Potentialities and Barriers of Online Psychotherapy During the COVID-19 Pandemic: Scoping Review

Abstract

The pandemic of COVID-19 demanded unprecedented efforts from psychologists to adapt to technology-mediated care. This study aimed to analyze the scientific production concerning the perception of Brazilian psychologists on online psychotherapy during the pandemic through a scoping review. We consulted four databases, while the reviewed corpus comprehended 29 studies. Psychologists identified both benefits and barriers in the transition to online psychotherapy practice, but the perception that the sparing use of this resource is valid and beneficial predominated. There is a strong perception that information and communication technologies will definitely integrate the repertoire of resources used by psychotherapists, as another relevant alternative, posing the need for further studies.

Keywords:
covid-19; pandemics; psychotherapy; social isolation; mental health

Resumo

A pandemia da COVID-19 exigiu esforços sem precedentes das/os psicólogas/os para adaptação ao atendimento mediado por tecnologia. O objetivo deste estudo é analisar a produção científica acerca da percepção de psicólogas/os brasileiras/o sobre psicoterapia on-line durante a pandemia por meio de uma scoping review. Foram consultadas quatro bases de dados e o corpus revisado foi composto por 29 estudos. Psicólogas/os identificaram tanto benefícios como barreiras na transição para prática da psicoterapia on-line, porém predominou a percepção de que o uso parcimonioso deste recurso é válido e benéfico. Há forte percepção de que tecnologias da informação e comunicação integrarão, em definitivo, o repertório de recursos utilizados por psicoterapeutas, como mais uma alternativa relevante, o que coloca a necessidade de novos estudos.

Palavras-chave:
covid-19; pandemias; psicoterapia; isolamento social; saúde mental

The impacts of the COVID-19 pandemic on the mental health of the population are complex and multidimensional. They range from expected reactions of acute stress and worsening of preexisting symptoms to the onset of psychiatric disorders related to psychological suffering resulting from the experience of the situation of collective calamity, loss, and disenfranchised grief (Klomek, 2020; Oliveira, Oliveira-Cardoso, et al., 2020; Oliveira-Cardoso et al., 2020; Sher, 2021). The health measures implemented to reduce the rate of new infections and lethality of COVID-19 have imposed severe restrictions on the free circulation of individuals and, despite having undeniable relevance in the set of non-pharmacological strategies, they have a high potential for adverse effects on mental health (Ferreira, 2021; Klomek, 2020; Oliveira et al., 2021; Oliveira, Silva, et al., 2020; Sher, 2021). This context has repercussions on mental health, pressures the demand, and requires adjustments in psychological care programs and services.

Like other professional categories, the performance of psychologists was substantially impacted due to the restriction of physical contact, which required adaptations in clinical practice, such as the transition to exclusive online care (Regional Council of Psychology of São Paulo [CRP SP], 2020). Psychological care mediated by Information and Communication Technologies (ICTs) in Brazil began to be regulated by Resolution No. 3 of the Federal Council of Psychology (CFP, 2000), which authorized its conduct only on an experimental basis, as part of research projects on “computer-mediated psychotherapeutic care.”

Since then, important changes have occurred, culminating in Resolution No. 11 of the CFP (2018), which authorized psychological consultations through any information and communication technologies through the Internet, as long as the professional performed prior registration in the National Register of Professionals for the Provision of Psychological Services through ICTs, called e-Psi Register, obtaining authorization from the class entity. The emergence of the global health crisis accelerated the gradual and cautious advances obtained over two decades of research toward the regulation of online practices. With the COVID-19 pandemic, Resolution No. 4 of the CFP (2020a) was published, allowing the provision of online care by simply filling out the registration form, without having to wait for authorization, to facilitate adjustments for the psychologists during this exceptional period.

Regarding the number of psychologists registered in e-Psi, the CFP reported that only in March and early April 2020, 39,510 new registrations were made, while in the entire previous period, 15 months after Resolution No. 11/2018 came into effect, only 30,677 registrations had been made (CFP, 2020b). Other quantitative information about this demand was released by CRP SP (2020), which approved 23,195 requests on the e-Psi platform in six months of the pandemic (between March and September 2020), whereas this mark, previously, had taken more than twice as long. These data show the magnitude of the change experienced by psychologists in the performance of their work since the turbulent situation triggered by COVID-19.

To adapt to the innovations introduced, the professionals must receive adequate training, with digital literacy, if necessary, and provision of practical skills to master the knowledge and be proficient in the ICTs mediated care. Moreover, psychologists must have supervision, so that they can take ownership of the necessary tools to perform their work through technology (Klomek, 2020; Torous & Wykes, 2020). For most professionals registered in the Sistema Conselhos, the migration to online practice happened unexpectedly, without preparation or prior experience (CRP SP, 2020).

From the perspective of clinical psychologists, besides the abrupt practical change of their work paradigm, we must consider that the professionals themselves face similar issues to those that permeate the experiences of their patients since they are also inserted in the pandemic context and, therefore, susceptible to the same injunctions, restrictions, and threats like anyone else. Therefore, they also live the repercussions of the disruptive experiences and are affected by the limitations that the global health emergency brings to the organization of daily life, suffering the emotional, physical, financial, educational, social, and family impacts of the humanitarian crisis. In this scenario, psychologists have reported their experiences in the care of patients, while they also experience psychological suffering and often feel apprehensive, afraid, and even impotent in the face of the epidemiological scenario and the unusual dynamics of experiencing a pandemic (Aroser, 2020; CRP SP, 2020; Mellem, 2020). Thus, this study analyzes the scientific production of the perception of Brazilian psychologists about online psychotherapy during the pandemic.

Method

Study Type

In this study, we systematized information from a scoping review (The Joanna Briggs Institute, 2015), which aims to document the recent literature aspects that have not yet been explored by research, enabling a more extensive literature search, favoring the understanding of certain topics before focusing on more precise issues (Arksey & O'Malley, 2005). This is considered to represent an advantage over other methods. In the case of the pandemic of COVID-19, an emerging field of knowledge, empirical research designs are still quite limited, coexisting with theoretical studies and experience reports, reflecting the current state of the art. Studies are, in general, exploratory, with heterogeneous data, many still under development, focusing on the search for understanding the problem when still experiencing a situation, such as the global health crisis.

Considering these challenges, this scoping review aimed to encourage discussion about the subject from a theoretical and contextual perspective that included different vertices of knowledge production, from the critical analysis of various types of publications that address the topic of interest. For an inclusive and panoramic look at how the practice of psychotherapy by clinical psychologists has been affected by the pandemic, in addition to examining the extent and variety of scientific literature on the subject, the scoping review is a relevant methodological tool. It provides access to relevant information, organized from the point of view of clinical practice, which favors the qualification of the debate in a rapidly expanding field, considering emerging issues.

Methodological Procedures

This study followed the recommendations for the preparation of a scoping review, following five steps: delimitation of the research question; identification of relevant studies; selection of studies; analysis of the reviewed data; grouping, summarization, and dissemination of results (Arksey & O'Malley, 2005). Two reviewers independently conducted the database searches, having their findings reviewed by a third reviewer, who also independently validated the decisions made. The reviewers have expertise in the field of psychotherapy research and familiarity with review studies. We identified the studies and performed data collection in June 2021.

Guiding Question

We built the research question from the acronym PCC (P = population; C = concept; C = context) (The Joanna Briggs Institute, 2015): What are the perceptions of Brazilian psychologists about online psychotherapy during the COVID-19 pandemic?

Inclusion and Exclusion Criteria

We included studies and communications produced in the Brazilian context, published in Portuguese, Spanish, and English, which addressed the topic of interest. We excluded studies that addressed other types of telehealth or online psychological interventions that were inserted in areas of knowledge and practice of psychology other than clinical care in psychotherapy.

Data Source Selection

We selected the SciELO, PePSIC, LILACS, and Google Scholar databases for consultation. We chose them because they include results from national research since the interest lies in investigating the perception of Brazilian psychologists about online psychotherapeutic care during the COVID-19 pandemic.

Collection, Organization, and Data Analysis

We collected data in June 2021, covering studies published from March 2020 to May 2021. We used the Health Sciences Descriptors (DeCS) and their respective similar or equivalent, as well as their entry terms, separated by the Boolean operators OR / AND, with the following search strategy: online psychology OR online psychotherapy OR online therapy OR telepsychology AND pandemic OR COVID-19 OR coronavirus pandemic. In a scoping review, it is important to adopt both broad and specific definitions to ensure that no relevant studies are lost in the selection process (Arksey & O'Malley, 2005). We followed PRISMA guidelines to systematize the inclusion of studies (Moher et al., 2009). Figure 1 shows the flow chart for the search and selection of publications.

Figure 1.
Flow Diagram of the Search Process and Selection of Articles that Comprised the Review Analysis Corpus According to PRISMA Guidelines

Two independent reviewers with expertise in the study area conducted the electronic search process. The publications were selected by reading the titles, abstracts, and full texts, and those that met the objective of this study and contemplated the inclusion criteria were chosen.

After removing the duplicate studies, we proceeded to retrieve the full articles according to the eligibility criteria adopted to identify the perceptions of Brazilian psychologists about online psychotherapy during the COVID-19 pandemic. The evaluators' lists were compared, and eventual divergences were solved by consensus and with the help of the third evaluator. At the end of this refinement process, the articles selected constituted the corpus of analysis.

To extract data from the articles included in the review, we used an Excel spreadsheet to fill in the following information: authors, year of publication, type of publication, objective of the study, population/sample, methodological design, and main results. We will present data in a narrative format, covering aspects that answer the question that guided the scoping review. This stage of analysis aims to describe the main themes already researched on the subject of interest and point out significant gaps that other investigations can explore (Arksey & O'Malley, 2005).

Results

After the evaluation and selection process, 29 studies were included in the scoping review. Regarding the methodological design, the publications were distributed as experience report (10), theoretical study (nine), review (four), qualitative study (three, one of them being a monograph), quantitative (one monograph), and case study (one). One editorial was also included. The data collection procedures used in the empirical studies included interview guides (applied individually or in focus groups), questionnaires, and self-completion electronic surveys.

The theoretical approaches and techniques contemplated in the studies covered a wide variety: psychoanalysis (of various orientations), phenomenological-existential psychology, gestalt therapy, psychodrama, Reichian psychotherapy, and cognitive-behavioral therapy (CBT). Individual, group, couples, and family online psychotherapeutic interventions are among the types of care reported, with different age groups and carried out by one or two psychotherapists concomitantly, in co-therapy. Table 1 summarizes the characterization of the included studies and their main results.

Table 1
Characterization of the Included Studies

Authors and year	Publishing	Methodological design	Population and Sample	Objective
Almeida, 2020	Revista Brasileira de Psicanálise.	Theoretical	-	Reflect on the psychoanalytic clinic and its possible plasticity from new modalities of care beyond the physical face-to-face.
Almeida et al., 2020	Revista Sociedade e Cultura,3(1/2), 97-109.	Theoretical	-	To analyze the role of Psychology in the face of the pandemic situation from the perspective of training and professional performance.
Alves et al., 2020	IGT na Rede	Case report	-	Present the project “IGT com Você,” (IGT with you) developed by the Institute of Gestalt-Therapy and Family Care during the COVID-19 pandemic.
Archangelo et al., 2020	Jornal de Psicanálise	Theoretical	-	Problematize how the pandemic represents a cut in the temporality of today's society and discuss how analytical setting has been impacted.
Bittencourt et al., 2020	Diaphora	Review	-	Conduct a narrative review of the literature to understand the conceptual foundations involved in the online therapeutic process.
Evangelista and Cardoso, 2021	Perspectivas em Psicologia	Review	-	Reflect on how to provide psychological attention in online psychological counseling services in the context of the pandemic.
Fioroni et al., 2021	Cadernos da Pedagogia	Case report	-	Present the analysis of an experience of assistance to the student population in the context of the COVID-19 pandemic.
Fleury, 2020	Revista Brasileira de Psicodrama	Editorial	-	Collect information about the specifics of online psychotherapy.
Fossati, 2020	Diaphora	Review	-	To address possible difficulties faced by psychoanalysts regarding the applicability of the psychoanalytic method in the pandemic period of uncertainty.
Henderson et al., 2020	Reverso	Theoretical	-	Discuss the challenges of the psychoanalytic clinic at a distance, seeking to understand its limits and possibilities of (re)invention for the analyst.
Khouri, 2020	Revista Brasileira de Psicanálise.	Theoretical	-	Discuss how the times of crisis caused by the new coronavirus have put psychoanalysts to the test, evidencing challenges and efficacy/potency.
Oliveira and Pena, 2020	Polêm!ca.	Theoretical	-	Discuss the possibility of establishing the transference in the online format.
Oliveira and Santos, 2020	Revista Brasileira de Psicanálise.	Case report	-	Report intervention experience in the initial relationships of early childhood, implemented during the COVID-19 pandemic, in the light of psychoanalysis.
Pinto et al., 2021	Psicologia e Saúde em Debate	Case report	145 patients	Describe the experience and results of an online psychological care service aimed at the general population and health professionals.
Pontes, 2021	PSI UNISC	Theoretical	-	Point and discuss concerns experienced by the author and the questions raised in psychotherapeutic practice during the quarantine period.
Ribeiro, 2020	Ide	Case report	-	Present a narrative construction (psychoanalytic chronicle) of the author's personal experience during the pandemic and online care.
Rodrigues, 2020	Monograph	Qualitative	Three psychologists	Understand perceptions, feelings, and strategies of action adopted by Brazilian clinical psychologists in the face of the COVID-19 pandemic.
Romano, 2020	Revista do CEPdePA	Theoretical	-	Investigate the observed and/or expected changes in the setting in the new modality of remote care.
Santana et al., 2020	Folha de Rosto	Qualitative, document analysis	-	Critically reflect on the role of technology in psychological care mediated by ICTs in the context of the pandemic.
Schmidt et al., 2020	Psicologia: Ciência e Profissão	Review	-	Systematize knowledge about the experience of online psychotherapy experienced by couples and families, weaving considerations for clinical practice and professional training in the context of the pandemic.
Silva et al., 2020	HU Revista	Case report	-	Report an ongoing experience of telepsychology with families, using telepsychotherapy and telepsychoeducation.
Silva and Ramos, 2020	IGT na Rede	Case report	-	To analyze the perception and elaboration of professional doing in times of pandemic from the experience of the authors.
Susemihl, 2020	Revista Brasileira de Psicanálise.	Case report	-	Reflect on the psychoanalytic process that is established in the online modality.
Unikowski, 2020	Revista Brasileira de Psicanálise.	Case report	-	Describe and reflect on the implications of the pandemic in psychoanalytic formation.
Viana, 2020	Cadernos ESP Ceará	Qualitative, document analysis	-	Discuss the factors involving the provision of psychological and health services mediated by Information and Communication Technologies (ICTs).
Vidal and Cardoso, 2020	Revista Brasileira de Psicodrama	Case study	-	To analyze the possibilities of application of online psychodrama through the psychotherapy method of the relationship and the technique of internal psychodrama.
Vidal and Castro, 2020	Revista Brasileira de Psicodrama	Case report	-	Reflect on the possibilities of acting in relationship psychotherapy, bipersonal psychodrama, and internal psychodrama in online care.
Zeferino, 2020	Monograph	Quantitative	111 psychologists	To evaluate the results of the absence of face-to-face encounters in ICT-mediated psychotherapy, perceived by clinical psychologists during the COVID-19 pandemic.
Zerbinatti, 2020	Jornal de Psicanálise	Theoretical	-	Reflect on the difference in rhythm between the face-to-face and non-face-to-face sessions and its possible relationship with tiredness at the end of virtual sessions.

Discussion

From the results of this scoping review, we outlined two categories of analysis for discussion: Possibilities, advantages, and perceived benefits of ICT-mediated psychotherapy; Barriers, challenges, and limits of online psychotherapeutic care. In each category, we listed subcategories that contemplate the topics that stood out and that will be presented in descending order, considering the number of publications in which such aspects were identified.

Possibilities, Advantages, and Benefits Perceived in ICT-mediated Therapy

Maintenance, in the On-line Context, of the Structural Principles that Regulate the Practice of Face-to-face Psychotherapy

Although there are still many insecurities and doubts in the transition to telehealth, the studies show a significant portion of professionals that consider this type of service intrinsically beneficial. This coincides with the conclusion drawn from one of the studies “Feeling listened to, having an interlocutor to whom you explain your current situation, your dilemmas, and your pain would not be a prerogative of the face-to-face meeting” (Evangelista & Cardoso, 2021, p. 146). Several authors emphasize that the setting is, first of all, internalized as a mental experience of the psychologists in their relationship with the patient, and not only an external set of rules, conduct prescriptions, and ambiance (Almeida, 2020; Bittencourt et al., 2020; Romano, 2020; Zerbinatti, 2020), which makes the obstacles produced by the transition to the online modality relative.

Regarding the therapeutic bond, a study indicated that, despite 66.7% of the psychologists considered the impossibility of maintaining physical presence a disadvantage, most of the participants (73.8%) did not perceive losses in empathy, quality of the bond, and patient confidence in the process after the transition to a remote environment (Zeferino, 2020). In the mentioned study, this finding was positive even in cases of psychotherapies that had already begun with mediation by ICTs before the pandemic, which is corroborated by literature (Alves et al., 2020; Evangelista & Cardoso, 2021; Ribeiro, 2020; Rodrigues, 2020; Vidal & Castro, 2020).

The maintenance of a satisfactory therapeutic bond can be understood from the notions of the “illusion of non-mediation” and “telepresence”, explained by Pieta (2014). Such issues are addressed by several studies, which postulate the fact that the absence of the body in telehealth should no longer support the idea that such encounters are non-presential (Pontes, 2021) or remote (Oliveira & Santos, 2020), as they provide the experience of an “online presence” (Oliveira & Pena, 2020). In appropriate circumstances, ICT mediation may favor closeness rather than distancing between psychotherapist and patient.

Oliveira and Santos (2020) defend a pragmatic argument: the importance of online care in the context of the pandemic precisely to enable the therapeutic bond to continue and the work to not be interrupted, especially because the health emergency is marked by insecurity and unpredictability. If they could not count on the online resource, patients experiencing so much psychic suffering and emotional demands, often urgent, raised by the pandemic scenario, could be left helpless (Almeida, 2020; Evangelista & Cardoso, 2021; Henderson et al., 2020; Oliveira & Santos, 2020).

Regarding the psychotherapeutic intervention procedures, Zeferino (2020) evidenced that most professionals did not notice any changes in the conduction of the sessions and their processes, nor the patient’s engagement, spontaneity, and verbal communication. Some defend the “power of technology as a contact channel with the primitive of bonds” (Almeida, 2020, p. 66), and the use of aspects of the online format as part of the psychotherapeutic process. They understand it as a potential resource for the understanding and interpretation of the patient’s internal world (Evangelista & Cardoso, 2021; Oliveira & Santos, 2020; Romano, 2020; Vidal & Cardoso, 2020).

Potentialities are seen even in more complex scenarios, such as psychoanalysis with children by remote mediation. Susemihl (2020, p. 60) argues that children make an appropriation of the screen “that becomes an object of the transference situation and a means to express something of their internal world,” from the contact established by the analytical dyad. Thus, the framing of image, sound, and even the way the patient handles the electronic equipment would reveal something of the unconscious dimension that is in progress in the session and that needs to be decoded to reveal psychic functioning.

Another crucial issue to consider when assessing the results of ICT-mediated psychotherapy is the patient’s satisfaction with the assistance. In most of the studies analyzed, the psychologists consider the online work satisfactory and unchanged in terms of therapeutic achievements and benefits, showing that it is also possible to provide introspection, expression of anguish, and internal reorganization of patients in the virtual environment. This favors the development of new ways of coping with grief, alternative ways of looking at life and relating to the external world (Alves et al., 2020; Evangelista & Cardoso, 2021; Fioroni et al., 2021; Khouri, 2020; Pinto et al., 2021; Rodrigues, 2020; Zeferino, 2020). Khouri (2020, p. 220) claims that the analytical act maintains its potency even at a distance, “emerging as a possibility of elaboration and healing at both the individual and collective levels.” A limitation found was the absence of client satisfaction studies conducted with the clients themselves, to verify to what extent their perceptions coincide with those of the therapists.

Breaking Down Geographical Barriers and Broadening Access to Psychotherapy

One of the main potentialities addressed by psychologists regarding online care concerns the benefits provided by the breaking of geographical barriers and shortening of distances, enabling the offer of psychotherapy also for patients living in other cities or states, and even in other countries. This increases the scope of prospecting patients and demands care since physical boundaries are diluted and psychotherapy can reach a much wider and diversified portion of individuals (Fleury, 2020; Pinto et al., 2021; Rodrigues, 2020; Silva & Ramos, 2020). Moreover, it is noteworthy the possibility of maintaining psychotherapy if the patient moves to another city or has to spend long periods traveling for work purposes (Evangelista & Cardoso, 2021; Vidal & Cardoso, 2020).

The social distance required in the pandemic scenario exacerbates this aspect. Yet, it is an intrinsic advantage of the remote modality, which goes beyond the crisis and can remain relevant and even expand access to many vulnerable groups of the population, such as immigrants, emigrants, refugees, people with visual and hearing disabilities (Bittencourt et al., 2020; Santana et al., 2020; Viana, 2020; Vidal & Castro, 2020). In addition, there is the possibility of offering the service to people who reside in cities that do not have specialized access to psychological care, which can facilitate the implementation by managers of public policy strategies in mental health (Almeida et al., 2020; Alves et al., 2020; Viana, 2020).

Another factor approached as positive, from the new Resolution No. 4 of the CFP (2020a) about online psychological care, concerns the possibility of the psychologist performing ICT-mediated care also in situations of emergencies and disasters. This can contribute to the offer of qualified assistance to bereaved people in acute and crucial moments of the experience of grief (Viana, 2020).

Learning and Developing New Professional Skills and Abilities

We identified recurrent mentions of increased learning of new skills and competencies in many areas, from the knowledge that expands the theoretical and technical repertoire, and skills in handling digital technologies, to the development of emotional resources. Knowledge was often produced or adapted in response to the new demands generated by the pandemic, to understand the new world into which we had been thrown. All this from a perspective of creative, transformative adjustment and collaboration among professionals (Alves et al., 2020; Bittencourt et al., 2020; Rodrigues, 2020; Santana et al., 2020; Silva & Ramos, 2020; Unikowski, 2020).

The psychologists who participated and the authors of the studies revealed that the effort expended to adjust to the new situation generated high stress, resulting in physical and mental fatigue and anxiety. However, the psychotherapists’ initial resistance and mistrust regarding online services dissipated as new skills and emotional resources were developed, stimulating creativity, and providing a more comfortable and safer environment, with feelings of personal and professional enrichment (Alves et al., 2020; Fioroni et al., 2021; Henderson et al., 2020; Pontes, 2021; Ribeiro, 2020; Susemihl, 2020). The psychologists were able to build “new perceptions and elaborations of the professional practice, finding potentialities amidst fragility, transformations in the midst of suffering” (Silva & Ramos, 2020, p. 30), “opening possibilities where only limits seemed to exist” (Evangelista & Cardoso, 2021, p. 147). Rodrigues (2020) highlights that the possibilities of reinventing the practice and expanding clinical methodologies are independent of the theoretical approach of the psychologists, endorsing the results of other studies included in this review.

Convenience, Practicality, Flexibility: the Mantra for the Pandemic Times

Psychologists approach the different aspects related to the comforts and/or practicalities offered by online psychotherapy. They recognize advantages, especially in terms of the flexibility offered by this modality. Among the benefits identified is the ease in the issue of urban mobility, by sparing patients and psychotherapists from having to travel to locations in which there is heavy traffic and the distances are considerable. Also, optimization of time, since it does not require displacements; greater protection considering the risk of being exposed to contagion by the new coronavirus or suffering violence, especially at night hours; reduction of expenses with fuel or public transportation; reduction of costs with renting office rooms; the possibility of continuing the appointments in case of physical illness of patients or in situations in which the person assisted faces specific conditions, which could limit the maintenance of regular sessions, as mothers of babies; more flexible possibilities of scheduling (Bittencourt et al., 2020; Evangelista & Cardoso, 2021; Fleury, 2020; Rodrigues, 2020; Silva & Ramos, 2020; Unikowski, 2020; Vidal & Cardoso, 2020). It was also mentioned how pleasant it can be to perform several tasks in the same space and where family life also occurs (Ribeiro, 2020), which contrasts with other perceptions, such as the understanding that the suppression of boundaries between remote work and personal life also potentializes overload and increases stress levels.

Another advantage reported concerns the possibility of creating resources for agile and timely service to the specific needs of vulnerable populations. Thus, psychologists can contribute to the provision of an ethical and humane response to the demands of mental health, which tend to be more pronounced in times of acute global crisis (Khouri, 2020; Viana, 2020). An example of this was the experience of the first months of the pandemic, in which there was an intensification of the offer of psychological support mediated by ICTs on a voluntary and free-of-charge basis, with the spontaneous organization of coordinated actions in a task force scheme, directed to health professionals who are on the front line of the fight against COVID-19, and family members bereaved by the loss of beloved ones due to the most severe forms of the infection.

Other Potentialities and Benefits Perceived in ICT-mediated Psychotherapy

Other potential benefits arising from the provision of ICT-mediated psychotherapy were identified, but they did not constitute a robust enough corpus to configure specific subcategories. Among these is a more symmetrical therapeutic relationship, favoring closer contact with the patient’s experiences, as long as the psychologists can make good use of this proximity and maintain their role (Archangelo et al., 2020; Khouri, 2020; Pontes, 2021; Rodrigues, 2020); lower inhibition of the patient when addressing issues considered sensitive, and could not be verbalized personally, which may accelerate the psychotherapeutic process (Archangelo et al, 2020; Pontes, 2021). Also, a greater acceptance of psychotherapy by introverted patients who are used to communicating almost exclusively on the Internet (Bittencourt et al., 2020); more time to devote to their personal life (Rodrigues, 2020); greater control of the psychotherapeutic process by the patient (Bittencourt et al., 2020); possible decrease in patient dropout (Rodrigues, 2020).

It is noteworthy that several aspects perceived as advantages and benefits by some professionals are explicitly identified as disadvantages and obstacles in the view of others. This shows how, in essence, it is neither possible nor desirable to assign rigid categorization to the aspects related to the psychologist’s performance after the migration to psychotherapeutic care exclusively mediated by ICTs during the pandemic of COVID-19. The positive or negative denotation attributed to the changes arising from this situation is also conditioned to the individual responses of the psychotherapists, their maturity, and readiness to adjust to the changes, and the singular way such experiences had repercussions on their professional performance. Thus, “being a psychotherapist during the pandemic has been an experience of multiple senses and meanings” (Silva & Ramos, 2020, p. 29).

Barriers, Challenges, and Limits of Online Psychotherapeutic Services

Before explaining the subcategories that compose this theme, it is convenient to mention that, somehow, all of them allude to reactions to some kind of change introduced in the therapeutic setting due to the migration to the online environment. Psychologists do not necessarily interpret the challenging dimensions as impeding or harmful to online psychotherapy. In cases where some explicit mention of losses resulting from the transposition to the remote model may have been identified, this will be duly highlighted.

Absence of Face-to-face Meeting, Sensory, and Non-verbal Communication

Considering the research corpus, the aspect most mentioned by the psychologists in the transition to online psychotherapy was the distancing of the corporal dimension in the appointments. The absence of the materiality of the bodies is perceived as a relevant change in the traditional psychotherapy setting. The relative removal of sensory clues imposes changes in the management of the clinical situation when the migration to the online environment occurs. Frequently, the deprivation of physical presence is denoted as a loss, which cannot be completely compensated by the resource of image and voice available in real-time, also restricting sensory elements, which may impoverish visual communication (Fioroni et al., 2021; Zeferino, 2020).

Some psychologists consider that online communication suppresses aspects of physical corporeality that, in face-to-face care, provided non-verbal clues or could function as additional sources of observation, from the patient’s arrival at the office to the farewell after each session. However, professionals recognize that facial expressions, gestures, movements, and other bodily manifestations can be captured online, as well as voice intonation, silences, and the emphasis the patient gives to certain words. Some caveats are also made; although several aspects of nonverbal communication may be preserved, the sensory elements do not have the same vividness of the encounter in which bodies share the same physical environment (Henderson et al., 2020; Santana et al., 2020; Susemihl, 2020; Unikowski, 2020).

Some psychotherapists report that they find it more difficult to grasp emotional experiences than they did in face-to-face practice, especially when they do not use video calls, only voice connections or text messages and e-mails. Previously, expressions derived from the patient’s physical and sensory dimensions more readily conveyed emotions, such as smiling or crying. Impairments also appear in the patient’s perception of their emotional expressions and the nuances of the psychotherapist’s communications, welcoming, and subtle manifestations of continence mediated by the gaze (Evangelista & Cardoso, 2021; Fleury, 2020; Fossati, 2020; Pontes, 2021; Schmidt et al., 2020).

In this line of reflection, some authors feel that there is a less intense and spontaneous, “more partial” and “weak” presence of the psychotherapist in the electronic environment. This favors the perception that the online setting increases the patient’s susceptibility to discomfort, and may, in certain cases, expose the patient to internal disorganization, stirring up resistance that may lead to interruptions in the therapeutic process (Archangelo et al., 2020; Bittencourt et al., 2020; Fleury, 2020; Fossati, 2020; Romano, 2020; Susemihl, 2020). Some psychotherapists were emphatic in making explicit that they experience a diffuse feeling of insufficiency, that there seems to be “something” missing in the online context. Ribeiro (2020) does not hesitate to state that this “something,” still unmentionable, does not take place in remote consultations, although the sessions take place regularly, always leaving an expectation of a face-to-face physical meeting to be held in the future.

Lack of Previous Experience and Insufficient Training

A substantial part of the studies highlighted the suddenness of the migration of psychotherapeutic care to the virtual setting due to the unexpected arrival of the pandemic, without any previous professional experience or preparation in terms of technical training to handle the technological resources (Fleury, 2020; Pontes, 2021; Rodrigues, 2020; Romano, 2020; Schmidt et al., 2020; Zerbinatti, 2020). A survey conducted with 111 psychologists from 16 Brazilian states showed that 54.1% had never worked with online care before the imposition of quarantine (Zeferino, 2020), which probably stems from the incipient attention (or, in most cases, non-existent) given to this modality during the academic training of professionals. The absence of technical references contributes to many of the obstacles identified in this type of psychological care. The lack of familiarity with technology and specific training can lead to problems, such as the attempt to simply transpose the face-to-face model disregarding the specificities of remote work (Silva et al., 2020; Viana, 2020).

Psychologists recognized, in themselves and professional colleagues, caution, and rejection based on previous fears and prejudices about the quality of the bond and the effectiveness of ICT-mediated psychotherapy. Many of them expressed inhibition and recognized their skepticism and resistance to the novelty that materialized in an imposing way and with such force, besides the challenges in handling the technologies. They said they had to deal with difficulties and gradually tried to adjust to this resource. This was because they understood that it was the only way they could continue to serve, holding on to the hope that they would resume face-to-face meetings as soon as possible (Henderson et al., 2020; Pontes, 2021; Schmidt et al., 2020; Silva et al., 2020; Silva & Ramos, 2020; Unikowski, 2020).

Difficulties in Handling Communication Technologies

Difficulties in mastering and handling technological resources were addressed in most studies. It comprehended lack of skill with new technologies and digital media resources, oscillations or absence of the Internet and telephone signal, distortions in sound and image quality, and even the framing and concrete conditions of the place where the patient is during the sessions (Bittencourt et al, 2020; Evangelista & Cardoso, 2021; Fioroni et al., 2021; Henderson et al., 2020; Rodrigues, 2020; Silva et al., 2020; Silva & Ramos, 2020; Unikowski, 2020; Viana, 2020). Authors postulate that eventual interruptions can generate false or distorted interpretations and impressions, for example, regarding silences, which can be confused with interruptions and technological failures (Fossati, 2020; Schmidt et al., 2020). However, although such obstacles hinder the running of the sessions, no direct mention was found of major losses arising from limitations in the use or quality of communication technology.

Concerns Regarding the Actual Conditions of Privacy and Confidentiality Preservation

One of the greatest concerns shared by psychologists was the fear about the feasibility of conditions to maintain the privacy and confidentiality of the sessions (Almeida et al., 2020; Evangelista & Cardoso, 2021; Fleury, 2020). Some consider this to be the main disadvantage of the online format of psychotherapy (Henderson et al., 2020; Zeferino, 2020). Reports about the need for many patients - and even professionals - to resort to unusual environments to feel safe and comfortable are common. Sometimes they need to seek shelter in the garage, inside the car, pantry, balcony, garden, service area, or external environments to the residence, such as leisure areas of buildings and condos, parking lots, and squares, in an attempt to ensure a reserved place that favors the intimacy and confidentiality of the sessions (Henderson et al., 2020; Rodrigues, 2020; Susemihl, 2020; Unikowski, 2020).

It also highlighted the need to share with patients the responsibility for the care with the preservation of privacy, secrecy, and even the safety of the physical environment and the device used for communication. Thus, the reconstruction and preservation of the setting constitute aspects that can and should be part of the therapeutic work itself (Schmidt et al., 2020; Susemihl, 2020).

It is important to mention another potential aggravating factor regarding the preservation of privacy in the pandemic, with possible deleterious consequences: the increased exposure of women, children, and adolescents to domestic violence resulting from the situation of home confinement and the accumulation of tensions due to prolonged cohabitation (Oliveira, Magrin, et al., 2020; Soares et al., 2020). As the aggressor is often in the same environment as the victim, the circumstances are favorable for the occurrence of various types of violence (Ferracioli et al., 2021; Lima et al., 2021; Santos et al., 2020). At the same time, it inhibits the possibility of the victims reporting to the psychologist or other people the dangerous situation to which they are subjected. In extreme cases, this vulnerability may culminate in attempts against life and eventual femicide (Braga et al., 2020).

Issues Related to the Nature of Home Office Work

The transposition of work to the residence (home office) and the overlapping of demands of professional and personal life, which were restricted to the domestic environment, are recurrent themes in the statements of the psychologists. Psychotherapists find it challenging to conciliate work at home with domestic chores, and activities that once could be delegated to other people and/or institutions are now performed exclusively by mothers and fathers, which includes childcare and supervision of school activities, contributing to increasing the number of unpaid work hours. If these vicissitudes were not enough, the excess of online commitments (appointments, meetings, classes, supervisions, and participation in scientific events) perpetuates the feeling that one is working practically non-stop. These conditions increase the risks of developing burnout, in addition to the challenges in terms of ergonomics, which was not previously designed for the home office, requiring modifications in the environment (Ribeiro, 2020; Rodrigues, 2020; Schmidt et al., 2020; Unikowski, 2020; Viana, 2020).

It also emerged as a challenge of the professional practice, now based in one’s residence, the fact that there is a rupture of the limits, which used to be clearer, between the proper spaces for work, rest, family interaction, and leisure. The concentration of activities in the domestic sphere, associated with the adverse impacts of confinement on lifestyle, make the sanitary protection measures also become sources of vulnerability and imprisonment, with repercussions on domestic relations, which demanded adaptations by all family members (Ribeiro, 2020; Rodrigues, 2020; Silva & Ramos, 2020). The permeability of the domestic spaces increased experiences of constant alertness and tension, with fears that interference and invasion by sounds arising from the routines of the house (for example, of doors closing, noises coming from the kitchen, voices, and dog barking) would negatively impact the sessions (Rodrigues, 2020).

Recurrent Complaints of Fatigue as a By-Product of Online Sessions

Some of the selected studies pointed to a greater susceptibility to chronic fatigue as a prominent adversity in ICT-mediated care, compared to the same workload that existed in the face-to-face setting in the pre-pandemic setting. Possible explanations for this phenomenon include screen time and greater demands on attention to grasp nuances during sessions and to adapt the psychic apparatus to changes, the need to expend greater effort to maintain concentration and the stability of the setting, which undergoes many internal and external pressures and requests (Unikowski, 2020), the quest to “mentally reconstruct a three-dimensional relationship from two-dimensional perception” (Susemihl, 2020, p. 51), tendency to accelerate the pace of work in online sessions (Zerbinatti, 2020) and tensions and anxieties inherent to the experiences of the psychotherapist immersed in the pandemic moment with the family (Ribeiro, 2020).

Decreased Asymmetries Between Therapist and Patient

As previously mentioned, one of the phenomena attributed to the online service is the perception of the reduction of asymmetries between psychologists and patients, since they are all affected by similar feelings arising from the limiting situation established by the pandemic. Some of the articles found approached the sharing of this existential dimension of proximity with finitude, highlighting the similarities of the experiences of loss and the feelings shared by patients and professionals as subjective effects of social distancing, although they take into consideration the social and subjective differences of the impacts. The processes of identification with the suffering of the other, when not under control, can cause an increase in the vulnerability of the professional, who risk mixing their own experience with the suffering of the patient. Psychologists, supported by their supervision and personal psychotherapy can mitigate these effects if there is full recognition of this dimension (Fossati, 2020; Khouri, 2020; Pontes, 2021; Susemihl, 2020).

Final Considerations

This scoping review pointed out the peculiarities of psychological care mediated by digital platforms during the pandemic, from the perspective of Brazilian psychologists. We identified potentialities and barriers perceived in this type of care, which provide elements to support reflections that can contribute to the establishment of references and guidelines for the use of technologies by the Psychology category.

We point out the importance of further research, especially of an empirical nature, which can evaluate the relevance and results of online psychotherapy in various situations, to provide technical and ethical support to reinventions and adaptations of the practice of psychologists who work with psychotherapy. There are still many doubts among professionals who practice psychotherapy: what is the real nature of online work? What changes and what remains equivalent to the face-to-face modality? In remote care, would psychotherapists be promoting effective and transforming work?

We cannot fail to consider that, in developing countries like Brazil, there is a digital gap for a large portion of the population that could benefit from online services. Considering social disparities, access to the virtual universe is also quite unequal, to the extent that countless individuals experience the lack of a stable internet connection, in the peripheries and rural or hard-to-reach areas. Financial resource limitations impede access to phone credits or smartphones, and there are also impediments for people living in prisons, shelters, and long-stay institutions. In addition to these barriers, there are difficulties in handling the technologies for older adults, those with cognitive or sensory deficits, and individuals with lower educational levels, hindering access to remote care for the most vulnerable people and groups. It is necessary to think of alternatives and adapt the tools to those who have different needs so that these barriers are minimized.

In the studies analyzed, we detected recognition, by the psychologists, of both positive and negative impacts of the practice of psychotherapy mediated by ICTs. In the context of COVID-19, the resource proved to be essential to avoid psychotherapeutic work being discontinued due to physical distance, which was evidenced even by professionals who were skeptical about the use of digital communication, since, despite doubts and reservations about the effectiveness and feasibility of remote meetings, they continued to perform their appointments online.

The ICTs may integrate the repertoire of resources used by the psychotherapist, as one more relevant tool, being necessary to evaluate, among the possibilities, in which cases this type of intervention will or will not be the most appropriate and viable, weighing the specific pros and cons in each situation.

The question remains: once the acute crisis precipitated by the pandemic is over, what should remain online? Considering that, until recently, this modality was restricted only to specific situations, the reflections raised in this exceptional period in which telehealth became the modus operandi of the psychological practice must provide evaluations about the future. In this reflexive movement about the exercise of psychotherapeutic practice, it is up to the professional category to ask: facing the new reality that is presented, where do we go from here?

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Publication Dates

• Publication in this collection
  24 July 2023
• Date of issue
  2023

History

• Received
  23 Dec 2021
• Accepted
  03 July 2022