Influence of COVID-19 infection prevention measures on face-to-face psychotherapy

Influence of COVID-19 infection prevention measures on face-to-face psychotherapy | 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 Influence of COVID-19 infection prevention measures on face-to-face psychotherapy Satoshi Ono, Hatuna Fukui, Sanae Aoki This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5317158/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 While knowledge of telepsychotherapy increased during the COVID-19 pandemic, little is known about face-to-face psychotherapy conducted under infection prevention measures. This study examined this model, assuming that infection prevention measures had the effect of increasing difficulties in face-to-face psychotherapy and psychologists' concerns, and that supportive devices were made to resolve these difficulties. An online survey of 471 Japanese psychologists was conducted.The results showed that an acrylic board separating client and therapist inhibited mutual information exchange and the maintenance of stable support. In addition, limiting the number of sessions, such as decreasing the time and frequency of support, caused the greatest variety of problems, including difficulty in communication and stability of support. When psychologists felt difficulties in stable support and communication difficulties in support, they were encouraged to clarify communication by overacting and confirming, both directly and through a sense of crisis in their identity as psychologists, to complement face-to-face psychotherapy stabilization. COVID-19 face-to-face༌ psychotherapy༌infection prevention structural analysis of covariance Figures Figure 1 Figure 2 1 Introduction The Coronavirus Disease2019 (COVID-19) pandemic has had a major impact on clinical psychological support in countries around the world. While face-to-face psychotherapy decreased, telepsychotherapy using online systems, telephone, and e-mail rapidly increased. Sammons, VandenBos, and Martin ( 2020 ) conducted a survey of psychologists in the United States in April 2020 during the early stages of the COVID-19 pandemic. They found that approximately 60% of psychologists reported a decrease in the number of patients served by face-to-face psychotherapy, while telepsychotherapy increased from 29% before the pandemic to 83% after the pandemic. A survey of psychologists in Italy during the same period showed that 42.1% of patients discontinued face-to-face psychotherapy, 68.1% of those who continued psychotherapy switched to telepsychotherapy, and 7.2% of those who continued face-to-face psychotherapy (Boldrini, Lomoriello Del Corno, Lingiardi, & Salcuni, 2020). Furthermore, in Austria, although the number of telepsychotherapy sessions increased compared to pre-pandemic levels, the number of patients receiving face-to-face psychotherapy decreased by 81% in the early weeks of lockdown, resulting in an overall decrease in the number of patients (Probst, Stippl, & Pieh, 2020 ). Compared to other countries, Japan was characterized by a higher retention rate of face-to-face psychotherapy even in the early stages of the pandemic. In Japan, emergency declarations in the spring of 2020 restricted non-essential activities. Due to this, approximately 80% of all psychologists changed in the structure of face-to-face psychotherapy, such as temporary suspension or reduction in the frequency and time of face-to-face psychotherapy (Nishi et al., 2021 ; Aoki, Ono, & Fukui, 2022 ). However, temporary suspensions of face-to-face psychotherapy were resumed within a short period of time, and sustained suspensions were uncommon (Aoki, Ono, & Fukui, 2022 ). In Japan, where retention of face-to-face psychotherapy is high, knowledge of the impact of the spread of COVID-19 infection on face-to-face psychotherapy is needed. However, although many studies have been published on the introduction of telepsychotherapy during a pandemic, there are few studies on face-to-face psychotherapy worldwide. In particular, in 2020, there were almost no studies that mentioned what specific infection prevention measures were taken to maintain face-to-face psychotherapy during the COVID-19 pandemic, what support difficulties were caused by these measures, and what measures were taken in clinical settings to deal with these difficulties. Aoki ( 2022 ) and Aoki, Ono, Fukui, and Kawashima ( 2022 ) are among the few studies that examined these issues. Aoki ( 2022 ) conducted an online interview survey of 42 clinical psychologists from August to October 2020. The survey asked what infection prevention measures were taken in face-to-face psychotherapy settings in the early stages of the pandemic, what difficulties these infection prevention measures caused for face-to-face psychotherapy, and what solutions were being taken to these difficulties. The data were analyzed by M-GTA (The Modified Grounded Theory Analysis). The results showed that the following six infection prevention measures were implemented in the face-to-face psychotherapy setting disinfection (disinfection of fingers, and doorknobs, chairs, desks in the counseling room, and items that clients may touch, such as psychological testing equipment and toys used in play therapy), wearing of droplet infection prevention equipment (masks, face shields, etc.), introduction of droplet infection prevention equipment between psychologists and clients in counseling rooms (shielding boards, plastic sheets, etc.), use of a 2-meter-long in-person counseling room, and use of a 2-meter-long in-person counseling room), maintaining an interpersonal distance of about 2 m, changing the layout of the room, including seating positions and angles, Constant ventilation by leaving the windows and doors of the counseling room open, and restricting contact by reducing the frequency and duration of support. When psychologists were asked about the obstacles these infection prevention measures caused to face-to-face psychotherapy, they reported difficulty in catching facial expressions due to the use of face masks and shielding boards, and difficulty in hearing the client's voice due to the constant ventilation and layout changes. The results indicated that infection prevention measures caused difficulties in understanding and communicating information and reduced the smoothness of conversations. Furthermore, the reduction of face-to-face psychotherapy may have made it difficult to maintain stable psychological support. Devices to solve these difficulties were reported, such as overreacting when presenting information to the client and using frequent confirmation. Based on the results of Aoki's (2022) interview survey, Aoki, Ono, Fukui, and Kawashima ( 2022 ) conducted an online survey of 318 clinical psychologists with the aim of quantitatively understanding the problems in face-to-face psychotherapy support caused by COVID-19 infection prevention measures and the psychologists' solutions to these problems. The results showed that six infection prevention measures similar to Aoki's (2022) were introduced, and that the impact of these measures resulted in verbal and nonverbal "difficulty in communication" such as difficulty in understanding the client's voice and facial expressions and difficulty in communicating one's own, "difficulties in stable support," as well as "conversation" where the client speaks only the minimum necessary amount. Difficulties in providing support were "poverty of conversation," "disagreement among staff" such as differences in support policies under the spread of COVID-19 infection, and "difficulties in maintaining stable psychological support. In addition, "concerns regarding communication," such as whether verbal and nonverbal information is being communicated well, "concerns regarding identity as a psychotherapist," such as whether they are fulfilling their role as a psychotherapist, and "concerns regarding infection" for the patients were also indicated as support concerns that psychotherapists have. Devising communication, verbalization, and strengthening cooperation among other professions were identified as solutions to these difficulties and concerns. The results of Aoki ( 2022 ) and Aoki, Ono, Fukui, and Kawashima ( 2022 ) indicated that various infection prevention measures may cause concerns in psychologists through difficulties such as reduced amount of information in the support relationship, difficulties in information transfer, and lack of stability in the support environment. It was also indicated that Devices may be made in the way of communication in support in order to dispel these difficulties and concerns. However, this model has not yet been quantitatively verified. Purpose of this study In May 2023, WHO declared COVID-19 to be an emergency declaration, and infection prevention measures such as wearing face masks in daily life became optional in Japan. However, infection prevention measures are still taken in many medical institutions and other face-to-face psychotherapy settings, and it is necessary to continue to examine the impact of infection prevention measures on face-to-face psychotherapy. Therefore, the purpose of this study was to examine a hypothetical model of the effect of infection prevention measures on face-to-face psychotherapy based on the findings of previous studies (Aoki, 2022 ; Aoki, Ono, Fukui, & Kawashima, 2022 ). The hypothetical model for this study, as assumed from previous studies, is shown in Fig. 1 . Since therapists reported difficulty catching client's facial expressions due to the use of face masks and shielding boards and hearing the client's voice due to the constant ventilation and layout changes (Aoki, 2022 ), face masks, shielding board, layout changes, and constant ventilation may promote "conversational poverty" and "communication difficulties". In addition, "reduction of face-to-face psychotherapy" may promote "difficulty in stable psychotherapy". "Poverty of conversation" and "difficulty in communication" may promote "devising communication" and "verbalization" mediated by "concerns regarding communication". "difficulty in stable psychotherapy" may promote "concerns regarding identity as a psychotherapist". Assuming this hypothetical model, this study quantitatively examines how infection prevention measures and the decrease in face-to-face psychotherapy affect difficulties, concerns, and devising face-to-face psychological support. 2 Methods 2.1 Participants The sample of this study is 471 psychotherapists (125 males, 346 females, M age =40.47 years, SD = 11.37). The occupational fields of the participants included 279 in medical and health, 125 in education, 109 in welfare, 39 in industry, 22 in university-related, 25 in justice and corrections, and 25 in private practice. The mean professional experience was 12.91 years ( SD = 9.95). This study was based on data from Aoki, Ono, Fukui, and Kawashima ( 2022 ) with 153 additional participants. 2.2 Procedure The study was conducted in the form of an online questionnaire using Google form from the end of December 2020 to May 2021. We asked clinical psychologists' associations, clinical psychology research groups, and other organizations that agreed to cooperate in recruiting study participants. In addition, we recruited study participants by snowball sampling via email with the survey outline, survey URL, and QR code. 2.3 Measures 2.3.1 Infection prevention measures on COVID-19 Participants completed 12 items regarding infection prevention measures on COVID-19 introduced for face-to-face psychotherapy (e.g., wearing face masks and face shields, using shielding boards such as acrylic board or plastic sheet, layout change such as maintaining an interpersonal distance of about 2 meters, constant ventilation of doors and windows). 2.3.2 Changes in the structures of psychotherapy Participants reported whether there were any changes in the structures of psychotherapy (e.g., form, location, frequency, and duration) and details of specific changes, associated with infection prevention measures on COVID-19. 2.3.3 Difficulties ( Aoki, Ono, Fukui, & Kawashima, 2022 ) Difficulties in face-to-face psychotherapy caused by infection prevention measures on COVID-19 consists of 17 items divided in four subscales (poverty of conversation, difficulty in communication, difficulty in stable psychotherapy, and disagreement among staff). Each item was asked on a five-point Likert scale ranging from 1‘not at all true’ to 5 ‘very true’. 2.3.4 Concerns ( Aoki, Ono, Fukui, & Kawashima, 2022 ) Concerns in face-to-face psychotherapy caused by infection prevention measures on COVID-19 consists of 13 items divided in three subscales (concerns regarding communication, concerns regarding identity as a psychotherapist, and concerns regarding infection). Each item was asked on a five-point Likert scale ranging from 1‘not at all true’ to 5 ‘very true’. 2.3.5 Devices ( Aoki, Ono, Fukui, & Kawashima, 2022 ) Devices in face-to-face psychotherapy caused by infection prevention measures on COVID-19 consists of 11 items divided in three subscales (devising communication, verbalization, and strengthening multidisciplinary cooperation). Each item was asked on a five-point Likert scale ranging from 1‘not at all true’ to 5 ‘very true’. 2.4 Ethical consideration This study was conducted with the approval of the Ethics Committee of the Graduate School of Human Sciences, University of Tsukuba (No.2020-147A). 2.5 Statistical analyses The statistical analysis software IBM SPSS Statistics26 and IBM SPSS Amos 26 were used in the analysis. 3 Results 3.1 Changes brought about in the clinical psychotherapy field by the spread of COVID-19 infection The infection prevention measures of COVID-19 introduced for face-to-face psychotherapy during the pandemic were: 469 (99.58%) used face masks, 133 (28.24%) used face shields, 255 (54.14%) used acrylic boards, 75 (15.92%) used plastic sheets, 241 (51.17%) kept an interpersonal distance at about 2 meters (51.17%), 135 (28.66%) changed the layout of the room, 216 (45.86%) changed the sitting position, 315 (66.88%) ventilated constantly, 297 (62.39%) ventilated only when changing clients, 99 (21.02%) installed air cleaners (21.02%), 439 (93.21%) had hand sanitizers, and 393 (83.44%) had disinfected doors and equipment. All participants had multiple infection prevention measures in place. The "changes in the structures of psychotherapy" were as follows. Regarding changes in the form of psychotherapy, 124 (26.05%) of the participants adopted online psychotherapy, 127 (26.68%) adopted telephone psychotherapy, and 289 (60.71%) did not make any changes. Regarding the change in the location of face-to-face psychotherapy, 141 (29.62%) of the participants changed to a room with a window, 132 (27.73%) to a larger room, and 277 (58.19%) to no change. Regarding changes in the frequency of psychotherapy, 31 (6.51%) interrupted psychotherapy, 156 (32.77%) temporarily stopped psychotherapy when an emergency situation was declared, 114 (23.59%) indicated that they decreased the frequency of psychotherapy, and 253 (53.15%) indicated no change. 90 (18.91%) indicated a reduction in psychotherapy time and 379 (79.62%) indicated no change. The means and standard deviations of the psychotherapy “difficulties”, “concerns”, and “devices” caused by infection prevention measures were calculated for each factor based on the results of factor analysis by Aoki, Ono, Fukui, and Kawashima ( 2022 ). The results are shown in Table 1 . Table 1 Mean and standard deviation of each factor Factors Mean SD A: Difficulties AF1: Poverty of conversation 9.73 4.51 AF2: Difficulties in communication 16.01 4.44 AF3: Difficulties in stable psychotherapy 13.58 4.71 AF4: Disagreement among staff 4.75 2.29 B: Concerns BF1: Concerns regarding communication 13.62 3.99 BF2: Concerns regarding identity as a psychotherapist 12.42 4.97 BF3: Concerns regarding infection 15.16 3.59 C: Devices CF1: Devising communication 18.26 4.45 CF2: Verbalization 12.37 3.78 CF3: Strengthening multidisciplinary cooperation 7.01 1.99 Insert Table 1 3.2 Impact of infection prevention measures on face-to-face psychotherapy A structural analysis of covariance was conducted to examine the effects of "infection prevention measures" and "changes in the structures of psychotherapy" on face-to-face psychotherapy. The following items were adopted as “infection prevention measures and changes in the structures of psychotherapy”. Of the 12 items related to infection prevention measures, "ventilation when changing clients," "setting air cleaners," "hand disinfection," and "disinfection of doors and equipment," which were not considered directly related to face-to-face psychotherapy, were deleted. A total of eight items were used in the analysis. Then, the eight items were further analyzed by organizing them into four categories: wearing face masks or other masks (hereinafter referred to as "face masks"), installation of shielding board between therapist and client such as acrylic boards (hereinafter referred to as "shielding board"), layout changes (total of three items: "keeping interpersonal distance at about 2 meters”, “changing room layout”, “changing sitting positions”), and constant ventilation. Among the items of "changes in the structure of psychotherapy," the following items were extracted that were considered to be related to face-to-face psychotherapy: "interruption of psychotherapy," "temporary suspension," "decrease in frequency of psychotherapy," and "reduction of psychotherapy time". The total of the four items was calculated as the item "reduction of face-to-face psychotherapy". For "difficulties," "concerns," and " devices" in psychotherapy, the factors in each were employed as variables. However, factors that were not considered to be directly related to face-to-face psychotherapy, i.e., "Disagreement among staff" (AF4), "Concerns regarding infection" (BF3), and "Strengthening multidisciplinary cooperation" (CF3), were excluded from the variables for analysis. When conducting the structural analysis of covariance, all paths were assumed and then those that were not significant at the 5% level were removed in order to indicate the possibility of effects other than those indicated in the hypothetical model. The results of the structural analysis of covariance are shown in Fig. 2 . The final model fit was good, χ2 (33) = 35.65 ( p = .10), TLI = .98, CFI = .99, and RMSEA = .03. Therefore, this model was adopted. The effects of "infection prevention measures" and "changes in the structures of psychotherapy" were as follows. Significant positive paths were found from "shielding boards" to "difficulty in communication" and "difficulty in stable psychotherapy" (in that order, β = .17, p < .001; β = .14, p < .001). There was a significant positive path from "Layout change" to "devising communication" ( β = .07, p < .05). There was a significant negative path from "constant ventilation" to "difficulty in stable psychotherapy" ( β =-.12, p < .001). Significant positive paths were found from "reduction of face-to-face psychotherapy" to "poverty of conversation," "difficulty in communication," and "difficulty in stable psychotherapy" ( β = .17, p < .001; β = .12, p < .01; β = .29, p < .001). The effects of "difficulties" were as follows. Significant positive paths were found from "difficulty in communication" to "concerns regarding identity as a psychotherapist," "devising communication," and "verbalization" (in that order, β = .16, p < .001; β = .17, p < .001; β = .23, p < .001). There was a significant positive path from "difficulty in communication" to "concerns regarding communication" ( β = .51, p < .001). Significant positive or negative paths were found from "difficulty in stable psychotherapy" to "concerns regarding communication," "concerns regarding identity as a psychotherapist," and "devising communication" (in that order, β = .22, p < .001; β = .27, p < .001; β = . -13, p < .01). The following were the influences of "concerns." Significant positive paths were found from "concerns regarding communication" to "devising communication" and "verbalization" ( β = .39, p < .001; β = .29, p < .001). Significant positive paths were also found from "concerns regarding identity as a psychotherapist" to "devising communication" and "verbalization" ( β = .12, p < .01; β = .13, p < .01). No significant paths were found from "face masks". Insert Fig. 2 4 Discussion The purpose of this study was to examine the impact of infection prevention measures taken during the COVID-19 outbreak on face-to-face psychotherapy. Although we developed the hypothetical model shown in Fig. 1 from previous studies, the results of this study (Fig. 2 ) differed from the hypothetical model in several ways. The most significant difference is the difference in the impact of specific infection prevention measures such as masks and the reduction of face-to-face support." We had assumed that facemasks, shielding boards, layout changes, and constant ventilation would have a significant impact on "poverty of conversation" and " difficulty in communication." However, in this study, no impact was found except for face shields. On the other hand, the reduction of face-to-face support was assumed to have only an effect on "difficulty in stable support" based on previous studies. However, contrary to our expectation, it affected a wider range of difficulties. Furthermore, the hypothesized model assumed a simple path from " reduction of face-to-face support" to "difficulty in stable support" and "concerns regarding identity as a psychotherapist." In reality, however, "difficulty in stable support" and "concerns regarding identity as a psychotherapist" were shown to have many effects on the concerns and devices. Other detailed results are discussed below. Difficulties in face-to-face psychotherapy due to COVID-19 infection prevention measures Among the measures taken to prevent infections during face-to-face psychotherapy the most diverse difficulties were caused by the "Reduction of face-to-face psychotherapy ". In other words, temporary suspension, reduction in frequency, and shortening of the duration of psychological support caused poverty of conversation, difficulties in communication, and difficulties in stable support. Based on these results, it is possible that the sudden unintended change in the treatment structure that accompanied the spread of COVID-19 infection caused difficulties and concerns in providing support from the supporters. It has conventionally been pointed out that maintaining a constant structure, such as support hours, in psychotherapy leads to ensuring the stability of support (Weiner, 1975 ), and it was again confirmed that, more than any other infection prevention measure, maintaining a constant support structure has an impact on the stability of support. In pandemic situations where face-to-face psychotherapy cannot be continued, it may be beneficial to continue support using alternatives to face-to-face psychotherapy, such as telepsychotherapy. Although a previous study (Aoki, 2022 ) suggested that wearing a face mask or face shield may affect the difficulty in reading facial expressions, no effect on face-to-face psychotherapy was observed in the present study. Various findings on the effects of wearing face masks on communication and support have been accumulated since the spread of COVID-19 infection, but the results are different. The negative effects of wearing face masks include the loss of information in the lower half of the face due to face masks, as facial expressions are the main non-verbal communication (Carbon, 2020 ; Gabrieli & Esposite, 2021), and the fact that psychological support provided while wearing a face mask is not effective in reducing the risk of psychological distress (Gabrieli & Esposite, 2021). psychological support provided while wearing a mask may interfere with the reading of nonverbal information, interpretation of emotions, and natural empathy (Clerici, Massimino, & Ferrari, 2020 ). On the other hand, findings indicating that face masks may reduce positive and negative perceptual biases (Marini et al., 2022 ) and that for many patients, face masks are not intrusive in psychotherapy and do not interfere with therapists' understanding of patients (Erschens et al, 2022 ), and findings regarding the impact of face masks on psychological support are not consistent. Such differences in findings may depend on cultural differences and the timing of the survey. It has been suggested that Japanese people are less resistant to wearing masks (Kito & Maeda, 2021 ), that because Japan is a collectivist culture that values harmony in relationships and tends to control emotional expression (Kito & Maeda, 2021 ), and that when interpreting the emotions of others, people focus more on the eyes, which are difficulties to control, than the mouth, which can be controlled spontaneously From these results (Yuki, Maddux, & Masuda, 2007 ), it can be inferred that for Japanese people, the inability to see the mouth may not be an obstacle in psychological support. Furthermore, since this study was conducted later than Aoki's (2022), at a time when communication wearing face masks was more common in daily life, it is possible that the wearing of masks and other infection-prevention equipment may have caused familiarity and had no effect on support. However, since this is not an area of speculation, further investigation is needed. On the other hand, the separation between psychologists and clients by acrylic panels or plastic sheets caused difficulties in obtaining and communicating information, and also affected difficulties in stable support. In Japanese clinical settings during the pandemic, acrylic plates and vinyl sheets were not used alone, but were often used in combination with face masks (Aoki, Ono, Fukui, & Kawashima, 2022 ). Previous studies have shown that in situations where people are doubly separated by a face mask and an acrylic sheet, it becomes difficulties in accurately hearing what is being said, and communication may be inhibited (Noda, Fukui, Matsumoto, Nakaishi, & Nakagawa, 2023 ). It has also been pointed out that the reflection of one's own face on the acrylic plate or vinyl sheet, as well as noise such as light reflection and distortion, contribute to the difficulty of seeing the other person's face (Aoki, 2022 ). Based on these findings, it is possible that difficulties in communication caused by the installation of acrylic panels may occur in a wide variety of modalities, including auditory and visual, but there are few previous studies on this subject, so further investigation is needed. In addition, changes in the layout, such as maintaining an interpersonal distance of about 2 m in the support setting, were linked to devising communication, not through support difficulties. It has been pointed out that in real-life conversations, speakers naturally adopt various strategies to optimize speech reception by listeners. For example, they devise vocalizations (Cooke, King, Garnier, & Aubanel, 2014 ; Lane & Tranel, 1971 ) and turn their heads toward the listener (Brimijoin, McShefferty, & Akeroyd, 2012 ; Grange & Culling, 2016 ). Hadley, Brimijoin, & Whitmer ( 2019 ) also noted that a distance of 1.5 m Devices such as leaning forward toward each other. Based on these findings, it is possible that in the situation of physical distance from the client under the spread of COVID-19 infection, the participants spontaneously made devising communication without psychological factors such as difficulties or concerns regarding communication. In the present study, keeping the window or door of the counseling room open at all times was shown to decrease difficulties in face-to-face psychotherapy, a result that differed from a previous study (Aoki, 2022 ). In Aoki's (2022) study, psychologists who worked mainly in urban areas responded that opening windows would interfere with conversation due to station broadcasts and car noise. Since this study was conducted not only in urban areas but also in the whole country, it is possible that the reduction of infection risk by ventilation was more reassuring to psychologists than the intrusion of outside noise by opening windows and doors. Effects of difficulties Caused by Infection Prevention Measures on psychologists' concerns and Devices for Support Devising communication" and "verbalization" were influenced by "poverty of conversation" directly or through "concerns regarding identity as a psychotherapist. Devising communication" such as voice inflection and activation of whole-body communication such as overreaction are used by psychologists when the content of conversation is simplified in support, such as when it is limited to the main points or problem-solving. In addition, it was shown that "checking" to confirm whether one's intentions are correctly conveyed to the client and whether one really understands the client's intentions, and "verbalization," in which one dares to clarify matters that had previously been inferred from facial expressions, etc., are encouraged. Furthermore, the poverty of conversation indirectly encouraged "devising communication" and "verbalization" through the identity crisis on the part of the psychologist, who wondered whether he/she was providing useful psychological support and whether he/she was fulfilling his/ her role as a psychologist. In addition, when psychologists felt difficulties in understanding clients, or felt difficulties in communicating their intentions and feelings to clients, concerns about whether or not communication was established led to "devising communication" and "verbalization" through mediation. A negative path from "difficulties in stable support" to "devising communication" was observed, while a positive path to "devising communication" was observed when mediated by "concerns regarding identity as a psychotherapist. In other words, while devising communication was suppressed in situations where stable psychological support was not maintained, devising communication and verbalization were promoted when concerns about not fulfilling one's role as a psychologist and psychologists' reflection on what their role as a psychologist is were intervened. Regarding the influence of interpersonal helpers' occupational identity on their supportive behavior, a finding in the nursing profession suggests that those with higher occupational identity perceive the situation positively in order to turn around the problem situation and promote supportive behavior toward the patient (Onodera, 2021 ). In light of this finding, it is possible that the external situation alone, in which stable psychological support cannot be maintained, may inhibit specific remedial actions, since it is not possible to determine what remedial actions are appropriate. However, when the psychologist's reflection on the situation stimulates professional identity, it may lead to incidental improvement behaviors such as increased efforts to communicate and to confirm the situation. The results of this study reveal the direction of influence in face-to-face psychotherapy support in the early stages of the COVID-19 pandemic, where the sudden introduction of infection prevention measures led to a sense of difficulties in support and concerns of the psychologists, and devices in support were made to deal with such situations. In particular, the result that the Reduction of face-to-face psychotherapy support structure promotes many problems and feelings of difficulties suggests the importance of continuing support even during a pandemic, for example, by introducing remote support. In addition, when face-to-face psychotherapy support is continued, body-worn infection prevention measures such as face masks are unlikely to have a negative impact on psychological support, but infection prevention measures that separate psychotherapists and clients with acrylic boards, etc. may reduce the quality of communication, and may also affect the stability of support. Furthermore, the results suggest that when psychologists feel difficulties in stable support or communication failures in support, they are prompted to take remedial actions in face-to-face psychotherapy support, sometimes directly and sometimes through a sense of crisis in their identity as psychotherapists. Limitations and Prospects of the Study This study is the result of a survey of psychologists and does not include the results of a survey of clients. Considering that psychological support is established by both psychologists and clients, it is necessary to conduct a survey on the other party, the client side, in the future to understand what problems both psychologists and clients felt about psychological support under the pandemic. 5 Conclusion This study examined the hypothetical model of difficulties and coping with face-to-face psychotherapy using infection prevention measures during the COVID-19 pandemic based on a previous study (Aoki, 2022 ). As a result, the hypothesis was partially supported, but some findings differed from the hypothesis. The results indicated that face masks did not cause any problems, but that the shielding boards separating clients and therapists interfered with communication and a sense of stability in psychological support. Specifically, therapists experienced a variety of difficulties in providing psychological support due to the reduced opportunities for face-to-face psychotherapy. These results suggested the importance of not stopping the flow of support by using alternative supports such as telepsychotherapy in situations where face-to-face support cannot be maintained. It also suggested that, in response to the problems posed by the numerous infection prevention measures, psychotherapists were attempting to ensure the stability of communication and support by increasing overactions and confirmations more than before. Since this study was conducted during the covid-19 pandemic, the current that the covid-19 pandemic has passed the nature of face-to-face psychotherapy may have changed. Future study should also examine whether the structure of face-to-face psychotherapy changed after the Covid-19 pandemic. Declarations Author Contribution Sanae Aoki wrote the main manuscript text. Haruna Fukui and Satoshi Ono added to it, and created Figures 1-2 and Table 1. All authors reviewed the manuscript. References Aoki, S. (2022). The influence of infection prevention measures on face-to-face psychological support in the early stages of the COVID-19 pandemic. Tsukuba Psychological Research , 60 , 55–64. Aoki, S., Ono, S., & Fukui, H. (2022). Clinical psychological support the COVID-19 pandemic: Comparison by region, support field, supported persons and supporters. Japanese Journal of Clinical Psychology , 22 (1), 110–120. Aoki, S., Ono, S., Fukui, H., & Kawashima, M. (2022). Difficulties caused by COVID-19 infection prevention measures and solutions in clinical psychological support. Japanese Journal of Psychology , 93 (4), 359–365. Boldrini, T., Schiano Lomoriello, A., Del Corno, F., Lingiardi, V., & Salcuni, S. (2020). Psychotherapy During COVID-19: How the Clinical Practice of Italian Psychotherapists Changed During the Pandemic. 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Psycho-Oncology , 29 (9), 1374–1376. https://doi.org/10.1002/pon.5418 Erschens, R., Adam, S. H., Weisshap, C., Giel, K. E., Wallis, H., Herrmann-Werner, A., Festl-Wietek, T., Mazurak, N., Zipfel, S., & Junne, F. (2022). The role of face masks within in-patient psychotherapy: Results of a survey among inpatients and healthcare professionals. Frontiers in Psychology , 16 , 1–10. https://doi.org/10.3389/fnins.2022.1030397 Gabrieli, G., & Esposito, G. (2021). Reduced perceived trustworthiness during face mask wearing. European Journal of Investigation in Health Psychology and Education , 11 (4), 1474–1484. https://doi.org/10.3390/ejihpe11040105 Grange, J. A., & Culling, J. F. (2016). The benefit of head orientation to speech intelligibility in noise. The Journal of the Acoustical Society of America , 139 (2), 703–712. https://doi.org/10.1121/1.4941655 Hadley, L. V., Brimijoin, W. O., & Whitmer, W. M. (2019). Speech, movement, and gaze behaviours during dyadic conversation in noise. Scientific reports , 9 (1), 10451. https://doi.org/10.1038/s41598-019-46416-0 Kito, M., & Maeda, Y. (2021). The effect of relational mobility on the early and late stages of the COVID-19 outbreak: Discussion from the socioecological perspective. Japanese Journal of Psychology , 92 (5), 473–481. https://doi.org/10.4992/jjpsy.92.20404 Lane, H., & Tranel, B. (1971). The Lombard sign and the role of hearing in speech. Journal of Speech and Hearing Research , 14 , 677–709. https://doi.org/10.1044/jshr.1404.677 Marini, M., Paglieri, F., Ansani, A., Caruana, F., & Viola, M. (2022). Facial impression of trustworthiness biases statement credibility unless suppressed by facemask. Current Psychology , 1–11. https://doi.org/10.1007/s12144-022-03277-7 Noda, T., Fukui, K., Matsumoto, N., Nakaishi, S., & Nakagawa, T. (2023). Quantifying hearing difficulty associated with COVID―19 infection control measures. Audiology Japan , 66 , 56–63. Nishi, M., Takahashi, Y., Ueda, Y., Nishioka, K., Urata, A., & Hoshino, S. (2021). The Impact of COVID-19 on Practice of Clinical Psychology: A questionnaire survey after the state of emergency. Japanese Journal of Psychotherapy , 47 (2), 178–183. Onodera, M. (2021). On the effect of professional identity on nurses’ caring behavior: Mediating roles of proactive behavior. Japanese Journal of Administrative Science , 32 (3), 73–89. https://doi.org/10.5651/jaas.32.73 Probst, T., Stippl, P., & Pieh, C. (2020). Changes in provision of psychotherapy in the early weeks of the COVID-19 lockdown in Austria. International Journal of Environmental Research and Public Health , 17 , 3815. https://doi.org/10.3390/ijerph17113815 Sammons, M. T., VandenBos, G. R., & Martin, J. N. (2020). Psychological Practice and the COVID-19 Crisis: A Rapid Response Survey. Journal of Health Service Psychology , 46 (2), 51–57. https://doi.org/10.1007/s42843-020-00013-2 Weiner, I. B. (1975). Principles of psychotherapy . Wiley. Yuki, M., Maddux, W. W., & Masuda, T. (2007). Are the windows to the soul the same in the East and West? Cultural differences in using the eyes and mouth as cues to recognize emotions in Japan and the United States. Journal of Experimental Social Psychology , 43 , 303311. https://doi.org/10.1016/j.jesp.2006.02.004 Additional Declarations No competing interests reported. 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-5317158","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":373853712,"identity":"9a29556c-b8ee-4221-a842-fce706fb040a","order_by":0,"name":"Satoshi Ono","email":"","orcid":"","institution":"Otsuma Women’s University","correspondingAuthor":false,"prefix":"","firstName":"Satoshi","middleName":"","lastName":"Ono","suffix":""},{"id":373853713,"identity":"92dc4c95-7b34-47e3-9a7a-ba6fe31b8da7","order_by":1,"name":"Hatuna Fukui","email":"","orcid":"","institution":"Rissho University","correspondingAuthor":false,"prefix":"","firstName":"Hatuna","middleName":"","lastName":"Fukui","suffix":""},{"id":373853714,"identity":"5934e7d2-ad46-4fe0-9e7c-cf1f84b1aa31","order_by":2,"name":"Sanae Aoki","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIie3QMUsDMRTA8XcE4nJwa7roV4gUWgTpZ8njoE52KYggtJnSRXDVRb/CScH5wUFvifttrXTtcJN0yOC13nipdRPJjxBCyB+SAATBn8SBvheMQMFuwH5mRyRcHZ80Ytkc/kEyM0jgBqNkdv9ZrdxklEDcW30YOOl7EmEXRJFJx8K+zx/R5OOOjvsSDbAL7WnKK02RZqjL6zmgJsyWm55QFpik9uJsl4Cb4styswblJphRfDiR5ZAIeI5ZGTNQnDXJrT85twtFaAp8tcMu1G/BJ81v6kR433JamG5VuTt8LvJ1tK0v9gDsrbOVl6nvx/ZUy55I5aGk1eD3SRAEwT/1BahfX7DUabXQAAAAAElFTkSuQmCC","orcid":"","institution":"Rissho University","correspondingAuthor":true,"prefix":"","firstName":"Sanae","middleName":"","lastName":"Aoki","suffix":""}],"badges":[],"createdAt":"2024-10-23 08:38:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5317158/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5317158/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":68415652,"identity":"d6ddc83e-426d-420a-828a-fb55ba08e4c3","added_by":"auto","created_at":"2024-11-07 05:01:12","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":366012,"visible":true,"origin":"","legend":"\u003cp\u003eThe hypothetical model for this study\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5317158/v1/2a6263b81a9bc8452fdf9520.jpeg"},{"id":68415653,"identity":"cf88baf0-6fd5-4e20-a5f0-40f33bba140c","added_by":"auto","created_at":"2024-11-07 05:01:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":60736,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eResults of covariance structure analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote. Error variables and covariance are omitted to avoid complication of the figure. Positive paths are indicated by solid lines and negative paths by dashed lines.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003cem\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e\u0026lt;.05, **\u003c/strong\u003e\u003cem\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e\u0026lt;.01, ***\u003c/strong\u003e\u003cem\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e\u0026lt;.001\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-5317158/v1/74f6eeec41391529cc1a3429.png"},{"id":68416256,"identity":"5b7ba201-749b-4c90-b6f6-2b187ea7a349","added_by":"auto","created_at":"2024-11-07 05:09:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1014500,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5317158/v1/4b9b02d0-b2d4-4688-aa7e-a1c2db22ada2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Influence of COVID-19 infection prevention measures on face-to-face psychotherapy","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eThe Coronavirus Disease2019 (COVID-19) pandemic has had a major impact on clinical psychological support in countries around the world. While face-to-face psychotherapy decreased, telepsychotherapy using online systems, telephone, and e-mail rapidly increased. Sammons, VandenBos, and Martin (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) conducted a survey of psychologists in the United States in April 2020 during the early stages of the COVID-19 pandemic. They found that approximately 60% of psychologists reported a decrease in the number of patients served by face-to-face psychotherapy, while telepsychotherapy increased from 29% before the pandemic to 83% after the pandemic. A survey of psychologists in Italy during the same period showed that 42.1% of patients discontinued face-to-face psychotherapy, 68.1% of those who continued psychotherapy switched to telepsychotherapy, and 7.2% of those who continued face-to-face psychotherapy (Boldrini, Lomoriello Del Corno, Lingiardi, \u0026amp; Salcuni, 2020).\u003c/p\u003e \u003cp\u003eFurthermore, in Austria, although the number of telepsychotherapy sessions increased compared to pre-pandemic levels, the number of patients receiving face-to-face psychotherapy decreased by 81% in the early weeks of lockdown, resulting in an overall decrease in the number of patients (Probst, Stippl, \u0026amp; Pieh, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCompared to other countries, Japan was characterized by a higher retention rate of face-to-face psychotherapy even in the early stages of the pandemic. In Japan, emergency declarations in the spring of 2020 restricted non-essential activities. Due to this, approximately 80% of all psychologists changed in the structure of face-to-face psychotherapy, such as temporary suspension or reduction in the frequency and time of face-to-face psychotherapy (Nishi et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Aoki, Ono, \u0026amp; Fukui, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). However, temporary suspensions of face-to-face psychotherapy were resumed within a short period of time, and sustained suspensions were uncommon (Aoki, Ono, \u0026amp; Fukui, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Japan, where retention of face-to-face psychotherapy is high, knowledge of the impact of the spread of COVID-19 infection on face-to-face psychotherapy is needed. However, although many studies have been published on the introduction of telepsychotherapy during a pandemic, there are few studies on face-to-face psychotherapy worldwide. In particular, in 2020, there were almost no studies that mentioned what specific infection prevention measures were taken to maintain face-to-face psychotherapy during the COVID-19 pandemic, what support difficulties were caused by these measures, and what measures were taken in clinical settings to deal with these difficulties. Aoki (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and Aoki, Ono, Fukui, and Kawashima (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) are among the few studies that examined these issues.\u003c/p\u003e \u003cp\u003eAoki (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) conducted an online interview survey of 42 clinical psychologists from August to October 2020. The survey asked what infection prevention measures were taken in face-to-face psychotherapy settings in the early stages of the pandemic, what difficulties these infection prevention measures caused for face-to-face psychotherapy, and what solutions were being taken to these difficulties. The data were analyzed by M-GTA (The Modified Grounded Theory Analysis). The results showed that the following six infection prevention measures were implemented in the face-to-face psychotherapy setting disinfection (disinfection of fingers, and doorknobs, chairs, desks in the counseling room, and items that clients may touch, such as psychological testing equipment and toys used in play therapy), wearing of droplet infection prevention equipment (masks, face shields, etc.), introduction of droplet infection prevention equipment between psychologists and clients in counseling rooms (shielding boards, plastic sheets, etc.), use of a 2-meter-long in-person counseling room, and use of a 2-meter-long in-person counseling room), maintaining an interpersonal distance of about 2 m, changing the layout of the room, including seating positions and angles, Constant ventilation by leaving the windows and doors of the counseling room open, and restricting contact by reducing the frequency and duration of support. When psychologists were asked about the obstacles these infection prevention measures caused to face-to-face psychotherapy, they reported difficulty in catching facial expressions due to the use of face masks and shielding boards, and difficulty in hearing the client's voice due to the constant ventilation and layout changes. The results indicated that infection prevention measures caused difficulties in understanding and communicating information and reduced the smoothness of conversations. Furthermore, the reduction of face-to-face psychotherapy may have made it difficult to maintain stable psychological support. Devices to solve these difficulties were reported, such as overreacting when presenting information to the client and using frequent confirmation.\u003c/p\u003e \u003cp\u003eBased on the results of Aoki's (2022) interview survey, Aoki, Ono, Fukui, and Kawashima (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) conducted an online survey of 318 clinical psychologists with the aim of quantitatively understanding the problems in face-to-face psychotherapy support caused by COVID-19 infection prevention measures and the psychologists' solutions to these problems. The results showed that six infection prevention measures similar to Aoki's (2022) were introduced, and that the impact of these measures resulted in verbal and nonverbal \"difficulty in communication\" such as difficulty in understanding the client's voice and facial expressions and difficulty in communicating one's own, \"difficulties in stable support,\" as well as \"conversation\" where the client speaks only the minimum necessary amount. Difficulties in providing support were \"poverty of conversation,\" \"disagreement among staff\" such as differences in support policies under the spread of COVID-19 infection, and \"difficulties in maintaining stable psychological support. In addition, \"concerns regarding communication,\" such as whether verbal and nonverbal information is being communicated well, \"concerns regarding identity as a psychotherapist,\" such as whether they are fulfilling their role as a psychotherapist, and \"concerns regarding infection\" for the patients were also indicated as support concerns that psychotherapists have. Devising communication, verbalization, and strengthening cooperation among other professions were identified as solutions to these difficulties and concerns.\u003c/p\u003e \u003cp\u003eThe results of Aoki (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and Aoki, Ono, Fukui, and Kawashima (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) indicated that various infection prevention measures may cause concerns in psychologists through difficulties such as reduced amount of information in the support relationship, difficulties in information transfer, and lack of stability in the support environment. It was also indicated that Devices may be made in the way of communication in support in order to dispel these difficulties and concerns. However, this model has not yet been quantitatively verified.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePurpose of this study\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn May 2023, WHO declared COVID-19 to be an emergency declaration, and infection prevention measures such as wearing face masks in daily life became optional in Japan. However, infection prevention measures are still taken in many medical institutions and other face-to-face psychotherapy settings, and it is necessary to continue to examine the impact of infection prevention measures on face-to-face psychotherapy. Therefore, the purpose of this study was to examine a hypothetical model of the effect of infection prevention measures on face-to-face psychotherapy based on the findings of previous studies (Aoki, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Aoki, Ono, Fukui, \u0026amp; Kawashima, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe hypothetical model for this study, as assumed from previous studies, is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Since therapists reported difficulty catching client's facial expressions due to the use of face masks and shielding boards and hearing the client's voice due to the constant ventilation and layout changes (Aoki, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), face masks, shielding board, layout changes, and constant ventilation may promote \"conversational poverty\" and \"communication difficulties\". In addition, \"reduction of face-to-face psychotherapy\" may promote \"difficulty in stable psychotherapy\". \"Poverty of conversation\" and \"difficulty in communication\" may promote \"devising communication\" and \"verbalization\" mediated by \"concerns regarding communication\". \"difficulty in stable psychotherapy\" may promote \"concerns regarding identity as a psychotherapist\". Assuming this hypothetical model, this study quantitatively examines how infection prevention measures and the decrease in face-to-face psychotherapy affect difficulties, concerns, and devising face-to-face psychological support.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"2 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Participants\u003c/h2\u003e \u003cp\u003eThe sample of this study is 471 psychotherapists (125 males, 346 females, \u003cem\u003eM\u003c/em\u003e\u003csub\u003eage\u003c/sub\u003e=40.47 years, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;11.37). The occupational fields of the participants included 279 in medical and health, 125 in education, 109 in welfare, 39 in industry, 22 in university-related, 25 in justice and corrections, and 25 in private practice. The mean professional experience was 12.91 years (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9.95). This study was based on data from Aoki, Ono, Fukui, and Kawashima (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) with 153 additional participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Procedure\u003c/h2\u003e \u003cp\u003eThe study was conducted in the form of an online questionnaire using Google form from the end of December 2020 to May 2021. We asked clinical psychologists' associations, clinical psychology research groups, and other organizations that agreed to cooperate in recruiting study participants. In addition, we recruited study participants by snowball sampling via email with the survey outline, survey URL, and QR code.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Measures\u003c/h2\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.3.1 Infection prevention measures on COVID-19\u003c/h2\u003e \u003cp\u003eParticipants completed 12 items regarding infection prevention measures on COVID-19 introduced for face-to-face psychotherapy (e.g., wearing face masks and face shields, using shielding boards such as acrylic board or plastic sheet, layout change such as maintaining an interpersonal distance of about 2 meters, constant ventilation of doors and windows).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.3.2 Changes in the structures of psychotherapy\u003c/h2\u003e \u003cp\u003e Participants reported whether there were any changes in the structures of psychotherapy (e.g., form, location, frequency, and duration) and details of specific changes, associated with infection prevention measures on COVID-19.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e\u003cb\u003e2.3.3 Difficulties (\u003c/b\u003eAoki, Ono, Fukui, \u0026amp; Kawashima, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eDifficulties in face-to-face psychotherapy caused by infection prevention measures on COVID-19 consists of 17 items divided in four subscales (poverty of conversation, difficulty in communication, difficulty in stable psychotherapy, and disagreement among staff). Each item was asked on a five-point Likert scale ranging from 1\u0026lsquo;not at all true\u0026rsquo; to 5 \u0026lsquo;very true\u0026rsquo;.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e\u003cb\u003e2.3.4 Concerns (\u003c/b\u003eAoki, Ono, Fukui, \u0026amp; Kawashima, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eConcerns in face-to-face psychotherapy caused by infection prevention measures on COVID-19 consists of 13 items divided in three subscales (concerns regarding communication, concerns regarding identity as a psychotherapist, and concerns regarding infection). Each item was asked on a five-point Likert scale ranging from 1\u0026lsquo;not at all true\u0026rsquo; to 5 \u0026lsquo;very true\u0026rsquo;.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e\u003cb\u003e2.3.5 Devices (\u003c/b\u003eAoki, Ono, Fukui, \u0026amp; Kawashima, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eDevices in face-to-face psychotherapy caused by infection prevention measures on COVID-19 consists of 11 items divided in three subscales (devising communication, verbalization, and strengthening multidisciplinary cooperation). Each item was asked on a five-point Likert scale ranging from 1\u0026lsquo;not at all true\u0026rsquo; to 5 \u0026lsquo;very true\u0026rsquo;.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Ethical consideration\u003c/h2\u003e \u003cp\u003e This study was conducted with the approval of the Ethics Committee of the Graduate School of Human Sciences, University of Tsukuba (No.2020-147A).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Statistical analyses\u003c/h2\u003e \u003cp\u003eThe statistical analysis software IBM SPSS Statistics26 and IBM SPSS Amos 26 were used in the analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Changes brought about in the clinical psychotherapy field by the spread of COVID-19 infection\u003c/h2\u003e \u003cp\u003eThe infection prevention measures of COVID-19 introduced for face-to-face psychotherapy during the pandemic were: 469 (99.58%) used face masks, 133 (28.24%) used face shields, 255 (54.14%) used acrylic boards, 75 (15.92%) used plastic sheets, 241 (51.17%) kept an interpersonal distance at about 2 meters (51.17%), 135 (28.66%) changed the layout of the room, 216 (45.86%) changed the sitting position, 315 (66.88%) ventilated constantly, 297 (62.39%) ventilated only when changing clients, 99 (21.02%) installed air cleaners (21.02%), 439 (93.21%) had hand sanitizers, and 393 (83.44%) had disinfected doors and equipment. All participants had multiple infection prevention measures in place.\u003c/p\u003e \u003cp\u003eThe \"changes in the structures of psychotherapy\" were as follows. Regarding changes in the form of psychotherapy, 124 (26.05%) of the participants adopted online psychotherapy, 127 (26.68%) adopted telephone psychotherapy, and 289 (60.71%) did not make any changes. Regarding the change in the location of face-to-face psychotherapy, 141 (29.62%) of the participants changed to a room with a window, 132 (27.73%) to a larger room, and 277 (58.19%) to no change. Regarding changes in the frequency of psychotherapy, 31 (6.51%) interrupted psychotherapy, 156 (32.77%) temporarily stopped psychotherapy when an emergency situation was declared, 114 (23.59%) indicated that they decreased the frequency of psychotherapy, and 253 (53.15%) indicated no change. 90 (18.91%) indicated a reduction in psychotherapy time and 379 (79.62%) indicated no change.\u003c/p\u003e \u003cp\u003eThe means and standard deviations of the psychotherapy \u0026ldquo;difficulties\u0026rdquo;, \u0026ldquo;concerns\u0026rdquo;, and \u0026ldquo;devices\u0026rdquo; caused by infection prevention measures were calculated for each factor based on the results of factor analysis by Aoki, Ono, Fukui, and Kawashima (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The results are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean and standard deviation of each factor\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eSD\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 \u003cp\u003eA: Difficulties\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAF1: Poverty of conversation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAF2: Difficulties in communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAF3: Difficulties in stable psychotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAF4: Disagreement among staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB: Concerns\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBF1: Concerns regarding communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBF2: Concerns regarding identity as a psychotherapist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBF3: Concerns regarding infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC: Devices\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCF1: Devising communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCF2: Verbalization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCF3: Strengthening multidisciplinary cooperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eInsert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Impact of infection prevention measures on face-to-face psychotherapy\u003c/h2\u003e \u003cp\u003eA structural analysis of covariance was conducted to examine the effects of \"infection prevention measures\" and \"changes in the structures of psychotherapy\" on face-to-face psychotherapy.\u003c/p\u003e \u003cp\u003eThe following items were adopted as \u0026ldquo;infection prevention measures and changes in the structures of psychotherapy\u0026rdquo;. Of the 12 items related to infection prevention measures, \"ventilation when changing clients,\" \"setting air cleaners,\" \"hand disinfection,\" and \"disinfection of doors and equipment,\" which were not considered directly related to face-to-face psychotherapy, were deleted. A total of eight items were used in the analysis. Then, the eight items were further analyzed by organizing them into four categories: wearing face masks or other masks (hereinafter referred to as \"face masks\"), installation of shielding board between therapist and client such as acrylic boards (hereinafter referred to as \"shielding board\"), layout changes (total of three items: \"keeping interpersonal distance at about 2 meters\u0026rdquo;, \u0026ldquo;changing room layout\u0026rdquo;, \u0026ldquo;changing sitting positions\u0026rdquo;), and constant ventilation.\u003c/p\u003e \u003cp\u003eAmong the items of \"changes in the structure of psychotherapy,\" the following items were extracted that were considered to be related to face-to-face psychotherapy: \"interruption of psychotherapy,\" \"temporary suspension,\" \"decrease in frequency of psychotherapy,\" and \"reduction of psychotherapy time\". The total of the four items was calculated as the item \"reduction of face-to-face psychotherapy\".\u003c/p\u003e \u003cp\u003eFor \"difficulties,\" \"concerns,\" and \" devices\" in psychotherapy, the factors in each were employed as variables. However, factors that were not considered to be directly related to face-to-face psychotherapy, i.e., \"Disagreement among staff\" (AF4), \"Concerns regarding infection\" (BF3), and \"Strengthening multidisciplinary cooperation\" (CF3), were excluded from the variables for analysis.\u003c/p\u003e \u003cp\u003eWhen conducting the structural analysis of covariance, all paths were assumed and then those that were not significant at the 5% level were removed in order to indicate the possibility of effects other than those indicated in the hypothetical model. The results of the structural analysis of covariance are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The final model fit was good, \u003cem\u003eχ2\u003c/em\u003e(33)\u0026thinsp;=\u0026thinsp;35.65 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.10), TLI\u0026thinsp;=\u0026thinsp;.98, CFI\u0026thinsp;=\u0026thinsp;.99, and RMSEA\u0026thinsp;=\u0026thinsp;.03. Therefore, this model was adopted.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe effects of \"infection prevention measures\" and \"changes in the structures of psychotherapy\" were as follows. Significant positive paths were found from \"shielding boards\" to \"difficulty in communication\" and \"difficulty in stable psychotherapy\" (in that order, \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.17, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001; \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.14, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). There was a significant positive path from \"Layout change\" to \"devising communication\" (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.07, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05). There was a significant negative path from \"constant ventilation\" to \"difficulty in stable psychotherapy\" (\u003cem\u003eβ\u003c/em\u003e=-.12, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Significant positive paths were found from \"reduction of face-to-face psychotherapy\" to \"poverty of conversation,\" \"difficulty in communication,\" and \"difficulty in stable psychotherapy\" (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.17, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001; \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.12, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01; \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.29, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e \u003cp\u003eThe effects of \"difficulties\" were as follows. Significant positive paths were found from \"difficulty in communication\" to \"concerns regarding identity as a psychotherapist,\" \"devising communication,\" and \"verbalization\" (in that order, \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.16, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001; \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.17, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001; \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.23, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). There was a significant positive path from \"difficulty in communication\" to \"concerns regarding communication\" (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.51, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Significant positive or negative paths were found from \"difficulty in stable psychotherapy\" to \"concerns regarding communication,\" \"concerns regarding identity as a psychotherapist,\" and \"devising communication\" (in that order, \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.22, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001; \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.27, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001; \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;. -13, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01).\u003c/p\u003e \u003cp\u003eThe following were the influences of \"concerns.\" Significant positive paths were found from \"concerns regarding communication\" to \"devising communication\" and \"verbalization\" (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.39, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001; \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.29, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Significant positive paths were also found from \"concerns regarding identity as a psychotherapist\" to \"devising communication\" and \"verbalization\" (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.12, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01; \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.13, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01).\u003c/p\u003e \u003cp\u003eNo significant paths were found from \"face masks\".\u003c/p\u003e \u003cp\u003eInsert Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThe purpose of this study was to examine the impact of infection prevention measures taken during the COVID-19 outbreak on face-to-face psychotherapy. Although we developed the hypothetical model shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e from previous studies, the results of this study (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) differed from the hypothetical model in several ways. The most significant difference is the difference in the impact of specific infection prevention measures such as masks and the reduction of face-to-face support.\" We had assumed that facemasks, shielding boards, layout changes, and constant ventilation would have a significant impact on \"poverty of conversation\" and \" difficulty in communication.\" However, in this study, no impact was found except for face shields. On the other hand, the reduction of face-to-face support was assumed to have only an effect on \"difficulty in stable support\" based on previous studies. However, contrary to our expectation, it affected a wider range of difficulties. Furthermore, the hypothesized model assumed a simple path from \" reduction of face-to-face support\" to \"difficulty in stable support\" and \"concerns regarding identity as a psychotherapist.\" In reality, however, \"difficulty in stable support\" and \"concerns regarding identity as a psychotherapist\" were shown to have many effects on the concerns and devices. Other detailed results are discussed below.\u003c/p\u003e \u003cp\u003e \u003cb\u003eDifficulties in face-to-face psychotherapy due to COVID-19 infection prevention measures\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAmong the measures taken to prevent infections during face-to-face psychotherapy the most diverse difficulties were caused by the \"Reduction of face-to-face psychotherapy \". In other words, temporary suspension, reduction in frequency, and shortening of the duration of psychological support caused poverty of conversation, difficulties in communication, and difficulties in stable support. Based on these results, it is possible that the sudden unintended change in the treatment structure that accompanied the spread of COVID-19 infection caused difficulties and concerns in providing support from the supporters. It has conventionally been pointed out that maintaining a constant structure, such as support hours, in psychotherapy leads to ensuring the stability of support (Weiner, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e1975\u003c/span\u003e), and it was again confirmed that, more than any other infection prevention measure, maintaining a constant support structure has an impact on the stability of support. In pandemic situations where face-to-face psychotherapy cannot be continued, it may be beneficial to continue support using alternatives to face-to-face psychotherapy, such as telepsychotherapy. Although a previous study (Aoki, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) suggested that wearing a face mask or face shield may affect the difficulty in reading facial expressions, no effect on face-to-face psychotherapy was observed in the present study. Various findings on the effects of wearing face masks on communication and support have been accumulated since the spread of COVID-19 infection, but the results are different. The negative effects of wearing face masks include the loss of information in the lower half of the face due to face masks, as facial expressions are the main non-verbal communication (Carbon, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Gabrieli \u0026amp; Esposite, 2021), and the fact that psychological support provided while wearing a face mask is not effective in reducing the risk of psychological distress (Gabrieli \u0026amp; Esposite, 2021). psychological support provided while wearing a mask may interfere with the reading of nonverbal information, interpretation of emotions, and natural empathy (Clerici, Massimino, \u0026amp; Ferrari, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOn the other hand, findings indicating that face masks may reduce positive and negative perceptual biases (Marini et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and that for many patients, face masks are not intrusive in psychotherapy and do not interfere with therapists' understanding of patients (Erschens et al, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), and findings regarding the impact of face masks on psychological support are not consistent. Such differences in findings may depend on cultural differences and the timing of the survey. It has been suggested that Japanese people are less resistant to wearing masks (Kito \u0026amp; Maeda, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), that because Japan is a collectivist culture that values harmony in relationships and tends to control emotional expression (Kito \u0026amp; Maeda, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), and that when interpreting the emotions of others, people focus more on the eyes, which are difficulties to control, than the mouth, which can be controlled spontaneously From these results (Yuki, Maddux, \u0026amp; Masuda, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2007\u003c/span\u003e), it can be inferred that for Japanese people, the inability to see the mouth may not be an obstacle in psychological support. Furthermore, since this study was conducted later than Aoki's (2022), at a time when communication wearing face masks was more common in daily life, it is possible that the wearing of masks and other infection-prevention equipment may have caused familiarity and had no effect on support. However, since this is not an area of speculation, further investigation is needed.\u003c/p\u003e \u003cp\u003eOn the other hand, the separation between psychologists and clients by acrylic panels or plastic sheets caused difficulties in obtaining and communicating information, and also affected difficulties in stable support. In Japanese clinical settings during the pandemic, acrylic plates and vinyl sheets were not used alone, but were often used in combination with face masks (Aoki, Ono, Fukui, \u0026amp; Kawashima, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Previous studies have shown that in situations where people are doubly separated by a face mask and an acrylic sheet, it becomes difficulties in accurately hearing what is being said, and communication may be inhibited (Noda, Fukui, Matsumoto, Nakaishi, \u0026amp; Nakagawa, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). It has also been pointed out that the reflection of one's own face on the acrylic plate or vinyl sheet, as well as noise such as light reflection and distortion, contribute to the difficulty of seeing the other person's face (Aoki, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Based on these findings, it is possible that difficulties in communication caused by the installation of acrylic panels may occur in a wide variety of modalities, including auditory and visual, but there are few previous studies on this subject, so further investigation is needed.\u003c/p\u003e \u003cp\u003eIn addition, changes in the layout, such as maintaining an interpersonal distance of about 2 m in the support setting, were linked to devising communication, not through support difficulties. It has been pointed out that in real-life conversations, speakers naturally adopt various strategies to optimize speech reception by listeners. For example, they devise vocalizations (Cooke, King, Garnier, \u0026amp; Aubanel, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Lane \u0026amp; Tranel, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e1971\u003c/span\u003e) and turn their heads toward the listener (Brimijoin, McShefferty, \u0026amp; Akeroyd, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Grange \u0026amp; Culling, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Hadley, Brimijoin, \u0026amp; Whitmer (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) also noted that a distance of 1.5 m Devices such as leaning forward toward each other. Based on these findings, it is possible that in the situation of physical distance from the client under the spread of COVID-19 infection, the participants spontaneously made devising communication without psychological factors such as difficulties or concerns regarding communication.\u003c/p\u003e \u003cp\u003eIn the present study, keeping the window or door of the counseling room open at all times was shown to decrease difficulties in face-to-face psychotherapy, a result that differed from a previous study (Aoki, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In Aoki's (2022) study, psychologists who worked mainly in urban areas responded that opening windows would interfere with conversation due to station broadcasts and car noise. Since this study was conducted not only in urban areas but also in the whole country, it is possible that the reduction of infection risk by ventilation was more reassuring to psychologists than the intrusion of outside noise by opening windows and doors.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEffects of difficulties Caused by Infection Prevention Measures on psychologists' concerns and Devices for Support\u003c/b\u003e \u003c/p\u003e \u003cp\u003e Devising communication\" and \"verbalization\" were influenced by \"poverty of conversation\" directly or through \"concerns regarding identity as a psychotherapist. Devising communication\" such as voice inflection and activation of whole-body communication such as overreaction are used by psychologists when the content of conversation is simplified in support, such as when it is limited to the main points or problem-solving. In addition, it was shown that \"checking\" to confirm whether one's intentions are correctly conveyed to the client and whether one really understands the client's intentions, and \"verbalization,\" in which one dares to clarify matters that had previously been inferred from facial expressions, etc., are encouraged. Furthermore, the poverty of conversation indirectly encouraged \"devising communication\" and \"verbalization\" through the identity crisis on the part of the psychologist, who wondered whether he/she was providing useful psychological support and whether he/she was fulfilling his/ her role as a psychologist. In addition, when psychologists felt difficulties in understanding clients, or felt difficulties in communicating their intentions and feelings to clients, concerns about whether or not communication was established led to \"devising communication\" and \"verbalization\" through mediation.\u003c/p\u003e \u003cp\u003eA negative path from \"difficulties in stable support\" to \"devising communication\" was observed, while a positive path to \"devising communication\" was observed when mediated by \"concerns regarding identity as a psychotherapist. In other words, while devising communication was suppressed in situations where stable psychological support was not maintained, devising communication and verbalization were promoted when concerns about not fulfilling one's role as a psychologist and psychologists' reflection on what their role as a psychologist is were intervened. Regarding the influence of interpersonal helpers' occupational identity on their supportive behavior, a finding in the nursing profession suggests that those with higher occupational identity perceive the situation positively in order to turn around the problem situation and promote supportive behavior toward the patient (Onodera, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In light of this finding, it is possible that the external situation alone, in which stable psychological support cannot be maintained, may inhibit specific remedial actions, since it is not possible to determine what remedial actions are appropriate. However, when the psychologist's reflection on the situation stimulates professional identity, it may lead to incidental improvement behaviors such as increased efforts to communicate and to confirm the situation.\u003c/p\u003e \u003cp\u003eThe results of this study reveal the direction of influence in face-to-face psychotherapy support in the early stages of the COVID-19 pandemic, where the sudden introduction of infection prevention measures led to a sense of difficulties in support and concerns of the psychologists, and devices in support were made to deal with such situations. In particular, the result that the Reduction of face-to-face psychotherapy support structure promotes many problems and feelings of difficulties suggests the importance of continuing support even during a pandemic, for example, by introducing remote support. In addition, when face-to-face psychotherapy support is continued, body-worn infection prevention measures such as face masks are unlikely to have a negative impact on psychological support, but infection prevention measures that separate psychotherapists and clients with acrylic boards, etc. may reduce the quality of communication, and may also affect the stability of support. Furthermore, the results suggest that when psychologists feel difficulties in stable support or communication failures in support, they are prompted to take remedial actions in face-to-face psychotherapy support, sometimes directly and sometimes through a sense of crisis in their identity as psychotherapists.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations and Prospects of the Study\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study is the result of a survey of psychologists and does not include the results of a survey of clients. Considering that psychological support is established by both psychologists and clients, it is necessary to conduct a survey on the other party, the client side, in the future to understand what problems both psychologists and clients felt about psychological support under the pandemic.\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eThis study examined the hypothetical model of difficulties and coping with face-to-face psychotherapy using infection prevention measures during the COVID-19 pandemic based on a previous study (Aoki, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). As a result, the hypothesis was partially supported, but some findings differed from the hypothesis. The results indicated that face masks did not cause any problems, but that the shielding boards separating clients and therapists interfered with communication and a sense of stability in psychological support. Specifically, therapists experienced a variety of difficulties in providing psychological support due to the reduced opportunities for face-to-face psychotherapy. These results suggested the importance of not stopping the flow of support by using alternative supports such as telepsychotherapy in situations where face-to-face support cannot be maintained. It also suggested that, in response to the problems posed by the numerous infection prevention measures, psychotherapists were attempting to ensure the stability of communication and support by increasing overactions and confirmations more than before. Since this study was conducted during the covid-19 pandemic, the current that the covid-19 pandemic has passed the nature of face-to-face psychotherapy may have changed. Future study should also examine whether the structure of face-to-face psychotherapy changed after the Covid-19 pandemic.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSanae Aoki wrote the main manuscript text. Haruna Fukui and Satoshi Ono added to it, and created Figures 1-2 and Table 1. All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAoki, S. (2022). The influence of infection prevention measures on face-to-face psychological support in the early stages of the COVID-19 pandemic. \u003cem\u003eTsukuba Psychological Research\u003c/em\u003e, \u003cem\u003e60\u003c/em\u003e, 55\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAoki, S., Ono, S., \u0026amp; Fukui, H. (2022). 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Cultural differences in using the eyes and mouth as cues to recognize emotions in Japan and the United States. \u003cem\u003eJournal of Experimental Social Psychology\u003c/em\u003e, \u003cem\u003e43\u003c/em\u003e, 303311. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jesp.2006.02.004\u003c/span\u003e\u003cspan address=\"10.1016/j.jesp.2006.02.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","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":"COVID-19, face-to-face༌ psychotherapy༌infection prevention, structural analysis of covariance","lastPublishedDoi":"10.21203/rs.3.rs-5317158/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5317158/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWhile knowledge of telepsychotherapy increased during the COVID-19 pandemic, little is known about face-to-face psychotherapy conducted under infection prevention measures. This study examined this model, assuming that infection prevention measures had the effect of increasing difficulties in face-to-face psychotherapy and psychologists' concerns, and that supportive devices were made to resolve these difficulties. An online survey of 471 Japanese psychologists was conducted.The results showed that an acrylic board separating client and therapist inhibited mutual information exchange and the maintenance of stable support. In addition, limiting the number of sessions, such as decreasing the time and frequency of support, caused the greatest variety of problems, including difficulty in communication and stability of support. When psychologists felt difficulties in stable support and communication difficulties in support, they were encouraged to clarify communication by overacting and confirming, both directly and through a sense of crisis in their identity as psychologists, to complement face-to-face psychotherapy stabilization.\u003c/p\u003e","manuscriptTitle":"Influence of COVID-19 infection prevention measures on face-to-face psychotherapy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-07 05:01:07","doi":"10.21203/rs.3.rs-5317158/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":"04734ef8-503a-4883-b4e8-e48390b39d39","owner":[],"postedDate":"November 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-04T06:53:53+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-07 05:01:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5317158","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5317158","identity":"rs-5317158","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}