Psychotherapy Under Lockdown: The Use and Experience of Teleconsultation by Psychotherapists During the First Wave of the COVID-19 Pandemic Research Articles Psychotherapy Under Lockdown: The Use and Experience of Teleconsultation by Psychotherapists During the First Wave of the COVID-19 Pandemic Jessica Notermans 1,2 , Pierre Philippot 1,2 [1] Consultations Psychologiques Spécialisées, Université Catholique de Louvain, Louvain-La-Neuve, Belgium. [2] Laboratory for Experimental Psychopathology, Université Catholique de Louvain, Louvain-La-Neuve, Belgium. Clinical Psychology in Europe, 2022, Vol. 4(3), Article e6821, https://doi.org/10.32872/cpe.6821 Received: 2021-05-27 • Accepted: 2022-05-31 • Published (VoR): 2022-09-30 Handling Editor: Anton-Rupert Laireiter, University of Vienna, Vienna, Austria Corresponding Author: Jessica Notermans, Institut de Recherche en Sciences Psychologiques, Université Catholique de Louvain, place du Cardinal Mercier, 10, B-1348 Louvain-la-Neuve, Belgium. Phone: +32489195018. E- mail: jessicanotermans@gmail.com Supplementary Materials: Materials [see Index of Supplementary Materials] Abstract Background: Facing the COVID-19 pandemic, some psychotherapists had to propose remote consultations, i.e., teleconsultation. While some evidence suggests positive outcomes from teleconsultation, professionals still hold negative beliefs towards it. Additionally, no rigorous and integrative practice framework for teleconsultation has yet been developed. This article aims to explore the use and experience of teleconsultation by 1) investigating differences between psychotherapists proposing and not proposing it; 2) evaluating the impact of negative attitudes towards teleconsultation on various variables; 3) determining the perceived detrimental effect of teleconsultation, as opposed to in-person, on the therapeutic relationship and personal experience; and 4) providing insights for the development of a teleconsultation practice framework. Method: An online survey was distributed via different professional organisations across several countries to 246 (195 women) French-speaking psychotherapists. Results: Psychotherapists who did not propose teleconsultation believed it to be more technically challenging than psychotherapists who proposed it, but felt less constrained to propose it, and had less colleagues offering it. Attitudes towards teleconsultation showed no significant associations with therapeutic relationship, personal experience, and percentage of teleconsultation. As compared to in-person, empathy, congruence, and therapeutic alliance were perceived to significantly deteriorate online, whereas work organisation was perceived to be significantly This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License, CC BY 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.6821&domain=pdf&date_stamp=2022-09-30 https://orcid.org/0000-0002-0602-560X https://orcid.org/0000-0003-0207-2430 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ better. While most psychotherapists proposed remote consultations, they did not provide adaptations to such setting (e.g., ascertaining a neutral video background); nor used videoconferencing platforms meeting privacy and confidentiality criteria. Conclusion: Training and evidenced-based information should be urgently provided to practitioners to develop rigorous guidelines and an ethically and legally safe practice framework. Keywords teleconsultation, COVID-19, attitudes, online psychotherapy, ethics, therapeutic relationship Highlights • Psychotherapists differ in their perceptions of teleconsultation as whether they propose it or not. • Attitudes towards teleconsultation are not related to its use nor to the therapeutic relationship. • Teleconsultation worsens perceived therapeutic relationship, but improves work organisation. • Training is needed to improve an ethically and legally safe practice of teleconsultation. Following the first wave of the COVID-19 pandemic, many countries imposed a lock­ down, which resulted in the suspension of various healthcare practices, including face- to-face psychotherapy. Consequently, many psychotherapists had to rapidly adapt their services and propose consultations at a distance, i.e., teleconsultation. Teleconsultation refers to “interactions that happen between a clinician and a client for the purpose of providing diagnostic or therapeutic advice through electronic means” (Pan American Health Organization, 2021). This drastic change in the provision of mental health serv­ ices was largely improvised as most psychotherapists and professional organisations were unprepared for this challenge. Some evidence suggests positive outcomes from teleconsultation for the treatment of specific conditions (Acierno et al., 2016; Poletti et al., 2021; Wright & Caudill, 2020). Moreover, recent evidence from the COVID-19 pandemic also shows that most psycho­ therapists experience remote psychotherapy rather positively (Feijt et al., 2020; Humer et al., 2020; McBeath et al., 2020). These attitudes towards teleconsultation are influenced by a set of factors (Connolly et al., 2020), such as previous online experience, clinical experi­ ence (Békés & Aafjes-van Doorn, 2020), perceived ability to develop a strong therapeutic relationship (Aafjes-van Doorn et al., 2021; Roesler, 2017), and perceived therapeutic efficacy (Aafjes-van Doorn et al., 2021). In contrast, other evidence reports that mental health practitioners hold negative attitudes towards teleconsultation (Mendes-Santos et al., 2020; Perle et al., 2013; Varker et al., 2019). Beliefs regarding poor efficacy (Schulze et al., 2019) and ethical limitations (Stoll et al., 2020) of such practices may hamper its Psychotherapy Under Lockdown 2 Clinical Psychology in Europe 2022, Vol. 4(3), Article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ use and implementation, as well as reduce clients’ adhesion. Questions regarding the strengths and limitations of online therapy are known topics of discussion among mental health professionals (Rochlen et al., 2004). Therefore, it is important to further investigate current attitudes towards teleconsultation and evaluate their potential impact. Last but not least, with the drastic transition from in-person to remote consultation, several authors underlined the importance to develop an integrative and balanced prac­ tice framework with specific guidelines to inform psychotherapists about the use of teleconsultation (Smith et al., 2020). Boldrini and colleagues (2020) provided a set of recommendations to help professionals support the implementation and use of telecon­ sultation. Moreover, another team of researchers listed useful evidence-based guidelines for clinicians using telepsychiatry (Smith et al., 2020). However, these recommendations are gathered from country-specific sources (Italy and England respectively), and thus do not allow for a global perspective on the matter. Finally, while a set of valuable recom­ mendations regarding the policy and practice of telepsychotherapy was also developed in field studies (Shore et al., 2018; Van Daele et al., 2020), and suggested by professional organisations (British Association for Behavioral & Cognitive Psychotherapies, 2021), they are largely based on clinical consensus. Further empirical data are thus required to provide a rigorous, ethical, and safe framework to support the provision of remote mental healthcare in times of crisis (Ohannessian et al., 2020). In this perspective, the present survey aims to explore the use and experience of teleconsultation among French-speaking psychotherapists in order to provide insights regarding its challenges and benefits. First, we hypothesise that there will be significant differences between psychotherapists proposing teleconsultation and those who do not, specifically in terms of attitudes towards it, previous online experience, feelings of con­ straint, perceived support, and colleagues’ usage. Second, attitudes towards teleconsulta­ tion will have significant and negative associations with the therapeutic relationship, the personal experience of teleconsultation, and the percentage of teleconsultation proposed. Third, the therapeutic relationship and personal experience of teleconsultation will be perceived as significantly worse than in-person. Lastly, this study will explore how various elements of teleconsultations (e.g., legal and ethical questions, adaptations, etc.) may contribute to the elaboration of a practice framework. Altogether, it investigates the information, skills, and knowledge that would help psychotherapists improve their prac­ tice of teleconsultation, in terms of effectiveness, ethics, and well-being at work. Thus, it may serve as a basis for establishing psychotherapists’ potential needs for training in teleconsultation, as suggested by recent studies (Van Daele et al., 2020; Wijesooriya et al., 2020). Notermans & Philippot 3 Clinical Psychology in Europe 2022, Vol. 4(3), Article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ M e t h o d Recruitment and Procedure The survey was developed online (on the Qualtrics platform), and distributed via dif­ ferent professional organisations (e.g. UPPCF, AEMTC) to 246 French-speaking psycho­ therapists between September 15th and October 31st of 2020 in Belgium, France, Morocco, Switzerland, and Tunisia. The study was approved by the IPSY Ethics Committee of UCLouvain (Project 2020-30; approved on June 10th, 2020). Survey Questionnaire The questionnaire (Appendix 1, Supplementary Materials) comprises four sections. Sec­ tion 1 presents the aim of the study and provides informed consent details. If consent was given, participants were asked whether they proposed teleconsultations from the first lockdown (March 16th, 2020) onwards. Those who answered positively were directed to Section 2; others were directed to Section 3. Section 2 includes questions pertaining to the use and experience of teleconsultation for psychotherapists proposing it. Section 3 examines the attitudes towards teleconsulta­ tion of psychotherapists not proposing it, as well as other variables that may shed light on the motives behind their non-adhesion to teleconsultation. Section 4, was given to all participants, and covers demographics, namely gender, level of education, level of psychotherapy training, psychotherapeutic orientation, work status, years of experience, percentage of teleconsultations proposed since June 2020, living situation, number of dependent children and their age, if any, the extent to which the charge of dependent children living at home impacted their psychotherapy activities during the lockdown, age, and country of residence. Measures To the authors’ knowledge, no valid and reliable measures evaluating their questions of interest were found in the literature. Therefore, the survey’s validity and reliability are limited. Survey’s questions are detailed below (see Appendix 1 in the Supplementary Materials for the full survey). Section 2 contains 20 questions inquiring on: 1) whether the number of consulta­ tions in 2020 decreased or increased (ranging from -100 to +100%) between March and June, and 2) between July and September, as compared to the same period in 2019; 3) attitudes (i.e., negative beliefs) towards teleconsultation, evaluated on a 5-point Likert scale ranging from 0 “Strongly disagree” to 4 “Strongly agree”, from an 11-item ad hoc questionnaire; 4) what remote mediums were utilised (telephone, chat messaging, e-mails, and/or videoconferencing); 5) the type of platforms used (e.g., Zoom, Whatsapp, Whereby, etc.); 6) whether they had prior experience with teleconsultation (No experi­ Psychotherapy Under Lockdown 4 Clinical Psychology in Europe 2022, Vol. 4(3), Article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ ence; Experience as a supervisee/or as a patient; Experience as a supervisor; and/or Experience as a psychotherapist); 7) whether they felt constrained to use it (Not at all, Slightly, Moderately, or Strongly); 8) whether their colleagues used it (None; A few, Some, Most, or All); 9) whether they had specific concerns regarding data protection and confidentiality (No; “Yes, I found satisfactory answers”; or “Yes, but I still have ques­ tions (specify)”); 10) whether they received support to set up teleconsultation (No, Mild, Moderate, or Complete support); 11) whether (Yes or No), and 12) how they encouraged clients to engage in teleconsultation (selecting from a 10-item ad hoc questionnaire items such as “providing information regarding the efficacy of teleconsultation”, “providing a short free trial on the media used”, etc.); 13) whether they provided adaptations to the teleconsultation setting (“Generally, I did not have to adapt the teleconsultation setting” or “I had to do minor changes”), and 14) how they adapted their online interventions, based on the population (e.g., children, adolescents, adults, etc.), and 15) disorder (e.g., mood disorder(s), anxiety disorder(s), eating disorder(s), etc.). Question 16 investigated the percentage of clients for whom their issue was directly linked to the pandemic, aggravated by it, or independent from it. Question 17 evaluated, on a 5-point Likert scale (from 0 “Highly degraded” to 4 “Highly improved”), psychotherapists’ experience of teleconsultation as compared to in-person for the therapeutic relationship (empathy, con­ gruence, positive regard, and therapeutic alliance). Question 18 asked whether psycho­ therapists will continue to propose teleconsultation after the pandemic (“Yes, based on the patient/client demand, teleconsultation will be an option”; “Yes, teleconsultation will become major in my clinical practice”; or No). Question 19, evaluated on a 5-point Likert scale (from 0 “Much worse” to 4 “Much better”), psychotherapists’ personal experience of teleconsultation (therapeutic efficacy, professional satisfaction, fatigue/exhaustion, work organisation, and ease of payment) as opposed to in-person. A final open-ended question asked about additional comments/remarks regarding teleconsultation. Section 3 includes seven questions. First, a 7-item ad hoc questionnaire evaluates on a 5-point Likert scale (from 0 “Not at all important” to 4 “Very important) psychothera­ pists’ motives for not providing teleconsultation (e.g., “this mode of communication does not seem appropriate for a psychotherapy”, or “people did not wish to start/continue via teleconsultation”). Then, participants were asked whether they could have received support if they proposed teleconsultation (No, Mild, Moderate, or Complete support); whether they felt constrained to offer it (Not at all, Slightly, Moderately, or Strongly); whether they had previous experience with it (No experience; Experience as a supervi­ see/or as a patient; Experience as a supervisor; and/or Experience as a psychotherapist); whether their colleagues were offering it (None, a Few, Some, Most, or All); and whether they intended to propose it in the future (No; “Yes, if the pandemic persists”; or “Yes, no matter what”). Finally, the same ad-hoc questionnaire from section 2 investigated their attitudes towards teleconsultation. Notermans & Philippot 5 Clinical Psychology in Europe 2022, Vol. 4(3), Article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ Data Analysis For Hypothesis 1, an exploratory factor analysis (EFA) explored the internal structure of attitudes. The Kaiser–Meyer–Olkin index and the Bartlett sphericity test were computed to assess the robustness of the results. Then, independent t-tests evaluated the significant differences in attitudes between psychotherapists who did and did not propose telecon­ sultation, as well as for previous experiences, feelings of constraint, perceived support, and colleagues’ usage. Levene's corrections were used for cases in which variances differed between groups. For Hypothesis 2, Pearson’s correlations were calculated be­ tween attitudes towards teleconsultation, therapeutic relationship, personal experience, and percentage of teleconsultation. For Hypothesis 3, single sample t-tests determined whether teleconsultations were perceived as worse than in-person, for the therapeutic relationship and personal experience. Finally, for Hypothesis 4, single sample t-tests and descriptive statistics explored variables related to the use and experience of teleconsulta­ tion, and participants’ demographics. Qualitative data complemented quantitative results. IBM SPSS Statistics for Windows, Version 21.0, was used for all analyses. R e s u l t s Participants Characteristics A total of 246 individuals (195 women; 35 men) participated in the study. 16 participants did not fill the entire survey, mainly on demographic questions. They were aged between 25 and 70 years (M = 42.4). Out of 230 participants, all were psychotherapists and most of them (186) had at least 3 years of postgraduate training in psychotherapy. They were mostly from Belgium (133), Switzerland (45), and France (37). The majority were self-em­ ployed (114) or part-time self-employed (59), while 94 were employees. Most participants identified themselves as CBT (156) or integrative (58) psychotherapists. The majority (158) lived as a couple and 115 had children living at home (average 1.90 children). Dependent children living at home were aged between 0 and 29 years of age (M = 11.32). Out of the total sample (N = 246), 222 psychotherapists proposed teleconsultation (173 females; 33 males; 16 did not answer), and 24 (22 females; 2 males) did not. Hypothesis 1 The factorability of the 11 attitudes towards teleconsultation was examined for the total sample. A three-factor solution explained 58.2% of the variance for the entire set of variables, with eigenvalues greater than 1 and a minimum of 10% of variance explained by each factor. The Kaiser–Meyer–Olkin index for sampling quality was good: 0.191, and the Bartlett sphericity test was correct, χ2(55) = 75.84, p > .04. The scree plot also suggests a three-factor solution. The factor solution, after Oblimin rotation, is displayed in Table Psychotherapy Under Lockdown 6 Clinical Psychology in Europe 2022, Vol. 4(3), Article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ 1. The first factor, “attention”, pertains to the belief that teleconsultation entails attention difficulties in both the client/patient and therapist. The second factor, “technical issues”, covers beliefs that teleconsultation requires significant technical skills and infrastructure. The last factor, “interpersonal communication”, reflects the belief that teleconsultation is detrimental to the communication quality between client/patient and therapist. Table 1 Factor Loadings, After Oblimin Rotation, for the 11 Items of Attitudes Towards Teleconsultation for Psychotherapists Proposing and not Proposing it Items of attitudes towards teleconsultation Factors (1) Attention (2) Technical Issues (3) Interpersonal Communication (reversed) I will be too distracted .883 I will not be engaged/present enough .851 The client/patient will not be engaged/present enough .647 There will be too many distractions in the individual .572 My personal infrastructure will not be adequate for teleconsultation (e.g., limited infrastructure, isolated room for the session, etc.) .387 .328 Teleconsultation requires a good handling of informatics tools .838 Technical issues will have too big of an impact on communication .729 The lack of non-verbal information will be too important -.854 Teleconsultation will limit the development of a good therapeutic relationship -.778 It will be difficult to set up some interventions .433 -.505 Teleconsultation will increase dropout number in certain individuals (e.g., addictions) -.357 t-tests were run to determine whether attitudes differed between psychotherapists as a function of whether they proposed teleconsultations. A significant difference was ob­ served only for Factor 2, “technical issues”, indicating that psychotherapists who did not propose teleconsultations believed they entailed more technical issues, t(32.247) = -3.159, Notermans & Philippot 7 Clinical Psychology in Europe 2022, Vol. 4(3), Article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ p = .003, than those who proposed them. Mean differences for each attitude towards tel­ econsultation between psychotherapists proposing and not proposing teleconsultations are found in Appendix 2, Supplementary Materials. Most psychotherapists had no experience with teleconsultation before the pandemic, whether they proposed it (n = 188) or not (n = 19), with no difference between these two groups, χ2(1, N = 243) = 0.764, p = .382. Most psychotherapists who proposed teleconsul­ tation felt significantly more constrained (i.e., Strongly constrained; M = 2.78, SD = 1.17) to do so than those who did not (i.e., Slightly constrained; M = 1.79, SD = .66), t(41.249) = 6.340, p < .001. In addition, psychotherapists reported having received little support to set up teleconsultation, whether they offered it (M = 1.69, SD = .88) or not (M = 1.75, SD = 1.07), t(240)= -.321, p = .749. Qualitative data indicate that support mainly came from colleagues (n = 55), IT services (n = 22), supervisors (n = 13), friends and family (n = 15), and professional associations (n = 11). Finally, the majority of psychotherapists (n = 116) expressed that some colleagues used teleconsultation. Yet, psychotherapists proposing teleconsultation reported that most of their colleagues used it (M = 3.24, SD = .87) as opposed to colleagues of psychotherapists not offering it (M = 2.38, SD = .77), t(241) = 4.677, p < .001. Hypothesis 2 No significant correlations above the coefficient .30 were found. However, for explorato­ ry purposes, significant (p < .001) and positive associations were found between thera­ peutic relationship, personal experience, and percentage of teleconsultation (Appendix 3, Supplementary Materials). Regarding the therapeutic relationship, empathy is correlated with congruence (r = .389), unconditional positive regard (r = .411), therapeutic alliance (r = .417), therapeutic efficacy (r = .378), and professional satisfaction (r = .303). Thus, the more psychothera­ pists perceived empathy as better online than in-person, the more the above variables were perceived similarly, and vice versa. Comparably, congruence is correlated with therapeutic alliance (r = .394), and therapeutic efficacy (r = .413), while unconditional positive regard is only correlated with therapeutic alliance (r = .309). Finally, therapeutic alliance is correlated with therapeutic efficacy (r = .472), and professional satisfaction (r = .382). Regarding therapeutic experience, therapeutic efficacy is correlated with professional satisfaction (r = .592), such that the more psychotherapists perceived therapeutic efficacy as better online than in-person, the more they perceived professional satisfaction as better online than in-person, and vice versa. Therapeutic efficacy is also correlated with percentage of consultation (r = .343), meaning that the more psychotherapists perceived therapeutic efficacy as better online than in-person, the more their percentage of teleconsultation increased from June 2020, and vice versa. Similarly, professional satisfaction is correlated with strain (r = .438), efficiency in work organisation (r = .352), Psychotherapy Under Lockdown 8 Clinical Psychology in Europe 2022, Vol. 4(3), Article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ and percentage of consultation (r = .356). Finally, strain is also correlated with efficiency in work organisation (r = .403). Hypothesis 3 Single sample t-tests against 3 (neutral “no change” point) showed significant changes in three aspects of the therapeutic relationship: empathy, congruence, and therapeutic alliance. Specifically, participants perceived that these significantly degraded online as compared to in-person (Table 2). Table 2 Perceived Effect of Teleconsultation on Therapeutic Relationship as Compared to Face-To-Face (n = 207) (1: highly degraded, 3: no change, 5: highly improved) Aspects of therapeutic relationship M SD p Empathy 2.81 0.59 < .001 Congruence 2.76 0.67 < .001 Unconditional Positive Regard 2.96 0.51 .206 Therapeutic Alliance 2.86 0.70 .006 Similarly, single sample t-tests against 3 showed that all variables of personal experience of teleconsultation were perceived as significantly worse online, as compared to in-per­ son, except ‘Organisation, time and task management, etc.’ which was perceived as significantly better (Table 3). Table 3 Experience of Teleconsultation as Compared to Face-to-Face (n = 206) (1: much worse; 3: no difference, 5: much better) Variables of personal experience of teleconsultation M SD p Organisation, time and task management, etc. 3.24 1.17 .004 Ease/Rapidity to receive payments 2.49 0.91 < .001 Therapeutic Efficacy 2.39 0.77 < .001 Professional Satisfaction 2.24 0.96 < .001 Strain, Fatigue 2.24 1.12 < .001 Notermans & Philippot 9 Clinical Psychology in Europe 2022, Vol. 4(3), Article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ Hypothesis 4 Data From Psychotherapists Proposing Teleconsultation During the first lockdown (from March to June 2020), consultations significantly dropped by almost 24% (SD = 46.03), t(221) = -7.759, p < .001 (single sample t-test against 0). This decrease was observed for all job status: self-employed (n = 110, M = -24.81, SD = 58.46); employees (n = 83, M = -20.34, SD = 42.31); and part-time self-employed (n = 47; M = -40.28, SD = 44.71). However, from June to September 2020, consultations appeared to have slightly but significantly increased by 6.3%, (SD = 31.68), t(220) = 2.945, p = .004, as compared to the same period in 2019. Such increase is also observed in all status: self-employed (n = 109, M = 2.95, SD = 30.09); employees (n = 83, M = 10.72, SD = 30.39); and part-time self-employed (n = 47, M = 11.57, SD = 39.56). Then, from June to September 2020, 19.1% of consultations, on average, occurred remotely. Out of 115 participants with dependent children at home, 53.9% did not report a decrease in their professional activities. However, 20.0% slightly reduced (10.0% to 30.0%) their professional activities, 14.8% moderately reduced (31.0 to 60.0%), 6.1% strongly reduced (61.0 to 80.0%), and 5.2% extremely reduced them (81.0 to 100.0%). No significant gender difference was found; such that dependent children did not present more difficul­ ties in professional activities for men, and vice versa. Participants reported that the majority of their clients (n = 207, M = 64.9%, SD = 24.40) consulted for reasons independent of the COVID-19 crisis. 12.8% (n = 207, SD = 15.56) consulted for issues mainly related to COVID-19, and 29.5% (n = 207, SD = 21.23) consulted for issues significantly aggravated by COVID-19. Out of 222 participants, 94.1% used videoconference for teleconsultations; 67.1% used the telephone; 12.6% used e-mails; and 4.5% used chat messaging. Regarding videoconfer­ encing platforms, 63.6% of psychotherapists reported using Skype, 42.6% used Zoom, 29.2% used Whatsapp, and 26.3% used Whereby (Appendix 4, Supplementary Materials). More than half of the participants (n = 116, 52.3%) found satisfactory answers regard­ ing data protection and deontology issues, whereas a third (n = 61, 27.5%) did not have questions regarding these issues. Still, a fifth (n = 41, 18.9%) found answers but had remaining questions, mainly concerning the confidentiality of videoconferencing platforms (n = 32). The majority of practitioners (n = 119, 54.6%) set up actions to encourage clients’ adhesion (Table 4). Most participants (n = 128, 57.7%) did not adapt their practice to the teleconsultation setting, while 27% (n = 60) provided minor changes. Some (n = 19, 8.6%) adapted their therapeutic procedures (e.g., screen sharing to show schemas or other visuals; printing materials to present before the camera; emailing questionnaires and other documents); others (n = 18, 8.1%) adapted their room, desk, and/or video back­ ground; and 12 participants (5.4%) adapted their schedules and/or consultation timing and frequency. A small portion of respondents, 12.6% (n = 28), adapted significantly their consultation based on the type of population (see Appendix 5, Supplementary Materials), Psychotherapy Under Lockdown 10 Clinical Psychology in Europe 2022, Vol. 4(3), Article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ while 10.4% (n = 23) adapted significantly their consultation based on the type of disorder (see Appendix 5, Supplementary Materials). Changes pertained mainly to therapeutic procedures and interventions (e.g., shortened session, flexible schedule, adaptation of interventions, etc.). Table 4 Actions Set up to Encourage Adherence to Teleconsultation Actions to encourage adherence to teleconsultation N = 222 % Communicating with the patient/client to assess the situation (via email, telephone, or other) 97 43.7 Giving general advice to ensure optimal conditions for teleconsultations (e.g., be in a quiet space to avoid distractions and increase privacy, ensure a good internet connection, have charged devices, etc.) 79 35.6 Underlining the importance of psychotherapy continuity for the well-being of the patient/client 75 33.8 Giving information on the use of virtual platform (or other used media) 69 31.1 Being flexible regarding schedule 67 30.2 Giving information on the privacy of personal data (confidentiality regarding the session and the used media) 51 23 Doing a trial test on the used media 45 20.3 Giving information on the efficacy of teleconsultations 41 18.5 Being flexible regarding payments 29 13.1 Finally, out of 207 respondents, 65.8% (n = 146) intend to keep teleconsultation as an option, after the lockdown, if requested by their client. Only, 6.8% (n = 15) intend to rely mainly on teleconsultation in their clinical practice. In contrast, 20.7% (n = 46) intend to not use teleconsultation anymore after the lockdown. Qualitative results from participants’ comments (n = 74) provided additional useful information. Some participants (n = 12) underlined numerous advantages (e.g., facility to consult regardless of geographical distance, schedule flexibility), while others (n = 17) enumerated disadvantages and difficulties (e.g., increased fatigue, lack of warmth, difficulty to set up specific intervention and/or share therapeutic information). Few (n = 5) underlined that there was no important difference between teleconsultation and in-person. Some (n = 4) were agreeably surprised by teleconsultation and saw their attitudes improved after using it. Finally, 12 participants explained that the majority of clients refused to pursue via teleconsultation. Notermans & Philippot 11 Clinical Psychology in Europe 2022, Vol. 4(3), Article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ Data From Psychotherapists not Proposing Teleconsultation Only 24 participants did not propose teleconsultation during the lockdown. The two main reasons behind this decision concerned personal issues, and the belief that this type of communication was not appropriate for psychotherapy (Table 5). Open answers showed that personal reasons (n = 8) pertained mainly to limited infrastructure (n = 6), such as having access to adequate IT material or a private room. More than half (n = 14; 58.3%) do not have the intention to use teleconsultation in the near future; over a third (n = 9; 37.5%) will use it if the pandemic persists; and one participant definitely intends to use it in a near future. Table 5 Reasons for Not Proposing Teleconsultation (from 1: not at all important to 5: very important) Reasons for not proposing teleconsultation M SD Personal reasons (e.g., limited infrastructure, childcare, etc.) 3.75 1.62 This type of communication does not seem appropriate for psychotherapy 3.54 1.10 Individuals did not want to start or pursue via teleconsultation 3.54 1.38 Lack of IT support 3.46 1.44 I have doubts regarding the therapeutic efficacy in teleconsultation 3.13 1.23 The (mental) state of individuals did not require the continuity of therapy 2.42 1.21 Financial reasons (e.g., to receive governmental or other financial aid) 1.75 1.11 D i s c u s s i o n This survey shows that most psychotherapists rapidly responded to the sanitary crisis by proposing teleconsultations. They did so with little support and no previous experience with teleconsultation. The important drop (24%) in consultations observed during the first lockdown might have fostered for some the rapid transition to teleconsultation. Regarding the first hypothesis, while psychotherapists who did not propose telecon­ sultation believed it to be more technically challenging, received less support, and had less colleagues using it, than those proposing it, attitudes towards teleconsultation did not appear to significantly influence its use. Similar findings from a recent systematic review (Connolly et al., 2020) suggest that, overall, practitioners tend to have positive attitudes towards telemental health regardless of its disadvantages. Moreover, they sug­ gest that previous experience as well as repetitive use of telemental health is related to positive attitudes and acceptance of such method. Comparably, our qualitative data sug­ gest that most therapists felt reassured about these issues after gaining some experience with teleconsultation, and surprisingly pleased; a finding also expressed in Elford et al.’s study (2000). Additionally, qualitative data suggest that the main determinant for not proposing teleconsultation lied in contextual factors, rather than being a personal choice. Psychotherapy Under Lockdown 12 Clinical Psychology in Europe 2022, Vol. 4(3), Article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ For example, working in an institution (e.g., hospital, prison) or at home made it difficult to set up teleconsultations due to the lack of appropriate infrastructure (e.g., IT material, stable internet connection, private room). Connolly et al. (2020) describe similar negative attitudes regarding the disadvantages of telepsychiatry but underline that the benefits of such methods often outweigh its costs. Nevertheless, it is important to note that the sample of psychotherapists not proposing teleconsultation in the present survey is rather small, which calls for caution in interpreting the findings. Rejecting our second hypothesis, no significant correlations were evidenced between attitudes and teleconsultation’s use and experience. A similar finding was reported by Monthuy-Blanc and colleagues (2013), such that intention to use telepsychotherapy was not determined by providers’ attitudes towards it, neither by how difficult they expected it to be, but merely by how useful they thought it to be to First Nations clients in Australia. Nevertheless, a recent study also reported that therapists’ concerns about online connectedness predicted negative attitudes towards teleconsultation and decreased perceived efficacy (Békés et al., 2021). Therefore, it would be of interest to pursue researching the impact of attitudes on the experience of teleconsultation. In accordance to our third hypothesis, most aspects of the therapeutic relationship (empathy, congruence, and therapeutic alliance) were perceived as significantly deterio­ rated online, as compared to in-person, with the exception of unconditional positive regard. Moreover, participants also reported that their personal experience with tele­ consultation in terms of ease of payment, work exhaustion, therapeutic efficacy, and professional satisfaction was also perceived as significantly worse online. Unexpectedly, however, work organisation was perceived as significantly better online. Regarding our fourth hypothesis, a plethora of findings could be used to help in the development of a practice framework. First, privacy and confidentiality information and trainings should be urgently provided to professionals. In fact, in our survey, the major­ ity of platforms used (e.g., Skype, Whatsapp, Messenger) does not reach the minimal legal criteria for privacy and confidentiality (e.g., some platforms record and sell commu­ nication data) as requested by psychotherapy. Moreover, ethical concerns are raised by the fact that many respondents (27.5%) did not seem concerned about deontology and data protection issues with respect to teleconsultation. However, current guidelines and recommendations from different countries strongly underline the importance of ensuring the privacy and confidentiality of videoconferencing platforms (American Psychological Association, 2020; British Association for Behavioral & Cognitive Psychotherapies, 2021; Commission des Psychologues, 2020; Shore et al., 2018; Smith et al., 2020; Van Daele et al., 2020). As Lustgarten et al. (2020) explain, even if some platforms (e.g., Skype, FaceTime) may be familiar for most providers and clients, other platforms may be more secure and legally compliant. These authors also provide further recommendations regarding safe practice. Evidently, guidelines and recommendations must be made more accessible to all psychotherapists, and professional organisations should work actively Notermans & Philippot 13 Clinical Psychology in Europe 2022, Vol. 4(3), Article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ in providing recommendations and safe-to-use platforms and apps protecting clients’ personal information (Ohannessian et al., 2020). Second, psychotherapists should keep encouraging clients’ adhesion to teleconsulta­ tion. In the survey, half of the psychotherapists proposing teleconsultation actively sought to motivate their clients to accept teleconsultation. They mostly kept in touch with them and provided information regarding its use, safety, and efficacy. In fact, showing informational videos discussing the benefits of internet-based mental health services increases clients’ acceptance (Ebert et al., 2015). Surprisingly, however, only 20% proposed a trial on the chosen media, while theory and anecdotal evidence suggest this action to be very effective (Sasangohar et al., 2020; Smith et al., 2020). Third, information and training should be provided regarding contextual and thera­ peutic adaptions to the teleconsultation setting. In the survey, most therapists did not significantly adapt their way of delivering psychotherapy beyond the switch towards teleconsultation. However, it is important to have a proper and professional setting for teleconsultation (British Association for Behavioral & Cognitive Psychotherapies, 2021; De Witte et al., 2021; Sasangohar et al., 2020; Smith et al., 2020), such as ensuring that their video background conveys a feeling of safety and intimacy, and ensuring that clients are benefiting from a quiet, secure, and undisrupted space for the therapy session. More importantly, therapists should be aware of their clients’ location in order to contact them in case of communication failure (e.g., having a contact cell phone number) or emo­ tional breakdown (e.g., having a backup person in the client’s immediate surrounding who could be reached and intervene). Regarding interventions, only slight adaptations were provided. Our qualitative data and anecdotal evidence suggest that many therapists avoid interventions entailing the activation of intense or aversive emotions, such as exposure. However, recent evidence suggests that such interventions can be successfully and safely provided online (Wells et al., 2020). Furthermore, few adaptations were repor­ ted as a function of clients’ age or disorder, although some authors (Smith et al., 2020; Van Daele et al., 2020) emphasise that teleconsultation be adapted to the population, its context, and the conditions they are facing. Other authors and clinicians provide recommendations on how to adapt therapeutic interventions to the teleconsultation setting for groups (Banbury et al., 2018), children (American Academy of Children and Adolescent Psychiatry, 2021; American Psychiatric Association, 2020; Becqueriaux, 2020; Landrum, 2020), as well as for people suffering from eating disorders (Waller et al., 2020) and post-traumatic stress (Kaltenbach et al., 2021; Moring et al., 2020). Nevertheless, such works are still in their infancy and more empirical evidence is needed to optimise the provision of teleconsultation. The present survey suffers from some limitations. First, it has been conducted online and among French-speaking psychotherapists, thus reducing its reach to participants from other countries, and with minimal Internet literacy and/or accessibility. Second, from a lack of valid measurements in the literature, no psychometrically sound measures Psychotherapy Under Lockdown 14 Clinical Psychology in Europe 2022, Vol. 4(3), Article e6821 https://doi.org/10.32872/cpe.6821 https://www.psychopen.eu/ could be used to evaluate our hypotheses. Third, a memory bias may have impacted our findings, as psychotherapists were asked retrospectively about their use and experience of teleconsultation. Finally, it should also be noted that while this survey addressed the first lockdown, the situation kept evolving. Further surveys, targeting the following phases of the pandemic should examine these evolutions in terms of increase in the provision of teleconsultation and professionals’ exhaustion. Conclusion While some findings enlightened the use and experience of teleconsultation by psycho­ therapists during the first lockdown, many questions remain in all discussed domains: the impact of attitudes towards the use and experience of teleconsultation; the legal and ethical aspects of videoconferencing platforms; and ways to develop contextual and therapeutic adaptations to the teleconsultation setting. It is the authors’ opinion that basic psychotherapy training should address these questions, and that professional organisations should provide detailed information and instructions about the use of ethically and legally safe teleconsultation platforms. Funding: The authors have no funding to report. Acknowledgments: We would like to thank the team of the Consultations Psychologiques Spécialisées for their support during the development of this survey, as well as the numerous professional associations (e.g., UPPCF, AEMTC, AFForTheC, ASPCo) of psychotherapists who helped us distributing the survey. Competing Interests: The authors have declared that no competing interests exist. Twitter Accounts: @PhilippotP_ucl S u p p l e m e n t a r y M a t e r i a l s The Supplementary Materials include the entire survey questionnaire and additional tables related to some results (e.g., mean differences, correlations, etc.). For access see Index of Supplementary Materials below. Index of Supplementary Materials Notermans, J., & Philippot, P. (2022). Supplementary materials to "Psychotherapy under lockdown: The use and experience of teleconsultation by psychotherapists during the first wave of the COVID-19 pandemic" [Survey questionnaire, and additional tables]. PsychOpen GOLD. https://doi.org/10.23668/psycharchives.8181 Notermans & Philippot 15 Clinical Psychology in Europe 2022, Vol. 4(3), Article e6821 https://doi.org/10.32872/cpe.6821 https://twitter.com/philippotp_ucl https://doi.org/10.23668/psycharchives.8181 https://www.psychopen.eu/ R e f e r e n c e s Aafjes-van Doorn, K., Békés, V., & Prout, T. A. (2021). Grappling with our therapeutic relationship and professional self-doubt during COVID-19: Will we use video therapy again? Counselling Psychology Quarterly, 34(3-4), 473–484. https://doi.org/10.1080/09515070.2020.1773404 Acierno, R., Gros, D. F., Ruggiero, K. J., Hernandez‐Tejada, M. A., Knapp, R. G., Lejuez, C. W., Muzy, W., Frueh, C. B., Egede, L. E., & Tuerk, P. W. (2016). Behavioral activation and therapeutic exposure for posttraumatic stress disorder: A noninferiority trial of treatment delivered in person versus home‐based telehealth. Depression and Anxiety, 33(5), 415–423. https://doi.org/10.1002/da.22476 American Academy of Children and Adolescent Psychiatry. (2021). AACAP's Telepsychiatry Toolkit. Retrieved from https://www.aacap.org/AACAP/Clinical_Practice_Center/Business_of_Practice/Telepsychiatry/ toolkit_videos.aspx American Psychiatric Association. (2020). Child & Adolescent Telepsychiatry. Retrieved from https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/child-adolescent American Psychological Association. (2020, June 5). Psychologists embrace telehealth to prevent the spread of COVID-19. American Psychological Association Services. Retrieved from http://www.apaservices.org/practice/legal/technology/psychologists-embrace-telehealth Banbury, A., Nancarrow, S., Dart, J., Gray, L., & Parkinson, L. (2018). Telehealth interventions delivering home-based support group videoconferencing: Systematic review. Journal of Medical Internet Research, 20(2), Article e25. https://doi.org/10.2196/jmir.8090 Becqueriaux, C. (2020, March 23). La téléconsultation psychologique avec de jeunes patients [Psychological teleconsultation with young patients]. Coralie Becqueriaux: Consultations psychologiques et neuropsychologiques pour enfants, adolescents ou jeunes adultes… et leurs parents! Retrieved from http://www.psy-enfant-lille.com/consultation-psy-visio Békés, V., & Aafjes-van Doorn, K. (2020). Psychotherapists’ attitudes toward online therapy during the COVID-19 pandemic. Journal of Psychotherapy Integration, 30(2), 238–247. https://doi.org/10.1037/int0000214 Békés, V., Aafjes­van Doorn, K., Zilcha‐Mano, S., Prout, T., & Hoffman, L. (2021). Psychotherapists’ acceptance of telepsychotherapy during the COVID‐19 pandemic: A machine learning approach. Clinical Psychology & Psychotherapy, 28(6), 1403–1415. https://doi.org/10.1002/cpp.2682 Boldrini, T., Schiano Lomoriello, A., Del Corno, F., Lingiardi, V., & Salcuni, S. (2020). Psychotherapy during COVID-19: How the clinical practice of Italian psychotherapists changed during the pandemic. Frontiers in Psychology, 11, Article 591170. https://doi.org/10.3389/fpsyg.2020.591170 British Association for Behavioral & Cognitive Psychotherapies. (2021). Tips related to remote therapy provision. Retrieved from https://www.babcp.com/Therapists/Remote-Therapy-Provision.aspx Commission des Psychologues. (2020, April 14). Coronavirus (Covid-19): téléconsultation. Retrieved from https://www.compsy.be/fr/coronatele Psychotherapy Under Lockdown 16 Clinical Psychology in Europe 2022, Vol. 4(3), Article e6821 https://doi.org/10.32872/cpe.6821 https://doi.org/10.1080/09515070.2020.1773404 https://doi.org/10.1002/da.22476 https://www.aacap.org/AACAP/Clinical_Practice_Center/Business_of_Practice/Telepsychiatry/toolkit_videos.aspx https://www.aacap.org/AACAP/Clinical_Practice_Center/Business_of_Practice/Telepsychiatry/toolkit_videos.aspx https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/child-adolescent http://www.apaservices.org/practice/legal/technology/psychologists-embrace-telehealth https://doi.org/10.2196/jmir.8090 http://www.psy-enfant-lille.com/consultation-psy-visio https://doi.org/10.1037/int0000214 https://doi.org/10.1002/cpp.2682 https://doi.org/10.3389/fpsyg.2020.591170 https://www.babcp.com/Therapists/Remote-Therapy-Provision.aspx https://www.compsy.be/fr/coronatele https://www.psychopen.eu/ Connolly, S. L., Miller, C. J., Lindsay, J. A., & Bauer, M. S. (2020). A systematic review of providers’ attitudes toward telemental health via videoconferencing. Clinical Psychology: Science and Practice, 27(2), Article e12311. https://doi.org/10.1111/cpsp.12311 De Witte, N., Bernaerts, S., Van Assche, E., Willems, S., & Van Daele, T. (2021). FAQ on teleconsultations. European Federation of Psychologists’ Associations. Retrieved from http://ehealth.efpa.eu/covid-19/faq-on-online-consultations Ebert, D. D., Berking, M., Cuijpers, P., Lehr, D., Pörtner, M., & Baumeister, H. (2015). Increasing the acceptance of internet-based mental health interventions in primary care patients with depressive symptoms: A randomized controlled trial. Journal of Affective Disorders, 176, 9–17. https://doi.org/10.1016/j.jad.2015.01.056 Elford, R., White, H., Bowering, R., Ghandi, A., Maddiggan, B., & John, K. S. (2000). A randomized, controlled trial of child psychiatric assessments conducted using videoconferencing. Journal of Telemedicine and Telecare, 6(2), 73–82. https://doi.org/10.1258/1357633001935086 Feijt, M., de Kort, Y., Bongers, I., Bierbooms, J., Westerink, J., & IJsselsteijn, W. (2020). Mental health care goes online: Practitioners’ experiences of providing mental health care during the COVID-19 pandemic. Cyberpsychology, Behavior, and Social Networking, 23(12), 860–864. https://doi.org/10.1089/cyber.2020.0370 Humer, E., Stippl, P., Pieh, C., Pryss, R., & Probst, T. (2020). Experiences of psychotherapists with remote psychotherapy during the COVID-19 pandemic: Cross-sectional web-based survey study. Journal of Medical Internet Research, 22(11), Article e20246. https://doi.org/10.2196/20246 Kaltenbach, E., McGrath, P. J., Schauer, M., Kaiser, E., Crombach, A., & Robjant, K. (2021). Practical guidelines for online Narrative Exposure Therapy (e-NET)–A short-term treatment for posttraumatic stress disorder adapted for remote delivery. European Journal of Psychotraumatology, 12(1), Article 1881728. https://doi.org/10.1080/20008198.2021.1881728 Landrum, A. (2020, March 15). Interventions for online therapy with children and youth. Guidance Teletherapy. Retrieved from https://www.guidancett.com/blog/interventions-for-online-therapy-with-children-and- youth-2020 Lustgarten, S. D., Garrison, Y. L., Sinnard, M. T., & Flynn, A. W. (2020). Digital privacy in mental healthcare: Current issues and recommendations for technology use. Current Opinion in Psychology, 36, 25–31. https://doi.org/10.1016/j.copsyc.2020.03.012 McBeath, A. G., Du Plock, S., & Bager-Charleson, S. (2020). The challenges and experiences of psychotherapists working remotely during the coronavirus pandemic. Counselling & Psychotherapy Research, 20(3), 394–405. https://doi.org/10.1002/capr.12326 Mendes-Santos, C., Weiderpass, E., Santana, R., & Andersson, G. (2020). Portuguese Psychologists’ attitudes towards internet interventions: An exploratory cross-sectional study. JMIR Mental Health, 7(4), Article e16817. https://doi.org/10.2196/16817 Monthuy-Blanc, J., Bouchard, S., Maïano, C., & Seguin, M. (2013). Factors influencing mental health providers’ intention to use telepsychotherapy in First Nations communities. Transcultural Psychiatry, 50(2), 323–343. https://doi.org/10.1177/1363461513487665 Notermans & Philippot 17 Clinical Psychology in Europe 2022, Vol. 4(3), Article e6821 https://doi.org/10.32872/cpe.6821 https://doi.org/10.1111/cpsp.12311 http://ehealth.efpa.eu/covid-19/faq-on-online-consultations https://doi.org/10.1016/j.jad.2015.01.056 https://doi.org/10.1258/1357633001935086 https://doi.org/10.1089/cyber.2020.0370 https://doi.org/10.2196/20246 https://doi.org/10.1080/20008198.2021.1881728 https://www.guidancett.com/blog/interventions-for-online-therapy-with-children-and-youth-2020 https://www.guidancett.com/blog/interventions-for-online-therapy-with-children-and-youth-2020 https://doi.org/10.1016/j.copsyc.2020.03.012 https://doi.org/10.1002/capr.12326 https://doi.org/10.2196/16817 https://doi.org/10.1177/1363461513487665 https://www.psychopen.eu/ Moring, J. C., Dondanville, K. A., Fina, B. A., Hassija, C., Chard, K., Monson, C., LoSavio, S. T., Wells, S. Y., Morland, L. A., Kaysen, D., Galovski, T. E., & Resick, P. A. (2020). Cognitive processing therapy for posttraumatic stress disorder via telehealth: Practical considerations during the COVID‐19 pandemic. Journal of Traumatic Stress, 33(4), 371–379. https://doi.org/10.1002/jts.22544 Ohannessian, R., Duong, T. A., & Odone, A. (2020). Global telemedicine implementation and integration within health systems to fight the COVID-19 pandemic: A call to action. JMIR Public Health and Surveillance, 6(2), Article e18810. https://doi.org/10.2196/18810 Pan American Health Organization. (2021, January 5). Teleconsultation during a pandemic. IRIS PAHO. Retrieved from https://iris.paho.org/handle/10665.2/52006 Perle, J. G., Langsam, L. C., Randel, A., Lutchman, S., Levine, A. B., Odland, A. P., Nierenberge, B., & Marker, C. D. (2013). Attitudes toward psychological telehealth: Current and future clinical psychologists’ opinions of Internet‐based interventions. Journal of Clinical Psychology, 69(1), 100–113. https://doi.org/10.1002/jclp.21912 Poletti, B., Tagini, S., Brugnera, A., Parolin, L., Pievani, L., Ferrucci, R., Compare, A., & Silani, V. (2021). Telepsychotherapy: A leaflet for psychotherapists in the age of COVID-19. A review of the evidence. Counselling Psychology Quarterly, 34(3-4), 352–367. https://doi.org/10.1080/09515070.2020.1769557 Rochlen, A. B., Zack, J. S., & Speyer, C. (2004). Online therapy: Review of relevant definitions, debates, and current empirical support. Journal of Clinical Psychology, 60(3), 269–283. https://doi.org/10.1002/jclp.10263 Roesler, C. (2017). Tele-analysis: The use of media technology in psychotherapy and its impact on the therapeutic relationship. The Journal of Analytical Psychology, 62(3), 372–394. https://doi.org/10.1111/1468-5922.12317 Sasangohar, F., Bradshaw, M. R., Carlson, M. M., Flack, J. N., Fowler, J. C., Freeland, D., Head, J., Marder, K., Orme, W., Weinstein, B., Kolman, J. M., Kash, B., & Madan, A. (2020). Adapting an outpatient psychiatric clinic to telehealth during the COVID-19 pandemic: A practice perspective. Journal of Medical Internet Research, 22(10), Article e22523. https://doi.org/10.2196/22523 Schulze, N., Reuter, S. C., Kuchler, I., Reinke, B., Hinkelmann, L., Stoeckigt, S., Siemoneit, H., & Tonn, P. (2019). Differences in attitudes toward online interventions in psychiatry and psychotherapy between health care professionals and nonprofessionals: A survey. Telemedicine Journal and e-Health, 25(10), 926–932. https://doi.org/10.1089/tmj.2018.0225 Shore, J. H., Yellowlees, P., Caudill, R., Johnston, B., Turvey, C., Mishkind, M., Krupinski, E., Myers, K., Shore, P., Kaftarian, E., & Hilty, D. (2018). Best practices in videoconferencing-based telemental health April 2018. Telemedicine Journal and e-Health, 24(11), 827–832. https://doi.org/10.1089/tmj.2018.0237 Smith, K., Ostinelli, E., Macdonald, O., & Cipriani, A. (2020). COVID-19 and telepsychiatry: Development of evidence-based guidance for clinicians. JMIR Mental Health, 7(8), Article e21108. https://doi.org/10.2196/21108 Psychotherapy Under Lockdown 18 Clinical Psychology in Europe 2022, Vol. 4(3), Article e6821 https://doi.org/10.32872/cpe.6821 https://doi.org/10.1002/jts.22544 https://doi.org/10.2196/18810 https://iris.paho.org/handle/10665.2/52006 https://doi.org/10.1002/jclp.21912 https://doi.org/10.1080/09515070.2020.1769557 https://doi.org/10.1002/jclp.10263 https://doi.org/10.1111/1468-5922.12317 https://doi.org/10.2196/22523 https://doi.org/10.1089/tmj.2018.0225 https://doi.org/10.1089/tmj.2018.0237 https://doi.org/10.2196/21108 https://www.psychopen.eu/ Stoll, J., Müller, J. A., & Trachsel, M. (2020). Ethical issues in online psychotherapy: A narrative review. Frontiers in Psychiatry, 10, Article 993. https://doi.org/10.3389/fpsyt.2019.00993 Van Daele, T., Karekla, M., Kassianos, A. P., Compare, A., Haddouk, L., Salgado, J., Ebert, D. D., Trebbi, G., Bernaerts, S., Van Assche, E., & De Witte, N. A. J. (2020). Recommendations for policy and practice of telepsychotherapy and e-mental health in Europe and beyond. Journal of Psychotherapy Integration, 30(2), 160–173. https://doi.org/10.1037/int0000218 Varker, T., Brand, R. M., Ward, J., Terhaag, S., & Phelps, A. (2019). Efficacy of synchronous telepsychology interventions for people with anxiety, depression, posttraumatic-stress disorder, and adjustment disorder: A rapid evidence assessment. Psychological Services, 16(4), 621–635. https://doi.org/10.1037/ser0000239 Waller, G., Pugh, M., Mulkens, S., Moore, E., Mountford, V. A., Carter, J., Wicksteed, A., Maharaj, A., Wade, T. D., Wisniewski, L., Farrell, N. R., Raykos, B., Jorgensen, S., Evans, J., Thomas, J. J., Osenk, I., Paddock, C., Bohrer, B., Aderson, K., . . . Smit, V. (2020). Cognitive‐behavioral therapy in the time of coronavirus: Clinician tips for working with eating disorders via telehealth when face‐to‐face meetings are not possible. International Journal of Eating Disorders, 53(7), 1132– 1141. https://doi.org/10.1002/eat.23289 Wells, S. Y., Morland, L. A., Wilhite, E. R., Grubbs, K. M., Rauch, S., Acierno, R., & McLean, C. P. (2020). Delivering prolonged exposure therapy via videoconferencing during the COVID-19 Pandemic: An overview of the research and special considerations for providers. Journal of Traumatic Stress, 33(4), 380–390. https://doi.org/10.1002/jts.22573 Wijesooriya, N. R., Mishra, V., Brand, P. L. P., & Rubin, B. K. (2020). COVID-19 and telehealth, education, and research adaptations. Paediatric Respiratory Reviews, 35, 38–42. https://doi.org/10.1016/j.prrv.2020.06.009 Wright, J. H., & Caudill, R. (2020). Remote treatment delivery in response to the COVID-19 Pandemic. Psychotherapy and Psychosomatics, 89(3), 130–132. https://doi.org/10.1159/000507376 Clinical Psychology in Europe (CPE) is the official journal of the European Association of Clinical Psychology and Psychological Treatment (EACLIPT). PsychOpen GOLD is a publishing service by Leibniz Institute for Psychology (ZPID), Germany. Notermans & Philippot 19 Clinical Psychology in Europe 2022, Vol. 4(3), Article e6821 https://doi.org/10.32872/cpe.6821 https://doi.org/10.3389/fpsyt.2019.00993 https://doi.org/10.1037/int0000218 https://doi.org/10.1037/ser0000239 https://doi.org/10.1002/eat.23289 https://doi.org/10.1002/jts.22573 https://doi.org/10.1016/j.prrv.2020.06.009 https://doi.org/10.1159/000507376 https://www.psychopen.eu/ Psychotherapy Under Lockdown (Introduction) Method Recruitment and Procedure Survey Questionnaire Measures Data Analysis Results Participants Characteristics Hypothesis 1 Hypothesis 2 Hypothesis 3 Hypothesis 4 Discussion Conclusion (Additional Information) Funding Acknowledgments Competing Interests Twitter Accounts Supplementary Materials References