International Psychoanalytical Association.
Status
The first step of this research program was ongoing in 2021. The second step, ongoing in 2022–2023, was a follow-up and replication of the initial studies one year later, and a new study of child and adolescent therapies, focusing on long-term consequences of transitions to telepsychotherapy. The third step was initiated based on findings from previous studies and focuses on experiences of transitions back to the therapist’s office, experiences from hybrid models and different therapeutic approaches, and how patients and therapists experience and use the transitions in time and space between the therapy session and the context of everyday life. Stage three will run until 31 December 2025.