Comparing Chinese and US practitioners' attitudes towards teletherapy during the COVID-19 pandemic.

INTRODUCTION: The China American Psychoanalytic Alliance (CAPA) has been offering psychoanalytic psychotherapy training and treatment to Chinese mental health professionals entirely over the Internet since 2006. When the COVID-19 pandemic began, most practitioners worldwide had to turn to teletherapy. US psychoanalytic practitioners were more negative towards teletherapy than those from other theoretical orientations. We predicted that CAPA practitioners as compared to US psychoanalytic practitioners would be more prepared for teletherapy services during the pandemic, since they their training and treatment had been on-line.
METHOD: We compared survey results from 164 CAPA practitioners with 165 US psychoanalytic practitioners (matched for age) who had recently psychoanalytically treated a patient on-line. CAPA participants were recruited from CAPA email lists and the US sample were recruited from the Society for Psychoanalysis and Psychoanalytic Psychology of the American Psychological Association, the American Psychoanalytic Association and International Psychotherapy Institute.
RESULTS: CAPA practitioners as compared to US psychoanalytic practitioners had more positive opinions about teletherapy before the pandemic; had more positive opinions about teletherapy during the pandemic; and had more positive opinions about the effectiveness of teletherapy in working with transference, relational issues and resistance. The CAPA practitioners were more prepared to do psychoanalytic psychotherapy during the pandemic than the US psychoanalytic practitioners. DISCUSSION: Xiubing Wang discusses these findings in terms of her own experience as a CAPA graduate and treater before, during and after the COVID-19 pandemic in China.

INTRODUCTION

The COVID‐19 pandemic forced psychotherapists to go on‐line. Sammons, VandenBos, and Martin (2020) surveyed 3038 doctoral psychologists at the beginning of the COVID‐19 pandemic. Prior to the COVID‐19 crisis, only 29% reported using any form of telepsychology, but after the onset of the crisis, 83% of respondents reported using it almost exclusively. Poletti et al. (2020) reviewed the evidence of the effectiveness of telepsychotherapy from 18 recent articles. Their results showed that, despite the skepticism of some therapists and some the public, telepsychotherapy is a trustworthy option that can be used effectively to treat common mental‐health disorders. They also found that low familiarity with videoconferencing and technical issues might reduce the effectiveness of telepsychotherapy.

Despite the favorable research on the effectiveness of distance psychotherapy, psychoanalytic practitioners have been reluctant to use it as compared to practitioners who favor other theoretical orientations. Perle et al. (2013) in their survey of 717 therapists found that cognitive‐behavioral and systems psychologists were significantly more accepting of teletherapy interventions than were psychodynamic/analytic or existential therapists. Bekes and Aafjes‐van Doorn (2020) surveyed 145 psychotherapists during the pandemic and also found that CBT therapists had a more positive attitude towards online therapy compared to psychodynamic psychotherapists.

Soon after videoconferencing became available, training programs began offering psychoanalytic and psychotherapy training and treatment online to other countries. One of the earliest was the China American Psychoanalytic Alliance (CAPA) which has been offering psychodynamic psychotherapy training and treatment to Chinese mental health professionals entirely over the Internet since 2006. Elise Snyder traveled to China in 2001 and was invited to speak at Sichuan University in Chengdu on psychoanalysis. After the lecture many asked for psychoanalytic supervision. Ubaldo Leli conducted the first analysis over SKYPE in 2006. This was the beginning of CAPA's training and teaching through videoconferencing (VCON). In 2008, CAPA training began with 160 Chinese mental health professionals that applied for training. Of those, 40 were chosen for the first class. CAPA's mission from the beginning has been to train the leaders of the next generation of Chinese psychodynamic psychotherapists. Currently, 38 CAPA Advanced Training (4‐year Program) graduates are in distance analytic training at American Psychoanalytic Association institutes. CAPA now has about 500 Active members: teachers, treaters and supervisors. They have educated more than 500 Chinese mental health professionals (Snyder, 2020).

Two studies from the point of view of the providers and the point of view of the consumers, evaluated the effectiveness of CAPA's program. Gordon, Wang, and Tune (2015) studied the expert opinions of 130 teachers, 152 supervisors and 163 psychoanalytic therapists in CAPA and found good support for distance training and treatment. CAPA strongly recommends, just as is the case in the psychotherapy training programs of the affiliates of the American Psychoanalytic Association, that students undertake personal treatment (Fishkin, 2020). Gordon and Lan (2017) surveyed 90 CAPA graduates, most of whom had local treatment before having distance psychoanalytic treatment. The graduate/patients had a median of three average days a week in their own treatment. The graduates highly rated the effectiveness of their own psychoanalytic therapy over VCON. The graduates/patients felt that the therapist variables (warmth, wisdom, empathy, and skillfulness) were much more important in the effectiveness of their treatment than whether the treatment was in‐office or with VCON, or because of any issues related to cultural differences.

CAPA students and graduates have formed a national organization CAPA IN CHINA (CIC). They organize conferences, supervision groups and encourage students and graduates to form local organizations. There are now 12 local organizations. Groups in three cities have organized psychotherapy training institutes where the CAPA curriculum is taught in Mandarin and all books and papers are now being translated. The CAPA Translation Project in association with the East China Normal University Press has published 12 books, translations of classic psychoanalytic books.

CAPA students and graduates, who have had their treatment on‐line were well equipped to work psychoanalytically with teletherapy when COVID‐19 hit China. In 2020, CAPA held 13 Zoom meetings which met weekly where CAPA students and graduates educated and supported Western CAPA members about their experiences of treating during the pandemic.

In our research, we wanted to test the hypothesis that the CAPA practitioners as compared to US psychoanalytic practitioners would be more prepared for psychoanalytic teletherapy services during the pandemic, since their training and treatment was on‐line.

METHOD

Sample

Our methodology employed the expert opinions of psychoanalytic/psychodynamic practitioners collected in the early phase of the pandemic (between May 14 and June 8, 2020). We used populations of convenience from email lists and listservs from: China American Psychoanalytic Alliance (CAPA trained students and graduates); International Psychotherapy Institute (both institute trained and interested parties); Society for Psychoanalysis and Psychoanalytic Psychology of the American Psychological Association (both institute trained and interested parties), and the American Psychoanalytic Association (mainly institute trained). They received, along with the link to our on‐line survey the following notice: “Please help us with our research: Telepsychotherapy During the 2020 Pandemic. We are considerate of your time, so we kept the survey to less than 4 minutes. If you have recently psychoanalytically treated a patient by telepsychotherapy (ie, phone, videoconferencing) click on this link….”

We received 877 surveys from US residents and 164 surveys from Chinese residents. In order to compare the US and Chinese samples we matched the US sample to the age of the Chinese sample so that they both had the same age distribution (χ2 [3] = .003, P = 1.00). The modal age for the US sample was 60‐69. This brought the US sample to N = 165. The modal age range for both samples after the adjusted US sample was age 30‐39 (see Table 1).

TABLE 1

Characteristics of survey participants

	United States		CAPA		Sig. Difference
	N	%	N	%
Gender					χ2, P = .731
Female	118	71.52%	120	73.17%
Male	44	26.67%	43	26.22%
Not Listed	1	0.61%	0	0.00%
Prefer not to say	1	0.61%	1	0.61%
Unknown	1	0.61%	0	0.00%
Age					χ2, P = 1.00
20‐29	6	3.64%	6	3.66%
30–39	86	52.12%	85	51.83%
40‐49	57	34.55%	57	34.76%
50‐59	16	9.70%	16	9.76%
Mental health profession					χ2, P < .001
Counselor	64	38.79%	93	56.71%
Psychiatrist	13	7.88%	13	7.93%
Psychologist	49	29.70%	51	31.10%
Social Worker	27	16.36%	2	1.22%
Other	12	7.27%	5	3.05%
Theoretical orientation					χ2, P < .001
CBT/Behavioral	18	10.91%	2	1.22%
Family Systems	5	3.03%	1	0.61%
Humanistic/Existential	11	6.67%	2	1.22%
Psychoanalytic/psychodynamic	124	75.15%	159	96.95%
Other	7	4.24%	0	0.00%

Note: United States vs CAPA (Matched Sample via Age).

Most of the respondents identified as female (US: 71% female, 27% male, 2% other; China: 73% female and 26% male, 1% other). In our recruitment notice we asked for practitioners who “had recently psychoanalytically treated a patient by telepsychotherapy.” In our survey, we also asked for primary theoretical orientation, since some practitioners might treat patients psychoanalytically, although they might have another primary theoretical orientation. Psychoanalytic/psychodynamic was by far the most reported primary theoretical orientation (US 75%, China 97%). All responses were anonymous. The Washington Baltimore Center for Psychoanalysis Institutional Review Board gave full approval to conduct this study.

INSTRUMENT

Our on‐line survey asked about the use of teletherapy before and during the pandemic. Also, we asked about the effectiveness of specific psychodynamic issues such as working with transference, relational problems, and resistance on‐line. We know that there are more issues, but we found from previous research that the responses to many of these psychodynamic factors are highly correlated with each other (Gordon et al., 2015).

RESULTS

Ours results over‐all support our hypotheses

Before the pandemic about 25% of US psychoanalytic practitioners felt mainly negative about teletherapy as compared to only about 9% of CAPA practitioners. Before the pandemic only about 36% of US practitioners felt mainly positive about teletherapy as compared to about 49% of CAPA practitioners.

During the pandemic about 23% of US psychoanalytic practitioners felt mainly negative about teletherapy as compared to only about 2% of CAPA practitioners. During the pandemic only about 37% of US practitioners felt mainly positive about teletherapy as compared to about 58% of CAPA practitioners.

It is interesting to note the very large differences in attitudes between the CAPA practitioners and the US psychoanalytic practitioners when it comes to teletherapy both before and during the COVID‐19 crisis. It is also very interesting that the US sample changed little in their opinion about teletherapy despite the need for it. In comparison, the CAPA practitioners increased their value of teletherapy during the COVID‐19 crisis. (See Table 2).

TABLE 2

Attitudes towards teletherapy before and during the pandemic

1. What did you think about using teletherapy before the pandemic?
	United States	China
Mainly negative	41 (24.85%)	14 (8.54%)
Mixed	65 (39.39%)	70 (41.03%)
Mainly positive	59 (35.76%)	80 (48.78%)
Grand Total	165 (100%)	164 (100%)

Note: χ2 tests comparing US and CAPA samples are all statically significant P < .0001.

Additionally our hypotheses were supported in that CAPA practitioners as compared to US psychoanalytic practitioners had more positive opinions about the effectiveness of teletherapy in working with transference, relational issues and resistance. (See Table 3).

TABLE 3

Perceived effectiveness of teletherapy

	US		CAPA
	Mean	SD	Mean	SD
1. How effective is teletherapy compared to in‐office treatment in working with transference?	3.2	1.1	3.6	0.9
2. How effective is teletherapy compared to in‐office treatment in working with relational problems?	3.2	1.1	3.4	1.0
3. How effective is teletherapy compared to in‐office treatment in working with resistance?	3.0	1.1	3.3	0.9

Note: Scales are rated from 1–5 (5 is highest score); χ2 for 1 P < .0001; for 2 and 3 P = .02.

DISCUSSION

Our results found that CAPA practitioners as compared to US psychoanalytic practitioners:

Had more positive opinions about teletherapy before the pandemic

Had more positive opinions about teletherapy during the pandemic;

Had more positive opinions about the effectiveness of teletherapy in working with transference, relational issues and resistance.

The CAPA practitioners were more prepared to do psychoanalytic psychotherapy during the pandemic than the US psychoanalytic practitioners. This might be a result from CAPA practitioners having or having had their treatment on‐line and treating more of their own patients on‐line before the pandemic than the US practitioners. Prior research has shown that low familiarity with videoconferencing and technical issues may reduce the effectiveness of telepsychotherapy. The study was based on a survey of populations of convenience, which may be the only ethical methodology for conducting such research, but it has sources of bias. Sources of bias include the volunteer nature of the survey. There may also be cultural differences as well. CAPA trained practitioners were more experienced with distance treatment before the pandemic. But also, Confucian based cultures such as China are more likely to value and follow expert opinion than the US culture that is more individualistic and rebellious in their thinking (Littrell, 2006). Dealing with the COVID‐19 pandemic was a matter of following the expert advice.

In the following narrative excerpt, Xiubing Wang will additionally offer an account as a full‐time therapist in Shenzhen, China:

I joined CAPA in 2012, and finished the 2 years basic training, 2 years advanced training, 1‐year supervisor training and 1‐year infant observation training. In all, I had more than 500 hours online training by CAPA. Then I joined Chicago Institute of Psychoanalysis where I am a fourth year candidate. I had local treatment before I joined CAPA. Then my analysis started when I joined CAPA, from 3 times a week and then to 4 times a week. I have had over 1200 hours of psychoanalysis, all over VCON, started on SKYPE and more recently on ZOOM. Before the pandemic, 35% of my patients had sessions over VCON. During the pandemic, it became 100%. After the pandemic, it stabilized at 60%.

Before the pandemic:

Patients sought online therapy for different reasons. They often could not find a well enough‐trained therapist in their city. They might have not wanted to invest too much time on traveling and felt more comfortable and safer in their own space. I felt comfortable working with patients over VCON because that is the way I was analyzed. It worked well for me, so I had the expectation that it should work well for most of my patients. This expectation was communicated to patients. I found that online therapy is different than in‐office therapy, but not in lowered quality. When I worked lying on the couch in my analyst's office, my analyst's physical presence made me feel more engaged, safe and warm. But working on‐line, exploring my mental life, transferences, defenses, and conflicts nearly felt the same and achieved the same. The sensation, and not the work, was different.

Patients are not guests in your office when conducting online therapy (Campbell, 2020 ). When you are the invited guest into the personal space of your patient, you are now viewing the patients' furnishings, artwork, children and pets that may intrude. Your face would be on the laptop of your patient's computer, and they can see their own face. All this should be considered as a different experience than in‐office work. All these reactions are valuable for analysis and exploration.

I still remember how lost I felt the first time I visited my supervisor's office in Chicago. His face was not 20 in. close to mine like during the last few years. The distance I felt when I finally met him in person made me feel destabilized. This experience helped me understand why some patients prefer meeting online. As one patient said, “on‐line I feel closer and I feel that I get full attention since there is nothing but the therapist's caring eyes in my field of vision.”

During the pandemic

All my sessions with patients were changed to meeting over videoconference since my city was in lockdown. All my patients transferred to online therapy smoothly. I am grateful that on‐line connections helped us not to feel so isolated. We could face the crisis together. The pandemic triggered a lot of traumatic issues in us. Patients responded in different ways. A few patients needed to find private spaces in their homes for meeting online now that their family was nearby. I was impressed by their creativity and resilience.

I once believed that patients with severe early childhood trauma are not suitable for online therapy, but I learned that they often got less defensive and felt safer to open up in their own space. I think the distance helped them to feel less overwhelmed in an intense relationship with the therapist, while others can use this as a defense. Either way, it is analyzable.

The quarantine created a situation on‐line where we are all in our homes at the same time, and that we are together when we have sessions. For the first time, we all shared the same trauma together. We could explore how our reaction to the pandemic was being affected by past traumas, our personality dynamics and how our parents made us feel secure.

We could peer into each other's homes, and that created an inclusiveness that is not available with in‐office treatment. For example, and intruding pet or the noise from a child, all stimulate the patient's fantasy life. It was a comforting experience for me when my analyst introduced his dog to me. My patients might have a different reaction of jealousy or disruption. Either way it is a great chance to work with transference and relationships. Continuing to be available by telepsychotherapy during social distancing was essential to the emotional well‐being of my patients.

After the pandemic

After 2 months of quarantine, my office opened again. After the pandemic, 60% of my patients chose therapy over videoconference compared to 35% before pandemic. Some patients needed to see the embodied therapist to have a sense of my reality and emotional availability. They might have more dependency or object constancy issues that made them feel that an embodied presence is better. There are some patients that reported that they like online therapy better. The distance created by the internet helped some patients feel less anxious, so they can have more space to feel and express themselves as well as save time from commuting. The reactions to distance treatment are based on the patients' dynamics, all of which is analyzable.

The empirical results of our research closely correspond with my personal experience as a practitioner and as a patient in China. I would not been able to seamlessly make the transition to seeing all my patients on‐line during the COVID‐19 pandemic and understand their issues without my distance training and treatment from the China American Psychoanalytic Alliance.

CONFLICT OF INTEREST

There were no conflicts of interest involved with this research.