Navigating psychotherapy in the COVID-19 Era: overcoming challenges, harnessing benefits, and practical recommendations

Navigating psychotherapy in the COVID-19 Era: overcoming challenges, harnessing benefits, and practical recommendations | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Navigating psychotherapy in the COVID-19 Era: overcoming challenges, harnessing benefits, and practical recommendations Vânia Silva, Laura Koppensteiner, Eugénia Ribeiro This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6098189/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives: As the world struggled with the COVID-19 pandemic, adopting preventive measures, such as wearing face masks and videoconferencing, became ubiquitous in various settings, including psychotherapy. Identifying challenges, benefits, and recommendations may support the effective delivery of psychotherapeutic care in similar conditions in the future. Recent literature has highlighted mostly therapists’ perspectives on those challenges, benefits, and recommendations. Since therapists and clients seem to differ on what they experience and value in therapy, understanding psychotherapeutic care from clients’ perspectives should also be considered. Thus, the present study aimed to understand therapists’ and clients’ perspectives on challenges, benefits, and recommendations for videoconference therapy and therapy using face masks and if there are differences regarding those perspectives. Methods: We analyzed 738 responses to the open-ended questions of a larger online survey on the quality of relational processes in psychotherapy during the COVID-19 pandemic. The participants’ responses were collected worldwide between December 2022 and July 2023. A total of 117 therapists and 64 clients participated in the study. We conducted a deductive content analysis to examine trends in participants’ answers and Fisher-Freeman-Halton tests to determine differences between therapists and clients across categories. Results: The findings highlighted that while clients tended to focus on normalizing and trusting the new therapeutic environments, therapists were concerned with improving communication and refining their therapeutic skills to maintain the effectiveness of therapy under the new conditions. Conclusions: This understanding enabled the formulation of targeted recommendations that address the unique needs of each group to enhance their therapeutic experiences. Psychology Videoconference psychotherapy Psychotherapy with face masks Challenges Benefits Recommendations Therapists’ and clients’ perspectives Figures Figure 1 Figure 2 Introduction As the world struggled with the COVID-19 pandemic, adopting preventive measures, such as wearing face masks and videoconferencing, has become ubiquitous in various settings, including psychotherapy sessions. While the primary purpose of face masks was to mitigate the spread of infectious diseases, their incorporation into therapeutic encounters introduced a unique set of considerations, encompassing both challenges and advantages. Research specifically focusing on psychotherapy wearing face masks is still limited due to its relatively recent emergence and rapidly changing pandemic context. However, existing literature highlights the multifaceted challenges associated with wearing masks in therapeutic settings (Bani et al., 2023 ; Erschens et al., 2022 ; Kidd, 2022; Mitzkovitz et al, 2022 ; Ribeiro et al., 2021 ). The primary challenges associated with mask wearing include the physical discomfort caused by masks, such as breathing difficulties, unpleasant odors, and increased sweating (Erschens et al., 2022 ; Ribeiro et al., 2021 ). Additionally, masks have been found to interfere with the accurate recognition of emotion conveyed by facial expressions (Bani et al., 2023 ; Mitzkovitz et al., 2022 ), the therapeutic relationship, specifically emphatic rapport, emotional bond (Ribeiro et al., 2021 ), and relational depth (Kidd, 2022), verbal and non-verbal communication (Erschens et al., 2022 ; Ribeiro et al., 2021 ), and the therapeutic work, preventing the use of some therapeutic tasks depending on the therapeutic approach (Erschens et al., 2022 ; Ribeiro et al., 2021 ). However, alongside its challenges, previous research sheds light on some benefits of the widespread adoption of face masks in psychotherapy (Kidd, 2022; Ribeiro et al., 2021 ). For instance, a study by Ribeiro et al. ( 2021 ) found that therapists acknowledged the importance of masks in reducing viral transmission risks, thereby safeguarding the health of both therapists and clients and fostering a sense of safety conducive to therapeutic engagement. Furthermore, therapists reported minimal impact of the use of masks on psychotherapy, with some expressing a preference for in-person therapy despite the presence of masks (Ribeiro et al., 2021 ). Moreover, Kidd (2022) found that masks facilitated a collective experience and a stronger willingness to connect, which could enhance relational depth. To optimize the efficacy of psychotherapy in the context of mask-wearing, some recommendations have merited consideration in recent research (Erschens et al., 2022 ; Mitzkovitz et al., 2022 ; Ribeiro et al., 2021 ). For instance, the literature suggests that therapists should proactively address the potential impact of masks on communication dynamics during sessions, openly acknowledging any challenges and collaboratively exploring strategies to overcome them (Mitzkovitz et al., 2022 ; Ribeiro et al., 2021 ). This may involve utilizing alternative modes of expression, such as verbalizing emotions more explicitly or incorporating supplementary visual aids to compensate for the loss of facial cues (Erschens et al., 2022 ; Mitzkovitz et al., 2022 ; Ribeiro et al., 2021 ). Additionally, creating a supportive and empathetic atmosphere where clients feel comfortable to voice any concerns related to mask-wearing without fear of judgment seemed crucial (Ribeiro et al., 2021 ). In contrast to the relatively emerging research on psychotherapy with face masks, the study of videoconference psychotherapy has been discussed for some time ago (e.g., Baker & Ray, 2011 ) and is still rapidly growing. Videoconference psychotherapy has revolutionized mental health care, providing unprecedented opportunities for remote therapeutic engagement. As with any emerging practice, videoconference psychotherapy brought forth a plethora of benefits, along with unique challenges and considerations that warrant careful attention (Asbrand et al., 2023 ; Simpson et al., 2021 ; Stoll et al., 2020 ). Existing research has found that the benefits of videoconference psychotherapy are manifold (Asbrand et al., 2023 ; Buckman et al., 2021 ; Feijt et al., 2020 ; Stefan et al., 2021 ; Stoll et al., 2020 ; Thomas et al., 2021 ). For instance, geographical barriers are virtually dissolved, enabling individuals from diverse locations to access mental health support conveniently (Buckman et al., 2021 ; Stoll et al., 2020 ; Thomas et al., 2021 ). This accessibility is particularly advantageous for those residing in rural or underserved areas, where traditional face-to-face therapy may be scarce (Stoll et al., 2020 ; Thomas et al., 2021 ). Moreover, the flexibility of scheduling sessions online accommodates busy lifestyles, enhancing convenience and treatment adherence (Asbrand et al., 2023 ; Buckman et al., 2021 ; Feijt et al., 2020 ). Moreover, videoconferencing can offer a sense of anonymity and privacy, fostering a safe environment for clients to explore their emotions and experiences from the comfort of their own space (Stefan et al., 2021 ; Stoll et al., 2020 ). However, amidst its advantages, videoconference psychotherapy also presents notable challenges (Asbrand et al., 2023 ; Buckman et al., 2021 ; Cataldo et al., 2021 ; Dolev-Amit et al., 2021 ; Feijt et al., 2020 ; García et al., 2022 ; Mancinelli et al., 2021 ; Stefan et al., 2021 ; Stoll et al., 2020 ; Thomas et al., 2021 ). Technical glitches, such as poor internet connection or audiovisual distortions, can disrupt the flow of therapy and inhibit effective communication between the therapist and client (Buckman et al., 2021 ; Dolev-Amit et al., 2021 ; Feijt et al., 2020 ; Stoll et al., 2020 ; Thomas et al., 2021 ). Furthermore, data security and confidentiality concerns may arise, necessitating robust measures to safeguard sensitive information transmitted over digital channels (Stoll et al., 2020 ). Additionally, the absence of physical presence in virtual interactions may compromise the therapist's ability to assess non-verbal cues accurately, potentially hindering the depth of therapeutic rapport and understanding (Cataldo et al., 2021 ; Dolev-Amit et al., 2021 ; Feijt et al., 2020 ; Stoll et al., 2020 ). Several recommendations have merited consideration in recent literature to optimize the efficacy of videoconference psychotherapy while mitigating its challenges (see Asbrand et al., 2023 ; Simpson et al., 2021 ; Stoll et al., 2020 ). Firstly, existing literature underlies that therapists should undergo specialized training to familiarize themselves with the nuances of providing therapy through digital platforms and to develop strategies for navigating technical issues seamlessly (Buckman et al., 2021 ; Stoll et al., 2020 ). Furthermore, some studies state that before beginning sessions, it is imperative to establish clear protocols for ensuring data privacy and encryption to uphold confidentiality standards rigorously (Simpson et al., 2021 ; Stoll et al., 2020 ). Moreover, therapists should employ techniques to compensate for the lack of physical presence, increasing verbal and non-verbal activity (García et al., 2022 ), emphasizing active listening, and encouraging clients to articulate their emotions explicitly (Simpson et al., 2021 ). Recognizing and addressing the challenges, benefits, and recommendations associated with both mask-wearing and videoconference psychotherapy is essential for enhancing the adaptability of psychotherapy and ensuring continuity of care in similar circumstances in the future. While research on these topics is expanding, recent studies have predominantly focused on therapists’ perspectives (e.g., Asbrand et al., 2023 ; Bani et al., 2022; Buckman et al., 2021 ; Feijt et al., 2020 ; Kidd, 2023 ; Mancinelli et al., 2021 ; Ribeiro et al., 2021 ; Stefan et al., 2021 ). Although research on clients’ experiences with psychotherapy is established (e.g., Elliott, 1993; Ladmanová et al., 2021 ), recent studies addressing clients’ perspectives on videoconference therapy are limited (e.g., Giordano et al., 2022 ; van Kessel et al., 2022), and those examining clients’ experiences of therapy involving mask-wearing are even scarcer (e.g., Erschens et al., 2022 ). Additionally, studies that compare both therapists’ and clients’ perspectives have identified some discrepancies in how each group perceives videoconference therapy (e.g., Cataldo et al., 2021 ; Simpson et al., 2021 ) or in-person therapy with masks (e.g., Erschens et al., 2022 ). These findings underscore the importance of integrating clients’ perspectives to address such disparities and improve psychotherapeutic care in these specific contexts. To address these gaps, the present study aims to explore both therapists’ and clients’ perspectives on the challenges, benefits, and recommendations for videoconference therapy (VT) and in-person therapy with face masks (IPTFM) while identifying and analyzing any differences between these perspectives. Methods This qualitative study was guided by a post-positivist approach, which informed a structured, although flexible, methodological framework. The methodological procedures ensured a rigorous analysis of therapists’ and clients’ perspectives while recognizing that the researchers’ subjectivity inherently influenced their interpretations. This perspective informed our study's design and analysis, allowing us to employ deductive content analysis to examine participants' responses systematically. Recognizing the potential for researcher bias, we implemented strategies such as researchers’ training in codebooks and the calculation of agreement between them to enhance the credibility and trustworthiness of our findings. The present study is part of a major study focused on studying therapists’ and clients’ experiences regarding relational processes in different therapy modalities. The data analyzed in this study were not considered in a previous study, and the studies address different and specific research questions. The study received ethical approval from the Institutional Ethics Committee of the University of Minho (CEICSH 116/2021). Participants A total of 117 therapists and 64 clients participated in this study. Therapists Most therapists were female ( N = 80; 68,4%), caucasian ( N = 83; 70,9%), married or in a partnership ( N = 80; 68,4%), held a master’s degree ( N = 46; 39,3%) or a Ph.D ( N = 35; 29,9%), had more than 8 years of clinical experience ( N = 81; 69,2%), and reported no impairments ( N = 97; 82,9%). Therapists’ ages ranged from 22 to 82 years, with an average age of 49,6 years (SD = 15,4). 90 therapists (76.9%) reported having prior psychotherapy experience before the outbreak of the COVID-19 pandemic. For additional details on therapists’ characteristics (e.g., geographical location, treated disorders, and therapeutic approach), please refer to Table 1 . Clients Most clients were female ( N = 53; 82,8%), caucasian ( N = 43; 67,2%), single ( N = 42; 65,6%), had completed a master’s degree ( N = 25; 39,1%) or graduation ( N = 23; 35,9%), and reported no impairments ( N = 53; 82,8%). Clients’ ages ranged from 20 to 75 years, with an average age of 33,3 years (SD = 12,7). 51 clients (79,7%) had a previous in-person therapy experience before the outbreak of the COVID-19 pandemic. For additional details on clients' characteristics (e.g., geographical location and disorders), please refer to Table 1 . Table 1 Additional sociodemographic characteristics of participants Therapists ( N = 117) Clients ( N = 64) Characteristic n % n % Geographic location Africa 2 1,71 1 1,56 Asia 5 4,27 9 14,06 Central and Eastern Europe 11 9,40 10 15,62 Central and South America 14 11,97 3 4,69 North America 28 23,93 11 17,19 Northern Europe 10 8,55 18 28,13 Oceania 4 3,42 1 1,56 Southern Europe 28 23,93 8 12,5 Western Europe 9 7,69 3 4,69 Prefer not to say 6 5,13 --- --- Disorder Anxiety 111 94,87 48 75,0 Depression 103 88,03 36 56,25 Personality disorders 64 54,70 9 14,06 OCD 49 41,88 7 10,94 Eating disorders 41 35,04 8 12,5 Substance and other addictive disorders 39 33,33 3 4,69 Psychotic disorders 22 18,80 --- --- Other 19 16,24 14 21,88 Therapeutic approach Psychodynamic/Psychoanalytic 61 52,2 --- --- Cognitive-behavioral 47 40,2 --- --- Humanistic/Experiential 35 29,9 --- --- Systemic 16 13,7 --- --- Constructivist 16 13,7 --- --- Other 9 7,7 --- --- Procedure Data collecting We employed a purposive sampling method to recruit participants via social media platforms (e.g., Facebook; Reddit) and through therapists’ mailing lists available on the online pages of international psychotherapy associations. Eligible participants included psychologists/psychotherapists who conducted individual psychotherapy with adult clients, either via videoconference or in-person while wearing face masks, and adult clients (18+) who had undergone psychotherapy during the pandemic through the same modalities (VT or IPTFM). An online survey was developed to examine the quality of relational processes in psychotherapy during the COVID-19 pandemic. While a previous study focused exclusively on the quantitative data derived from the survey (authors, 2025 ), the present study analyzed the qualitative data. The qualitative component of the survey included the following three questions for IPTFM: 1) "Please identify a positive aspect of IPTFM"; 2) "Please identify a negative aspect of IPTFM", and 3) "What suggestions would you give to a friend or family member who is now going to start an in-person psychotherapeutic process wearing face masks?" (client version), or "What suggestions would you give to a professional colleague who is now going to start an in-person psychotherapeutic process wearing face masks?" (therapist version). The same set of questions was also formulated for VT. Participant responses were collected between December 2022 and July 2023. Upon accessing the survey links, participants were provided with detailed information about the study’s goals, eligibility criteria, estimated completion time, and informed consent. A total of 139 therapists and 71 clients consented to participate in the study and concluded the survey. However, responses were evaluated for quality and relevance to the research questions before analysis. Consequently, 22 therapists and 7 clients were excluded due to providing non-substantive responses (e.g., “ok,” “0,” or “.”). Of the remaining participants, 117 therapists and 64 clients were included. Among the therapists, 68 provided responses to the open-ended questions concerning IPTFM, and 98 responded to the questions concerning VT. Among the clients, 24 answered the open-ended questions for IPTFM, and 56 provided responses for VT. Data analysis strategy We conducted a deductive content analysis to examine trends in participant’s answers regarding the positive and negative aspects of IPTFM and VT, and their recommendations for overcoming difficulties. For this purpose, we followed the steps defined by Krippendorf (2018) and summarized by McKibben et al. ( 2020 ), namely unitizing, sampling, recording, and reducing. Our units of analysis were the participants’ (therapists and clients) answers to the open-ended questions. Our data sample consisted of 738 units of analysis: 276 units for IPTFM (72 units for clients and 204 for therapists) and 462 units for VT (168 units for clients and 294 for therapists). Because we analyzed the participants’ answers to an online survey, the data were recorded as a written text. For the reducing process, which involves condensing the data into categories or themes (Krippendorf, 2018), we used a deductive approach, specifying categories a priori. For this purpose, we reviewed recent literature (Asbrand et al., 2023 ; Buckman et al., 2021 ; Cataldo et al., 2021 ; Dolev-Amit et al., 2021 ; Erschens et al., 2022 ; Feijt et al., 2020 ; García et al., 2022 ; Kidd, 2022; Mancinelli et al., 2021 ; Mitzkovitz et al., 2022 ; Ribeiro et al., 2021 ; Simpson et al., 2021 ; Stefan et al., 2021 ; Stoll et al., 2020 ; and Thomas et al, 2021 ) on the positive and negative aspects, and recommendations for each therapy modality (IPTFM and VT), and developed codebooks containing the benefits, challenges and resources for each therapy modality. Before starting the coding process, the codebooks were reviewed by three external researchers to ensure that categories were clearly defined. Feedback from these researchers served to clarify and improve the codebook by eliminating unnecessary existing categories, adding relevant new ones, and refining the definitions of others. A “not suitable for coding” category was added to each modality’s codebook so that coders could assign all passages that were not suitable for coding or did not fit with previously defined categories to this category. These units were later coded inductively if suitable for coding or remained in the “not suitable for coding” category if they were too vague or not explicit (e.g., answers like “recommend” to the question about recommendations or “intimate” in response to the question about positive aspects). Both the deductively and inductively coded categories were not mutually exclusive, as the same unit of analysis could produce different coding references, and different units of analysis could contribute to the same category. Next, using the codebooks, two coders independently coded a subsample of 30% of randomly selected participants’ answers, including all types of open-ended questions. Interrater reliability was calculated using Cohen’s Kappa to test for the consistency of the coding systems, and it showed good values, with .87 for IPTFM codings and .91 for VT codings. Subsequently, the two coders met to discuss discrepancies in coding. Since the Cohen’s Kappa was > .75 regarding the 30% of coded answers, one of the coders proceeded to code the remaining 70%. In addition, regarding data not suitable for coding with the codebook, the coders discussed the themes that emerged inductively and reached a consensus. We used descriptive statistics (i.e., percentages and frequency counts) to describe the data and report the categories’ prevalence. Rare categories (i.e., ≤ 5% of coded references) were excluded from the results report. To investigate whether there were differences in the frequency of benefits, challenges, and recommendations categories across the two groups (i.e., therapists, clients) we used tests of independence (Avent et al., 2015 ; Bledsoe et al., 2019 ). As more than 20% of the cells in the VT’s benefits’ table, in the IPTFM’s challenges’ table and in the recommendation’s tables (IPTFM and VT) contained zeros, we used Fisher-Freeman-Halton (FFH) tests instead of chi-square tests. The FFH tests are similar to chi-square analysis but are more appropriate when the frequency of empty cells is high (Bledsoe et al., 2019 ; Freeman & Halton, 1951 ) as is the case in the present study. To get an indication of which cells are responsible for the discrepancies between therapists and clients in the categories’ frequencies, we calculated and used the adjusted standardized residuals (Avent et al., 2015 ). An adjusted residual greater than 1.96 indicates that the number of observed cases in that cell is significantly larger than expected (IBM, 2020). Results The results are presented in two stages. First, the findings are described in general for each modality (IPTFM and VT), combining responses from both therapists and clients (with n representing the total number of references coded within each category including both groups). In this stage, benefits, challenges, and recommendations’ categories and sub-categories are illustrated with participants’ quotations and the used identifications (ID) refer to the participants (e.g., T75 refers to the therapist 75, while C36 refers to the client 36). Second, the results are analyzed in terms of comparisons between therapists and clients regarding the categories presented in stage 1. Benefits of IPTFM The most frequently mentioned category in IPTFM’s benefits was physical presence as a condition to enable therapy (n = 58; 59,18%). This category primarily included references to the face mask creating a safe environment and protecting the physical health of both clients and therapists, thus making in-person therapy feasible ( the face masks made therapy feasible; n = 49). For example, a therapist (T75) noted that “during COVID, it {the mask} fulfilled the function of increasing the feeling of security during the in-person sessions”, and another therapist (T138) mentioned “protecting each other by wearing the mask and still be able to visit one on one”. Similarly, clients commented on the reduced risk of spreading COVID-19, such as C36 who stated, “the risk of spreading covid-19 was reduced”, and C21 who appreciated that “at least we met in person”. The categories harmlessness and adaptation experience ( n = 20; 20,41%) and relational depth through disconnection ( n = 20; 20,41%) were secondly mentioned, with an equal number of references. The first ( harmlessness and adaptation experience ) included mainly references to the therapy with face masks being perceived as tolerable, safe, acceptable, quiet and/or comfortable ( satisfactory experience ; n = 9), and to the use of face masks facilitating the development of new communication and therapeutic abilities ( development of new abilities ; n = 6). For instance, in the satisfactory experience sub-category, a therapist (T58) stated that “it worked quite well”, and another (T73) remarked that “it will be ok, not perfect, but good enough”. Similarly, clients described the IPTFM experience as “good” (C27) and “more comfortable” (C61). In the development of new abilities sub-category, a therapist (T19) highlighted the opportunity to “learning to deal with the unknown”, and another (T23) noted a “greater focus on other forms of non-verbal communication”. The second category ( relational depth through disconnection ) mainly referred to clients’ or therapists’ comfort due to feeling emotionally protected by the mask ( client/therapist feel less exposed ; n = 9), and to an increased sense of connectedness based on the shared experience of the pandemic ( collective experience ; n = 5). For example, in the client/therapist feel less exposed sub-category, therapists wrote that it was positive “not showing my facial expression, yawning, coughing” (T12), and “not showing my spontaneity or discomfort in some situations” (T27). Similarly, clients expressed that “part of my face was covered, making me feel less exposed” (C1), or “I like hiding behind the mask” (C57). In the collective experience sub-category, a therapist (T112) noted that “we were part of a larger social event (the pandemic) as symbolized by mask-wearing, which might have increased feelings of closeness”, and another (T57) added that the masks created “a mutual understanding of collective identity of ‘sitting in the same boat’ during the pandemic”. Challenges of IPTFM The most frequently mentioned category in IPTFMs’ challenges was communication and perception issues ( n = 56; 50,9%). This category primarily included references to more misunderstandings and comprehension problems due to lack of facial expressions and/or difficulties recognizing clients’ and therapists’ mood of state or emotions ( non-verbal communication difficulties/difficulties recognizing emotions; n = 40). For example, two therapists noted, “Clients' and therapists' faces are hidden, and a lot of non-verbal cues are missed” (T66), and “hard to express, perceive and evaluate emotional expressions” (T57). Similarly, two clients expressed, “not being able to understand my therapist's face language” (C58) and that “lack of seeing face, made emotions harder to read probably” (C28). Physical and environmental issues was the second most frequently mentioned category ( n = 31; 28,18%). This category mainly included references to the demanding and uncomfortable nature of wearing masks due to physical symptoms, such as breathing difficulties, increased sweating or itching, fogged glasses, and disturbances when crying or when having a cold ( physical and breathing discomfort ; n = 26). For instance, a therapist (T65) mentioned, “difficult to speak and breath for 50 minutes while wearing a mask”, and another therapist (T40) added, “crying for clients is really tough and awkward”. Therapeutic relationship issues ( n = 12; 10,91%) and treatment related issues ( n = 9; 8,18%) were less frequently observed categories. The first ( therapeutic relationship issues ) mainly included references to therapists’ and clients’ feelings that connections remained at a surface level due to problems with interpreting the other ( loss ; n = 7), and the disinhibition/anonymity effects of the masks and the intrapersonal challenges to connect ( masked disinhibition ; n = 4). For instance, a therapist (T138) wrote that “it’s hard when you can’t connect because they {the clients} have a mask on their face”. Clients also expressed sentiments such as, “the sessions felt lackluster and shallow, lacking any real connection” (C36) or that “increased perceived distance increased mistrust towards therapist” (C65). The second ( treatment related issues ) mostly included references to therapists and clients rating IPTFM negatively or clearly stating a preference for VT ( motivation to use face masks ; n = 5). For example, a client (C26) stated that “virtual is better”, and another (C27) rated the IPTFM experience as “bad”. Similarly, two therapists rated IPTFM as “inconvenient” (T93) and “uneasy” (T72). Recommendations for IPTFM The most frequently mentioned recommendations for IPTFM were to normalize the face masks use ( n = 17; 19,32%) and to take care of the communication ( n = 17; 19,32%). The first ( normalize the face masks use ) included references to discussing the pertinence of using face masks and its implications on the therapeutic process, as well as trusting the therapeutic process despite using face masks. For example, two therapists stated, “tell the client about the difficulties that may occur during the sessions and be open to communicate about that” (T47) and “address the discomfort of wearing masks and address the limitations that more frequent check-ins/clarifications are needed” (T68). Clients focused more on trusting the therapeutic process despite the use of face masks, as indicated by statements such as “the mask is not an issue, you’ll be able to express yourself the same way” (C50) or “go anyway {to therapy}” (C21) and “do it {IPTFM} without fear” (C48). The second ( take care of communication ) included suggestions from therapists and clients to improve communication, such as “listen more carefully” (C33), “try to speak clearly” (C54), “pay more attention to voice and intonation, posture and gestures - yours and your client's” (T71), “when any information you consider relevant is missing, communicate it to the patient” (T11), and “ask patients to express feelings and emotions clearly” (T1). The second most frequently mentioned category was to use alternatives to face masks ( n = 15; 17,5%). This category emerged inductively and included suggestions to remove face masks if possible while maintaining a safe distance, or if not possible, to remove them at least once during the process or use plexiglass/see-through masks. For instance, therapists wrote, “Don't {do it with masks}. There are other options, like plexiglass and distance” (T92) or “keep distance in the room but don't do it {the therapy} with mask” (T91). Clients also stated, “Look for a see-through/plastic mask” (C65) and “there's always the option of sitting further across each other to being able to take it off” (C44). To strengthen the focus on therapeutic skills ( n = 14; 15,91%) and to take care of the therapeutic relationship ( n = 14; 15,91%) were the third most frequently mentioned categories. The first ( strengthen the focus on therapeutic skills) included suggestions to improve therapists’ therapeutic skills, such as “even if you are uncomfortable or uneasy don't make it obvious to the client” (T139), and “use more confirmations and validations of client’s emotions” (T19). The second ( take care of the therapeutic relationship ) included suggestions to improve therapeutic rapport and bond, such as “show your face and see the client's face before starting the process. Count on a certain slowdown in the advancement of establishing the therapeutic relationship.” (T25), “introduce yourselves without the mask first, then put it on” (T35), “need to be more patient” (C38), and “do not use a mask to hide crying or laughing, because the eyes also express emotions and language” (C48) Benefits of VT The most common category in VT’s benefits was flexibility and accessibility ( n = 109; 66,06%), including mostly references to VT being convenient and comfortable due to greater flexibility in terms of time and location. This increased accessibility for clients and therapists, making it more time and cost efficient for them ( convenience; n = 77). For instance, a therapist (T59) said that VT was “convenient as there is no need to travel”, and another (T22) added that it was good to “reach some clients who would have great difficulty to come in-person because of their work schedule”. Clients referred to convenience as well, for example, “timing was good and I did not need to travel or pay for travel” (C12), “more convenient since I did not need to leave the house” (C18), and “fit into my schedule better” (C24). This category ( flexibility and accessibility ) also included some references to VT creating a safety climate and protecting the clients’ and therapists’ physical health allowing the continuity of mental care during the COVID-19 pandemic ( continuity of care; n = 25). As a therapist (T25) wrote, “not leaving people without support when it was not possible to provide another type of therapy at all”, and a client (C58) added, “the fact that my sessions were not disturbed because of the pandemic, I appreciated that”. Effectiveness or advantages for the therapeutic work ( n = 30; 18,18%) was the second most referred category in VT’s benefits. It included mostly references to therapists or clients comparing video therapy with in-person therapy and stating the effectiveness of video therapy ( as effective or nearly as effective as in-person therapy ; n = 10), followed by video therapy providing additional information about the client’s home environment and behaviors outside the physical therapy room ( new information about clients ; n = 6), the shift to video therapy allowing the development of new communication and therapeutic abilities ( development of new abilities ; n = 5), and the therapy environment being less formal, which facilitated some therapeutic tasks ( less intense therapy environment ; n = 4). For example, with respect to the as effective or nearly as effective as in-person therapy sub-category, a therapist (T16) stated that “it worked in the same way {as in-person}” and a client (C45) reported that VT “is very comfortable and the same as in-person”. Regarding the new information about clients’ sub-category, a therapist (T66) stated that VT gave a “close-up of face and emotions, often alongside other aspects of clients' life in the background”. Considering the development of new abilities , a therapist (T32) wrote that video therapy permitted to “learn and pay attention to details and micro gestures, {and a} greater clarification of information” and a client (C16) stated that “it felt educational on both sides”. Finally, regarding to the less intense therapy environment sub-category, clients said that “sometimes it felt less tense” (C41) or “perhaps less formal feeling” (C62). The third most frequent category was advantages for the therapeutic relationship ( n = 20; 12,12%), including references to the client feeling less pressured in video therapy due to not entering the therapy room and less intense therapy environment ( client feels less pressured ; n = 8), the video therapy setting facilitating the client’s disclosure around topics that are difficult or “shameful” as the client feels less self-conscious ( easier for the client to open-up more ; n = 7), and the changes in the structure of the therapeutic relationship allowing the client’s empowerment and sense of control ( client empowerment and greater sense of control ; n = 6). For instance, regarding the client feels less pressured sub-category, two therapists stated that “clients often felt safer in their own apartments” (T47) or felt “less threatened” (T51) in VT. Clients agreed, saying that “at home I was more comfortable and didn't feel too much under a gaze” (C41) or “feeling more comfortable because of being in my room, somewhere familiar” (C42). Regarding the easier for the client to open-up more sub-category, a therapist (T63) said that “sometimes the patient dared to say something that he would have said with more difficulties face to face” (T63) and a client (C5) stated, “when I was too ashamed to say certain things, my therapist suggested to turn off my camera if it would help, which I did, and it made me feel more open to sharing what I needed to say”. Finally, with respect to client empowerment and greater sense of control , a therapist (T57) wrote that “the client is on his/her territory, which enhances stronger self-determinative acts of communication”, and another (T44) added that “the client feels calmer and more confident when he/she is at home, in familiar conditions”. Challenges of VT The most common category in VT’s challenges was technological issues ( n = 53; 29,61%) primarily involving references to technological interferences (e.g., problems with internet connection; platform and/or device; signal latency) which impacted the ability to provide or receive video sessions ( technological issues impacting on the delivery of therapy; n = 52). Therapists stated, for example, that “technical difficulties meant sometimes sessions had to stop and continue via telephone” (T54) or “technological glitches often disrupted the flow of sessions” (T112). Similarly, clients wrote that “sometimes bad connection causes issues and the session has to be postponed” (C40) or that “sometimes there were technical issues interrupting the session” (C55). The second most frequent category in VT’s challenges was communication and perception issues ( n = 42; 23,46%) which included references mostly related to the lack of some non-verbal cues, including emotional cues, in the therapeutic interaction and/or misunderstandings due to the absence of these cues ( lack of body language; n = 26), followed by references related to lack of other sensory information and physical presence impeding a full picture of the client or therapist ( decrease of full-sensory perception; n = 17). Regarding the lack of body language , for example, therapists stated: “not able to see client's whole body so miss out on some non-verbal cues” (T85) and “felt I missed a lot of non-verbal data such as if client's feet were shaking etc.” (T36); and clients wrote that it was “harder to express and understand emotions through body language” (C66) or that “body language not visible. {So} Relied on trust” (C31). With respect to the decrease of full-sensory perception , therapists stated as negative points of VT “only having a visual image and not the whole sensory experience of being with another person in a room” (T59) or that “the ‘speaking bust’ in the video format does not give any clue on physical condition like weight gain or loss and might lead to create an avatar of a non-authentic self-image” (T57). Similarly, a client (C4) said that in VT you “can’t ‘read the room’ as well”. Therapeutic relationship issues was the third most frequently referred category ( n = 33; 18,44%), followed by treatment related issues ( n = 31; 17,32%). The first ( therapeutic relationship issues ) included mostly references related with therapists or clients feeling emotionally distant and/or a superficial connection with therapist/client ( therapeutic relationship feels more distant and/or superficial ; n = 21). For example, therapists wrote that “it’s less deep than in-person” (T64) or that “there seemed to be less of a connection during the sessions” (T128). Also, clients agreed that in VT “the interaction felt not as personal” (C3) and “can’t feel any connection through a screen” (C30). The second ( treatment related issues ) referred mainly to therapists and clients feeling that therapeutic work was more difficult due to lack of physical presence ( treatment more difficult ; n = 21). For instance, two therapists stated that “it gives more work, you need to pay a lot of attention, as it’s easy to get distracted” (T9), and that “several interventions and conversations in general are more complicated” (T33). Also, a client (C14) said that “it’s harder to concentrate” in VT. The least frequent category in VT’s challenges was physical and environmental issues ( n = 20; 11,17%) and included mostly references related to lack on presence and therapeutic space and/or control over this space, which are seen as conditions to enable the therapeutic process ( lack of therapeutic space and physical presence ; n = 10). This was followed by statements of negative physical symptoms associated with the video therapy setting ( rapid fatigue and exhaustion ; n = 6), and concerns about privacy, confidentiality, and security ( privacy, confidentiality and security issues ; n = 4). For example, regarding the lack of therapeutic space and physical presence , therapists complained about the “lack of ‘presence’” (T34) and the “artificiality of the process” (T1), and a client (C47) stated that there was “no therapeutic space”. Regarding the rapid fatigue and exhaustion , therapists reported: “there seem to be some losses that lead to greater fatigue at work” (T28) and “more tiring at the end of the day” (T31). Considering the privacy, confidentiality and security issues , a client (C54) said, “roommates can potentially overhear the conversation”, and a therapist (T46) added “for me it was a bit off putting if a client was in bed half-dressed when we talked {and} of other family members hanging by. Sometimes they wanted to say hello, which I felt was a bit weird.” Recommendations for VT The most referred recommendation for VT was to create a therapeutic space ( n = 30; 19,74%). This category included references regarding recommendations to create a space at home to support privacy for clients and therapists when therapy conditions are unusual. For instance, therapists stated to “make sure you have a 100% safe and quiet space for work” (T46) and to “ask clients to be in a private room, where they feel comfortable to talk” (T35); and clients referred “to make sure they are in a comfortable place and that they can speak freely without worrying someone within their environment can hear them” (C20) and “remove all distractions, establish a safe private environment, turn off app notifications” (C66). The second most frequent category in VT’s recommendations emerged inductively and was to trust the therapeutic process and normalize videoconference therapy ( n = 26; 17,11%). This category included suggestions to trust the therapeutic process despite it being in a video format and accept it and/or changes naturally, not as a challenge. For example, therapists wrote to “trust your ability to listen, trust the device and your and your clients’ ability to adapt” (T8) and to “go forth, a person who could establish a genuine connection in-person, should be able to do so through any technology or channel” (T118). Technical communication enhancement was the third most referred category ( n = 24; 15,79%) and included mostly suggestions to making sure therapists and clients have a good internet connection. For instance, a client (C42) wrote “I would only advise to have stable internet connection”, and a therapist (T112) added to “be sure you and your patient have a fully functioning laptop and Wi-Fi or cellphone connection”. Human communication enhancement ( n = 20; 13,16%) was the fourth most frequent category. For therapists, this category included mainly references to pay closer attention to facial expressions, voice tone and body gestures. For example, a therapist reported to “pay attention to all the nuances of emotional, body, facial, verbal behavior and even the surrounding environment” (T75). For clients, this category included mainly references to be open and honest with the therapist, and truthful with oneself. For example, a client wrote, “try and be open and honest as that is the best way to get help and build a relationship with the therapist” (C37). The next most referred categories were session preparation ( n = 14; 9,21%) and complement with in-person therapy ( n = 13; 8,55%). The first ( session preparation ) included recommendations to spend more time preparing to enhance video therapy's quality and effectiveness. The second ( complement with in-person therapy ) referred to, if possible, complement the video therapy with in-person sessions to overcome challenges due to the video format. Regarding session preparation , a client (C66) reported, for example, to “prepare 10–15 min in advance”, and therapists stated, for example, to “train specifically for online work” (T43), and to “read up guidelines which are now available from most therapeutic practices/organizations” (T54). With respect to the complement with in-person therapy category, a client (C65) said, for example, “I would recommend in-person therapy whenever possible”, and a therapist (T40) stated “Just don't make it the entire practice. Have a mix either within caseload or within client if possible”. Similarities and Differences between therapists and clients Regarding IPTFM (see Fig. 1), physical presence as a condition to enable therapy was the most common benefits category for both groups (therapists – n = 46; 63,89%, clients – n = 12; 46,15%). The second most common benefit for clients was relational depth through disconnection ( n = 8; 30,77%), while for therapists, it was harmlessness and adaptation experience (n = 14; 19,44%). Communication and perception issues was the most common challenges category in IPTFM for both groups (therapists – n = 43; 52,44%, clients – n = 13; 46,43%), followed by physical and environmental issues (therapists – n = 23; 28,05%, clients – n = 8; 28,57%). The most referred recommendation for IPTFM by clients was to normalize the face masks use ( n = 7; 36,84%), whereas for therapists, it was to take care of the communication ( n = 15; 21,74%). The second most referred recommendation for clients was to use alternatives to face masks (n = 3; 15,79%), whereas for therapists, it was to strengthen the focus on therapeutic skills (n = 14; 20,29%). Regarding VT (see Fig. 2), flexibility and accessibility was the most common benefits category for both groups (therapists – n = 68; 68,69%, clients – n = 40; 61,54%), followed by effectiveness/advantages for the therapeutic work (therapists – n = 16; 16,16%, clients – n = 14; 21,54%). Therapeutic relationship issues was the most common challenges category for clients in VT ( n = 19; 32,2%), followed by technological issues ( n = 18; 30,51%), whereas for therapists, it was technological issues ( n = 35; 29,41%), followed by communication and perception issues (n = 32; 26,89%). The most common recommendation for VT by clients was to create a therapeutic space ( n = 15; 29,41%), followed by to trust the therapeutic process and normalize video therapy ( n = 13; 25,49%). For therapists, the most common recommendation was technical communication enhancement ( n = 17; 17%), followed by to create a therapeutic space ( n = 15; 15%), and human communication enhancement (n = 14; 14%). The Fisher-Freeman-Halton (FFH) tests showed that therapists and clients did not differ significantly regarding what they found positive about IPTFM ( p = .229) and VT ( p = .815), what they found negative about IPTFM (p = .213), and what they recommend for overcoming possible difficulties in VT ( p = .061). However, the FFH tests showed significant differences in the frequency of the VT’s challenges categories ( p = .011) across the two groups (i.e., therapists, clients) (Table 2 ). The Adjusted Standardized Residuals (ASR) showed that clients contributed significantly more (ASR = 3.3) to the therapeutic relationship issues category than expected, while therapists contributed significantly less (ASR = -3.3) to this category. Table 2 Challenges of VT categories’ frequency counts and adjusted standardized residuals (ARS) by group (therapists or clients) Group Therapists (Total N of references = 119) Clients (Total N of references = 59) Challenges of VT categories n of references ASR n of references ASR Technological issues 35 -0,15 18 0,15 Communication and perception issues 32 1,47 10 -1,47 Therapeutic relationship issues 14 -3,30 19 3,30 Treatment related issues 21 0,40 9 -0,40 Physical or environmental issues 17 1,83 3 -1,83 Fisher-Freeman-Halton Test ( p = .011) Moreover, the FFH tests showed significant differences in the frequency of the IPTFM’s recommendations categories ( p = .008) (Table 3 ). The ASR showed that clients contributed significantly more (ASR = 2.19) to the normalize the face masks’ use category than expected, while therapists contributed significantly less (ASR = -2.19) to this category. The ASR showed as well that therapists contributed significantly more to the strengthen the therapeutic skills category (ASR = 2.19), whereas clients contributed significantly less (ASR = -2.19). It is important to note that this category was specifically designed for therapists. Therefore, it was expected that clients would not contribute to this category. Nonetheless, the descriptive statistics referred above indicated that therapists prioritized this category over others. Table 3 Resources of IPTFM categories’ frequency counts and adjusted standardized residuals (ARS) by group (therapists or clients) Group Therapists (Total N of references = 63) Clients (Total N of references = 14) Resources of IPTFM categories n of references ASR n of references ASR Normalize the face masks’ use 10 -2,19 7 2,19 Take care of communication 15 1,10 2 -1,10 Use alternatives to face masks 12 0,16 3 -0,16 Strengthen therapeutic skills 14 2,14 0 -2,14 Take care of therapeutic relationship 12 0,72 2 -0,72 Fisher-Freeman-Halton Test ( p = .008) Discussion This study explored the perspectives of both therapists and clients regarding videoconference therapy (VT) and in-person therapy with face masks (IPTFM), aiming to uncover the challenges, benefits, and recommendations for these modalities. Our findings regarding IPTFM resonate with existing research (Bani et al., 2023 ; Erschens et al., 2022 ; Mitzkovitz et al., 2022 ; Ribeiro et al., 2021 ), with both therapists and clients reinforcing that masks pose challenges related to the interpretation of non-verbal communication ( communication and perception issues ) and physical discomfort ( physical and environmental issues ). Despite these challenges, both groups recognized the benefits of face masks in addressing safety concerns and enabling in-person therapy sessions ( physical presence as a condition to enable therapy ) (Ribeiro et al., 2021 ). However, there were some differences in the recommendations made by therapists and clients. Clients emphasized the importance of normalizing the face masks’ use , contributing significantly more for this recommendation than therapists did. The accommodation of masks appeared to meet a clients’ need for normality, ensuring their trust in the therapeutic process and its continuity (Ribeiro et al., 2021 ). By advocating for the integration of masks ( normalizing the face masks’ use ), clients showed a willingness to accept and adapt to new circumstances. Nevertheless, their suggestion to use alternatives to masks might indicate a desire to mitigate the physical and emotional barriers posed by face masks while maintaining a connection with the therapist. Conversely, even though therapists didn’t contribute significantly more for the take care of communication recommendation than clients did, the findings highlighted that they placed a greater emphasis on this recommendation than on others. The focus on this recommendation ( take care of communication) as well as on strengthening the focus on therapeutic skills suggests that therapists are motivated to adapt and refine their skills to meet clients’ needs effectively (Hill, 2005 ; Orlinsky & Rønnestad, 2005 ; Rønnestad & Skovholt, 2003 ). By improving communication strategies (e.g., listening more carefully, speaking clearly, paying greater attention to non-verbal cues) and enhancing therapeutic skills, therapists aim to maintain the quality of the therapeutic relationship and ensure clients feel understood and supported (Ackerman & Hilsenroth, 2003 ; Ribeiro et al., 2021 ). The findings regarding VT highlight that both therapists and clients perceive flexibility and accessibility as the primary benefits, followed by its effectiveness and advantages for therapeutic work. This recognition aligns with previous research (Asbrand et al., 2023 ; Buckman et al., 2021 ; Feijt et al., 2020 ; Stoll et al., 2020 ; Thomas et al., 2021 ), emphasizing that VT removes geographical barriers, allows clients to access therapy from the comfort of their homes, making it easier for clients to attend the sessions regularly and for therapists to manage their schedules efficiently. The perceived effectiveness of VT aligns with research on the therapeutic alliance and treatment outcomes in online therapy (Chakrabarti, 2015 ; Simpson et al., 2021 ; Thomas et al., 2021 ), indicating that core elements of effective therapy can be maintained through videoconferencing. However, technological issues , such as internet connection problems, stressed by both therapists and clients, can potentially undermine their willingness to adopt and continue using VT. Therefore, addressing this challenge ( technological issues ) is crucial for optimizing the use of videoconference psychotherapy as a viable alternative to traditional in-person therapy (Wootton et al., 2020 ). Moreover, clients' perceptions of an increased emotional distance and superficial connection in VT ( therapeutic relationship issues ) may reflect the limitations of the mediated environment, hindering rapport and trust development (Cataldo et al., 2021 ). This finding suggests that the therapeutic relationship, as conceived by clients, might not yet be optimal in a videoconference setting (Cataldo et al., 2021 ; Leuchtenberg et al., 2022). Regarding the recommendations for VT, both therapists and clients emphasized the importance of creating a therapeutic space , reflecting a shared understanding of the significance of a dedicated space for therapy (Eichenberg et al., 2022 ). For therapists, ensuring clients have a suitable therapeutic space supports the overall therapy process and helps maintain the integrity of the therapeutic setting (Downing et al., 2021 ) as well as therapeutic boundaries (James et al., 2021). For clients, separating everyday-life space from the therapy space provides a sense of privacy and containment, essential for emotional safety and comfort to open up (García et al., 2022 ). Although there were no significant differences between therapists and clients regarding VT’s recommendations, certain recommendations were prioritized over others, introducing distinctions worth considering. Clients' recommendation to trust the therapeutic process and normalize video therapy indicates their need for reassurance and acceptance of this new modality. This aligns with the concept of therapeutic alliance and the need for clients to feel confident and committed to the therapy process (Bachelor, 2013 ), regardless of the medium. Normalizing video therapy can possibly increase engagement, essential for the therapeutic relationship and positive outcomes (Hill, 2005 ). On the other hand, therapists appeared committed to their role of facilitators of therapeutic change (Marín-Medina et al., 2024 ), feeling responsible for improving the technological and communication conditions to prevent interference with the therapeutic process. Enhancing technical communication ensures that sessions are smooth, clear, and free from disruptions that could detract from the therapeutic work (Wootton et al, 2020 ). Moreover, enhancing human communication , which involves adjusting verbal and non-verbal strategies to compensate for videoconferencing limitations, helps preserve the therapeutic alliance and ensures that clients feel understood and supported despite the lack of a physical therapeutic space (Downing et al., 2021 ; Simpson et al., 2021 ). In summary, the findings revealed a complementary dynamic between clients' and therapists' perspectives on adapting to new therapeutic environments. Clients appeared to prioritize normalizing and building trust in these environments, focusing on their comfort and ability to engage meaningfully in therapy. These efforts seemed directed at reducing emotional distress and maintaining their engagement, despite the changes. Therapists, in contrast, were primarily concerned with maintaining the quality and effectiveness of the therapeutic process by improving communication and refining their professional skills. Their actions focused on addressing the practical and technical challenges posed by the new therapeutic contexts. Together, these perspectives seem to reflect a shared goal of fostering a therapeutic environment that is both supportive and effective. While clients concentrated on overcoming barriers to their participation, therapists worked to address the structural and relational aspects necessary for successful therapy. This alignment, though distinct in focus, underscores the interdependence of their roles in co-creating a therapeutic process that meets the needs of both parties. Moreover, Clients’ insights highlighted the importance of addressing emotional and relational factors, providing critical feedback on how therapeutic environments could better support their engagement and comfort. These findings emphasize the importance of enhancing therapists’ training to develop skills that improve communication, foster trust, and create a sense of normalcy in both IPTFM and VT. Implications for practice Recognizing the differences in how clients and therapists perceive and cope with new therapeutic environments seems essential for developing effective interventions. By integrating both perspectives, this study facilitated the formulation of targeted recommendations that address the unique needs of each group, ultimately enhancing their therapeutic experiences. For therapists, it seems that ongoing professional development is crucial. This can be achieved, for example, through regular training focused on enhancing communication skills in virtual and masked settings, workshops on using videoconferencing tools effectively, troubleshooting technical issues, and ensuring data security. On the other hand, to address clients’ needs, therapists could emphasize open communication about any discomfort with virtual and masked formats as well as encourage clients to actively participate in sessions, ask questions, and express their feelings about the new format to build a sense of normalcy and control. Furthermore, the superficial connection encountered by clients in VT should be further addressed as well, by enhancing initial engagement (discussing expectations, concerns, and goals to build rapport from the beginning), improving communication strategies (active listening, summarizing, reflecting emotions to ensure clients feel heard and understood), fostering emotional connection (regular check-ins on client’s current emotional state; reinforce their feelings and experiences as important and valid), and implement regular feedback mechanisms. Limitations and future studies This study encountered several limitations that may have impacted the results and their generalizability. While we addressed differences and similarities between therapists and clients, it is important to note that the therapists and clients in this study were not matched dyads (i.e., therapists and clients from the same therapeutic relationship). As a result, while the findings highlight complementary perspectives between the two groups, the lack of dyadic data limits our ability to explore how therapists’ and clients’ views might align, diverge, or co-evolve in response to shared challenges in the same therapeutic process. The survey was conducted in Portuguese, Spanish, and English, potentially reducing linguistic diversity and representativeness. Additionally, retrospective evaluations may have introduced recall bias, as memories may not accurately reflect past events. Given that the survey was conducted toward the end of the pandemic, participants’ adaptation to new therapeutic environments may have influenced their responses. Future research could benefit from recruiting therapist-client dyads to explore the interplay between their perspectives within a shared therapeutic context. Such an approach could offer richer and more nuanced insights into how therapists and clients negotiate, adapt to, and overcome the challenges associated with videoconference therapy (VT) and in-person therapy with face masks (IPTFM). Expanding linguistic diversity by translating surveys into multiple languages would improve inclusivity. To mitigate recall bias, longitudinal designs could track changes in perceptions and coping strategies over time. Furthermore, examining the long-term impact of VT and IPTFM on therapeutic outcomes and the therapeutic alliance would offer valuable insights into optimizing mental health care in evolving contexts. Declarations Funding: This work was conducted at CIPsi, School of Psychology, University of Minho, supported by the Portuguese Foundation for Science and Technology (FCT; UID/01662: Centro de Investigação em Psicologia) through national funds. This work was also supported by the Portuguese Foundation for Science and Technology (FCT), under Grant 2021.05711.BD. Compliance with Ethical Standards : All procedures performed in studies involving human participants were in accordance with the ethical standards of the Ethics Committee for Research in Social and Human Sciences, Universidade do Minho (CEICSH 116/2021), and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Conflicts of Interest : The authors declare they have no conflict of interest. Informed Consent : Informed consent was obtained from all individual adult participants included in the study. Data availability statement: The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. 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Counselling Psychother Res 24(1):27–38. https://doi.org/10.1002/capr.12610 Wootton AR, McCuistian C, Legnitto Packard DA, Gruber VA, Saberi P (2020) Overcoming technological challenges: Lessons learned from a telehealth counseling study. Telemedicine e-Health 26(10):1278–1283. https://doi.org/10.1089/tmj.2019.0191 Additional Declarations The authors declare no competing interests. Supplementary Files CodebookforIPTFM.docx CodebookforVT.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6098189","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":420263834,"identity":"cee83d7b-f68e-4010-899a-7b9506526c98","order_by":0,"name":"Vânia Silva","email":"","orcid":"https://orcid.org/0000-0002-0298-5726","institution":"Psychotherapy and Psychopathology Research Lab, Psychology Research Center (CIPsi), School of Psychology, University of Minho","correspondingAuthor":false,"prefix":"","firstName":"Vânia","middleName":"","lastName":"Silva","suffix":""},{"id":420263835,"identity":"dab9b6f3-9f0f-46c8-97e2-92161f2627b3","order_by":1,"name":"Laura Koppensteiner","email":"","orcid":"","institution":"Psychotherapy and Psychopathology Research Lab, Psychology Research Center (CIPsi), School of Psychology, University of Minho","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"","lastName":"Koppensteiner","suffix":""},{"id":420263836,"identity":"f4354679-0d6a-4e4d-97ed-1ffd3e7c2d3f","order_by":2,"name":"Eugénia Ribeiro","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYNACAwY5BgbGBiBLAsgmUosxqpYDRGhKbEBoJ6CFXyL94uOCArv07fyHG5h5cyzyzNkb2B5/wKNFckZOsfEMg+TcnTMSgVq2SRRb9hxgN8Bni8GNnDRpHgPm3A03GMFaEjfcSGCTwKfF/kZO+m8eg/p0g/MHidRiIJF+jJnH4HCCwYFEIrVInHnDDHTYcUOQXw7OBWk5c7Dd4AweLfzt6Q8/8/ypljfnP/7wwdttdYkbjjcfe1CBRwsDAw8kukEk1DmMbXg1MDCwP4BrgQE2AlpGwSgYBaNghAEAetlPrBuD88AAAAAASUVORK5CYII=","orcid":"","institution":"Psychotherapy and Psychopathology Research Lab, Psychology Research Center (CIPsi), School of Psychology, University of Minho","correspondingAuthor":true,"prefix":"","firstName":"Eugénia","middleName":"","lastName":"Ribeiro","suffix":""}],"badges":[],"createdAt":"2025-02-24 15:14:55","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6098189/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6098189/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":77393036,"identity":"c44a5b03-ea25-4185-84c4-967021f87f6c","added_by":"auto","created_at":"2025-02-28 06:56:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":109532,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-6098189/v1/4b2f45617b80019c16b52659.png"},{"id":77391906,"identity":"38414e83-de64-4bb9-a346-316f046a14a7","added_by":"auto","created_at":"2025-02-28 06:48:36","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":117073,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-6098189/v1/bd1ec9c15723823468007b53.png"},{"id":77394451,"identity":"ca5fae26-6234-434e-84ab-e87806415a90","added_by":"auto","created_at":"2025-02-28 07:12:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2333445,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6098189/v1/2edd817a-2cd0-48e9-9e53-31e3ebbb6501.pdf"},{"id":77391903,"identity":"8dc4bf2e-8f38-45fc-a9bd-8460eafdf95b","added_by":"auto","created_at":"2025-02-28 06:48:36","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":24405,"visible":true,"origin":"","legend":"","description":"","filename":"CodebookforIPTFM.docx","url":"https://assets-eu.researchsquare.com/files/rs-6098189/v1/b7533fdcaaa1d62c5f657873.docx"},{"id":77393427,"identity":"fd696c40-7ec5-4352-9e23-02e1823f3bd2","added_by":"auto","created_at":"2025-02-28 07:04:36","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":27567,"visible":true,"origin":"","legend":"","description":"","filename":"CodebookforVT.docx","url":"https://assets-eu.researchsquare.com/files/rs-6098189/v1/7f9667d8ff799d6a78f3faab.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eNavigating psychotherapy in the COVID-19 Era: overcoming challenges, harnessing benefits, and practical recommendations\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAs the world struggled with the COVID-19 pandemic, adopting preventive measures, such as wearing face masks and videoconferencing, has become ubiquitous in various settings, including psychotherapy sessions. While the primary purpose of face masks was to mitigate the spread of infectious diseases, their incorporation into therapeutic encounters introduced a unique set of considerations, encompassing both challenges and advantages. Research specifically focusing on psychotherapy wearing face masks is still limited due to its relatively recent emergence and rapidly changing pandemic context. However, existing literature highlights the multifaceted challenges associated with wearing masks in therapeutic settings (Bani et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Erschens et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Kidd, 2022; Mitzkovitz et al, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ribeiro et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The primary challenges associated with mask wearing include the physical discomfort caused by masks, such as breathing difficulties, unpleasant odors, and increased sweating (Erschens et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ribeiro et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Additionally, masks have been found to interfere with the accurate recognition of emotion conveyed by facial expressions (Bani et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Mitzkovitz et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), the therapeutic relationship, specifically emphatic rapport, emotional bond (Ribeiro et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), and relational depth (Kidd, 2022), verbal and non-verbal communication (Erschens et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ribeiro et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), and the therapeutic work, preventing the use of some therapeutic tasks depending on the therapeutic approach (Erschens et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ribeiro et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, alongside its challenges, previous research sheds light on some benefits of the widespread adoption of face masks in psychotherapy (Kidd, 2022; Ribeiro et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). For instance, a study by Ribeiro et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) found that therapists acknowledged the importance of masks in reducing viral transmission risks, thereby safeguarding the health of both therapists and clients and fostering a sense of safety conducive to therapeutic engagement. Furthermore, therapists reported minimal impact of the use of masks on psychotherapy, with some expressing a preference for in-person therapy despite the presence of masks (Ribeiro et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Moreover, Kidd (2022) found that masks facilitated a collective experience and a stronger willingness to connect, which could enhance relational depth.\u003c/p\u003e \u003cp\u003eTo optimize the efficacy of psychotherapy in the context of mask-wearing, some recommendations have merited consideration in recent research (Erschens et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Mitzkovitz et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ribeiro et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). For instance, the literature suggests that therapists should proactively address the potential impact of masks on communication dynamics during sessions, openly acknowledging any challenges and collaboratively exploring strategies to overcome them (Mitzkovitz et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ribeiro et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This may involve utilizing alternative modes of expression, such as verbalizing emotions more explicitly or incorporating supplementary visual aids to compensate for the loss of facial cues (Erschens et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Mitzkovitz et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ribeiro et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Additionally, creating a supportive and empathetic atmosphere where clients feel comfortable to voice any concerns related to mask-wearing without fear of judgment seemed crucial (Ribeiro et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn contrast to the relatively emerging research on psychotherapy with face masks, the study of videoconference psychotherapy has been discussed for some time ago (e.g., Baker \u0026amp; Ray, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) and is still rapidly growing. Videoconference psychotherapy has revolutionized mental health care, providing unprecedented opportunities for remote therapeutic engagement. As with any emerging practice, videoconference psychotherapy brought forth a plethora of benefits, along with unique challenges and considerations that warrant careful attention (Asbrand et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Simpson et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Stoll et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Existing research has found that the benefits of videoconference psychotherapy are manifold (Asbrand et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Buckman et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Feijt et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Stefan et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Stoll et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Thomas et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). For instance, geographical barriers are virtually dissolved, enabling individuals from diverse locations to access mental health support conveniently (Buckman et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Stoll et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Thomas et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This accessibility is particularly advantageous for those residing in rural or underserved areas, where traditional face-to-face therapy may be scarce (Stoll et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Thomas et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Moreover, the flexibility of scheduling sessions online accommodates busy lifestyles, enhancing convenience and treatment adherence (Asbrand et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Buckman et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Feijt et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Moreover, videoconferencing can offer a sense of anonymity and privacy, fostering a safe environment for clients to explore their emotions and experiences from the comfort of their own space (Stefan et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Stoll et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, amidst its advantages, videoconference psychotherapy also presents notable challenges (Asbrand et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Buckman et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Cataldo et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Dolev-Amit et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Feijt et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Garc\u0026iacute;a et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Mancinelli et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Stefan et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Stoll et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Thomas et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Technical glitches, such as poor internet connection or audiovisual distortions, can disrupt the flow of therapy and inhibit effective communication between the therapist and client (Buckman et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Dolev-Amit et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Feijt et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Stoll et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Thomas et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Furthermore, data security and confidentiality concerns may arise, necessitating robust measures to safeguard sensitive information transmitted over digital channels (Stoll et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Additionally, the absence of physical presence in virtual interactions may compromise the therapist's ability to assess non-verbal cues accurately, potentially hindering the depth of therapeutic rapport and understanding (Cataldo et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Dolev-Amit et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Feijt et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Stoll et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeveral recommendations have merited consideration in recent literature to optimize the efficacy of videoconference psychotherapy while mitigating its challenges (see Asbrand et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Simpson et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Stoll et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Firstly, existing literature underlies that therapists should undergo specialized training to familiarize themselves with the nuances of providing therapy through digital platforms and to develop strategies for navigating technical issues seamlessly (Buckman et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Stoll et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Furthermore, some studies state that before beginning sessions, it is imperative to establish clear protocols for ensuring data privacy and encryption to uphold confidentiality standards rigorously (Simpson et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Stoll et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Moreover, therapists should employ techniques to compensate for the lack of physical presence, increasing verbal and non-verbal activity (Garc\u0026iacute;a et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), emphasizing active listening, and encouraging clients to articulate their emotions explicitly (Simpson et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRecognizing and addressing the challenges, benefits, and recommendations associated with both mask-wearing and videoconference psychotherapy is essential for enhancing the adaptability of psychotherapy and ensuring continuity of care in similar circumstances in the future. While research on these topics is expanding, recent studies have predominantly focused on therapists\u0026rsquo; perspectives (e.g., Asbrand et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Bani et al., 2022; Buckman et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Feijt et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Kidd, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Mancinelli et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Ribeiro et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Stefan et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Although research on clients\u0026rsquo; experiences with psychotherapy is established (e.g., Elliott, 1993; Ladmanov\u0026aacute; et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), recent studies addressing clients\u0026rsquo; perspectives on videoconference therapy are limited (e.g., Giordano et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; van Kessel et al., 2022), and those examining clients\u0026rsquo; experiences of therapy involving mask-wearing are even scarcer (e.g., Erschens et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Additionally, studies that compare both therapists\u0026rsquo; and clients\u0026rsquo; perspectives have identified some discrepancies in how each group perceives videoconference therapy (e.g., Cataldo et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Simpson et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) or in-person therapy with masks (e.g., Erschens et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). These findings underscore the importance of integrating clients\u0026rsquo; perspectives to address such disparities and improve psychotherapeutic care in these specific contexts. To address these gaps, the present study aims to explore both therapists\u0026rsquo; and clients\u0026rsquo; perspectives on the challenges, benefits, and recommendations for videoconference therapy (VT) and in-person therapy with face masks (IPTFM) while identifying and analyzing any differences between these perspectives.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis qualitative study was guided by a post-positivist approach, which informed a structured, although flexible, methodological framework. The methodological procedures ensured a rigorous analysis of therapists\u0026rsquo; and clients\u0026rsquo; perspectives while recognizing that the researchers\u0026rsquo; subjectivity inherently influenced their interpretations. This perspective informed our study\u0026apos;s design and analysis, allowing us to employ deductive content analysis to examine participants\u0026apos; responses systematically. Recognizing the potential for researcher bias, we implemented strategies such as researchers\u0026rsquo; training in codebooks and the calculation of agreement between them to enhance the credibility and trustworthiness of our findings.\u003c/p\u003e\n\u003cp\u003eThe present study is part of a major study focused on studying therapists\u0026rsquo; and clients\u0026rsquo; experiences regarding relational processes in different therapy modalities. The data analyzed in this study were not considered in a previous study, and the studies address different and specific research questions. The study received ethical approval from the Institutional Ethics Committee of the University of Minho (CEICSH 116/2021).\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eParticipants\u003c/h2\u003e\n \u003cp\u003eA total of 117 therapists and 64 clients participated in this study.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eTherapists\u003c/h3\u003e\n\u003cp\u003eMost therapists were female (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;80; 68,4%), caucasian (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;83; 70,9%), married or in a partnership (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;80; 68,4%), held a master\u0026rsquo;s degree (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;46; 39,3%) or a Ph.D (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;35; 29,9%), had more than 8 years of clinical experience (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;81; 69,2%), and reported no impairments (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;97; 82,9%). Therapists\u0026rsquo; ages ranged from 22 to 82 years, with an average age of 49,6 years (SD\u0026thinsp;=\u0026thinsp;15,4). 90 therapists (76.9%) reported having prior psychotherapy experience before the outbreak of the COVID-19 pandemic. For additional details on therapists\u0026rsquo; characteristics (e.g., geographical location, treated disorders, and therapeutic approach), please refer to Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003ch3\u003eClients\u003c/h3\u003e\n\u003cp\u003eMost clients were female (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;53; 82,8%), caucasian (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;43; 67,2%), single (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;42; 65,6%), had completed a master\u0026rsquo;s degree (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;25; 39,1%) or graduation (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;23; 35,9%), and reported no impairments (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;53; 82,8%). Clients\u0026rsquo; ages ranged from 20 to 75 years, with an average age of 33,3 years (SD\u0026thinsp;=\u0026thinsp;12,7). 51 clients (79,7%) had a previous in-person therapy experience before the outbreak of the COVID-19 pandemic. For additional details on clients\u0026apos; characteristics (e.g., geographical location and disorders), please refer to Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"5\" style=\"width: 81.0885%;\"\u003e\n \u003cp\u003e\u003cem\u003eAdditional sociodemographic characteristics of participants\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 24.011%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTherapists\u003c/strong\u003e (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;117)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" style=\"width: 18.5228%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClients\u003c/strong\u003e (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;64)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeographic location\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003eAfrica\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e1,71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e1,56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003eAsia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e4,27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e14,06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003eCentral and Eastern Europe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e9,40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e15,62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003eCentral and South America\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e11,97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e4,69\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003eNorth America\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e23,93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e17,19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003eNorthern Europe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e8,55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e28,13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003eOceania\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e3,42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e1,56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003eSouthern Europe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e23,93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e12,5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003eWestern Europe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e7,69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e4,69\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003ePrefer not to say\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e5,13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisorder\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e94,87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e75,0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e88,03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e56,25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003ePersonality disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e54,70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e14,06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003eOCD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e41,88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e10,94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003eEating disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e35,04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e12,5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003eSubstance and other addictive disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e33,33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e4,69\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003ePsychotic disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e18,80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e16,24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e21,88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTherapeutic approach\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003ePsychodynamic/Psychoanalytic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e52,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003eCognitive-behavioral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e40,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003eHumanistic/Experiential\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e29,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003eSystemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e13,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003eConstructivist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e13,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 44.2488%;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 9.7759%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.2351%;\"\u003e\n \u003cp\u003e7,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.1743%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.3485%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eData collecting\u003c/h2\u003e\n \u003cp\u003eWe employed a purposive sampling method to recruit participants via social media platforms (e.g., Facebook; Reddit) and through therapists\u0026rsquo; mailing lists available on the online pages of international psychotherapy associations. Eligible participants included psychologists/psychotherapists who conducted individual psychotherapy with adult clients, either via videoconference or in-person while wearing face masks, and adult clients (18+) who had undergone psychotherapy during the pandemic through the same modalities (VT or IPTFM).\u003c/p\u003e\n \u003cp\u003eAn online survey was developed to examine the quality of relational processes in psychotherapy during the COVID-19 pandemic. While a previous study focused exclusively on the quantitative data derived from the survey (authors, \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e), the present study analyzed the qualitative data. The qualitative component of the survey included the following three questions for IPTFM: 1) \u0026quot;Please identify a positive aspect of IPTFM\u0026quot;; 2) \u0026quot;Please identify a negative aspect of IPTFM\u0026quot;, and 3) \u0026quot;What suggestions would you give to a friend or family member who is now going to start an in-person psychotherapeutic process wearing face masks?\u0026quot; (client version), or \u0026quot;What suggestions would you give to a professional colleague who is now going to start an in-person psychotherapeutic process wearing face masks?\u0026quot; (therapist version). The same set of questions was also formulated for VT.\u003c/p\u003e\n \u003cp\u003eParticipant responses were collected between December 2022 and July 2023. Upon accessing the survey links, participants were provided with detailed information about the study\u0026rsquo;s goals, eligibility criteria, estimated completion time, and informed consent. A total of 139 therapists and 71 clients consented to participate in the study and concluded the survey. However, responses were evaluated for quality and relevance to the research questions before analysis. Consequently, 22 therapists and 7 clients were excluded due to providing non-substantive responses (e.g., \u0026ldquo;ok,\u0026rdquo; \u0026ldquo;0,\u0026rdquo; or \u0026ldquo;.\u0026rdquo;). Of the remaining participants, 117 therapists and 64 clients were included. Among the therapists, 68 provided responses to the open-ended questions concerning IPTFM, and 98 responded to the questions concerning VT. Among the clients, 24 answered the open-ended questions for IPTFM, and 56 provided responses for VT.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eData analysis strategy\u003c/h2\u003e\n \u003cp\u003eWe conducted a deductive content analysis to examine trends in participant\u0026rsquo;s answers regarding the positive and negative aspects of IPTFM and VT, and their recommendations for overcoming difficulties. For this purpose, we followed the steps defined by Krippendorf (2018) and summarized by McKibben et al. (\u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e), namely unitizing, sampling, recording, and reducing. Our \u003cem\u003eunits of analysis\u003c/em\u003e were the participants\u0026rsquo; (therapists and clients) answers to the open-ended questions. Our data \u003cem\u003esample\u003c/em\u003e consisted of 738 units of analysis: 276 units for IPTFM (72 units for clients and 204 for therapists) and 462 units for VT (168 units for clients and 294 for therapists). Because we analyzed the participants\u0026rsquo; answers to an online survey, the data were \u003cem\u003erecorded\u003c/em\u003e as a written text. For the \u003cem\u003ereducing\u003c/em\u003e process, which involves condensing the data into categories or themes (Krippendorf, 2018), we used a deductive approach, specifying categories a priori. For this purpose, we reviewed recent literature (Asbrand et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e; Buckman et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Cataldo et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Dolev-Amit et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Erschens et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e; Feijt et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e; Garc\u0026iacute;a et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e; Kidd, 2022; Mancinelli et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Mitzkovitz et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ribeiro et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Simpson et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Stefan et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Stoll et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e; and Thomas et al, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e) on the positive and negative aspects, and recommendations for each therapy modality (IPTFM and VT), and developed codebooks containing the benefits, challenges and resources for each therapy modality. Before starting the coding process, the codebooks were reviewed by three external researchers to ensure that categories were clearly defined. Feedback from these researchers served to clarify and improve the codebook by eliminating unnecessary existing categories, adding relevant new ones, and refining the definitions of others. A \u0026ldquo;not suitable for coding\u0026rdquo; category was added to each modality\u0026rsquo;s codebook so that coders could assign all passages that were not suitable for coding or did not fit with previously defined categories to this category. These units were later coded inductively if suitable for coding or remained in the \u0026ldquo;not suitable for coding\u0026rdquo; category if they were too vague or not explicit (e.g., answers like \u0026ldquo;recommend\u0026rdquo; to the question about recommendations or \u0026ldquo;intimate\u0026rdquo; in response to the question about positive aspects). Both the deductively and inductively coded categories were not mutually exclusive, as the same unit of analysis could produce different coding references, and different units of analysis could contribute to the same category.\u003c/p\u003e\n \u003cp\u003eNext, using the codebooks, two coders independently coded a subsample of 30% of randomly selected participants\u0026rsquo; answers, including all types of open-ended questions. Interrater reliability was calculated using Cohen\u0026rsquo;s Kappa to test for the consistency of the coding systems, and it showed good values, with .87 for IPTFM codings and .91 for VT codings. Subsequently, the two coders met to discuss discrepancies in coding. Since the Cohen\u0026rsquo;s Kappa was \u0026gt;\u0026thinsp;.75 regarding the 30% of coded answers, one of the coders proceeded to code the remaining 70%. In addition, regarding data not suitable for coding with the codebook, the coders discussed the themes that emerged inductively and reached a consensus. We used descriptive statistics (i.e., percentages and frequency counts) to describe the data and report the categories\u0026rsquo; prevalence. Rare categories (i.e., \u0026le; 5% of coded references) were excluded from the results report.\u003c/p\u003e\n \u003cp\u003eTo investigate whether there were differences in the frequency of benefits, challenges, and recommendations categories across the two groups (i.e., therapists, clients) we used tests of independence (Avent et al., \u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e; Bledsoe et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). As more than 20% of the cells in the VT\u0026rsquo;s benefits\u0026rsquo; table, in the IPTFM\u0026rsquo;s challenges\u0026rsquo; table and in the recommendation\u0026rsquo;s tables (IPTFM and VT) contained zeros, we used Fisher-Freeman-Halton (FFH) tests instead of chi-square tests. The FFH tests are similar to chi-square analysis but are more appropriate when the frequency of empty cells is high (Bledsoe et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e; Freeman \u0026amp; Halton, \u003cspan class=\"CitationRef\"\u003e1951\u003c/span\u003e) as is the case in the present study. To get an indication of which cells are responsible for the discrepancies between therapists and clients in the categories\u0026rsquo; frequencies, we calculated and used the adjusted standardized residuals (Avent et al., \u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e). An adjusted residual greater than 1.96 indicates that the number of observed cases in that cell is significantly larger than expected (IBM, 2020).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe results are presented in two stages. First, the findings are described in general for each modality (IPTFM and VT), combining responses from both therapists and clients (with \u003cem\u003en\u003c/em\u003e representing the total number of references coded within each category including both groups). In this stage, benefits, challenges, and recommendations\u0026rsquo; categories and sub-categories are illustrated with participants\u0026rsquo; quotations and the used identifications (ID) refer to the participants (e.g., T75 refers to the therapist 75, while C36 refers to the client 36). Second, the results are analyzed in terms of comparisons between therapists and clients regarding the categories presented in stage 1.\u003c/p\u003e\n\u003ch3\u003eBenefits of IPTFM\u003c/h3\u003e\n\u003cp\u003eThe most frequently mentioned category in IPTFM\u0026rsquo;s benefits was \u003cb\u003ephysical presence as a condition to enable therapy\u003c/b\u003e \u003cem\u003e(n\u003c/em\u003e\u0026thinsp;=\u0026thinsp;58; 59,18%). This category primarily included references to the face mask creating a safe environment and protecting the physical health of both clients and therapists, thus making in-person therapy feasible (\u003cem\u003ethe face masks made therapy feasible; n\u003c/em\u003e\u0026thinsp;=\u0026thinsp;49). For example, a therapist (T75) noted that \u0026ldquo;during COVID, it {the mask} fulfilled the function of increasing the feeling of security during the in-person sessions\u0026rdquo;, and another therapist (T138) mentioned \u0026ldquo;protecting each other by wearing the mask and still be able to visit one on one\u0026rdquo;. Similarly, clients commented on the reduced risk of spreading COVID-19, such as C36 who stated, \u0026ldquo;the risk of spreading covid-19 was reduced\u0026rdquo;, and C21 who appreciated that \u0026ldquo;at least we met in person\u0026rdquo;.\u003c/p\u003e \u003cp\u003eThe categories \u003cb\u003eharmlessness and adaptation experience\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;20; 20,41%) and \u003cb\u003erelational depth through disconnection\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;20; 20,41%) were secondly mentioned, with an equal number of references. The first (\u003cb\u003eharmlessness and adaptation experience\u003c/b\u003e) included mainly references to the therapy with face masks being perceived as tolerable, safe, acceptable, quiet and/or comfortable (\u003cem\u003esatisfactory experience\u003c/em\u003e; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9), and to the use of face masks facilitating the development of new communication and therapeutic abilities (\u003cem\u003edevelopment of new abilities\u003c/em\u003e; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6). For instance, in the \u003cem\u003esatisfactory experience\u003c/em\u003e sub-category, a therapist (T58) stated that \u0026ldquo;it worked quite well\u0026rdquo;, and another (T73) remarked that \u0026ldquo;it will be ok, not perfect, but good enough\u0026rdquo;. Similarly, clients described the IPTFM experience as \u0026ldquo;good\u0026rdquo; (C27) and \u0026ldquo;more comfortable\u0026rdquo; (C61). In the \u003cem\u003edevelopment of new abilities\u003c/em\u003e sub-category, a therapist (T19) highlighted the opportunity to \u0026ldquo;learning to deal with the unknown\u0026rdquo;, and another (T23) noted a \u0026ldquo;greater focus on other forms of non-verbal communication\u0026rdquo;. The second category (\u003cb\u003erelational depth through disconnection\u003c/b\u003e) mainly referred to clients\u0026rsquo; or therapists\u0026rsquo; comfort due to feeling emotionally protected by the mask (\u003cem\u003eclient/therapist feel less exposed\u003c/em\u003e; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9), and to an increased sense of connectedness based on the shared experience of the pandemic (\u003cem\u003ecollective experience\u003c/em\u003e; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5). For example, in the \u003cem\u003eclient/therapist feel less exposed\u003c/em\u003e sub-category, therapists wrote that it was positive \u0026ldquo;not showing my facial expression, yawning, coughing\u0026rdquo; (T12), and \u0026ldquo;not showing my spontaneity or discomfort in some situations\u0026rdquo; (T27). Similarly, clients expressed that \u0026ldquo;part of my face was covered, making me feel less exposed\u0026rdquo; (C1), or \u0026ldquo;I like hiding behind the mask\u0026rdquo; (C57). In the \u003cem\u003ecollective experience\u003c/em\u003e sub-category, a therapist (T112) noted that \u0026ldquo;we were part of a larger social event (the pandemic) as symbolized by mask-wearing, which might have increased feelings of closeness\u0026rdquo;, and another (T57) added that the masks created \u0026ldquo;a mutual understanding of collective identity of \u0026lsquo;sitting in the same boat\u0026rsquo; during the pandemic\u0026rdquo;.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eChallenges of IPTFM\u003c/h2\u003e \u003cp\u003eThe most frequently mentioned category in IPTFMs\u0026rsquo; challenges was \u003cb\u003ecommunication and perception issues\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;56; 50,9%). This category primarily included references to more misunderstandings and comprehension problems due to lack of facial expressions and/or difficulties recognizing clients\u0026rsquo; and therapists\u0026rsquo; mood of state or emotions (\u003cem\u003enon-verbal communication difficulties/difficulties recognizing emotions; n\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40). For example, two therapists noted, \u0026ldquo;Clients' and therapists' faces are hidden, and a lot of non-verbal cues are missed\u0026rdquo; (T66), and \u0026ldquo;hard to express, perceive and evaluate emotional expressions\u0026rdquo; (T57). Similarly, two clients expressed, \u0026ldquo;not being able to understand my therapist's face language\u0026rdquo; (C58) and that \u0026ldquo;lack of seeing face, made emotions harder to read probably\u0026rdquo; (C28).\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhysical and environmental issues\u003c/b\u003e was the second most frequently mentioned category (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;31; 28,18%). This category mainly included references to the demanding and uncomfortable nature of wearing masks due to physical symptoms, such as breathing difficulties, increased sweating or itching, fogged glasses, and disturbances when crying or when having a cold (\u003cem\u003ephysical and breathing discomfort\u003c/em\u003e; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;26). For instance, a therapist (T65) mentioned, \u0026ldquo;difficult to speak and breath for 50 minutes while wearing a mask\u0026rdquo;, and another therapist (T40) added, \u0026ldquo;crying for clients is really tough and awkward\u0026rdquo;.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTherapeutic relationship issues\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12; 10,91%) and \u003cb\u003etreatment related issues\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9; 8,18%) were less frequently observed categories. The first (\u003cb\u003etherapeutic relationship issues\u003c/b\u003e) mainly included references to therapists\u0026rsquo; and clients\u0026rsquo; feelings that connections remained at a surface level due to problems with interpreting the other (\u003cem\u003eloss\u003c/em\u003e; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7), and the disinhibition/anonymity effects of the masks and the intrapersonal challenges to connect (\u003cem\u003emasked disinhibition\u003c/em\u003e; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4). For instance, a therapist (T138) wrote that \u0026ldquo;it\u0026rsquo;s hard when you can\u0026rsquo;t connect because they {the clients} have a mask on their face\u0026rdquo;. Clients also expressed sentiments such as, \u0026ldquo;the sessions felt lackluster and shallow, lacking any real connection\u0026rdquo; (C36) or that \u0026ldquo;increased perceived distance increased mistrust towards therapist\u0026rdquo; (C65). The second (\u003cb\u003etreatment related issues\u003c/b\u003e) mostly included references to therapists and clients rating IPTFM negatively or clearly stating a preference for VT (\u003cem\u003emotivation to use face masks\u003c/em\u003e; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5). For example, a client (C26) stated that \u0026ldquo;virtual is better\u0026rdquo;, and another (C27) rated the IPTFM experience as \u0026ldquo;bad\u0026rdquo;. Similarly, two therapists rated IPTFM as \u0026ldquo;inconvenient\u0026rdquo; (T93) and \u0026ldquo;uneasy\u0026rdquo; (T72).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations for IPTFM\u003c/h2\u003e \u003cp\u003eThe most frequently mentioned recommendations for IPTFM were to \u003cb\u003enormalize the face masks use\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;17; 19,32%) and to \u003cb\u003etake care of the communication\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;17; 19,32%). The first (\u003cb\u003enormalize the face masks use\u003c/b\u003e) included references to discussing the pertinence of using face masks and its implications on the therapeutic process, as well as trusting the therapeutic process despite using face masks. For example, two therapists stated, \u0026ldquo;tell the client about the difficulties that may occur during the sessions and be open to communicate about that\u0026rdquo; (T47) and \u0026ldquo;address the discomfort of wearing masks and address the limitations that more frequent check-ins/clarifications are needed\u0026rdquo; (T68). Clients focused more on trusting the therapeutic process despite the use of face masks, as indicated by statements such as \u0026ldquo;the mask is not an issue, you\u0026rsquo;ll be able to express yourself the same way\u0026rdquo; (C50) or \u0026ldquo;go anyway {to therapy}\u0026rdquo; (C21) and \u0026ldquo;do it {IPTFM} without fear\u0026rdquo; (C48). The second (\u003cb\u003etake care of communication\u003c/b\u003e) included suggestions from therapists and clients to improve communication, such as \u0026ldquo;listen more carefully\u0026rdquo; (C33), \u0026ldquo;try to speak clearly\u0026rdquo; (C54), \u0026ldquo;pay more attention to voice and intonation, posture and gestures - yours and your client's\u0026rdquo; (T71), \u0026ldquo;when any information you consider relevant is missing, communicate it to the patient\u0026rdquo; (T11), and \u0026ldquo;ask patients to express feelings and emotions clearly\u0026rdquo; (T1).\u003c/p\u003e \u003cp\u003eThe second most frequently mentioned category was to \u003cb\u003euse alternatives to face masks\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;15; 17,5%). This category emerged inductively and included suggestions to remove face masks if possible while maintaining a safe distance, or if not possible, to remove them at least once during the process or use plexiglass/see-through masks. For instance, therapists wrote, \u0026ldquo;Don't {do it with masks}. There are other options, like plexiglass and distance\u0026rdquo; (T92) or \u0026ldquo;keep distance in the room but don't do it {the therapy} with mask\u0026rdquo; (T91). Clients also stated, \u0026ldquo;Look for a see-through/plastic mask\u0026rdquo; (C65) and \u0026ldquo;there's always the option of sitting further across each other to being able to take it off\u0026rdquo; (C44).\u003c/p\u003e \u003cp\u003eTo \u003cb\u003estrengthen the focus on therapeutic skills\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;14; 15,91%) and to \u003cb\u003etake care of the therapeutic relationship\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;14; 15,91%) were the third most frequently mentioned categories. The first (\u003cb\u003estrengthen the focus on therapeutic skills)\u003c/b\u003e included suggestions to improve therapists\u0026rsquo; therapeutic skills, such as \u0026ldquo;even if you are uncomfortable or uneasy don't make it obvious to the client\u0026rdquo; (T139), and \u0026ldquo;use more confirmations and validations of client\u0026rsquo;s emotions\u0026rdquo; (T19). The second (\u003cb\u003etake care of the therapeutic relationship\u003c/b\u003e) included suggestions to improve therapeutic rapport and bond, such as \u0026ldquo;show your face and see the client's face before starting the process. Count on a certain slowdown in the advancement of establishing the therapeutic relationship.\u0026rdquo; (T25), \u0026ldquo;introduce yourselves without the mask first, then put it on\u0026rdquo; (T35), \u0026ldquo;need to be more patient\u0026rdquo; (C38), and \u0026ldquo;do not use a mask to hide crying or laughing, because the eyes also express emotions and language\u0026rdquo; (C48)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eBenefits of VT\u003c/h2\u003e \u003cp\u003eThe most common category in VT\u0026rsquo;s benefits was \u003cb\u003eflexibility and accessibility\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;109; 66,06%), including mostly references to VT being convenient and comfortable due to greater flexibility in terms of time and location. This increased accessibility for clients and therapists, making it more time and cost efficient for them (\u003cem\u003econvenience; n\u003c/em\u003e\u0026thinsp;=\u0026thinsp;77). For instance, a therapist (T59) said that VT was \u0026ldquo;convenient as there is no need to travel\u0026rdquo;, and another (T22) added that it was good to \u0026ldquo;reach some clients who would have great difficulty to come in-person because of their work schedule\u0026rdquo;. Clients referred to convenience as well, for example, \u0026ldquo;timing was good and I did not need to travel or pay for travel\u0026rdquo; (C12), \u0026ldquo;more convenient since I did not need to leave the house\u0026rdquo; (C18), and \u0026ldquo;fit into my schedule better\u0026rdquo; (C24). This category (\u003cb\u003eflexibility and accessibility\u003c/b\u003e) also included some references to VT creating a safety climate and protecting the clients\u0026rsquo; and therapists\u0026rsquo; physical health allowing the continuity of mental care during the COVID-19 pandemic (\u003cem\u003econtinuity of care; n\u003c/em\u003e\u0026thinsp;=\u0026thinsp;25). As a therapist (T25) wrote, \u0026ldquo;not leaving people without support when it was not possible to provide another type of therapy at all\u0026rdquo;, and a client (C58) added, \u0026ldquo;the fact that my sessions were not disturbed because of the pandemic, I appreciated that\u0026rdquo;.\u003c/p\u003e \u003cp\u003e\u003cb\u003eEffectiveness or advantages for the therapeutic work\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;30; 18,18%) was the second most referred category in VT\u0026rsquo;s benefits. It included mostly references to therapists or clients comparing video therapy with in-person therapy and stating the effectiveness of video therapy (\u003cem\u003eas effective or nearly as effective as in-person therapy\u003c/em\u003e; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10), followed by video therapy providing additional information about the client\u0026rsquo;s home environment and behaviors outside the physical therapy room (\u003cem\u003enew information about clients\u003c/em\u003e; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6), the shift to video therapy allowing the development of new communication and therapeutic abilities (\u003cem\u003edevelopment of new abilities\u003c/em\u003e; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5), and the therapy environment being less formal, which facilitated some therapeutic tasks (\u003cem\u003eless intense therapy environment\u003c/em\u003e; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4). For example, with respect to the \u003cem\u003eas effective or nearly as effective as in-person therapy\u003c/em\u003e sub-category, a therapist (T16) stated that \u0026ldquo;it worked in the same way {as in-person}\u0026rdquo; and a client (C45) reported that VT \u0026ldquo;is very comfortable and the same as in-person\u0026rdquo;. Regarding the \u003cem\u003enew information about clients\u0026rsquo;\u003c/em\u003e sub-category, a therapist (T66) stated that VT gave a \u0026ldquo;close-up of face and emotions, often alongside other aspects of clients' life in the background\u0026rdquo;. Considering the \u003cem\u003edevelopment of new abilities\u003c/em\u003e, a therapist (T32) wrote that video therapy permitted to \u0026ldquo;learn and pay attention to details and micro gestures, {and a} greater clarification of information\u0026rdquo; and a client (C16) stated that \u0026ldquo;it felt educational on both sides\u0026rdquo;. Finally, regarding to the \u003cem\u003eless intense therapy environment\u003c/em\u003e sub-category, clients said that \u0026ldquo;sometimes it felt less tense\u0026rdquo; (C41) or \u0026ldquo;perhaps less formal feeling\u0026rdquo; (C62).\u003c/p\u003e \u003cp\u003eThe third most frequent category was \u003cb\u003eadvantages for the therapeutic relationship\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;20; 12,12%), including references to the client feeling less pressured in video therapy due to not entering the therapy room and less intense therapy environment (\u003cem\u003eclient feels less pressured\u003c/em\u003e; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8), the video therapy setting facilitating the client\u0026rsquo;s disclosure around topics that are difficult or \u0026ldquo;shameful\u0026rdquo; as the client feels less self-conscious (\u003cem\u003eeasier for the client to open-up more\u003c/em\u003e; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7), and the changes in the structure of the therapeutic relationship allowing the client\u0026rsquo;s empowerment and sense of control (\u003cem\u003eclient empowerment and greater sense of control\u003c/em\u003e; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6). For instance, regarding the \u003cem\u003eclient feels less pressured\u003c/em\u003e sub-category, two therapists stated that \u0026ldquo;clients often felt safer in their own apartments\u0026rdquo; (T47) or felt \u0026ldquo;less threatened\u0026rdquo; (T51) in VT. Clients agreed, saying that \u0026ldquo;at home I was more comfortable and didn't feel too much under a gaze\u0026rdquo; (C41) or \u0026ldquo;feeling more comfortable because of being in my room, somewhere familiar\u0026rdquo; (C42). Regarding the \u003cem\u003eeasier for the client to open-up more\u003c/em\u003e sub-category, a therapist (T63) said that \u0026ldquo;sometimes the patient dared to say something that he would have said with more difficulties face to face\u0026rdquo; (T63) and a client (C5) stated, \u0026ldquo;when I was too ashamed to say certain things, my therapist suggested to turn off my camera if it would help, which I did, and it made me feel more open to sharing what I needed to say\u0026rdquo;. Finally, with respect to \u003cem\u003eclient empowerment and greater sense of control\u003c/em\u003e, a therapist (T57) wrote that \u0026ldquo;the client is on his/her territory, which enhances stronger self-determinative acts of communication\u0026rdquo;, and another (T44) added that \u0026ldquo;the client feels calmer and more confident when he/she is at home, in familiar conditions\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eChallenges of VT\u003c/h2\u003e \u003cp\u003eThe most common category in VT\u0026rsquo;s challenges was \u003cb\u003etechnological issues\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;53; 29,61%) primarily involving references to technological interferences (e.g., problems with internet connection; platform and/or device; signal latency) which impacted the ability to provide or receive video sessions (\u003cem\u003etechnological issues impacting on the delivery of therapy; n\u003c/em\u003e\u0026thinsp;=\u0026thinsp;52). Therapists stated, for example, that \u0026ldquo;technical difficulties meant sometimes sessions had to stop and continue via telephone\u0026rdquo; (T54) or \u0026ldquo;technological glitches often disrupted the flow of sessions\u0026rdquo; (T112). Similarly, clients wrote that \u0026ldquo;sometimes bad connection causes issues and the session has to be postponed\u0026rdquo; (C40) or that \u0026ldquo;sometimes there were technical issues interrupting the session\u0026rdquo; (C55).\u003c/p\u003e \u003cp\u003eThe second most frequent category in VT\u0026rsquo;s challenges was \u003cb\u003ecommunication and perception issues\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;42; 23,46%) which included references mostly related to the lack of some non-verbal cues, including emotional cues, in the therapeutic interaction and/or misunderstandings due to the absence of these cues (\u003cem\u003elack of body language; n\u003c/em\u003e\u0026thinsp;=\u0026thinsp;26), followed by references related to lack of other sensory information and physical presence impeding a full picture of the client or therapist (\u003cem\u003edecrease of full-sensory perception; n\u003c/em\u003e\u0026thinsp;=\u0026thinsp;17). Regarding the \u003cem\u003elack of body language\u003c/em\u003e, for example, therapists stated: \u0026ldquo;not able to see client's whole body so miss out on some non-verbal cues\u0026rdquo; (T85) and \u0026ldquo;felt I missed a lot of non-verbal data such as if client's feet were shaking etc.\u0026rdquo; (T36); and clients wrote that it was \u0026ldquo;harder to express and understand emotions through body language\u0026rdquo; (C66) or that \u0026ldquo;body language not visible. {So} Relied on trust\u0026rdquo; (C31). With respect to the \u003cem\u003edecrease of full-sensory perception\u003c/em\u003e, therapists stated as negative points of VT \u0026ldquo;only having a visual image and not the whole sensory experience of being with another person in a room\u0026rdquo; (T59) or that \u0026ldquo;the \u0026lsquo;speaking bust\u0026rsquo; in the video format does not give any clue on physical condition like weight gain or loss and might lead to create an avatar of a non-authentic self-image\u0026rdquo; (T57). Similarly, a client (C4) said that in VT you \u0026ldquo;can\u0026rsquo;t \u0026lsquo;read the room\u0026rsquo; as well\u0026rdquo;.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTherapeutic relationship issues\u003c/b\u003e was the third most frequently referred category (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;33; 18,44%), followed by \u003cb\u003etreatment related issues\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;31; 17,32%). The first (\u003cb\u003etherapeutic relationship issues\u003c/b\u003e) included mostly references related with therapists or clients feeling emotionally distant and/or a superficial connection with therapist/client (\u003cem\u003etherapeutic relationship feels more distant and/or superficial\u003c/em\u003e; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;21). For example, therapists wrote that \u0026ldquo;it\u0026rsquo;s less deep than in-person\u0026rdquo; (T64) or that \u0026ldquo;there seemed to be less of a connection during the sessions\u0026rdquo; (T128). Also, clients agreed that in VT \u0026ldquo;the interaction felt not as personal\u0026rdquo; (C3) and \u0026ldquo;can\u0026rsquo;t feel any connection through a screen\u0026rdquo; (C30). The second (\u003cb\u003etreatment related issues\u003c/b\u003e) referred mainly to therapists and clients feeling that therapeutic work was more difficult due to lack of physical presence (\u003cem\u003etreatment more difficult\u003c/em\u003e; n\u0026thinsp;=\u0026thinsp;21). For instance, two therapists stated that \u0026ldquo;it gives more work, you need to pay a lot of attention, as it\u0026rsquo;s easy to get distracted\u0026rdquo; (T9), and that \u0026ldquo;several interventions and conversations in general are more complicated\u0026rdquo; (T33). Also, a client (C14) said that \u0026ldquo;it\u0026rsquo;s harder to concentrate\u0026rdquo; in VT.\u003c/p\u003e \u003cp\u003eThe least frequent category in VT\u0026rsquo;s challenges was \u003cb\u003ephysical and environmental issues\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;20; 11,17%) and included mostly references related to lack on presence and therapeutic space and/or control over this space, which are seen as conditions to enable the therapeutic process (\u003cem\u003elack of therapeutic space and physical presence\u003c/em\u003e; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10). This was followed by statements of negative physical symptoms associated with the video therapy setting (\u003cem\u003erapid fatigue and exhaustion\u003c/em\u003e; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6), and concerns about privacy, confidentiality, and security (\u003cem\u003eprivacy, confidentiality and security issues\u003c/em\u003e; n\u0026thinsp;=\u0026thinsp;4). For example, regarding the \u003cem\u003elack of therapeutic space and physical presence\u003c/em\u003e, therapists complained about the \u0026ldquo;lack of \u0026lsquo;presence\u0026rsquo;\u0026rdquo; (T34) and the \u0026ldquo;artificiality of the process\u0026rdquo; (T1), and a client (C47) stated that there was \u0026ldquo;no therapeutic space\u0026rdquo;. Regarding the \u003cem\u003erapid fatigue and exhaustion\u003c/em\u003e, therapists reported: \u0026ldquo;there seem to be some losses that lead to greater fatigue at work\u0026rdquo; (T28) and \u0026ldquo;more tiring at the end of the day\u0026rdquo; (T31). Considering the \u003cem\u003eprivacy, confidentiality and security issues\u003c/em\u003e, a client (C54) said, \u0026ldquo;roommates can potentially overhear the conversation\u0026rdquo;, and a therapist (T46) added \u0026ldquo;for me it was a bit off putting if a client was in bed half-dressed when we talked {and} of other family members hanging by. Sometimes they wanted to say hello, which I felt was a bit weird.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations for VT\u003c/h2\u003e \u003cp\u003eThe most referred recommendation for VT was to \u003cb\u003ecreate a therapeutic space\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;30; 19,74%). This category included references regarding recommendations to create a space at home to support privacy for clients and therapists when therapy conditions are unusual. For instance, therapists stated to \u0026ldquo;make sure you have a 100% safe and quiet space for work\u0026rdquo; (T46) and to \u0026ldquo;ask clients to be in a private room, where they feel comfortable to talk\u0026rdquo; (T35); and clients referred \u0026ldquo;to make sure they are in a comfortable place and that they can speak freely without worrying someone within their environment can hear them\u0026rdquo; (C20) and \u0026ldquo;remove all distractions, establish a safe private environment, turn off app notifications\u0026rdquo; (C66).\u003c/p\u003e \u003cp\u003eThe second most frequent category in VT\u0026rsquo;s recommendations emerged inductively and was to \u003cb\u003etrust the therapeutic process and normalize videoconference therapy\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;26; 17,11%). This category included suggestions to trust the therapeutic process despite it being in a video format and accept it and/or changes naturally, not as a challenge. For example, therapists wrote to \u0026ldquo;trust your ability to listen, trust the device and your and your clients\u0026rsquo; ability to adapt\u0026rdquo; (T8) and to \u0026ldquo;go forth, a person who could establish a genuine connection in-person, should be able to do so through any technology or channel\u0026rdquo; (T118).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTechnical communication enhancement\u003c/b\u003e was the third most referred category (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;24; 15,79%) and included mostly suggestions to making sure therapists and clients have a good internet connection. For instance, a client (C42) wrote \u0026ldquo;I would only advise to have stable internet connection\u0026rdquo;, and a therapist (T112) added to \u0026ldquo;be sure you and your patient have a fully functioning laptop and Wi-Fi or cellphone connection\u0026rdquo;.\u003c/p\u003e \u003cp\u003e\u003cb\u003eHuman communication enhancement\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;20; 13,16%) was the fourth most frequent category. For therapists, this category included mainly references to pay closer attention to facial expressions, voice tone and body gestures. For example, a therapist reported to \u0026ldquo;pay attention to all the nuances of emotional, body, facial, verbal behavior and even the surrounding environment\u0026rdquo; (T75). For clients, this category included mainly references to be open and honest with the therapist, and truthful with oneself. For example, a client wrote, \u0026ldquo;try and be open and honest as that is the best way to get help and build a relationship with the therapist\u0026rdquo; (C37).\u003c/p\u003e \u003cp\u003eThe next most referred categories were \u003cb\u003esession preparation\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;14; 9,21%) and \u003cb\u003ecomplement with in-person therapy\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;13; 8,55%). The first (\u003cb\u003esession preparation\u003c/b\u003e) included recommendations to spend more time preparing to enhance video therapy's quality and effectiveness. The second (\u003cb\u003ecomplement with in-person therapy\u003c/b\u003e) referred to, if possible, complement the video therapy with in-person sessions to overcome challenges due to the video format. Regarding \u003cb\u003esession preparation\u003c/b\u003e, a client (C66) reported, for example, to \u0026ldquo;prepare 10\u0026ndash;15 min in advance\u0026rdquo;, and therapists stated, for example, to \u0026ldquo;train specifically for online work\u0026rdquo; (T43), and to \u0026ldquo;read up guidelines which are now available from most therapeutic practices/organizations\u0026rdquo; (T54). With respect to the \u003cb\u003ecomplement with in-person therapy\u003c/b\u003e category, a client (C65) said, for example, \u0026ldquo;I would recommend in-person therapy whenever possible\u0026rdquo;, and a therapist (T40) stated \u0026ldquo;Just don't make it the entire practice. Have a mix either within caseload or within client if possible\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSimilarities and Differences between therapists and clients\u003c/h2\u003e \u003cp\u003eRegarding IPTFM (see Fig.\u0026nbsp;1), \u003cb\u003ephysical presence as a condition to enable therapy\u003c/b\u003e was the most common benefits category for both groups (therapists \u0026ndash; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;46; 63,89%, clients \u0026ndash; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12; 46,15%). The second most common benefit for clients was \u003cb\u003erelational depth through disconnection\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8; 30,77%), while for therapists, it was \u003cb\u003eharmlessness and adaptation experience\u003c/b\u003e (n\u0026thinsp;=\u0026thinsp;14; 19,44%).\u003c/p\u003e \u003cp\u003e\u003cb\u003eCommunication and perception issues\u003c/b\u003e was the most common challenges category in IPTFM for both groups (therapists \u0026ndash; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;43; 52,44%, clients \u0026ndash; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;13; 46,43%), followed by \u003cb\u003ephysical and environmental issues\u003c/b\u003e (therapists \u0026ndash; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;23; 28,05%, clients \u0026ndash; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8; 28,57%).\u003c/p\u003e \u003cp\u003eThe most referred recommendation for IPTFM by clients was to \u003cb\u003enormalize the face masks use\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7; 36,84%), whereas for therapists, it was to \u003cb\u003etake care of the communication\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;15; 21,74%). The second most referred recommendation for clients was to \u003cb\u003euse alternatives to face masks\u003c/b\u003e (n\u0026thinsp;=\u0026thinsp;3; 15,79%), whereas for therapists, it was to \u003cb\u003estrengthen the focus on therapeutic skills\u003c/b\u003e \u003cem\u003e(n\u003c/em\u003e\u0026thinsp;=\u0026thinsp;14; 20,29%).\u003c/p\u003e \u003cp\u003eRegarding VT (see Fig.\u0026nbsp;2), \u003cb\u003eflexibility and accessibility\u003c/b\u003e was the most common benefits category for both groups (therapists \u0026ndash; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;68; 68,69%, clients \u0026ndash; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40; 61,54%), followed by \u003cb\u003eeffectiveness/advantages for the therapeutic work\u003c/b\u003e (therapists \u0026ndash; n\u0026thinsp;=\u0026thinsp;16; 16,16%, clients \u0026ndash; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;14; 21,54%).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTherapeutic relationship issues\u003c/b\u003e was the most common challenges category for clients in VT (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;19; 32,2%), followed by \u003cb\u003etechnological issues\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;18; 30,51%), whereas for therapists, it was \u003cb\u003etechnological issues\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;35; 29,41%), followed by \u003cb\u003ecommunication and perception issues\u003c/b\u003e \u003cem\u003e(n\u003c/em\u003e\u0026thinsp;=\u0026thinsp;32; 26,89%).\u003c/p\u003e \u003cp\u003eThe most common recommendation for VT by clients was to \u003cb\u003ecreate a therapeutic space\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;15; 29,41%), followed by to \u003cb\u003etrust the therapeutic process and normalize video therapy\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;13; 25,49%). For therapists, the most common recommendation was \u003cb\u003etechnical communication enhancement\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;17; 17%), followed by to \u003cb\u003ecreate a therapeutic space\u003c/b\u003e (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;15; 15%), and \u003cb\u003ehuman communication enhancement\u003c/b\u003e \u003cem\u003e(n\u003c/em\u003e\u0026thinsp;=\u0026thinsp;14; 14%).\u003c/p\u003e \u003cp\u003eThe Fisher-Freeman-Halton (FFH) tests showed that therapists and clients did not differ significantly regarding what they found positive about IPTFM (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.229) and VT (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.815), what they found negative about IPTFM \u003cem\u003e(p\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.213), and what they recommend for overcoming possible difficulties in VT (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.061). However, the FFH tests showed significant differences in the frequency of the VT\u0026rsquo;s challenges categories (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.011) across the two groups (i.e., therapists, clients) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The Adjusted Standardized Residuals (ASR) showed that clients contributed significantly more (ASR\u0026thinsp;=\u0026thinsp;3.3) to the \u003cb\u003etherapeutic relationship issues\u003c/b\u003e category than expected, while therapists contributed significantly less (ASR = -3.3) to this category.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eChallenges of VT categories\u0026rsquo; frequency counts and adjusted standardized residuals (ARS) by group (therapists or clients)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eGroup\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTherapists\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(Total N\u003c/b\u003e of references\u0026thinsp;=\u0026thinsp;\u003cb\u003e119)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eClients\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(Total N\u003c/b\u003e of references\u0026thinsp;=\u0026thinsp;\u003cb\u003e59)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChallenges of VT categories\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e \u003cb\u003eof references\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eASR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e \u003cb\u003eof references\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eASR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTechnological issues\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0,15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunication and perception issues\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1,47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTherapeutic relationship issues\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-3,30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3,30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment related issues\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0,40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0,40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical or environmental issues\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1,83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFisher-Freeman-Halton Test (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.011)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMoreover, the FFH tests showed significant differences in the frequency of the IPTFM\u0026rsquo;s recommendations categories (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.008) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The ASR showed that clients contributed significantly more (ASR\u0026thinsp;=\u0026thinsp;2.19) to the \u003cb\u003enormalize the face masks\u0026rsquo; use\u003c/b\u003e category than expected, while therapists contributed significantly less (ASR = -2.19) to this category. The ASR showed as well that therapists contributed significantly more to the \u003cb\u003estrengthen the therapeutic skills\u003c/b\u003e category (ASR\u0026thinsp;=\u0026thinsp;2.19), whereas clients contributed significantly less (ASR = -2.19). It is important to note that this category was specifically designed for therapists. Therefore, it was expected that clients would not contribute to this category. Nonetheless, the descriptive statistics referred above indicated that therapists prioritized this category over others.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eResources of IPTFM categories\u0026rsquo; frequency counts and adjusted standardized residuals (ARS) by group (therapists or clients)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eGroup\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTherapists\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(Total N\u003c/b\u003e of references\u0026thinsp;=\u0026thinsp;\u003cb\u003e63)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eClients\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(Total N\u003c/b\u003e of references\u0026thinsp;\u003cb\u003e=\u0026thinsp;14)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResources of IPTFM categories\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e \u003cb\u003eof references\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eASR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e \u003cb\u003eof references\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eASR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNormalize the face masks\u0026rsquo; use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-2,19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2,19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTake care of communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1,10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse alternatives to face masks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0,16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0,16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStrengthen therapeutic skills\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-2,14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTake care of therapeutic relationship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0,72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0,72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFisher-Freeman-Halton Test (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.008)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored the perspectives of both therapists and clients regarding videoconference therapy (VT) and in-person therapy with face masks (IPTFM), aiming to uncover the challenges, benefits, and recommendations for these modalities.\u003c/p\u003e \u003cp\u003eOur findings regarding IPTFM resonate with existing research (Bani et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Erschens et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Mitzkovitz et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ribeiro et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), with both therapists and clients reinforcing that masks pose challenges related to the interpretation of non-verbal communication (\u003cem\u003ecommunication and perception issues\u003c/em\u003e) and physical discomfort (\u003cem\u003ephysical and environmental issues\u003c/em\u003e). Despite these challenges, both groups recognized the benefits of face masks in addressing safety concerns and enabling in-person therapy sessions (\u003cem\u003ephysical presence as a condition to enable therapy\u003c/em\u003e) (Ribeiro et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, there were some differences in the recommendations made by therapists and clients. Clients emphasized the importance of \u003cem\u003enormalizing the face masks\u0026rsquo; use\u003c/em\u003e, contributing significantly more for this recommendation than therapists did. The accommodation of masks appeared to meet a clients\u0026rsquo; need for normality, ensuring their trust in the therapeutic process and its continuity (Ribeiro et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). By advocating for the integration of masks (\u003cem\u003enormalizing the face masks\u0026rsquo; use\u003c/em\u003e), clients showed a willingness to accept and adapt to new circumstances. Nevertheless, their suggestion to \u003cem\u003euse alternatives to masks\u003c/em\u003e might indicate a desire to mitigate the physical and emotional barriers posed by face masks while maintaining a connection with the therapist. Conversely, even though therapists didn\u0026rsquo;t contribute significantly more for the \u003cem\u003etake care of communication\u003c/em\u003e recommendation than clients did, the findings highlighted that they placed a greater emphasis on this recommendation than on others. The focus on this recommendation (\u003cem\u003etake care of communication)\u003c/em\u003e as well as on \u003cem\u003estrengthening the focus on therapeutic skills\u003c/em\u003e suggests that therapists are motivated to adapt and refine their skills to meet clients\u0026rsquo; needs effectively (Hill, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Orlinsky \u0026amp; R\u0026oslash;nnestad, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; R\u0026oslash;nnestad \u0026amp; Skovholt, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). By improving communication strategies (e.g., listening more carefully, speaking clearly, paying greater attention to non-verbal cues) and enhancing therapeutic skills, therapists aim to maintain the quality of the therapeutic relationship and ensure clients feel understood and supported (Ackerman \u0026amp; Hilsenroth, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2003\u003c/span\u003e; Ribeiro et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe findings regarding VT highlight that both therapists and clients perceive \u003cem\u003eflexibility and accessibility\u003c/em\u003e as the primary benefits, followed by its \u003cem\u003eeffectiveness and advantages for therapeutic work.\u003c/em\u003e This recognition aligns with previous research (Asbrand et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Buckman et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Feijt et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Stoll et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Thomas et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), emphasizing that VT removes geographical barriers, allows clients to access therapy from the comfort of their homes, making it easier for clients to attend the sessions regularly and for therapists to manage their schedules efficiently. The perceived \u003cem\u003eeffectiveness\u003c/em\u003e of VT aligns with research on the therapeutic alliance and treatment outcomes in online therapy (Chakrabarti, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Simpson et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Thomas et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), indicating that core elements of effective therapy can be maintained through videoconferencing. However, \u003cem\u003etechnological issues\u003c/em\u003e, such as internet connection problems, stressed by both therapists and clients, can potentially undermine their willingness to adopt and continue using VT. Therefore, addressing this challenge (\u003cem\u003etechnological issues\u003c/em\u003e) is crucial for optimizing the use of videoconference psychotherapy as a viable alternative to traditional in-person therapy (Wootton et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Moreover, clients' perceptions of an increased emotional distance and superficial connection in VT (\u003cem\u003etherapeutic relationship issues\u003c/em\u003e) may reflect the limitations of the mediated environment, hindering rapport and trust development (Cataldo et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This finding suggests that the therapeutic relationship, as conceived by clients, might not yet be optimal in a videoconference setting (Cataldo et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Leuchtenberg et al., 2022).\u003c/p\u003e \u003cp\u003eRegarding the recommendations for VT, both therapists and clients emphasized the importance of \u003cem\u003ecreating a therapeutic space\u003c/em\u003e, reflecting a shared understanding of the significance of a dedicated space for therapy (Eichenberg et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). For therapists, ensuring clients have a suitable therapeutic space supports the overall therapy process and helps maintain the integrity of the therapeutic setting (Downing et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) as well as therapeutic boundaries (James et al., 2021). For clients, separating everyday-life space from the therapy space provides a sense of privacy and containment, essential for emotional safety and comfort to open up (Garc\u0026iacute;a et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough there were no significant differences between therapists and clients regarding VT\u0026rsquo;s recommendations, certain recommendations were prioritized over others, introducing distinctions worth considering. Clients' recommendation to \u003cem\u003etrust the therapeutic process and normalize video therapy\u003c/em\u003e indicates their need for reassurance and acceptance of this new modality. This aligns with the concept of therapeutic alliance and the need for clients to feel confident and committed to the therapy process (Bachelor, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2013\u003c/span\u003e), regardless of the medium. Normalizing video therapy can possibly increase engagement, essential for the therapeutic relationship and positive outcomes (Hill, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). On the other hand, therapists appeared committed to their role of facilitators of therapeutic change (Mar\u0026iacute;n-Medina et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), feeling responsible for improving the technological and communication conditions to prevent interference with the therapeutic process. \u003cem\u003eEnhancing technical communication\u003c/em\u003e ensures that sessions are smooth, clear, and free from disruptions that could detract from the therapeutic work (Wootton et al, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Moreover, \u003cem\u003eenhancing human communication\u003c/em\u003e, which involves adjusting verbal and non-verbal strategies to compensate for videoconferencing limitations, helps preserve the therapeutic alliance and ensures that clients feel understood and supported despite the lack of a physical therapeutic space (Downing et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Simpson et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn summary, the findings revealed a complementary dynamic between clients' and therapists' perspectives on adapting to new therapeutic environments. Clients appeared to prioritize normalizing and building trust in these environments, focusing on their comfort and ability to engage meaningfully in therapy. These efforts seemed directed at reducing emotional distress and maintaining their engagement, despite the changes. Therapists, in contrast, were primarily concerned with maintaining the quality and effectiveness of the therapeutic process by improving communication and refining their professional skills. Their actions focused on addressing the practical and technical challenges posed by the new therapeutic contexts. Together, these perspectives seem to reflect a shared goal of fostering a therapeutic environment that is both supportive and effective. While clients concentrated on overcoming barriers to their participation, therapists worked to address the structural and relational aspects necessary for successful therapy. This alignment, though distinct in focus, underscores the interdependence of their roles in co-creating a therapeutic process that meets the needs of both parties. Moreover, Clients\u0026rsquo; insights highlighted the importance of addressing emotional and relational factors, providing critical feedback on how therapeutic environments could better support their engagement and comfort. These findings emphasize the importance of enhancing therapists\u0026rsquo; training to develop skills that improve communication, foster trust, and create a sense of normalcy in both IPTFM and VT.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eImplications for practice\u003c/h2\u003e \u003cp\u003eRecognizing the differences in how clients and therapists perceive and cope with new therapeutic environments seems essential for developing effective interventions. By integrating both perspectives, this study facilitated the formulation of targeted recommendations that address the unique needs of each group, ultimately enhancing their therapeutic experiences. For therapists, it seems that ongoing professional development is crucial. This can be achieved, for example, through regular training focused on enhancing communication skills in virtual and masked settings, workshops on using videoconferencing tools effectively, troubleshooting technical issues, and ensuring data security.\u003c/p\u003e \u003cp\u003e On the other hand, to address clients\u0026rsquo; needs, therapists could emphasize open communication about any discomfort with virtual and masked formats as well as encourage clients to actively participate in sessions, ask questions, and express their feelings about the new format to build a sense of normalcy and control. Furthermore, the superficial connection encountered by clients in VT should be further addressed as well, by enhancing initial engagement (discussing expectations, concerns, and goals to build rapport from the beginning), improving communication strategies (active listening, summarizing, reflecting emotions to ensure clients feel heard and understood), fostering emotional connection (regular check-ins on client\u0026rsquo;s current emotional state; reinforce their feelings and experiences as important and valid), and implement regular feedback mechanisms.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and future studies\u003c/h2\u003e \u003cp\u003eThis study encountered several limitations that may have impacted the results and their generalizability. While we addressed differences and similarities between therapists and clients, it is important to note that the therapists and clients in this study were not matched dyads (i.e., therapists and clients from the same therapeutic relationship). As a result, while the findings highlight complementary perspectives between the two groups, the lack of dyadic data limits our ability to explore how therapists\u0026rsquo; and clients\u0026rsquo; views might align, diverge, or co-evolve in response to shared challenges in the same therapeutic process.\u003c/p\u003e \u003cp\u003eThe survey was conducted in Portuguese, Spanish, and English, potentially reducing linguistic diversity and representativeness. Additionally, retrospective evaluations may have introduced recall bias, as memories may not accurately reflect past events. Given that the survey was conducted toward the end of the pandemic, participants\u0026rsquo; adaptation to new therapeutic environments may have influenced their responses.\u003c/p\u003e \u003cp\u003eFuture research could benefit from recruiting therapist-client dyads to explore the interplay between their perspectives within a shared therapeutic context. Such an approach could offer richer and more nuanced insights into how therapists and clients negotiate, adapt to, and overcome the challenges associated with videoconference therapy (VT) and in-person therapy with face masks (IPTFM). Expanding linguistic diversity by translating surveys into multiple languages would improve inclusivity. To mitigate recall bias, longitudinal designs could track changes in perceptions and coping strategies over time. Furthermore, examining the long-term impact of VT and IPTFM on therapeutic outcomes and the therapeutic alliance would offer valuable insights into optimizing mental health care in evolving contexts.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis work was conducted at CIPsi, School of Psychology, University of Minho, supported by the Portuguese Foundation for Science and Technology (FCT; UID/01662: Centro de Investiga\u0026ccedil;\u0026atilde;o em Psicologia) through national funds.\u003c/p\u003e \u003cp\u003eThis work was also supported by the Portuguese Foundation for Science and Technology (FCT), under Grant 2021.05711.BD.\u003c/p\u003e \u003cp\u003e\u003cb\u003eCompliance with Ethical Standards\u003c/b\u003e: All procedures performed in studies involving human participants were in accordance with the ethical standards of the Ethics Committee for Research in Social and Human Sciences, Universidade do Minho (CEICSH 116/2021), and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.\u003c/p\u003e \u003cp\u003e \u003cb\u003eConflicts of Interest\u003c/b\u003e: The authors declare they have no conflict of interest.\u003c/p\u003e \u003cp\u003e\u003cb\u003eInformed Consent\u003c/b\u003e: Informed consent was obtained from all individual adult participants included in the study.\u003c/p\u003e\u003ch2\u003eData availability statement:\u003c/h2\u003e \u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAckerman SJ, Hilsenroth MJ (2003) A review of therapist characteristics and techniques positively impacting the therapeutic alliance. Clin Psychol Rev 23(1):1\u0026ndash;33. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0272-7358(02)00146-0\u003c/span\u003e\u003cspan address=\"10.1016/S0272-7358(02)00146-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsbrand J, Gerdes S, Breedvelt J, Guidi J, Hirsch C, Maercker A, Bockting C (2023) Clinical psychology and the COVID-19 pandemic: A mixed methods survey among members of the European Association of Clinical Psychology and Psychological Treatment (EACLIPT). 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Counselling Psychother Res 24(1):27\u0026ndash;38. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/capr.12610\u003c/span\u003e\u003cspan address=\"10.1002/capr.12610\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWootton AR, McCuistian C, Legnitto Packard DA, Gruber VA, Saberi P (2020) Overcoming technological challenges: Lessons learned from a telehealth counseling study. Telemedicine e-Health 26(10):1278\u0026ndash;1283. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/tmj.2019.0191\u003c/span\u003e\u003cspan address=\"10.1089/tmj.2019.0191\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[{"identity":"f4c14249-489b-43c8-b72e-ff14784ed611","identifier":"10.13039/501100001871","name":"Fundação para a Ciência e a Tecnologia","awardNumber":"2021.05711.BD","order_by":0}],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"CIPsi, School of Psychology, University of Minho (UID/01662)","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Videoconference psychotherapy, Psychotherapy with face masks, Challenges, Benefits, Recommendations, Therapists’ and clients’ perspectives","lastPublishedDoi":"10.21203/rs.3.rs-6098189/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6098189/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e As the world struggled with the COVID-19 pandemic, adopting preventive measures, such as wearing face masks and videoconferencing, became ubiquitous in various settings, including psychotherapy. Identifying challenges, benefits, and recommendations may support the effective delivery of psychotherapeutic care in similar conditions in the future. Recent literature has highlighted mostly therapists’ perspectives on those challenges, benefits, and recommendations. Since therapists and clients seem to differ on what they experience and value in therapy, understanding psychotherapeutic care from clients’ perspectives should also be considered. Thus, the present study aimed to understand therapists’ and clients’ perspectives on challenges, benefits, and recommendations for videoconference therapy and therapy using face masks and if there are differences regarding those perspectives.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We analyzed 738 responses to the open-ended questions of a larger online survey on the quality of relational processes in psychotherapy during the COVID-19 pandemic. The participants’ responses were collected worldwide between December 2022 and July 2023. A total of 117 therapists and 64 clients participated in the study. We conducted a deductive content analysis to examine trends in participants’ answers and Fisher-Freeman-Halton tests to determine differences between therapists and clients across categories.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The findings highlighted that while clients tended to focus on normalizing and trusting the new therapeutic environments, therapists were concerned with improving communication and refining their therapeutic skills to maintain the effectiveness of therapy under the new conditions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e This understanding enabled the formulation of targeted recommendations that address the unique needs of each group to enhance their therapeutic experiences.\u003c/p\u003e","manuscriptTitle":"Navigating psychotherapy in the COVID-19 Era: overcoming challenges, harnessing benefits, and practical recommendations","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-28 06:48:32","doi":"10.21203/rs.3.rs-6098189/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"49231f40-afea-4b30-bcc3-9e270fe06df8","owner":[],"postedDate":"February 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":44800169,"name":"Psychology"}],"tags":[],"updatedAt":"2025-02-28T06:48:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-28 06:48:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6098189","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6098189","identity":"rs-6098189","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}