Kate Smaller dissertation

Institute for Clinical Social Work

Video Therapy: Attitudes among the Psychodynamic Community

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy

By Kate R. Smaller

Chicago, Illinois March 2020

Abstract

The purpose of this quantitative study was to examine attitudes towards video therapy among psychodynamic clinicians in private practice. An online survey was posted, primarily on professional listservs, resulting in a sample size of 148 participants (N=148).

The survey included a tool designed to measure attitudes towards video therapy (Video Therapy Attitudes Scale (VTAS)), which was adapted from the Online Counseling Attitude Scale (OCAS) by Rochlen, Beretvas & Zack (2004). Descriptive statistics were run on 25 independent variables, and statistical analyses were conducted to examine the relationship (if any) between attitudes towards video therapy (as measured by VTAS score) and all independent variables that met minimum subgroup sample size requirements. The two central null hypotheses were both rejected, for positive correlations (significant at the .01 level) were found between ‘attitudes towards video therapy’ and both ‘experience providing video therapy’ (r = .480) and ‘familiarity with research related to video therapy’ (r = .317). In other words, results showed that the more positive the attitude towards video therapy, the more years of experience one has in providing video therapy and the more familiar one is with research related to video therapy. Those findings (along with others) raised many questions for discussion and pointed to the need for much more research on this increasingly important topic.

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For Mark, Georgia, Samuel, Jessica, Benton and Evelyn

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It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change. ~ Charles Darwin

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Acknowledgements

I am grateful for the support of my dissertation chair, Dr. John Ridings, my committee members, and my readers. They have made this final chapter at The Institute for Clinical Social Work a pleasant and powerful learning experience. I am also grateful for my husband, Dr. Mark Smaller, whose personal support and enthusiasm for psychoanalysis kept urging me forward.

KRS

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Table of Contents

Page Abstract…………………………………………………………..…………………….. ii Acknowledgements………………………………………………………………......…. v List of Tables…………………………………………………………..……….......…... x List of Figures ………………………………………………………………..………... xi List of Abbreviations ……………………………………………………………….... xii Chapter I. Introduction …………………………………...…………………………….. 1 Statement of Purpose Significance for Clinical Social Work Statement of the Problem Stakeholder’s profit Research Questions and Hypotheses Theoretical and Operational Definitions Statement of Assumptions Epistemological Foundation Foregrounding

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Table of Contents—Continued

Chapter

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II. Literature Review ………………………………………………………..… 20 History and Background Information Psychoanalytic Theory Research Studies Deficiencies in the Literature Conclusion III. Methodology ………………………………………………………………. 41 Rationale for a Quantitative Design Rationale for a Survey Research Design Research Sample Research Plan or Process Data Collection Plan for Data Analysis Ethical Considerations Potential Benefits to Participants and Stakeholders Limitations and Delimitations The Role and Background of the Researcher Conclusion

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Table of Contents—Continued

Chapter

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IV. Results …………………………………………………………………… 67 Pilot Study Data Collection Data Management Reliability and Composite Scoring Statistical Analysis Findings Conclusion

V. Discussion ………………………...………………………………….……… 114 Interpretation of Findings Revisiting Assumptions from Chapter I Summary of Interpretation of Findings

VI. Implications and Recommendations ………………….…………...……..… 130 Implications for Practice Recommendations for Future Research Strengths and Limitations of the Study Research Reflections

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Table of Contents—Continued

Appendices

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A. List of Independent Variables…………………………………………....141 B. The Online Counseling Attitude Scale (OCAS) …………………….…..144 C. Video Therapy Attitude Scale (VTAS) ……….……………………….. 146 D. Survey ………………………………………..……………………….……149 E. Codebook …………………………………………………………..…….. 156 F. Recruiting Post and Direct Email………………………….……………..160 G. Subgroup Sample Sizes and Statistical Analysis Determinations …..... 162 H. Frequencies of Individual VTAS Item Responses…………………...… 165 I. Statistical Analyses Intended vs. Actually Conducted……………...… 169 References ………………………………………………………………........ 172

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List of Tables

Table

Page 1. Frequencies of Individual VTAS Items ……………………………...…….. 81 2. Descriptive Statistics of Additional Comments ……………………….…… 96 3. Pearson’s Correlation Findings ………………………………………........ 105 4. Independent-Sample T-Test Findings ………………………..………...…. 108 5. Interpretation of Mean Scores of VTAS Items ………………………....… 121

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List of Figures

Figure

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1. Survey Response Rates ……………………………………...…………………. 73 2. Frequencies of VTAS Scores …………………………………...…….………. 110

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List of Abbreviations

OCAS

Online Counseling Attitude Scale

VT

Video Therapy

VTAS

Video Therapy Attitude Scale

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Chapter I

Introduction Statement of Purpose The purpose of this quantitative survey research study was to identify variables that shape attitudes towards video therapy among clinicians in private practice with a psychodynamic orientation. For this study, ‘video therapy’ is being defined as psychotherapy that utilizes a synchronous, video-based application to conduct standard (45-minute) sessions between patients and clinicians in different physical locations.

Significance of the Study for Clinical Social Work This study is significant for clinical social work because it honors social work tradition and values, refines psychoanalytic theory, drives social work policy, and strengthens clinical social work practice.

Tradition and values.

The concept of the therapeutic frame was conceptualized differently in the foundations of psychoanalysis and social work. Freud conducted analysis on the couch with primarily middle-class Viennese women at an average of four hours per week (Fisher & Greenberg, 1985), while Jane Addams’ Hull House served over 2,000 people each week and tended to many needs beyond mental health (Elshtain, 2002). Today, the psychodynamic

2 literature seems to be evolving from a more rigid interpretation of the therapeutic frame to one with greater flexibility (Hernandez-Tubert, 2008). This represents a shift away from Freudian psychoanalytic tradition and towards a more inclusive, community-based social work tradition. Video therapy is one prominent example of how this is being done, especially by websites (e.g. TalkSpace, Betterhelp, etc.) that serve hundreds of thousands of people both nationally and internationally. By deepening the field’s knowledge of video therapy, this study therefore draws attention to the inherent and increasing value of social work history, tradition and principles.

Psychoanalytic theory.

The emergence of video therapy brings some long-standing questions regarding psychoanalytic theory to the forefront, and it raises questions about the place of video therapy in this field: What is psychoanalysis (Friedman, 2006; Blass, 2010; Berman, 2010; Migone, 2013)? Does video therapy still fall within its definition? What is transference, and what is countertransference (Freud, 1913; Racker, 1954)? Do these dynamics occur in an online relationship, and can they be effectively addressed? What is a holding environment (Winnicott, 1960; Modell, 1976)? Is it possible to create and maintain a virtual holding environment? These questions are all debatable, and nobody holds the authority to arrive at a final answer. However, by highlighting these questions and exploring some of the discourse around them, this study helps to refine psychoanalytic theory.

3 Policy.

This study also has significance for social work policy because legislation related to professional licensure and insurance coverage have struggled to keep up with the surge in technology. For instance, while there are a few exceptions, in general, clinicians must be licensed in their own state as well as every state in which a patient of theirs resides (Morland, Poizner, Williams, Masino & Thorp, 2015). This poses a challenge for an Illinois based therapist who wishes to do video therapy with a client living in New York.

Also, the requirements for licensure vary from state to state (Morland et al., 2015), so it can be a long, cumbersome, and expensive process for clinicians to complete each application individually.

Regarding insurance coverage, 32 states have parity laws that require insurance companies to cover ‘telehealth’1 to the same extent they would face-to-face services (“Telehealth Parity Laws,” 2016). Other states are working in that direction, but so far, video therapy is not covered by insurance as extensively as face-to-face therapy (“Telehealth Parity Laws,” 2016). Many clinicians and legislators believe telehealth services are not qualitatively equal to in-person services (“Telehealth Parity Laws,” 2016), which has generated heated debate. By looking at the research, examining those attitudes, and gaining a better understanding of what shapes attitudes, this study could pave the way for further legislative progress.

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Defined as “the use of technology to deliver health care, health information or health education at a distance” with three main types of services: “store and forward (also known as asynchronous conversation, real-time video (synchronous conversation), and remote patient monitoring” (“Telehealth Parity Laws,” 2016, p. 1).

4 Clinical practice.

Finally, this study has significance for social work clinical practice because individual clinicians are still adjusting to the surge in technology as well. Practice ‘by the book’ is based on the Freudian conceptualization of the frame and the traditional interpretation of Winnicott’s holding environment. And with so much of the literature focused on the obstacles that licensing laws and insurance coverage pose (Morland et al., 2015), it can be difficult to move beyond those deterrents. Research on the efficacy of video therapy or online treatment in general is encouraging (Mallen, Vogel, Rochlen & Day, 2005; Backhaus et al., 2012; Rees & MaClaine, 2015), but there has been very little research on online psychodynamic treatment (Backhaus et al. 2012, Russell, 2015; Machado et al., 2016). Additionally, there seems to be a critical atmosphere around non-traditional practices in the psychoanalytic community (Akhtar, 2011). Therefore, this study should contribute to the encouragement some clinicians may need to begin or continue providing video therapy in their own practices.

Statement of the Problem Societal problem.

Lack of access to mental health services is a serious problem in the United States, especially because of the crimes that are committed when more serious cases of mental illness are not addressed. As reported in the Congressional Research Service Report (Krouse & Richardson, 2015), the annual rate of mass public shootings in the United States has more than quadrupled since the 1970s. This report defines ‘mass public shooting’ (per the FBI) as, “A multiple homicide incident in which four or more victims

5 are murdered with firearms, within one event, and in one or more locations in close proximity” (Krouse & Richardson, 2015, p. 2). When the definition is broadened to include incidents where victims are injured and not necessarily killed, however, the numbers are even more staggering. By this broader definition, in 2015, for example, the United States had already seen 294 mass shootings by October 1 , just 274 days into the st

calendar year (Ingraham, 2015). That is an average of more than one mass shooting per day.

These tragedies have brought both gun control and mental health treatment to the national spotlight. Many believe better psychiatric intervention could prevent further violence (Metzl & MacLeish, 2015). And while these issues are at the center of debate, the above statistics make at least one thing clear: Massive trauma is occurring every day.

So, whether mental health services are needed for the perpetrators of these crimes or for the victims and their families, there is most certainly a need.

Mass shootings may evoke a more affectively charged response from the public, but violence is everywhere. According to the Children’s Defense Fund (2017), each day in America, 1,854 children are confirmed abused or neglected, four children are killed by abuse or neglect, and eight children or teens are killed by guns. Each day in America, 37 children or teens are injured with a gun, 167 children or teens are arrested for violent crimes, and 589 public school students are corporally punished (Children’s Defense Fund, 2017).

Violence is also not the only problem. Each day in America, 1,759 babies are born into poverty, 2,857 high school students drop out, 311 children are arrested for drug crimes, and 7 children or teens commit suicide (Children’s Defense Fund, 2017). In other

6 words, the need for large-scale mental health services has always been there, and the recent surge in mass shootings is just grabbing the nation’s attention and calling for that much more.

The problem is, primary service institutions such as hospitals, schools and community agencies cannot keep up with demand. For example, in the 2012-2013 school year, the Chicago Public Schools enrolled a total of 404,151 students, including over 15,000 homeless students, while only employing 370 school social workers (Chicago Teachers’ Union, 2012). That is approximately 1,092 students (including 40 homeless students) per social worker. In another example, from 2009 to 2012, budget restraints eliminated 4,500 psychiatric hospital beds, 10% of the nation’s total supply (Szabo, 2015). In 2012, the Treatment Advocacy Center reported there were 50,509 state psychiatric beds, or only 14 available beds per 100,000 people (Raphelson, 2017). There are simply not enough resources to go around, and as former representative Tim Murphy of Pennsylvania said, “We have replaced the hospital bed with the jail cell, the homeless shelter [with] the coffin” (Szabo, 2015). Not enough people are getting the help they need.

Meanwhile, there are many knowledgeable, skilled and experienced clinicians working either primarily or exclusively in private practice. This may be especially true of psychoanalysts or clinicians with a psychodynamic orientation (“Psychotherapy careers,” n.d.). Though the efficacy of psychodynamic treatment has been well shown (Shedler, 2010), its methods do not lend themselves as readily to replication and testing (Adams, Matto & LeCroy, 2009). Local institutions and community agencies have grown more centered on evidence-based practice (EBP), cognitive-behavioral treatment (CBT), and structured, time-limited interventions (Adams et al., 2009). This creates a push-factor for

7 psychodynamic clinicians to enter private practice, rendering them valuable resources who are less connected to the public.

Private psychodynamic clinicians are certainly still available, but their accessibility is another matter. Time, fee, and location are three common access barriers, as private psychodynamic treatment is typically longer, more expensive, and more remote than treatment in local agencies and institutions. In a survey of members of the American Psychoanalytic Association (2011), the most common fees for psychotherapy and psychoanalysis were reported to be $142 and $173 per session respectively. The membership also reported that 71% of their adult patients in analysis and 51% of their adult patients in psychodynamic therapy were entirely private pay, and roughly 85% of their adult patients in both psychoanalysis and psychotherapy were white/European American (American Psychoanalytic Association, 2011). Serving such an elite segment of the population leaves psychodynamic clinicians inaccessible to most Americans.

Access to mental health services is a large issue that will ultimately require more macro-level change, but individual clinicians in private practice can still contribute to a solution. Conducting video therapy is a primary strategy to increase mental health care access for many different groups of people: 1. those living in geographically remote areas where the choice in provider may be limited at best, 2. families who struggle to afford childcare or transportation, 3. those who are sick, injured, or with other physical limitations that make traveling to a therapist’s office difficult if not impossible,

8 4. those who are moving (e.g. adolescents leaving for college) who begin therapy in person and do not want to start over with someone new in the midst of a major transition, 5. those who move frequently (e.g. military families) who otherwise could not engage in long-term therapy, 6. those with major depression or severe anxiety disorders (e.g. agoraphobia) who may need professional help just getting out the door, 7. those who travel frequently and could otherwise not maintain continuity in their treatment process, or 8. those with busy schedules who can make time for therapy by eliminating the commute to a therapist’s office.

This list is not exhaustive, but it demonstrates a significant need, and it also demonstrates the significant impact that individual clinicians can have on access barriers right away.

Clinical problem.

Despite the need for greater access to mental health services, and despite individual clinicians’ ability to provide it, many are still reluctant to do so. There are concerns about the efficacy of online treatment (“Telehealth Parity Laws,” 2016), but the literature largely shows it to be just as effective when compared to face-to-face treatment or waiting list control groups (Backhaus et al., 2012; Rochlen, Zack & Speyer, 2004; Lange et al., 2003). State licensing laws and insurance coverage issues present deterrents, but those can also be navigated. Despite whatever evidence to the contrary, many clinicians still have a negative attitude towards online therapy. Research has shown this is to be

9 especially true for clinicians with a psychodynamic orientation (Wangberg, Gammon & Spitznogle, 2007), and it suggests there may be something more to understand.

Akhtar (2011) provides a clue. He describes the atmosphere in which ‘unusual interventions’ or deviations from the analyst’s typical technique are shared: “Hush-hush tales of analysts making such exceptional interventions circulate in cocktail parties, are passed on from chest to chest in local psychoanalytic societies, and are imbued in mystery” (Akhtar, 2011, p. xvii). Akhtar’s book (2011) is not about video therapy, but it is about altering the frame, trying something new, and taking risks that lead to a successful treatment outcome. It does not necessarily provide insight into why this atmosphere exists, but it supports the idea that psychodynamic clinicians seem resistant to change. That kind of attitude is what the current study seeks to understand.

Research problem.

Literature pertaining to psychotherapy via the Internet did not emerge until the late 1990s. The earliest publications referred mostly to cognitive-behavioral or other types of behavioral therapy, and they included various combinations of e-mail, telephone, chat, and other Internet-based modalities. The focus of these articles was primarily on emerging trends, potential problems, and/or guidelines for clinicians (VandenBos & Williams, 2000; Castelnuovo, Gaggioli, Mantovani & Riva, 2003; Sampson, Kolodisnky, & Greeno, 1997).

Another major focus was on future projections, as several authors anticipated the dramatic increase in the use of technology to conduct psychotherapy and urged the field to prepare (Norcross & Prochaska, 2002; VandenBos & Williams, 2000; Alleman, 2002).

10 Some authors wrote with enthusiasm and support of this growing trend (Tait, 1999; Manhal-Baugus, 2001; Fenichel et al., 2001; Alleman, 2002), while some wrote with greater caution and more questions (Maheu & Gordon, 2000; Suler, 2001). Discussions of the advantages and disadvantages of these new technologies were also woven throughout (Childress & Asamen, 1998; Alleman, 2002; & Young, 2000).

In terms of empirical research, there are three questions that naturally emerge when looking at any individual study related to online therapy: 1) What type of treatment is being used (CBT, psychodynamic, etc.)? 2) What is the treatment modality (video, email, chat, etc.)? and 3) What does the study measure (efficacy, working alliance or attitudes)? And while there is significant overlap if attempting to group studies in this way, addressing these questions makes the gaps in the literature clear.

Type of treatment.

The type of treatment being studied is largely CBT, and only very few studies look at treatment rooted in psychodynamic principles (Backhaus et al., 2012; Machado et al., 2016). Those few studies are also either outdated (Kaplan, 1997) or they are looking at self-guided online treatment programs that do not involve contact with an actual therapist (Andersson et al., 2012; Johansson et al., 2012).

Treatment modality.

In terms of treatment modality, many studies look at various combinations of video, email, chat, phone, and self-guided online programs. However, given that video therapy is far more similar to traditional face-to-face treatment than these other modalities (Migone,

11 2013), there is a much smaller presence of research related to video therapy in the literature than is warranted. Also, there does not seem to be any empirical study that has both a psychodynamic intervention and a video modality.

Measure.

In terms of what is being measured, there are three distinct groups: Efficacy, working alliance, and attitudes.

Efficacy.

The majority of empirical studies measures the effectiveness of online therapy. And while efficacy can be measured in a variety of ways through a variety of instruments (Brief Symptom Inventory (BSI), GAF scores, etc.), they all tend to look for some type of symptom reduction. In general, the results are supportive of online interventions. E-mail, chat, video, and other web-based interventions are just as effective when compared to both face-to-face and waiting list control groups (Mallen et al., 2005; Backhaus et al., 2012; Rees & MaClaine, 2015).

Working alliance.

Another group of studies seeks to understand if a working alliance can be established and maintained online. Again, this can be measured in a variety of ways with a variety of instruments (Working Alliance Inventory (WAI), Session Evaluation Questionnaire (SEQ), etc.). Some examine working alliance from the clinician’s perspective (Sucala et al., 2013), while some look at the patient’s perspective (Cook & Doyle, 2002), and some

12 look at both (Reynolds et al., 2006). Some use an experimental design (Reynolds et al., 2006) and others use a survey design (Sucala et al., 2013; Cook & Doyle, 2002). In general, this body of research indicates that a strong working alliance is possible in online therapy (Cook & Doyle, 2002; Reynolds et al., 2006), with only a couple studies showing more mixed results. For example, Sucala et al. (2013) found that while clinicians viewed the importance of working alliance equally in face-to-face or online therapy, they were less confident in their skills to create working alliance. Also, Reynolds et al. (2006) found that while there was no significant difference between session impact for face-to-face or online therapy, therapists rated the depth, smoothness and positivity aspect of session impact higher in face-to-face therapy.

Attitudes.

The final group of studies looks at attitudes towards online therapy, and there are several distinct divisions. Some seek to better understand the attitudes of patients (Rochlen et al., 2004; Young 2005; King et al., 2006) while some seek to better understand the attitudes of clinicians (Rees & Stone, 2005; Gibson, Simms, O’Donnell, & Molyneaux., 2009). Of the studies that focus on the clinician’s perspective, most are looking specifically at attitudes towards the working alliance (Sucala et al., 2003; Reese & Stone, 2005; Mallen, 2005). A few studies look at clinicians’ attitudes towards online therapy more generally, and there is some evidence that professional background may have some influence over attitudes (Wangberg et al., 2007; Perle, Langsam, Randel, Lutchman, Levine, Odland, Nierenberg & Marker., 2013). Attempts to gain a deeper

13 understanding of attitudes and understanding anything about how those attitudes are formed are not represented in the literature.

Deficiencies in the literature.

Research related to online therapy includes many different types of treatment and several different treatment modalities. Cognitive-behavioral treatment is an overwhelming focus, and video therapy does not have as large of a focus as it may warrant. This is the first study to look at both a psychodynamic treatment focus and a video-based modality.

Attitudinal studies represent a small portion of the whole, and they are further divided into studies that focus on the attitudes of patients and studies that focus on the attitudes of clinicians. Research has shown that psychodynamic clinicians are reported to have more negative attitudes towards online therapy (Wangberg et al., 2007), but nothing has been done to understand why that is.

Therefore, this study is different and necessary because: 1. It is specific to psychodynamic treatment.

2. It is specific to video therapy.

3. It is the first study to include both psychodynamic treatment and video.

4. It will seek to dig deeper and gain some insight into what psychodynamic clinicians’ attitudes toward video therapy may be about.

14 Stakeholders’ Profit There are several groups of stakeholders that stand to benefit from this study: (a) potential patients who are currently not receiving mental health services due to any number of access barriers, (b) current patients who are involved in a treatment process but feel video therapy could improve logistics and make it easier to fully engage in the process, (c) clinicians who are building a practice and looking for ways to expand their patient base, (d) clinicians who are curious about video therapy and looking for ways to stay current, and (e) clinicians who are already providing video therapy and want to feel like the good work they do is better recognized. And finally, the general public also stands to benefit from a safer society in which more people have access to the mental health services they need.

Research Questions and Hypotheses The primary, overarching research question was: “What variables (if any) influence attitudes towards video therapy among clinicians in private practice with a psychodynamic orientation?” This study included many variables for exploration, but there were two central null hypotheses it sought to either confirm or reject: 1. There will be no statistically significant relationship between clinicians’ years of experience providing video therapy and attitudes towards video therapy.

2. There will be no statistically significant relationship between clinicians’ familiarity with research related to video therapy and attitudes towards video therapy.

15 In addition to the central null hypotheses, this study sought to address the following four research questions: 1. What is the frequency and variation of scores on the Video Therapy Attitude Scale (VTAS) for participants in the study?

2. What are the variables (i.e., demographic, professional, etc.) that positively correlate with attitudes towards video therapy?

3. What are the variables (i.e., demographic, professional, etc.) that negatively correlate with attitudes towards video therapy?

4. What are the variables (i.e. demographic, professional, etc.) that demonstrate a statistically significant difference between subgroups as they relate to VTAS scores?

Theoretical and Operational Definitions Attitude. For the purpose of this study, ‘attitude’ was defined as a way of thinking or feeling about the general use of video technology to conduct psychodynamic psychotherapy, whether it be by themselves or by another clinician.

Video therapy. For the purpose of this study, ‘video therapy’ was defined as psychotherapy that utilizes a synchronous, video-based application to conduct standard (45-minute) sessions between patients and clinicians in different physical locations.

Online therapy. For the purpose of this study, ‘online therapy’ was defined as any type of therapy (CBT, DBT, psychodynamic, etc.) that makes uses of any type of online technology (e-mail, chat, etc.) conducted by any type of licensed clinician.

16 Synchronous. For the purpose of this study, ‘synchronous’ online therapy was defined as any type of online therapy that enables patients and therapists to engage in simultaneous communication (i.e. video or chat) (Castelnuovo et al., 2003).

Asynchronous. For the purpose of this study, ‘asynchronous’ online therapy was defined as any type of online therapy where patients and therapists engage in timedelayed communication (i.e. email) (Castelnuovo et al., 2003).

Clinician. For the purpose of this study, ‘clinician’ was defined as a licensed psychologist, social worker, physician or counselor who is based in the United States, has a psychodynamic orientation, is currently in private practice, and who has been in private practice for at least five years.

Private practice. For the purpose of this study, ‘private practice’ was defined as a practice operated by a licensed psychologist, social worker or counselor who is not directly affiliated with any public agency. The definition includes clinicians who work either independently or within a group practice.

Psychodynamic orientation. For the purpose of this study, ‘psychodynamic orientation’ was defined as a self-reported general characterization of one’s practice as being grounded in psychoanalytic theory and practice traditions.

Statement of Assumptions There were several assumptions made in this study by the researcher: 1. The researcher assumed that clinicians hold a set of beliefs or principles that guide their way of conducting treatment.

17 2. The researcher assumed that clinicians know what video therapy is and have some mental representation of how it is conducted.

3. The researcher assumed that clinicians have a subjective way of thinking or feeling about video therapy.

4. The researcher assumed that one’s subjective way of thinking or feeling about video therapy can be described numerically through the use of a valid and reliable tool.

Epistemological Foundation This study was rooted in postpositivism. Postpositivism accepts that “absolute truth can never be found” (Creswell, 2014, p.7), but it maintains that an objective truth exists “out there” (Creswell, 2014, p. 7), and that reality can be observed and measured (Creswell, 2014). While some studies have gathered clinicians’ self-reported opinions of online therapy (Mallen, 2005; Wangberg et al. 2007; Gibson et al. 2009; Finn & Barak, 2010; Sucala, 2013, Perle et al, 2013), this study was not interested in gaining a better understanding of those subjectivities. Rather, it assumed there are objective, observable, measurable factors (which may even be outside of a clinician’s awareness) that shape attitudes towards video therapy, and it was more interested in identifying those factors. It was more interested in what clinicians may not be able to report themselves. Therefore, a quantitative approach that upholds the tenets of postpositivism was most appropriate.

18 Foregrounding The researcher (Kate R. Smaller) is a Licensed Clinical Social Worker (LCSW) with a psychodynamic orientation, and this dissertation served as the final requirement towards her doctoral degree at the Institute for Clinical Social Work (ICSW) in Chicago, Illinois.

She began a private practice in Chicago in 2011, and in the beginning, was only seeing patients face-to-face. In 2014, she moved her practice to Saugatuck, Michigan full-time.

She knew some colleagues who were providing video therapy and decided to offer it to her patients as a way of continuing treatment. Kate got licensed in Michigan, maintained her license in Illinois, and all but one patient chose to continue with her. Since then, she has made a few trips back to Chicago to see patients, and some have made trips to see her. Kate has built a substantial face-to-face practice in Michigan as well, and even some of those patients will have occasional video sessions if the weather is bad or they cannot get to her office for another reason. She now even has some new patients in Chicago who she has not yet met face-to-face. Overall, Kate has personally found video therapy to be very effective, and also meaningful and essential for her patients.

While providing video therapy has been a positive experience for Kate, she has found it to be a tense and difficult topic with some colleagues in psychoanalytic circles. There have been several times in casual conversation that she told someone she provides video therapy, and they responded with a harsh and automatic response. She has been told she “should not be doing it,” that it is “unethical” and “very problematic.” At first, her impulse was to question herself and her practice. After all, perhaps there was something she had overlooked. But when Kate looked at the research and reflected more deeply on her experience with video therapy, she felt confident and proud of the work she was able

19 to do with patients. There are certainly some differences and even limitations, but some of the differences actually enhance the treatment process. Kate’s patients have stuck with video therapy for years, and most importantly, they continue to make progress in their lives and achieve the changes they were seeking in coming to see her.

The more Kate is met with professional confrontations, the more she wonders about where these intense responses are coming from. Why are some so against video therapy?

There is not much research to support that feeling, so there must be something else to understand about it. The researcher knows other providers of video therapy have experienced similar encounters, and she can only imagine there are many others. Kate’s fear is that too many clinicians will take these reactions at face value, and they will shy away from providing video therapy. Her hope for this study was that it will provide a better understanding of these attitudes, and it will equip clinicians with a more informed way of thinking when making decisions about whether or not to provide video therapy in their own practices.

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Chapter II

Literature Review

To begin conducting this literature review, several major search engines were utilized, including Primary Search, Academic Search Complete, Google Scholar, PsychInfo, PsycARTICLES, and PEP. This process revealed some of the many different names given to what this study is calling ‘video therapy’, so the search continued using the following terms: ‘videoconferencing’ (Backhaus et al., 2012), ‘telepsychiatry’ (Backhaus et al., 2012), ‘telemedicine’ (Backhaus et al., 2012), ‘online counseling’ (Alleman, 2002), ‘online therapy’ (Suler, 2001; Rochlen et al., 2004), ‘Internet therapy’ (Rochlen et al., 2004), ‘e-therapy’ (Manhal-Baugus, 2001; Castelnuovo, 2003), ‘virtual therapy services’ (Norcross and Prochaska, 2002), ‘telehealth services’ (VandenBos & Williams, 2000), and ‘Clinical Video Teleconferencing’ (CVT) (Morland et al., 2005).

First, publications with titles that appeared relevant were pulled, the abstracts were reviewed, and articles were either saved or discarded based on actual relevance. For the saved articles, the reference sections were then reviewed, and all of those relevant publications were sought individually. This process continued until the authors and articles coming up had already been reviewed, and the search had therefore appeared to reach saturation. Each of the articles was then read and annotated more thoroughly.

Next, the collection was examined as a whole, and the information was grouped to create an outline. Once a draft of this chapter was complete, the search process was repeated to

21 account for any gaps as well as anything that may have been published during the process.

This search strategy yielded a significant amount of literature, and much of what came up was related to mental health services provided over the telephone. For the sake of focus, those articles were excluded. Otherwise, this review includes literature related to all types of treatment (i.e. CBT, DBT, etc.) and all other online treatment modalities (i.e. email, chat, self-guided programs, etc.).

This literature review contains five major components: (a) history and background information, (b) a presentation of the literature on psychodynamic theory as it relates to online therapy, (c) empirical studies, (d) summary of deficiencies in the literature, and 5) conclusion.

History and Background Information The Internet was created in 1969, but literature related to online therapy did not emerge until the late 1990s (Childress & Asamen, 1998). And at first, there was hardly more than a mention of its existence. Even as late as 1995, for example, the American Psychological Association (APA) released a statement saying, “The ethics code is not specific with regard to telephone therapy or teleconferencing or any electronically provided services as such and has no rules prohibiting such services� (Kingsley & Henning, 2015, p. 186).

In 1997, that began to change. The International Society for Mental Health Online (ISMHO) was formed to study and promote the understanding, use and development of online communication (Manhal-Baugus, 2001). At the time, it was estimated that 275

22 providers were offering services over the Internet (Sampson et al., 1997), and those services ranged from answering a single question via email for $15 to a 60-minute chat session for $65 (Sampson et al., 1997). However, many of those providers were not credentialed, and the percentage of credentialed mental health providers offering those services was still low (Sampson et al., 1997). A survey study with 596 licensed psychologists revealed that while treatment over the phone was “nearly universal” only 2% had used the Internet to provide treatment (VandenBos & Williams, 2000, p. 491).

Despite this slow start, there were some indicators that online therapy was here to stay. For one, organizations began issuing ethical guidelines on conducting online therapy: The American Counseling Association (ACA) in 1999, the American Mental Health Counselors Association (AMHCA) in 2000, and the National Board for Certified Counselors (NBCC) in 2001 (Alleman, 2002). Also, the ISMHO published an article “busting the myth” that online therapy referred exclusively to treatment via email and asserted that video and especially chat were beginning to make a stronger presence (Fenichel et al., 2002). Types of online therapy began to be distinguished as “synchronous” and “asynchronous” to describe real-time exchanges such as chat or video and delayed exchanges such as e-mail respectively (Castelnuovo, 2003). In other words, the language around online therapy was growing as well. And finally, in 2002, a Delphi poll comprised of 62 psychotherapy experts published the prediction that tech therapy services would be among the top aspects of the field to expand (Norcross & Prochaska, 2002).

Once online therapy had established a presence in the field, authors began anticipating the implications of this trend. They urged individual clinicians to get on board with

23 questions like, “Is your practice hurting because you aren’t involved in the ‘telehealth movement’?” (VandenBos & Williams, 2000, p. 490) and statements like, “The issue is most likely to become ‘how’, not ‘whether’” [to provide online therapy] (VandenBos & Williams, 2000, p. 492). They also urged the field to prepare by addressing licensing issues, education, standardization, and research (Alleman, 2002; Childress & Asamen, 1998; VandenBos & Williams, 2000).

The enthusiasm around the “telehealth movement” (VandenBos & Williams, 2000) stemmed from the many advantages that online therapy offered to patients. For one, it was far more affordable than traditional therapy (Manhal-Baugas, 2001). It also provided greater accessibility to mental health care for those living in remote areas (Morland et al., 2005). The convenience and anonymity that online therapy provided were seen as major advantages (Childress & Asamen, 1998; Manhal-Baugus, 2001), and some authors pointed out that patients were less inhibited online (which was always something traditional therapy tried to facilitate) (Alleman, 2002; Young, 2002; Rochlen et al., 2004).

There were also disadvantages to online therapy, and authors wrote about those as well: (a) questions about efficacy (Childress & Asamen, 1998), (b) questions about the strength of working alliance (Kingsley & Henning, 2015), (c) the limited ability to see and read nonverbal cues (Rochlen et al., 2004; Manhal-Baugus, 2001); (d) the limited ability to adequately manage crisis intervention from a distance (Kingley & Henning, 2015; Childress & Asamen, 1998; Alleman, 2002), (e) the limited ability to protect patients’ confidentiality (Kingley & Henning, 2015; Childress & Asamen, 1998; Sampson et al., 1997), (f) technology’s lack of dependability (Kingley & Henning, 2015),

24 (g) the ability of traditional therapy to compete (Alleman, 2002), and (h) the potential for unknown consequences (Manhal-Baugus, 2001).

Despite the disadvantages perceived by many clinicians, the “telehealth movement” (VandenBos & Williams, 2000), continued to grow. And while there were important notes of caution (Maheu & Gordon, 2000), suggestions offered for clinicians (Koocher & Murrary, 2000), and guidelines offered for assessing which patients were suitable for online therapy (Suler, 2001), it seemed the movement had taken on a life of its own.

Potential clients were going to continue to seek professional help online, and some believed there would even become an ethical obligation for trained and credentialed therapists to provide it. As Alleman (2002) stated: “Going forward, the greatest ethical risk we may face is that we will write rules or enforce local laws in such a way that competent, principled professionals are forced to exclude themselves from online availability” (Alleman, 2000, p. 204).

Today, the total number of clinicians providing online therapy and the number of patients receiving it is difficult to determine. There are now large, popular websites such as American Well, BetterHelp, Breakthrough, Lantern, 7 Cups of Tea, Talkspace and others that allow patients to easily connect with therapists online (Novotney, 2017). In 2015, TalkSpace reported having over 100,000 users and 200 licensed therapists across the United States (Novellino, 2015). More sites are emerging, and while there may be some overlap, the numbers do not even include clinicians who are providing online therapy through private practice. The trend is clearly onward, but research indicates a reluctance among clinicians - especially those with a psychodynamic orientation (Wangberg et al., 2004; Perle et al., 2013). If the psychodynamic community does not try

25 to better understand what the reluctance is about, there is significant risk of being left behind. This study will therefore seek to examine clinicians’ attitudes and contribute to the sustainability of the psychodynamic community.

Psychodynamic Theory The emergence of online therapy brings some questions related to psychoanalytic theory to the forefront: What is psychoanalysis? What are transference and countertransference? What is a holding environment? Do these things still exist and maintain their integrity in the context of online therapy? This section will address some of these questions, and it will demonstrate how challenging it may be to arrive at any definitive answers.

What is Psychoanalysis?

Migone (2013) states: “Online therapy is interesting because it forces us to reflect on what it is not; that is, traditional psychoanalysis” (Migone, 2013, p. 284). But what is psychoanalysis? Freud described it as “a method of research into the neuroses” (Freud, 1913). While Freud discussed the specifics of the psychoanalytic process in many different publications, he was also intentionally unrestrictive. He went on to say, “psycho-analysis… like every new product of science, is unfinished. It is up to anyone to convince himself by his own investigations of the correctness of the theses embodied in it, and to help in the further development of the study” (Freud, 1913). For some, this is unsettling. Blass (2010) is a proponent of working towards a clear definition, arguing that “the dissipating concern with grasping reality, including the reality of psychoanalysis, is

26 problematic” (Blass, 2010, p. 97). Others disagree. Berman (2010) reminded readers that “Winnicott (ibid., p. 89)… [warned] against ‘restricting our work to the study and application of psychoanalytic theory in the form in which it crystallized out at any one point in its history” (Berman, 2010, p. 91). It is hard to imagine this debate will ever be resolved, and as it stands, nobody holds the authority to place boundaries on psychoanalysis as a concept. So, while online therapy may raise questions about the definition of psychoanalysis, so far, it does not bring answers.

Even without a clear definition of psychoanalysis, professionals are entitled to examine and question online therapy. There are clear differences from traditional psychoanalysis (the most obvious being that the patient and analyst are physically separated), and it is fair to challenge the implications of that. But Migone (2013) proposed that perhaps “online therapy is simply a different therapy, in the same way as two therapies, both offline (or both online), may be different from one another” (Migone, 2013, p. 281). No two therapies are the same, and who is to say that one difference (i.e. physical separation) is more significant than any other? Migone (2013) argued that no therapy (not even the classical model) is superior, for treatment is more about the idiosyncratic ways in which each patient responds to the clinical situation: As a very simplistic example, if a patient had quite reserved and silent parents perhaps he will be at ease with an ‘orthodox’ analyst, while a different patient with parents who were very warm and exuberant might perceive this same analyst as cold or detached. It is obvious that it would be wrong to see as transference only the latter’s reaction and consider as ‘normal’ (i.e. nonstransferrential) the nonconflictual

27 state the first patient is in when he is with a silent and reserved analyst. (Migone, 2013, p. 291) In other words, according to Migone (2013), there is no ‘gold standard’ of treatment. He argues that what matters more (as in any treatment) is the interpretation of transference and countertransference and that online therapy is no different. Again, this notion is certainly up for debate and there is no authority on an answer.

Transference and Countertransference.

Based on Migone’s (2010) suggestion, and as basic pillars of psychoanalytic theory, transference and countertransference should also be examined when thinking about online therapy. What is transference? What is countertransference? Do they occur in an online relationship? Again, these questions may be difficult to answer. Freud’s earliest mention of transference was in his publication of the case of Dora (Freud, 1905) where he defines transference as follows: A special class of mental structures, for the most part unconscious… They are new editions or facsimiles of the tendencies and fantasies which are aroused and made conscious during the progress of the analysis; but they have this peculiarity, which is characteristic for their species, that they replace some earlier person by the person of the physician. (Freud, 1905) In Orr’s historical survey of transference and countertransference (1954), he describes how Freud’s conceptualization is confusing, for he writes on these concepts in a variety of ways over the years. “In some instances, Freud seems to mean no more than rapport; in others he clearly means the transference neurosis; and in still others he implies some

28 intermediate varieties of displacement and intensities of affective relationship” (Orr, 1954, p. 624). So, if even Freud himself could not settle on one definition of transference or countertransference, in thinking about whether or not they exist online, it is difficult to determine exactly what one should be looking for.

Racker (1954) highlights one important distinction that is especially relevant to this question of online therapy. He points out that Freud deals with transference from two points of view: 1) “transference in general” and 2) “transference in psychoanalytic treatment and the reasons for the special intensity it there assumes” (Racker, 1954, p. 78).

According to Freud, the transference in treatment serves the resistance. “The analysand reproduces and acts upon his unconscious impulses in order to not ‘remember’ them” (Racker, 1954, p. 78). The result is an especially intense kind of transference. Racker wonders if there might be other factors that contribute to the intensity of transference in treatment, such as the abolition of rejection or the process of the analysis itself (Racker, 1954). The details of these suggestions are beyond the purpose here, but generally speaking, it raises the question of whether or not the factors that distinguish general transference from the type of transference in treatment are present in online therapy, in a virtual relationship. Again, it is difficult to determine without a clear sense of what exactly one should be looking for.

In the absence of clear definitions, it may be useful to consider anecdotal evidence.

What have clinicians seen and experienced in providing online therapy? Have they identified the kind of transference in their patients that is typically seen in traditional therapy or analysis? The literature is limited when it comes to the experience and observations of clinicians who provide online therapy, but there are some clinicians

29 writing about it (Stofle, 2002; Bell, 2013, Sehon, 2018). Fishkin & Fishkin (2011) wrote about their experiences providing treatment via Skype through the Chinese American Psychoanalytic Alliance (CAPA) and included some clinical examples. As for the question of transference and countertransference, they remark: The entire world, via the Internet, is available at the analyst’s fingertips… it may tempt the analyst to emerge his mind away from the patient during a heartfelt but, nevertheless, halting and awkwardly expressed statement. A whole new way of identifying one’s countertransference derivatives is now available. Exposed by this new perspective, they become just as evident to the analyst using Skype, with experience and the effort of self-analysis, as to the one sitting behind the patient.

(Fishkin & Fishkin, 2011, p. 108) From this example, it seems that while the experience of transference or countertransference and the evidence of its presence may be different in online treatment, it most certainly still exists. In another example, Russell (2015) quotes a skeptical colleague who agreed to provide treatment via Skype when it became the only option for continuing: When I began, I had no idea whether or not transference would occur in this medium or whether an analytic process could take place… I know my unconscious and my analysand’s unconscious were in communication when we began having similar dreams during one phase of the analysis, something that happens during my in-person analyses as well. (Russell, 2015, p. 153-154) It may be impossible to take a clear definition of transference or countertransference and determine whether or not it is universally present in online therapy. However, these

30 examples suggest that from what knowledgeable and experienced psychodynamic clinicians have integrated into their understanding of transference and countertransference, they believe these dynamics to be present online.

Holding Environment.

The ‘holding environment’ is another concept worthy of examination when it comes to online therapy. Winnicott (1960) coined this term to describe how the analytic situation should seek to emulate the early mother-infant relationship in a way that provides enough safety and security to facilitate emotional growth. He wrote, “The term ‘holding’ is used here to denote not only the actual physical holding of the infant, but also the total environmental provision prior to the concept of living with” (Winnicott, 1960, p.589). Physical presence is mentioned as a given, but as only one piece of what creates the holding environment. And in 1960, physical presence is an understandable given. But in 2020, the question could be raised: Is that piece essential? Is it possible to create and maintain a virtual holding environment online?

Modell (1976) lays out how Winnicott’s concept of the holding environment translates into practice or into the analyst’s technique: The analyst is constant and reliable; he responds to the patient’s affect; he accepts the patient, and his judgment is less critical and more benign; he is there primarily for the patient’s needs and not for his own; he does not retaliate; and he does at times have a better grasp of the patient’s psychic reality than does the patient himself, and may therefore clarify what is bewildering or confusing. (Modell, 1976, p. 291)

31 Is physical presence necessary for the analyst to provide these functions? Is there anything in Modell’s (1976) articulation that eliminates the possibility of a virtual holding environment? Again, these are questions raised, but too much is up for debate to arrive at any definitive answers.

Research Studies While the ‘funnel method’ is suggested and typically used to organize the literature review of a dissertation, it did not work very well for this topic. There were a couple of studies most similar to this one (Wangberg et al., 2007; Perle et al., 2013), but most studies were equally relevant. For example, while one study was relevant in that it focused on psychodynamic treatment, it did not include video sessions (Andersson et al., 2012). And while another study focused on video therapy, it did not include psychodynamic treatment (Simpson et al., 2014). There were many more examples of how this more circular pattern emerged when trying to group individual studies, and it was therefore difficult to start broadly and narrow in focus.

However, when reviewing any empirical study, the following three questions quickly emerged, and they led to three natural groupings: 1) What type of treatment was being used (CBT, psychodynamic, etc.)?

2) What was the treatment modality (video, email, chat, etc.)?

3) What did the study measure (efficacy, working alliance, attitudes, etc.)?

Individual studies fell into multiple categories, but these groupings made it possible to identify deficiencies in the literature. This section will speak to each of these questions, and the gaps in the literature will be made clear.

32 Type of Treatment.

In the body of research related to online therapy, the type of treatment being used is overwhelmingly cognitive-behavioral (CBT). For example, in one review (specific to video therapy) (Backhaus, 2012), of the 42 articles included, 19 (45%) named CBT as the primary type of treatment. Eleven (26%) described the treatment as “either eclectic, various or undefined” (Backhaus, 2012, p. 116), three (7%) used family therapy, and only one study used psychoanalysis (Kaplan, 1997). That study (Kaplan 1997) was conducted in 1997, when video therapy was in its infancy. The technology then was very different, and the study included psychotherapy by both video and phone (Backhaus, 2012). In another systematic review (Machado et al., 2016), of the 59 studies included, only two focused on psychodynamic treatment. The treatments utilized in those two studies (Andersson et al., 2012; Johansson et al., 2012) were both self-guided programs based in psychodynamic principles. Neither treatment involved contact with an actual therapist (Machado et al., 2016). Therefore, when it comes to the type of treatment being studied, there is a deficiency in the literature and a significant need for studies that focus on psychoanalysis or psychodynamic therapy.

Treatment Modality.

In the body of research related to online therapy, the treatment modalities used are email, text, chat, video and other web-based (often self-guided) programs. And while there are certainly a substantial number of studies that include video, only a small portion focus exclusively on video. As late as 2012, for example, one review stated, “As we anticipated, we did not find any literature reviews that were solely focused on VCP

33 [videoconferencing psychotherapy] (which was the impetus for the current review)” (Backhaus et al., 2012, p.115). Even within single studies, video is lumped together with other modalities. For example, Sucala et al. (2013) studied clinicians’ attitudes towards therapeutic alliance in e-therapy, and their definition of “e-therapy” was borrowed from Manhal-Baugus (2001): “A licensed mental health care professional providing mental health services via email, video conferencing, virtual reality technology, chat technology, or any combination of these” (Sucala et al., 2013, p.282). All forms of online therapy were treated together to as “e-therapy.”

Why is this significant? Video therapy most closely resembles traditional face-to-face therapy in that patients and therapists are able to see one another and in real time (synchronous). None of the other modalities contain both of these components. Migone (2013) explains further: “It is possible to simulate the session almost exactly. There are those who even simulate the waiting room. With audio and video synchronized in real time, it is possible also to duplicate the timing of interventions, silences, the length and times of scheduled ‘sessions’, and various other rituals as if both partners were in the office (Migone, 2013, p. 282). It follows, then, that attitudes towards video therapy might be different from attitudes towards other forms of online therapy and should therefore be studied separately. With the inclusion of 65 studies in its analysis, Backhaus and colleagues’ review (2012) demonstrated that studies on video therapy alone are not missing. However, given the important distinction just mentioned, and given that most research is comparing online therapy to traditional face-to-face therapy in some way, a much larger focus on video therapy is warranted.

34 Also, when it comes to psychodynamic treatment, as late as 2015, it was stated: “There are no research studies published specifically on psychoanalytic treatment conducted via video-conferencing” (Russell, 2015, p. 100). One later study by Behzad, Parvanah and Behrouz (2017) looked at dynamic treatment via Skype, but the treatment was “intensive short-term dynamic psychotherapy (ISTDP)” (Behzad et al., 2017, p.

133), which is different from the long-term type of psychodynamic treatment being discussed here. Therefore, when it comes to treatment modality, there is a deficiency in the literature and a significant need for research that focuses on video therapy.

Measure.

In the body of research related to online therapy, studies measure either: (a) the efficacy of treatment, (b) the strength of the working alliance between patient and therapist, or (c) attitudes towards online treatment.

Efficacy.

Efficacy studies are the large majority, and outcome is measured in a variety of ways.

Day and Schneider (2002), for example, utilized an experimental design and compared five sessions of face-to-face CBT to the equivalent of both video therapy and audio therapy. Outcome was measured using the Brief Symptom Inventory (BSI), a GAF (Global Assessment of Functioning) score given by the therapist, a self-reported Target Complaints Method score, and both patient and therapist satisfaction ratings. Most of the studies included in Backhaus and colleagues’ review (2012) looked for decreases in panic episodes, decreases in anxiety and depression, increases in physical health, or increases in

35 functioning and GAF score as outcome measures (Backhaus et al., 2012). There are many instruments that can be used to measure outcome, but all tend to look for some sign of reduction in patients’ symptoms or complaints. And regardless of how outcome is being measured, the general conclusion among efficacy studies is that online therapies (in various modalities) are just as effective as both face-to-face treatments and waiting list control groups. (Backhaus et al., 2012; Rees & MaClaine, 2015; Garcia-Lizana & Munoz-Mayorga, 2010).

Working alliance.

Studies looking at working alliance sought to determine if a working alliance could be established and maintained in online treatment and if the strength of the working alliance is comparable to that of face-to-face treatment. Sucala et al. (2013) had clinicians respond to an online survey about the importance of working alliance and their confidence in being able to build it. Cook and Doyle (2002) had patients complete the Working Alliance Inventory (WAI) after participating in either e-mail, chat or face-to-face therapy.

Reynolds et al. (2006) looked at therapy via email, measuring session impact through the Session Evaluation Questionnaire (SEQ) and the alliance through the Agnew Relationship Measure (ARM) and comparing results with previously published results on face-to-face therapy. Simpson et al. (2014) presented a review of studies that look at video therapy and working alliance, and some of the tools they used to measure working alliance include the Telepresence Scale, the Vanderbilt Psychotherapy Process Scale, the Communication Comfort Scale, and the Penn Helping Alliance Scale. Again, there are many ways to measure working alliance. The bulk of the research concludes that it is not

36 only possible to establish a working alliance online, but that the strength of the working alliance is comparable to that of face-to-face treatment (Cook & Doyle, 2002; Reynolds, Stiles & Grohol, 2006; Simpson et al., 2014).

Attitudes.

The attitudinal studies varied in what they were seeking and what types of conclusions they were able to draw. First, there was a clear division between studies that measured the attitudes of clinicians (Mallen, 2005; Gibson et al., 2009; Perle et al., 2013) and studies that measured the attitudes of patients (Young, 2005; King et al., 2006, Skinner & Latchford, 2006).

In the studies that focused on patients’ attitudes, there was significant attention on the characteristics of those seeking online treatment. Skinner and Latchford (2006) found attitudes correlated with exposure to the Internet, exposure to face-to-face therapy, and to “self-disclosure style� (Skinner & Latchford, 2006, p. 158). Young (2005) reported that Caucasian, middle-aged males with at least a four-year undergraduate degree were most likely to use online therapy (Young, 2005), and Rochlen et al. (2004) reported some correlation between attitudes and comfort with e-mail, interest in various types of therapies, and traditional help-seeking attitudes.

The body of research that focuses on the attitudes of clinicians is also limited. As in the efficacy studies, there is a group that looks specifically at attitudes towards working alliance. Sucala et al. (2003) utilized a survey design and found that clinicians had less confidence in their ability to develop a working alliance in e-therapy than face-to-face therapy. Reese and Stone (2005) utilized an experimental design and compared the

37 attitudes of two groups of clinicians who watched identical therapy sessions that were conducted either face-to-face or by video. Their prediction that clinicians watching the video session would rate the working alliance between therapist and patient significantly lower than those watching the face-to-face sessions was confirmed. And finally, a dissertation study by Mallen (2005) also utilized an experimental design, comparing attitudes towards online therapy of clinicians before and after participating in a synchronous online chat counseling session with a trained confederate posing as a client.

Results indicated that clinicians had a more positive view of the potential for working alliance after the session (Mallen, 2005). Together, these studies assert that clinicians are less confident in forming working alliances online, they perceive the working alliance to be stronger in face-to-face sessions, and they have more favorable views of the working alliance once they have some exposure to online treatment. Other than the factor of exposure, very little insight is gained into how the attitudes are formed.

There are a few studies that moved away from working alliance and tried to dig deeper into some understanding of the differences between attitudes. Wangberg et al. (2007) conducted a survey of Norwegian psychologists and concluded that having a psychodynamic orientation correlated with a more negative attitude towards “e-therapy.”

Perle et al. (2013) also utilized a survey design and found there was no significant difference between currently licensed psychologists and future psychologists (doctoral students), but that CBT and systems psychologists were more accepting of “telehealth interventions” than dynamic/analytic psychologists. So, there is evidence that both exposure to online therapy and one’s theoretical orientation may have some influence over attitudes, but that is as far as the research goes. Therefore, when it comes to what is

38 being measured, there is a deficiency in the literature and a significant need for attitudinal studies that look to dig deeper and gain insight into what influences attitudes towards video therapy.

Deficiencies in the Literature To summarize, when it comes to type of treatment, there is an overwhelming presence in the literature of CBT and other behavioral treatments. There is a deficiency in the literature and a significant need for studies that look at psychodynamic or psychoanalytic treatments.

When it comes to treatment modality, there are many studies that look at e-mail, chat, video, and self-guided programs or various combinations of the four. However, video therapy is more similar to traditional therapy than any of the other three, and it warrants a stronger presence in the literature. Therefore, there is a deficiency in the literature and a significant need for studies that focus on video as a treatment modality. There is also an especially significant need for studies that look at both psychodynamic treatment and video.

In terms of what is being measured, there seems to be three distinct categories in the literature: efficacy, working alliance, and attitudes. Efficacy studies are by far the majority. Attitudinal studies represent a relatively small portion of the whole, and they are further divided into studies that focus on the attitudes of patients and studies that focus on the attitudes of clinicians. In general, regardless of the population being studied, there has been very little insight gained into what influences attitudes beyond general comfort with the Internet and theoretical orientation. There is a deficiency in the literature

39 and a significant need for studies that seek to dig deeper and gain some better understanding of attitudes towards online treatment.

Therefore, the current study addressed the deficiencies in the literature listed above in each of the following ways: 1. It focused specifically on psychodynamic treatment.

2. It focused specifically on video therapy.

3. It sought to dig deeper and understand something more about attitudes of psychodynamic clinicians towards video therapy.

Most importantly, while there are deficiencies in the literature in each one of the areas listed above, this is the first study to address all three.

Conclusion In Chapter I, it was established that there is a dire need for increased access to mental health services in the United States. Video therapy and other forms of online therapy provide at least a partial solution, and the general public has responded. Online therapy services have grown exponentially since their emergence in the late 1990’s, and the trend should continue onward. However, there is a significant reluctance among clinicians with a psychodynamic orientation to provide online therapy. That leaves them less accessible to those in need and presents a risk of becoming irrelevant. For some reason, however, there does not seem to be much alarm among the psychoanalytic community.

There is almost no research on online psychodynamic therapy or online psychoanalysis. This is despite the large amount of research supporting the efficacy of other types of online therapies (CBT, DBT, etc.) and in many different modalities (video,

40 chat, e-mail, text, etc.). In other words, there is almost no effort being made to even see if psychodynamic treatment has a place online. Why is that? Why is the psychodynamic community sitting on the sidelines? What is it about?

An efficacy study of online psychodynamic treatment would certainly fill one major gap in the literature, but no amount of research could prove the efficacy of treatment.

The results of each study would only build support, and accumulation takes time. So, while that research certainly needs to be conducted, this study recognized that time is of the essence. It also borrowed from psychoanalytic principles in recognizing that clinicians with negative attitudes towards video therapy may not be satisfied by any amount of supportive research. In other words, the attitudes may be stemming from something less conscious. Therefore, this study sought to begin that exploration. It is intended to be a beginning, for more research will undoubtedly be needed. The goal is to draw attention to what is happening in the psychoanalytic community around this issue and begin examining what the reluctance and lack of participation is really about.

41

Chapter III

Methodology The purpose of this quantitative survey research study was to identify variables that shape attitudes towards video therapy among clinicians in private practice with a psychodynamic orientation. The overarching research question was: “What variables (if any) influence attitudes towards video therapy among clinicians in private practice with a psychodynamic orientation?” More specifically, the following four research questions were addressed: 1. What is the frequency and variation of scores on the VTAS (Video Therapy Attitude Scale) for participants in the study?

2. What are the variables (i.e. demographic, professional, etc.) that positively correlate with attitudes towards video therapy?

3. What are the variables (i.e. demographic, professional, etc.) that negatively correlate with attitudes towards video therapy?

4. What are the variables (i.e. demographic, professional, etc.) that demonstrate a statistically significant difference between subgroups as related to VTAS scores?

This study explored 25 independent variables (Appendix A), as they relate to participant scores on the VTAS, but there were two central null hypotheses this study sought to either confirm or reject: 1. There will be no statistically significant relationship between clinicians’ years of experience providing video therapy and attitudes towards video therapy.

42

2. There will be no statistically significant relationship between clinicians’ familiarity with research related to video therapy and attitudes towards video therapy.

These were chosen as central null hypotheses because they involve the two variables that pertain directly to video therapy, whereas the other variables are more about the clinicians themselves (i.e. age, theoretical orientation, etc.). Whether or not a significant relationship was found between ‘years of experience providing video therapy’ or ‘familiarity with research related to video therapy’ and attitudes towards video therapy, that information would have been meaningful. A significant positive correlation would reveal that attitudes are rooted in something about video therapy itself. No relationship or a significant negative correlation would give reason to believe that attitudes are being influenced by other variables emanating from within the therapist or analyst.

This chapter describes the research methodology and includes the following major components: 1. rationale for a quantitative design, 2. rationale for a survey design, 3. research sample, 4. research design, 5. data collection, 6. data analysis, 7. ethical considerations, 8. limitations and delimitations,

43 9. role and background of the researcher, and 10. summary.

Rationale for a Quantitative Design This study called for a quantitative design primarily because the research questions were rooted in a postpositivist worldview. “The knowledge that develops through a postpositivist lens is based on a careful observation and measurement of the objective reality that exists ‘out there’ in the world” (Creswell, 2014, p. 7). Other studies have looked at the subjective opinions of clinicians as they relate to therapy through the Internet (Gibson et al. 2009; Finn & Barak, 2010; Sucala, 2013). And while there is value in that, this study assumed there is also value in what clinicians cannot report themselves.

It was interested in the factors “out there” (Creswell, 2014, p. 7), the factors beyond clinicians’ own awareness, that may be influencing their attitudes towards video therapy.

The kind of interviews that are typically conducted for qualitative or mixed methods studies could not obtain that kind of information, so a quantitative design is necessary and most appropriate here.

Rationale for a Survey Research Design This study called for a survey research design over an experimental design primarily because the independent variables were impossible to manipulate (Creswell, 2014). The dependent variable in this study was ‘attitude towards video therapy’. There were 25 independent variables including ‘years of experience providing video therapy’, ‘familiarity with research related to video therapy’, as well as other personal and

44 professional demographic variables (i.e. age of clinician, race of clinician, theoretical orientation, etc.). None of these variables could be manipulated, for they were central to participants’ identities or their practices out in the real world. However, that spoke directly to this study’s interest. The goal was to obtain a “numeric description” (Creswell, 2014, p. 13) of the attitudes that exist among psychodynamic clinicians in private practice, and to identify which existing characteristics of clinicians and/or their practices may be influencing that numeric description in a significant way. Manufacturing or manipulating a difference between groups, as is done in an experimental design, was not relevant here. Therefore, a survey research design was most appropriate.

Research Sample This section will include the following information related to the research sample: (a) inclusionary criteria, (b) sampling method, and (c) sample size.

Inclusionary Criteria.

To be eligible for this research study, participants had to meet the following criteria: 1. They must have been a licensed psychologist, social worker, counselor or physician.

2. They must have self-reported having a primarily psychodynamic orientation.

3. They must have currently been in private practice.

4. They must have been in private practice for a minimum of five years.

5. Their private practice must have been based in the United States.

45 Sampling method.

This study used a non-probability, purposive sampling method to recruit participants (Rubin & Babbie, 2008). A survey was created and administered online through SurveyMonkey, and it was posted on professional listservs including The American Association for Psychoanalysis in Clinical Social Work (AAPCSW) and The American Psychoanalytic Association (APsaA). Both of these listservs were chosen because members were highly likely to meet the inclusionary criteria, and because the researcher was able to access them. The researcher also used direct email and social media postings (i.e. Facebook) to reach potential participants.

Sample size.

“Most sample size decisions do not focus on estimates for the total population; rather, they are concentrated on the minimum sample sizes that can be tolerated for the smallest subgroups of importance” (Fowler, 2014, p. 39). Those numbers could be calculated in advance, and they were based on the type of data analysis tests that are being used. The details of the data analysis for this study will be described later in this chapter, but there was a total of 25 independent variables tested against one dependent variable (‘attitudes towards video therapy’) using either a Pearson’s correlation, an independent-samples ttest, or a one-way between groups ANOVA. The Pearson’s correlation was used with the nine independent variables that were continuous (provide a ratio level of measurement), and (at a 0.05 level of significance) that test required a total sample size of 85 (Statistics Solutions, 2019). The remaining 15 independent variables were not continuous, as they contained two or more sub-groups

46 (i.e. the variable ‘type of professional license’ contains the sub-groups social work, psychology, counseling and MD/DO). The independent-samples t-test was used for each of the variables with only two sub-groups, and the one-way between-groups ANOVA was used for any of the variables with three or more subgroups. For the t-tests (at a 0.05 level of significance), at least 64 participants were needed for each of the two sub-groups or a total of 128 participants (Statistics Solutions, 2019). For the ANOVAs (at a 0.05 level of significance), at least 52 participants were needed for each sub-group (Statistics Solutions, 2018).

The numbers were monitored as data came in, and recruitment would have ideally continued until there were enough participants in each subgroup of each variable for data analysis to be conducted. However, it was unlikely that those numbers would be met. For example, the variable ‘race’ included seven subgroups, and it would be very difficult to recruit 52 participants for each group for a total of 364 participants. To address this, the researcher planned that if it seemed highly unlikely the minimums would be met, some subgroups would be combined into an ‘other’ category for data analysis. If there were not enough participants to represent at least two subgroups for the minimum requirements, then some variables would be dropped from the analysis altogether.

Research Plan or Process The specific steps to be implemented for this study were as follows: 1. A tool designed to measure ‘attitudes towards video therapy’ was created by adapting the previously validated Online Counseling Attitudes Scale (OCAS) (Appendix B), developed by Rochlen, Beretvas, and Zack (2004). The tool

47 adapted for this study was named the Video Therapy Attitudes Scale (VTAS) (Appendix C).

2. A survey was created via SurveyMonkey (Appendix D). The survey included a consent form with required electronic signature, detailed instructions, questions related to inclusionary criteria, questions related to the VTAS, questions related to both personal and professional demographics, questions related to the operation of the participant’s private practice, questions related to the participant’s current caseload, and a thank you message.

3. A codebook (Appendix E) was created to organize all of the variables and prepare for the entering of data into SPSS. 4. The VTAS and survey was tested for clarity and validity in a pilot study by sending an invitation email to five clinicians who are known by the researcher to have a positive attitude towards video therapy and five clinicians who are known by the researcher to have a negative attitude towards video therapy.

5. Changes to the VTAS and survey were made based on pilot study participant feedback.

6. Two tests for internal consistency and reliability of the VTAS were run using the pilot study data: Split-half method and Chronbach’s alpha (Statistics Solutions, 2019).

7. Survey participants were recruited through professional listservs, social media postings, and direct email invitations. The inclusionary criteria outlined above was made clear in all postings, and the survey was immediately available to participants through a posted hyperlink.

48 8. Responses were electronically collected, stored, and organized through SurveyMonkey.

9. Recruitment and data collection continued until there was enough data to run an analysis for as many variables as possible. If it seemed unlikely that the needed number of participants will be obtained, the remaining categories were grouped together as ‘other’, and data analysis began. Some items were eliminated if minimums are not met.

10. Data was reviewed for quality assurance. Review checked for missing or erroneous information.

11. The survey data was entered into SPSS (Statistical Package for the Social Sciences).

12. The two tests for internal consistency and reliability of the VTAS were run again (Chronbach’s alpha and the split-half method), this time using the study’s final data set (Statistics Solutions, 2019).

13. Descriptive statistics were run on each of the 25 independent variables, on the one dependent variable (VTAS score), and all 16 individual items that comprise VTAS scores.

14. Finally, each independent variable that met minimum subgroup sample size requirements were analyzed in terms of its relationship to the dependent variable (‘attitude towards video therapy’) using either Pearson correlation, independentsample t-test, or one-way between-groups ANOVA.

49 Data Collection This section will outline the components of both the content and process of data collection for this study. The content refers to survey questions that constitute the VTAS as well as survey questions associated with each independent variable (i.e. demographics, operation of professional practice, etc.). The process will include the pilot test, the final data collection, and the follow-up reliability tests.

VTAS. The survey included all questions that make up the Video Therapy Attitudes Scale (VTAS) (Appendix C). This scale was created by adapting the Online Counseling Attitudes Scale (OCAS) that was previously created and validated by Rochlen, Beretvas and Zack (2004) (Appendix B). Given the controversial debate about online counseling and the number of clinicians providing it, Rochlen et al. (2004) saw a need for an instrument that could provide valid and reliable scores to describe attitudes towards both face-to-face and online counseling. The FCAS was created to measure attitudes towards face-to-face counseling, and the OCAS was created to measure attitudes towards online counseling.

Subscales of OCAS. The current study was solely focused on online counseling, and therefore, only the OCAS was utilized. The OCAS contained ten total items and two subscales (with five items representing each): 1) value of online counseling, and 2) discomfort with online counseling (Rochlen et al., 2004). The OCAS was created in 2004, and much has changed over the last 15 years. Therefore, the VTAS adapted the OCAS to be more

50 inclusive of all current components of online treatment. Some items were added, some were deleted, and subscales were no longer appropriate.

Reliability and validity of OCAS. Several measures were taken to ensure reliability and validity of the OCAS. First, the individual items were written and selected through a fairly rigorous process that involved having graduate students and faculty members rate items on a five-point Likert scale and then eliminating items that did not achieve a mean rating of at least 3.5 (Rochlen et al., 2004). Next, evidence of reliability for the OCAS was provided through a test-retest of each scale over a three week period, yielding correlation coefficients (at 95% confidence intervals) of .88 (.85 to .91) and .77 (.71 to .82) for the Value of Online Counseling (OCV) and the Discomfort with Online Counseling (OC-D) subscales respectively (Rochlen et al., 2004, p. 103). And finally, evidence of validity was sought through a second sample, and they found “strong evidence of the internal consistency of scores on all subscales across the two studies (.77 to .90)” (Rochlen et al., 2004, p. 106).

Adaptation of the OCAS. While the OCAS used a six-point Likert scale, the VTAS used a similar five-point Likert scale that included the following response choices: “Strongly agree,” “Agree,” “Neutral,” “Disagree,” and “Strongly Disagree.” This difference was chosen because the six-point scale does not give participants the option of answering “neutral.” Also, because the OCAS was designed to survey patients instead of clinicians, the items needed to be significantly altered. For example, one item on the OCAS read, “I would dread

51 explaining my problems to an online counselor” (Rochlen et al., 2004, p. 99), and for the VTAS, it was changed to, “I would dread trying to understand my patients’ problems over video.” The VTAS used five items from the original OCAS and eleven additional items (16 total) to account for the aspects of attitudes towards online treatment that have changed since the OCAS was published in 2004. Therefore, the pilot test and follow-up reliability tests were used to further validate the VTAS with its alterations and additions.

Score calculation.

To score the OCAS, each item on the Likert was assigned a value of 1 - 6 (1 = strongly disagree; 6 = strongly agree). The values were then added for each of the two subscales. The ‘value toward online counseling’ subscale items were all written in such a way that a high score would indicate an overall high degree of value toward online therapy. The ‘discomfort toward online counseling’ subscale items were written in such a way that a high score would indicate a high degree of discomfort associated with online therapy. The VTAS was not using subscales, but some of the items (those more indicative of a negative attitude) were reversed for scoring. For example, the item that reads, “I think it is difficult if not impossible to provide an adequate holding environment for patients through video” will be reversed for scoring (1 = strongly agree; 5 = strongly disagree). The total added score could have ranged from 16 - 80 and represented each participant’s overall attitude towards video therapy.

52 Other survey questions.

In addition to the VTAS scores, there were four sets of information gathered: 1) inclusionary criteria, 2) information related to one’s private practice and caseload, 3) experience and familiarity with video therapy 4) personal demographics. Each one of these questions lent itself to an independent variable that could be tested for relationship with ‘attitudes towards video therapy’ as described above. The complete survey that includes VTAS items as well as all other survey questions can be found in Appendix D.

The pilot test.

In addition to the VTAS and demographic questions that were included in the final survey, the ten mental health professionals participating in the pilot test were asked to answer the following eight questions: 1) Did you find any of the questions, or language in the questions to be confusing? Please explain. 2) Did you find any of the questions to be offensive? Please explain. 3) Did you find any of the language in the survey to be outdated? Please explain. 4) Was the length of this survey too long, too short, or just right? Please explain. 5) Are there questions you would remove? Please explain. 6) Are there questions you would add? Please explain. 7) Please describe how you feel about the aesthetics of the survey (i.e., design, ordering of questions, color, etc.) 8) Other final comments regarding the survey. Based on these answers, changes to the VTAS and/or final survey were made.

53 Final survey collection.

Data collection involved the administration of the final survey to mental health professionals who met the inclusionary criteria outlined above. Participants from the pilot study were included, as they would have been primed to the questions. To be sure, the survey began with the question: “Did you previously participate in the pilot test for this study?” If anyone answered in the affirmative, they were given a thank you message and exited from the survey. All survey questions were required so missing data did not become an issue, and necessary skip patterns were built in.

Reliability tests.

Once the data was collected, tests for reliability were run using the split-half method and Chronbach’s alpha. While these tests are used to measure the same thing, they each have limitations, and were therefore both be used to strengthen results. Each of these methods are described below.

Split-half method.

The split-half method is a reliability test used to measure how well the components of a survey instrument (i.e. Likert scale surveys) measure what it intends to measure (Statistics Solutions, 2019). In this study, for example, the VTAS was designed to measure ‘attitudes towards video therapy’. The split-half method helped determine whether or not does, in fact, measure just that.

In following the split-half method, the VTAS questions were randomly split in half (8 and 8), and then each half of the test was scored for each of the participants. The

54 correlation coefficient between the two halves was then found using Pearson’s correlation. For the VTAS to be considered reliable, the scores from each half should closely correlate. This method has its limitations, for there are many ways a test can be split, potentially leading to different outcomes. Also, it generally works better for longer tests, and results can be misleading when used with shorter ones (Statistics Solutions, 2019).

Chronbach’s alpha.

The Chronbach’s alpha was developed to provide a stronger measure than the split-half method (Statistics Solutions, 2019). It is the most widely used objective measure of reliability, internal consistency, or the degree to which all items in an instrument measure the variable of interest (Tavakol & Dennick, 2011). Again, it helped to determine if the VTAS did, in fact, measure ‘attitudes towards video therapy’. The formula for Chronbach’s alpha (Tavakol & Dennick, 2011) is as follows: Nxc a = ------------v + (N-1) c “N” represents the number of items, “c” represents the average covariance between item parts, and “v” represents the average variance. The solution is expressed as a number between 0 and 1. In general, the higher the Chronbach’s alpha, the stronger the internal consistency or reliability, and a score of 0.7 or greater is considered acceptable (Statistics Solutions, 2018). The length of the survey and the sample size can also influence the Chronbach’s alpha, making it an imperfect measure. However, it is widely used, and it was able to offer some information regarding the strength of results.

55 Plan for Data Analysis The survey questions yielded a total of 26 variables. The only dependent variable was ‘attitude towards video therapy’ (measured by VTAS score on a range of 16 - 80). The two central independent variables were ‘years of experience providing video therapy’ and ‘familiarity with research related to video therapy’ (measured on a self-report scale of 0 100, ranging from “not at all familiar” to “extremely familiar”). There were 23 remaining variables for further exploration, and a complete list can be found in Appendix A. All of the data was entered into SPSS, and all analyses were conducted through SPSS. First, descriptive statistics were run on all variables. Next, a series of statistical tests were conducted to determine whether or not there is a relationship between ‘attitude towards video therapy’ and each other variable. The type of statistical analyses that could be run depended on the level of measurement that each variable provided (Pallant, 2016).

‘Attitude toward video therapy’ was a continuous variable that provided a ratio level of measurement, and it was being used in each one of the statistical tests. Therefore, the tests included Pearson’s correlation, independent-samples t-tests, and one-way betweengroups ANOVAs, as they could all be used with at least one of the variables being continuous (Pallant, 2016). Each of these tests and the rationale for running them with each variable is outlined below.

Pearson’s correlation.

The Pearson’s correlation is designed to describe the relationship between two continuous variables (variables that provide a ratio level of measurement) (Pallant, 2016).

It produces a value from -1 to 1, where the sign indicates the direction of the relationship

56 and the absolute value indicates the strength of the relationship (Pallant, 2016). ‘Attitude towards video therapy’ provided the first continuous variable, so a Pearson correlation could be run with all other continuous variables.

The two central independent variables that corresponded to the central null hypotheses were both continuous, so the Pearson’s correlation was used to either accept or reject the two central null hypotheses. Again, those two variables were: 1. Years of experience providing video therapy 2. Familiarity with research related to video therapy (measured by a self-report scale of 0-100, ranging from “not at all familiar” to “extremely familiar”).

In addition to the central variables, the Pearson’s correlation was used with the following seven continuous variables: 1. Years of experience in private practice 2. Clinical sessions per week 3. Gross income for 2018 4. Current regular fee 5. Lowest fee accepted on a sliding scale 6. Years of experience receiving video therapy 7. Age

Independent-samples t-test.

Independent-samples t-tests are used to determine if there is a significant difference between two distinct groups as they relate to a dependent continuous variable (Pallant, 2016, p. 244). The “independent-samples” means there is a comparison between two

57 groups, rather than a comparison of two scores for the same group on different occasions (Pallant, 2016). That was the case for all independent variables in this study, and again, the dependent variable, ‘attitude towards video therapy’, was continuous. Therefore, independent-samples t-tests were intended to be run in SPSS against each of the variables that contained two groups. Those included the following eight variables (described here by their subgroups): 1. Psychoanalysts and non-analysts.

2. Clinicians who offer a sliding scale and clinicians who do not.

3. Clinicians who are on an insurance panel and clinicians who are not.

4. Clinicians who accept Medicaid and clinicians who do not.

5. Clinicians who accept Medicare and clinicians who do not.

6. Clinicians who generally experience discomfort in meetings over video and those who do not.

7. Clinicians who have experienced a negative incident related to video therapy and clinicians who have not.

8. Clinicians whose current caseloads are comprised of patients who mostly (over 50%) fall into one particular racial group and clinicians whose current caseloads do not.

One-way between-groups ANOVAs. One-way between-groups ANOVA tests are used to compare values on a dependent continuous variable for three or more distinct groups (Pallant, 2016, p. 256). “The ‘oneway’ part of the title indicates there is only one independent variable, and ‘between-

58 groups’ means that you have different participants in each of the groups” (Pallant, 2016, p. 256). While there was more than one independent variable in this study, they were each going to be tested against the dependent variable separately, and for each one of the variables, there were different participants in each subgroup (the survey questions provide mutually exclusive answers to choose from).

Once again, this study’s dependent variable, ‘attitude towards video therapy’, was continuous, so a series of one-way, between-groups ANOVA tests were intended to be run in SPSS against each of the variables that contained three or more subgroups. Those included the following seven variables: 1. Type of professional license (subgroups will include social work, psychology, counseling and MD/DO).

2. Level of education (subgroups include MD, PhD, PsyD, MA, and other).

3. Specific theoretical orientation (subgroups will include object relations, ego psychology, self psychology, relational, eclectic, and other).

4. Practice location (subgroups will include urban, suburban, rural, and other).

5. Age demographics of current caseload (subgroups include mostly adults, mostly children and/or adolescents, and a fairly balanced mixture of adults and children and/or adolescents).

6. Race of clinician (subgroups will include White, Hispanic or Latino, black or African American, Native American or American Indian, Asian/ Pacific Islander, some combination of the above, and other) 7. Gender of clinician (subgroups will include male, female, and other)

59 Statistical tests to be determined.

The final survey question asked for any additional comments and allowed for a write-in answer. In this instance, the sub-groups were determined by reviewing the answers and drawing out themes after the data was collected. It was expected to yield at least three sub-groups, in which case a one-way between-groups ANOVA test was intended to be conducted against the VTAS scores. However, the researcher planned to run an independent sample t-test should the write-in answers yield a variable with only two subgroups or eliminate the question from analysis if there were not at least two viable subgroups.

Ethical Considerations This study was fairly low risk because did not involve a vulnerable population, nor did it involve qualitative interviews that sought in-depth information. Still, all research involves at least some risk. For this particular study, primary ethical considerations included informed consent and confidentiality. This section will discuss both of those ethical considerations along with the potential benefits of the study for participants and other stakeholders, and an explanation for how those benefits outweigh the minimal risks involved.

Informed consent.

A basic tenet of survey research is that participation is voluntary and that participants are fully informed about what they are agreeing to (Fowler, 2014). To that end, the survey included the name of the researcher and affiliated institution, a description of the

60 purpose of the study, a description of efforts that will be made to insure confidentiality, assurance that participation is completely voluntary, and assurance that participants may withdraw from the study at any time without consequence (Fowler, 2014). An electronic signature was collected from each participant to confirm that the information had been received, acknowledged and understood.

Confidentiality.

The other primary ethical consideration was confidentiality, and several steps were taken to protect participants. For one, only the researcher had access to the study’s raw data. Personal identifiers were removed from attachment to specific data. All data was stored in a password-protected file on a password-protected computer and will be maintained for a minimum of five years following the completion of the study. Once the information is no longer needed, all identifying information (i.e. email addresses) will be deleted and destroyed. And finally, the researcher will be careful about presenting information for any category of data that could make participants identifiable (Fowler, 2014).

Potential Benefits to Participants and Stakeholders Participants.

While there were the ethical considerations outlined above, there were also potential benefits to participants. First, they may have enjoyed the process of reflecting upon their attitude towards video therapy and/or the other aspects of their professional lives that the survey questions brought to the forefront. Also, participants may benefit from having

61 access to the results of this study, for they are potential stakeholders and could walk away feeling more empowered and supported in the professional decisions they make. Aside from these intrinsic benefits, there was no monetary benefit for participating in this study.

Other stakeholders.

As outlined in Chapter I, in addition to participants, there are several groups of stakeholders that stand to benefit from this study: 1. potential patients who are currently not receiving mental health services due to any of the aforementioned access barriers, 2. current patients who are involved in a treatment process, but feel video therapy could improve logistics and make it easier to fully engage in the process, 3. newer clinicians who are building a practice and looking for ways to expand their patient base, 4. more experienced clinicians who are curious about video therapy and looking for ways to stay current, 5. clinicians who are already providing video therapy and want to feel like the good work they do is better recognized, and 6. the general public that should benefit from a safer society in which more people have access to the mental health services they need.

Risk/benefit analysis.

While there were some ethical considerations involved in this study and a minimal level of risk that could not be avoided, there were concerted efforts to address those risks

62 and minimize them to the greatest extent possible. The population is not vulnerable, and the survey questions were fairly benign, so the risk of stirring up overly emotional content was minimal. The benefits that participants and other stakeholders stood to gain was great, for the study could contribute to greater access of sorely needed mental health services across the country. Therefore, the benefits outweighed the risks and justified the study being conducted.

Limitations and Delimitations Limitations.

Limitations of this study included reliability of the VTAS, a large number of variables, and sample size. Each of those limitations are discussed in this section.

Reliability of the VTAS. The VTAS is an instrument designed to measure ‘attitudes towards video therapy’. It was adapted from the OCAS previously developed by Rochlen and colleagues (2004), which underwent fairly rigorous tests for reliability and validity. However, the VTAS was significantly altered, as individual items were changed, deleted and added. The pilot test along with the split-half method and Chronbach’s alpha were used to address this limitation, but the process involved in writing and selecting each item for the VTAS was not as involved as that of the OCAS. Later chapters will discuss how the reliability tests in this study provided some support to the VTAS, but more research would be needed for the VTAS to be considered highly reliable.

63

Number of Variables.

This study involved 25 independent variables and one dependent variable with 16 component parts. These large numbers allowed for a lot of information to be gathered, but with so much data to consider, the study was only able to graze the surface. Again, the study was only intended to be a beginning, so further, more in-depth research will be needed to address for this limitation.

Sample.

Because this study used purposive sampling instead of random sampling, it is limited in terms of its generalizability. Also, ideally, the study would have been able to recruit at least as many participants that were needed for each of the sub-groups outlined for each variable. However, that was not possible, as the study was fairly narrow in focus and there were not enough clinicians to adequately populate the sub-groups. As a result, some of the variables being explored were excluded from analysis (beyond descriptive statistics) due to insufficient sample size.

Delimitations.

Delimitations refer to ways in which a study is narrowed in focus. This study focused exclusively on mental health professionals with a psychodynamic orientation who were currently in private practice in the United States, and who had been in private practice for a minimum of five years. It may also be useful to study the attitudes towards video therapy among clinicians with other theoretical orientations, who practice in local

64 agencies, who are just beginning their careers, or who are based in other countries. While the focus here was somewhat narrow, the hope was that results will inspire further research.

The Role and Background of the Researcher Kate R. Smaller is a Licensed Clinical Social Worker (LCSW) with a primarily psychodynamic theoretical orientation. This dissertation was the final requirement towards her Ph.D. from The Institute for Clinical Social Work in Chicago (ICSW). She has approximately 11 years of experience in the field of social work and eight years of experience in private practice.

As a researcher, her experience is minimal. She has conducted two small studies as part of her coursework at ICSW. The first was a qualitative study that looked at attitudes towards psychotherapy among non-patients. The study was phenomenological and focused on the experience of ambivalence among those who have considered but never actually sought out psychotherapy. Three semi-structured interviews were conducted with women between the ages of 20 and 32. Six categories capturing the experience of ambivalence emerged from the data: 1. lack of information 2. usefulness of friends and family 3. stereotypes and stigmas 4. first encounters with helping professionals 5. a longing for psychotherapy services, and 6. thoughts about who seeks psychotherapy.

65 The second was a quantitative study that looked at the working alliance between clinicians and patients in video therapy compared to the working alliance of clinicians and patients in face-to-face therapy. An electronic survey was administered to 31 clinicians, and 26 of the responses were usable (N=26). The survey consisted of demographic questions as well as questions adapted from The Working Alliance Inventory (WAI), a previously validated tool designed to measure working alliance. Of the 26 participants, 14 provided video therapy, and 12 only met with patients face-toface. Data was entered into SPSS, and these two groups were compared on WAI scores.

Results indicated no significant difference in WAI scores between the two groups, but the direction of the relationship suggested that the working alliance between clinicians and patients who meet via video conference may be even slightly stronger than that of clinicians and patients who meet face-to-face.

Conclusion This chapter has outlined the methodology intended for this research study. In sum, the rationale for a quantitative design is rooted in the study’s postpositivist epistemological stance. The rationale for a survey design stems from the inability to manipulate the independent variables and a greater interest in understanding the extent of the relationship between variables. The survey was created through SurveyMonkey, and a pilot test was conducted with ten mental health professionals before opening it up for data collection. The research sample included psychodynamic clinicians who were currently in private practice in the United States, and who had been in private practice for at least five years. Purposive sampling took place online through the use of professional

66 listservs, social media and direct email. Recruitment continued until minimum sub-group sample sizes were either met or deemed unattainable. A total of 25 independent variables were tested against the dependent variable, ‘attitudes towards video therapy’, using either a Pearson’s correlation, an independent-samples t-test, or a one-way between groups ANOVA. Ethical considerations for this study centered around issues of informed consent and confidentiality, but the potential benefits to participants and other stakeholders outweighed the risks and justified the research. Limitations of the study included reliability of the VTAS, the large number of variables, and issues related to the sample (sample size and lack of generalizability). The researcher employed several strategies to address those limitations. Finally, the role and background of the researcher was also discussed to provide context for the study.

67

Chapter IV

Results To review, the purpose of this study was to identify variables that shape attitudes towards video therapy among clinicians in private practice with a psychodynamic orientation. The overarching research question was: “What variables (if any) influence attitudes towards video therapy among clinicians in private practice with a psychodynamic orientation?� More specifically, the following four research questions were addressed: 1. What is the frequency and variation of scores on the VTAS (Video Therapy Attitude Scale) for participants in the study?

2. What are the variables (i.e. demographic, professional, etc.) that positively correlate with attitudes towards video therapy?

3. What are the variables (i.e. demographic, professional, etc.) that negatively correlate with attitudes towards video therapy?

4. What are the variables (i.e. demographic, professional, etc.) that demonstrate a statistically significant difference between subgroups as related to VTAS scores?

This study explored a total of 25 independent variables (Appendix A), as they relate to participant scores on the VTAS, but there were two central null hypotheses this study sought to either confirm or reject:

68 1. There will be no statistically significant relationship between clinicians’ years of experience providing video therapy and attitudes towards video therapy.

2. There will be no statistically significant relationship between clinicians’ familiarity with research related to video therapy and attitudes towards video therapy.

This chapter will include the following sections: 1. pilot study, 2. data collection, 3. data management, 4. reliability and composite scoring, 5. statistical analyses, 6. findings, and 7. conclusion.

Pilot Study The pilot test for this study included a total of 10 participants, five of whom were known by the researcher to hold a more positive view of video therapy and five of whom were known by the researcher to hold a more negative view of video therapy. Participants were recruited by direct invitation email with a hyperlink to the survey via SurveyMonkey.

69 Group demographics.

The group of pilot study participants was comprised of one social worker, four psychologists, and five physicians (MD/DO). Years of experience in private practice ranged from 33 years to 50 years with a mean of 39.7 years. All 10 participants were psychoanalysts. Six participants were located in urban areas, two were located in a suburb, one was located in a rural area, and one participant reported having multiple office locations. The age range for pilot study participants was 64 years old to 79 years old (M=71). The group included seven men and three women, and only one participant did not identify as White.

Feedback and changes.

Overall, the feedback from the pilot study was fairly minimal and mostly positive.

Nobody felt any question should be removed. There were two changes, however, that the researcher implemented in direct response to participant feedback. First, it was brought to the researcher’s attention that the category MD/DO for professional licenses (question three) had been unintentionally omitted. This answer choice was therefore simply added.

Second, one of the original inclusionary criteria questions proved to be confusing and unnecessary. In reference to professional licenses held, the question read, “Do you hold at least a master’s degree associated with that license?” After feedback and further thought, the researcher concluded that the criteria of being in private practice for at least five years was sufficient. The question was eliminated from the eligibility criteria but moved to a later portion of the survey (Question 26). This created another independent variable for

70 analysis (level of education), bringing the study to its current total of 25 independent variables (as opposed to 24 independent variables at the proposal stage of this research).

There was one change the researcher implemented that was not related to participant feedback. The format of the VTAS items on the survey was changed from a matrix to individual questions. This was done in an effort to prevent participants from glazing over items or moving too quickly. The researcher considered using page breaks between each VTAS item as well, but when tested, this proved to slow the process down and risk reducing completion rates.

Finally, there was some participant feedback that did not result in any changes. First, there was some confusion over the word “eclectic” in reference to question 26, “How would you describe your specific psychodynamic theoretical orientation?” The researcher chose to let this question remain the same because it offered an “other” option and an opportunity for participants to write-in any further thoughts or clarifications about their theoretical orientation. Second, there was some expression of discomfort or feeling intruded upon by the questions related to income. The researcher decided to keep those questions because they could produce meaningful results, and because the participant did not necessarily feel they should be removed. There were also a few concerns about the breadth of the survey. Participants would have liked to see a longer, more nuanced survey about the more subtle differences between video therapy and face-to-face therapy. And while the researcher also believes that could be useful, this study is only meant to be an initial exploration. More research will be needed, and the feedback from this pilot study indicated that participants are eager to share their perspectives.

71 Data Collection Data collection involved posting a hyperlink to the survey on professional listservs, social media and through direct emails. This section outlines the recruiting efforts made and the decision process for determining when data collection could be determined complete.

Recruiting efforts.

Data collection began with a post (Appendix F) on five professional listservs including the American Psychoanalytic Association (APsaA), the American Association for Psychoanalysis in Clinical Social Work (AAPCSW), Division 39 of the American Psychological Association (Society for Psychoanalysis and Psychoanalytic Psychology), the National Association of Social Workers, the Psychotherapy Action Network (PsiAN), and APsaA’s listserv for psychotherapy associates. Posts were repeated for each listserv up to three times at approximately one-week intervals.

Although clinicians were responsive through those listservs, the researcher could recognize that additional efforts would be needed to reach minimum sample size requirements for as many exploratory variables as possible. Therefore, the same post was made on Facebook through three different professional groups including LCSW connection, Loyola University Chicago Graduate School of Social Work Alumni, and Psychodynamic Counseling and Psychotherapy. Additionally, the researcher sent direct emails to over 200 clinicians through Psychology Today using filters to identify psychodynamic clinicians across the country and to target those who matched

72 demographic characteristics of subgroups needed for data analysis (i.e. location, license, race, gender, etc.).

Finally, because the sample was severely limited in terms of racial diversity, the researcher attempted to post the link on the listservs for The Association of Black Psychologists (ABPSI) and the National Latinx Psychological Association (NLPA).

Only members could post directly, so the researcher contacted the administrators of each.

It was unclear whether or not the link was posted, as there was no response to the email.

Determining completion.

After approximately three weeks of these recruiting efforts, the response rate dramatically declined (see Figure 1), and the researcher took stock of subgroup sample sizes to determine how much more recruiting should be done. All nine variables for Pearson’s correlations (including the two associated with the study’s central null hypotheses) had surpassed the minimum sample requirement of 85. Of the variables intended for other statistical analysis, some were close to meeting minimum sample size requirements, and some were clearly never going to achieve that. Recruiting continued until minimum sample sizes were met for any of the variables that were still feasible. The basis of these determinations is discussed below, but the details are also presented in Appendix G.

73 Figure 1.

# of responses (per day)

Survey Response Rates 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

Day (October 29, 2019 - December 1, 2019)

These recruiting efforts resulted in 206 total responses. However, 19 of those responses were disqualified based on their answers to the inclusionary criteria questions. An additional 39 respondents did not complete the survey. Those 58 responses were deleted, resulting in a total sample size of 148 (N=148). Again, all nine variables intended for Pearson’s correlation met the minimum sample size requirement of 85. Of the eight variables intended for independent sample t-tests, only two met the minimum requirement of 64 participants in each of two subgroups. Those variables were ‘psychoanalyst vs. non-analyst’ and ‘on an insurance panel vs. not on an insurance’. The remaining six variables demonstrated too great of an imbalance to warrant further recruiting efforts. For example, 137 participants reported they offer some type of sliding scale, while only 9 did not. But even for variables that were slightly more balanced, further recruiting efforts were unlikely to be fruitful. For example, 52 participants reported feeling some discomfort or awkwardness through video in general and 94 did not. And for 52 to reach the minimum of 64 (at roughly 1/3 of participants reporting

74 discomfort), roughly 36 more participants would need to be recruited. Based on dwindling response rates, that seemed highly unlikely to happen.

The variables intended for ANOVA were also limited in sample size. Those needed three or more subgroups of 52 participants each, and none of them were close to meeting that requirement. That was due to either an imbalance (similar to the t-tests just described) or to an overbalance of subgroups. The variable ‘theoretical orientation’ provides an example of overbalance. Twenty-five answered “object relations,” 6 answered “ego psychology,” 7 answered “self psychology,” 43 answered “relational,” 45 answered “eclectic,” and 20 answered “other.” In this example, not one subgroup reached the minimum size of 52, and there was no logical or meaningful way to combine subgroups to allow for further analysis.

However, for two of the eight variables intended for ANOVA, subgroup sample sizes allowed for independent-samples t-tests to be run instead. First, for ‘professional license’, 66 participants were social workers, 67 were psychologists, one was a counselor, and 12 were physicians (MD/DO). Therefore, a t-test (requiring two subgroups of 64) could be run between social workers and psychologists. The counselors and physicians (MD/DO) were just excluded from this part of analysis. Second, for ‘practice location’, 81 were located in an urban area, 51 were located in a suburban area, 8 were located in a rural area, and 6 were located in another type of area (i.e. college town, multiple locations). In this instance, there were enough participants in the ‘urban’ subgroup and all other subgroups could be combined to run a t-test between the subgroups ‘urban’ and ‘other’.

Again, this was only possible for two variables, for with the remaining six variables intended for ANOVA, there was either too great of an imbalance or no meaningful way

75 to combine subgroups. To close the survey and end recruiting, the result would be nine Pearson’s correlations, four independent-samples t-tests, and zero ANOVAs. It was determined to be highly unlikely that further recruiting efforts would change that. The survey was therefore closed after a total of 34 days.

Representativeness of sample.

One of the difficulties in studying the population of psychodynamic clinicians in private practice is that there is no way to identify the size of the total population, let alone the demographics of the total population. There is no known national registry for either psychodynamic clinicians or clinicians in private practice. Professional associations and listservs can provide some insight into those statistics, but there is some overlap and many clinicians choose not to participate at all. Still, it may be of some use to consider how the sample for this study compares to some segment of the population with the information that is available.

According to a 2018 survey of the American Psychoanalytic Association (APsaA), their membership is comprised of 2,880 members (not including academic associate and honorary members). 51.2% are male, 48.8% are female, and 29.8% of the membership are below the age of 60. In terms of educational background and professional license, 61.9% are “MD/DO,” 26.1% are “PhD/PsyD,” 8.0% are “social work,” 2.7% are “MA/MS,” and 1.3% are “other.” Racial demographics for the membership were not available, but according to former APsaA president, Dr. Mark Smaller (personal communication, January 2, 2020), he started a diversity committee during his presidency because people of color constituted less than 3% of the membership. Again, there is no

76 way of knowing how well APsaA represents the population of psychodynamic clinicians in private practice, but it provides at least some point of reference for the sample in this study. These statistics indicate that the current sample probably has more women and more social workers than the larger population but is fairly representative in terms of age and race. But again, it could also be that clinicians of particular demographics choose to belong to other professional associations or no associations at all.

Data Management To begin data management, the data set was first checked for errors (Pallant, 2016).

There were not any errors or entries out of range detected. However, when respondents were asked to provide an answer involving currency, there were a few issues. First, the answers were not entered in the same format. For example, those who earned $175,000 in 2018 may have entered “$175k,” “175,000,” “about 175k” or something similar. Second, instead of providing a single amount, some participants provided a range (i.e. $150175k). And finally, those who were not comfortable answering the question entered a comment rather than a numerical value (i.e. “prefer not to answer”). The questions with a different format were simply made uniform (i.e. 175000), and the answers with either ranges or comments were deleted from the data set. These issues indicated that the question should have asked for a specific format. However, it did not impact the ability to run statistical analysis on these questions, for there were still large enough sample sizes for each.

Once the data was cleared of these issues, the data set was changed according to the codebook (Appendix E). Variable labels were abbreviated, and subgroups were given

77 numerical values for data analysis. For the VTAS, composite scores needed to be calculated by adding together the numerical value for each item. This meant assigning a value of 1 – 5 (1= strongly disagree; 5= strongly agree) for all positively stated items (i.e.

“Using video therapy would help people learn about themselves”) and a value of 1 – 5 (1= strongly agree, 5= strongly disagree) for all negatively stated items (i.e. “I would dread trying to understand my patient’s problems through video”). All 16 items were then totaled for each participant and a new column labeled “VTAS” was generated.

Finally, there were also preparations that needed to be made in order to run the splithalf reliability test. Rather than totaling all 16 VTAS items, two columns were created by adding together each half of VTAS items that were assigned by the random number generator. The resulting columns were labeled “Split1” and “Split2” and were thus prepared for a Pearson’s correlation to be run between the two groups.

Reliability and Composite Scoring Composite scoring of the VTAS. The VTAS was comprised of 16 items, each containing the answer choices “Strongly Agree,” “Agree,” “Neutral,” “Disagree,” and “Strongly Disagree.” A value of 1 – 5 was assigned to each answer choice (5=Strongly agree; 1=Strongly disagree), but again, some items were negatively stated and therefore reversed for scoring (1=Strongly agree; 5=Strongly disagree). Item 9 provides an example of a positively stated item with regular scoring: “Using video therapy would help people learn about themselves.” Item 11 provides an example of a negatively stated item with reverse scoring: “I would dread trying to understand my patients’ problems through video.” Participants’ scores for the 16

78 items were then added together to produce a VTAS score that ranged from 16 – 80. A total of 148 participants (N=148) were included in the sample. The actual VTAS scores ranged from 20 – 78 with a mean score of 51.51 and a standard deviation of 13.179.

Reliability testing.

The split-half method and Chronbach’s alpha were conducted with both the pilot study data and final survey data to test reliability of the VTAS. Both tests are designed to determine how well the components of a survey instrument (i.e. Likert scale surveys) measure what it intends to measure (Statistics Solutions, 2019), and in this case, they were used to measure how well the VTAS actually measures attitudes towards video therapy.

Split-half method.

To conduct the split-half method, a random number generator (found online) was used to randomly split the 16 VTAS items into two groups (8 and 8). For the pilot study data, the following two groups resulted: Group 1: Items 9, 11, 12, 13, 18, 20, 21, and 23 Group 2: Items 10, 14, 15, 16, 17, 19, 22, and 24.

For the final survey data, the random number generator was used once again, and this time the resulting two groups were as follows: Group 1: Items 9, 12, 14, 17, 18, 20, 22, 24 Group 2: Items 10, 11, 13, 15, 16, 19, 21, 23

79 Each half of the VTAS was scored for each participant in each data set, and then a Pearson’s correlation coefficient between the two groups for each data set was found. If the VTAS is to be considered reliable, the scores from each half should closely correlate. Pearson correlation coefficients range from -1 to 1, where “a correlation of 0 indicates no relationship at all, a correlation of 1 indicates a perfect positive correlation, and a value of -1 indicates a perfect negative correlation” (Pallant, 2016, p. 137). And while the value is subject to interpretation, Pallant (2016) references Cohen (1988), and suggests that a coefficient (“r”) of 0.5 to 1.0 is strong (Pallant, 2016).

The Pearson’s correlation coefficient in the split-half method for the pilot study was .950, significant at the .01 level. This indicates a very strong positive correlation between the two halves and lends support to the reliability of the VTAS as an instrument (Pallant, 2016). The Pearson’s correlation coefficient in the split-half method using the final data set was .887, also significant at the .01 level. This also indicates a very strong correlation between the two halves and lends further support to the reliability of the VTAS as an instrument (Pallant, 2016).

Chronbach’s alpha.

The second reliability test, Chronbach’s alpha, uses the following formula (Tavakol & Dennick, 2011): Nxc a = ------------v + (N-1) c “N” represents the number of items, “c” represents the average covariance between item parts, and “v” represents the average variance. The solution is expressed as a number

80 between 0 and 1, and in general, the higher the Chronbach’s alpha, the stronger the internal consistency or reliability. A score of 0.7 or greater is considered acceptable (Statistics Solutions, 2018). For the pilot study’s data set, the Chronbach’s alpha coefficient was .956, and for the final survey data set, the Chronbach’s alpha coefficient was .940. These results are considered very strong, and they lend substantial support to the reliability of the VTAS as an instrument (Pallant, 2016).

Statistical Analysis There was one dependent variable and 25 independent variables involved in this study.

The dependent variable, ‘attitude towards video therapy’ was a composite of 16 items that are also of individual interest. Of the 25 independent variables considered, some met minimum sample size requirements for statistical analysis while others did not. All of this information is covered in this section with the following organizational structure: 1) descriptive statistics of the VTAS, 2) descriptive statistics of independent variables, 3) summary of statistical analyses conducted, 4) Pearson’s correlation findings, 5) independent sample t-test findings, and 6) research question findings.

Descriptive statistics of the VTAS. With a sample size of 148 (N=148), the VTAS scores ranged from 20 to 78 with a mean score of 51.51 and a standard deviation of 13.179. The descriptive statistics for each individual VTAS item are also of interest, and they are presented in Table 1.

Appendix H presents the same information in visual format.

81 Table 1 Frequencies of Individual VTAS Items Item

VTAS Statement

SA

A

N

D

SD

9

Using video therapy would help people learn about themselves

33

62

38

14

1

10

If a friend had personal problems, I might encourage him or her to consider video therapy.

14

31

30

48

25

11

I would dread trying to understand my patient’s problems through video.

12

16

24

59

37

12

I think it would be worthwhile to discuss patients’ problems through video.

25

55

44

21

3

13

If video therapy were available at no charge, I think people should consider trying it.

25

22

45

38

18

14

I think patients can experience symptom reduction by participating in video therapy.

32

69

42

4

1

15

I think it is difficult if not impossible to provide an adequate holding environment for patients through video.

16

29

25

48

30

16

I think patients and therapists can have a strong working alliance through video.

36

55

32

20

5

17

I think any benefits patients might gain from video therapy would take a very long time to emerge.

3

15

54

57

19

18

I would have major concerns about protecting patients’ confidentiality through video, even if I remained

13

26

24

58

27

82 HIPAA compliant.

19

I think video therapy can be just as effective as face-to-face therapy.

12

25

26

44

41

20

I think therapists have an ethical responsibility to consider providing video therapy.

7

23

44

47

27

21

I think it is difficult if not impossible to address transference issues with patients through video.

5

27

29

61

26

22

I would be happy to provide video therapy if I had a patient who was specifically asking for it.

30

34

33

41

10

23

Even if I could easily bill insurance for video therapy, I still would not provide it.

15

22

28

41

42

24

I think clinicians should meet a patient at least once in person before providing video therapy.

74

36

26

8

4

Note: SA = Strongly Agree; A= Agree; N = Neutral; D = Disagree; SD = Strongly Disagree

Descriptive statistics of independent variables.

Data was collected for 25 independent variables. While the total sample size was 148 (N=148), some participants chose not to answer some of the questions. Therefore, the sample sizes for some variables will vary. And again, while some variables met minimum sample size requirements for statistical analysis, some did not. This section addresses each variable individually by reviewing the associated survey question, presenting the descriptive data on participant responses, explaining whether or not sample size requirements were met, and outlining which statistical analyses were ultimately conducted (if any).

83 Type of license.

Question 3 was multiple choice and it read, “Which of the following professional licenses do you currently hold?” Answer choices included “social work,” “psychology,” “counseling,” “MD/DO” and “Other.” The “other” category was not part of data analysis because any participant with that answer was disqualified from the study. All 148 participants provided a valid answer to this question for a total sample size of 148 (N=148). Sixty-seven or 45.3% identified as social workers, 68 or 45.9% identified as psychologists, 1 or 0.7% identified as counselors, and 12 or 8.1% identified as physicians (MD/DO). The low number of counselors was likely because the researcher had greater access to professional listservs in the other professional communities.

ANOVA was the intended statistical test for this variable, and a minimum of 52 participants was needed for each sub-group. Only the subgroups ‘social worker’ and ‘psychologist’ met that requirement, so an ANOVA could not be run. However, because each of those subgroups reached the even larger sample size requirement of 64 for a t-test (64 and 69 respectively), a t-test was conducted to compare VTAS scores for social workers and psychologists. Results of the t-test are discussed in the following section.

Experience in private practice.

Question 7 read, “How many years have you been in private practice?” and participants were able to write in their answers. One participant did not provide a valid answer (provided a range) for a total sample size of 147 (N=147). Years of experience in private practice ranged from 5 to 50 years with a mean of 24.04 years and a standard deviation of 12.613. Because this is a continuous variable, Pearson’s correlation was the

84 intended statistical test, and a minimum of 85 participants was required. Again, the total sample size was 147 (N=147), and the Pearson’s correlation was therefore conducted as planned.

Psychoanalyst.

Question 25 was multiple choice and it read, “Are you a psychoanalyst?” Participants could choose to answer either “yes” or “no.” All 148 participants provided a valid answer to this question for a total sample size of 148. Seventy-five or 50.7% answered “yes” and 73 or 49.3% answered “no.” With two sub-groups, an independent-samples t-test was intended, and a minimum of 64 participants was required for each subgroup. With two fairly balanced subgroups of 75 psychoanalysts and 73 non-analysts, the independentsamples t-test was conducted as planned.

Level of education.

Question 26 was multiple choice and it read, “What is your highest level of completed education?” Again, all 148 participants provided a valid answer to this question for a total sample size of 148. Eleven or 7.4% answered “MD,” 59 or 39.9% answered “PhD,” 20 or 13.5% answered “PsyD,” 12 or 8.1% answered “MA,” and 46 or 31.1% answered “Other.” For those who answered “Other,” participants were given an opportunity to type-in an answer, and 27 participants entered “MSW.” This indicated that the question should have been more clearly worded, for an MSW is considered a master’s level degree. Had those respondents been included in the option “MA,” that subgroup would

85 have totaled 39 or 26%. The other most common themes among “other” responses included psychoanalytic training and/or more than one degree.

ANOVA was the intended statistical test for this variable, and a minimum of 52 participants was needed for each sub-group. Due to an overbalance of subgroups, none were able to reach the minimum requirement, and ANOVA could not be conducted.

Also, there was no meaningful way to combine these subgroups for a t-test. For instance, a t-test could have been conducted between PhDs and all other groups, but the other groups do not share enough in common when compared to a PhD to justify that grouping.

Therefore, no statistical analysis beyond the above descriptive statistics was conducted.

Theoretical orientation.

Question 27 was multiple choice and it read, “How would you describe your specific psychodynamic theoretical orientation?” All 148 participants provided a valid answer.

Twenty-six or 17.6% answered “object relations,” 6 or 4.1% answered “ego psychology,” 7 or 4.7% answered “self psychology,” 43 or 29.1% answered “relational,” 46 or 31.1% answered “eclectic,” and 20 or 13.5% answered “other.” For those who answered “other,” participants were given an opportunity to type-in an answer, and there was a wide variety of answers without any strong themes. Some of the more common answers included “integrative,” “Jungian” and “modern” or “contemporary psychoanalysis.”

ANOVA was the intended statistical test for this variable, and a minimum of 52 participants was needed for each sub-group. Again, the subgroups for this variable were too balanced and none were able to meet minimum sample size requirements. And once

86 again, there was no meaningful way to combine subgroups for a t-test. Statistical analyses beyond the descriptive statistics were therefore not possible.

Practice location.

Question 28 was multiple choice and it read, “How would you describe the physical location of your private practice?” All 148 participants provided a valid answer to this question. Eighty-one or 54.7% answered “urban,” 53 or 35.8% answered “suburban,” 8 or 5.4% answered “rural,” and 6 or 4.1% answered “Other.” For those who answered “Other,” participants were given an opportunity to type-in an answer, and these answers indicated that they were located in either a small city, a college town or multiple locations.

ANOVA was the intended statistical test for this variable, and a minimum of 52 participants was needed for each sub-group. This requirement was not met, but with 81 participants who answered “urban,” it made sense to combine “suburban,” “rural” and “other” to create the larger subgroup “non-urban.” This allowed for an independentsamples t-test (requiring two subgroups of 64) to be conducted between “urban” (81 participants) and “non-urban” (67 participants).

Clinical sessions per week.

Question 29 read, “On average, how many clinical sessions per week are you currently conducting with patients?” and participants were able to write in their answers. Of the148 participants, 138 provided a valid answer to this question. The number of clinical sessions per week ranged from 1 to 60 hours with a mean of 22.496 hours and a standard

87 deviation of 10.7109. Because this is a continuous variable, Pearson’s correlation was the intended statistical test, and a minimum of 85 participants was required. Again, the sample included 138 participants, and therefore, the Pearson’s correlation was conducted as planned.

Gross income 2018.

Question 30 read, “What was your gross annual income for your private practice in 2018?” and participants were able to write in their answers. Of the 148 participants, 120 provided a valid answer to this question. Gross income for 2018 ranged from $1,000 to $450,000 with a mean of $119,920.83 and a standard deviation of $83,290.72. Because this is a continuous variable, Pearson’s correlation was the intended statistical test, and a minimum of 85 participants was required. Again, the sample included 120 responses, so the Pearson’s correlation was conducted as planned.

Regular fee.

Question 31 read, “What is your current regular fee?” and participants were able to write in their answers. Some participants were not comfortable divulging this information and chose to enter “N/A” or something comparable. Of the 148 participants, 130 provided a valid answer to this question. Regular fee ranged from $80 to $400 per clinical hour with a mean of $186 and a standard deviation of $59.55. Because this is a continuous variable, Pearson’s correlation was the intended statistical test, and a minimum of 85 participants was required. Again, the sample included 130 responses, so the Pearson’s correlation was conducted as planned.

88 Sliding scale.

Question 32 was multiple choice and it read, “Do you offer a sliding scale of any kind?” Participants could choose to answer either “yes” or “no.” If they answered “yes,” they were asked to specify the lowest fee they currently accept. All 148 participants provided a valid answer to this question (139 participants or 93.9% answered “yes” and 9 participants or 6.1% answered “no”). With two sub-groups, an independent-samples t-test was intended, and a minimum of 64 participants was required for each subgroup. Because such a large percentage of participants offer some kind of sliding scale, it became clear that the minimum of 64 participants for sub-group “no” was not going to be met.

Therefore, this variable was not able to be tested for further data analysis.

Lowest fee.

Again, question 32 was multiple choice and it read, “Do you offer a sliding scale of any kind?” Participants could choose to answer either “yes” or “no.” If they answered “yes,” they were asked to specify the lowest fee they currently accept. Of the 139 participants that answered “yes” 132 participants provided a valid answer to this question. The lowest fee accepted ranged from $0 to $280 with a mean of $78.26 and a standard deviation of $47.25. Because this is a continuous variable, Pearson’s correlation was the intended statistical test, and a minimum of 85 participants was required. Again, the sample included 132 responses, so the Pearson’s correlation was conducted as planned.

89 Insurance panel.

Question 33 was multiple choice and it read, “Do you currently provide any innetwork care as a member of any insurance provider’s panel?” Participants could choose to answer either “yes” or “no.” All 148 participants provided a valid answer to this question (75 participants or 50.7% answered “yes” and 73 participants or 49.3% answered “no”). With two sub-groups, an independent-samples t-test was intended, and a minimum of 64 participants was required for each subgroup. Both of these subgroups surpassed the minimum size requirement, and an independent-samples t-test was therefore conducted as planned.

Medicaid.

Question 34 was multiple choice and it read, “Do you accept Medicaid?” Participants could choose to answer either “yes” or “no.” All 148 participants provided a valid answer to this question (16 participants or 10.8% answered “yes” and 132 participants or 89.2% answered “no”). With two sub-groups, an independent sample t-test was intended, and a minimum of 64 participants was required for each subgroup. With such a large imbalance, it was clear that the requirements for a t-test would not be met. Therefore, no statistical analysis beyond descriptive statistics was conducted.

Medicare.

Question 35 was multiple choice and it read, “Do you accept Medicare?” Participants could choose to answer either “yes” or “no.” All 148 participants provided a valid answer to this question (49 or 33.1% answered “yes” and 99 or 66.9% answered “no”). With two

90 sub-groups, an independent sample t-test was intended, and a minimum of 64 participants was required for each subgroup. Again, with such a large imbalance, it was clear that the requirements for a t-test would not be met. Therefore, no statistical analysis beyond descriptive statistics was conducted.

Caseload age demographics.

Question 36 was multiple choice and it read, “Which of the following best describes your current caseload?” All 148 participants provided a valid answer to this question (125 participants or 84.5% answered “mostly adults,” 1 participant or 0.7% answered “mostly children and/or adolescents,” and 22 participants or 14.9% answered “a fairly balanced mixture of adults, children and/or adolescents”). ANOVA was the intended statistical test for this variable, and a minimum of 52 participants was needed for each sub-group. It became clear that the minimum sample size for two of the three subgroups was not going to be met, statistical analysis beyond descriptive analysis could therefore not be conducted.

Caseload racial demographics.

Question 37 was multiple choice and it read, “Does more than 50% of your current caseload belong to any one particular racial group?” Participants could choose to answer either “yes” or “no.” If they answered “yes,” they were also asked to specify which racial group. All 148 participants provided a valid answer to this question (121 participants or 81.8% answered “yes” and 27 participants or 18.2% answered “no”). Of the 121 participants who answered “yes,” 113 or 93% specified white/Caucasian, 3 or 2.5%

91 specified a racial group other than white/Caucasian, and 5 or 4% entered some other answer (i.e. “not comfortable saying”).

With two sub-groups, an independent-samples t-test was intended, and a minimum of 64 participants was required for each subgroup. It became clear that the minimum sample size for category “no” was not going to be met, so further statistical analysis could not be conducted.

Years of experience providing video therapy.

Question 38 read, “Approximately how many years have you provided video therapy as a therapist or analyst?” and participants were able to write in their answers. Of the 148 participants, 146 provided a valid answer to this question. Experience providing video therapy ranged from zero to 25 years with a mean of 3.747 years and a standard deviation of 4.58 years. Because this is a continuous variable, Pearson’s correlation was the intended statistical test, and a minimum of 85 participants was required. Again, the sample included 146, and the Pearson’s correlation was therefore conducted as planned.

Years of experience receiving video therapy.

Question 39 read, “Approximately how many years have you received video therapy as a patient?” and participants were able to write in their answers. Of the 148, 143 participants provided a valid answer to this question. Experience receiving video therapy ranged from zero to eight years with a mean of .36 years and a standard deviation of 1.27 years. Because this is a continuous variable, Pearson’s correlation was the intended

92 statistical test, and a minimum of 85 participants was required. Again, the sample included 143, and the Pearson’s correlation was therefore conducted as planned.

General discomfort with video.

Question 40 was multiple choice and it read, “In general, do you feel uncomfortable or awkward meeting with people over video?” Participants could choose to answer either “yes” or “no.” All 148 participants provided a valid answer to this question (52 participants or 35.1% answered “yes” and 96 or 64.9% answered “no”). Those who answered “yes” were given the opportunity to say more. Of the 52 participants who answered “yes,” 35 participants or 67.3% chose to enter a comment. The most common themes included a mere preference for face-to-face interaction and the feeling of “something missing” in an exchange over video. There were also comments related to technology issues, things feeling “artificial,” feeling distracted, and having to learn or get used to the differences. With two sub-groups, an independent-samples t-test was intended, and a minimum of 64 participants was required for each subgroup. It became clear that the imbalance of subgroups was too great to meet minimum requirements, and therefore, no further statistical analysis could be conducted.

Negative experience.

Question 41 was multiple choice and it read, “Have you ever experienced a particularly negative incident related to video therapy” Participants could choose to answer either “yes” or “no.” All 148 participants provided a valid answer to this question (26 or 17.6% answered “yes” and 122 or 82.4% answered “no”). Those who answered

93 “yes” were given the opportunity to say more, and 18 or 69.2% chose to enter a comment. The strongest theme related to issues with technology. Other comments included adverse reactions in the patient, intense feelings of discomfort by the therapist, and concerns about the disregard of behavioral expectations in the therapeutic process by the patient and/or therapist. With two sub-groups, an independent-samples t-test was intended, and a minimum of 64 participants was required for each subgroup. Again, with such a large imbalance between subgroups, minimum requirements were not met, and no further statistical analysis could be conducted.

Familiarity with research.

Question 42 read, “How familiar are you with research related to video therapy?” and participants were asked to indicate their answer on a slider that ranged from 0 (not at all familiar) to 100 (extremely familiar). All 148 participants provided a valid answer to this question. Familiarity with research related to video therapy ranged from zero to 100 with a mean of 33.07 and a standard deviation of 28.646. Because this is a continuous variable, Pearson’s correlation was the intended statistical test, and a minimum of 85 participants was required. Again, the sample included 148, and the Pearson’s correlation was therefore conducted as planned.

Age. Question 43 read, “What is your age?” and participants were able to write in their answer. Of the 148 participants, 147 provided a valid answer to this question. The age of participants ranged from 35 to 80 years old with a mean of 61.53 years old and a standard

94 deviation of 11.316. Because this is a continuous variable, Pearson’s correlation was the intended statistical test, and a minimum of 85 participants was required. Again, the sample included 147 responses, and the Pearson’s correlation was therefore conducted as planned.

Race.

Question 44 was multiple choice and it read, “Which of the following best describes your racial identity?” All 148 participants provided a valid answer to this question (139 participants or 93.9% answered “white,” 2 participants or 1.4% answered “Hispanic or Latino,” zero answered “Black or African American,” zero answered “Native American or American Indian,” zero answered “Asian or Pacific Islander,” three or 2.0% answered “some combination of the above” and 4 or 2.7% answered “other”). Those that answered “other” were asked to specify, and three out of the four responses indicated that the choices provided were outdated. Only the fourth response gave some indication of how he or she self-identifies in terms of race. Based on these answers, the question may have needed to better reflect the most current and appropriate way to capture racial and ethnic demographics. For the current study, because nearly all participants identified with the racial categories listed, this limitation did not affect results.

ANOVA was the intended statistical test for this variable, and a minimum of 52 participants was needed for each sub-group. The minimum sample size for every subgroup other than “white” was clearly not going to be met, and this variable could therefore not be included in further statistical analysis.

95 Gender.

Question 45 was multiple choice and it read, “What is your gender?” All 148 participants provided a valid answer (38 participants or 25.7% answered “male,” 110 or 74.3% answered “female,” and zero answered “other”). ANOVA was the intended statistical test for this variable, and a minimum of 52 participants was needed for each sub-group. It became clear that not only were the minimum sample sizes for an ANOVA not going to be met, but there would not be enough males to conduct a t-test either.

Analysis beyond the descriptive statistics could therefore not be conducted.

Additional comments.

Question 46 read, “Is there anything else you would like to add?” and participants were given the opportunity to write in their answers. Of the total sample (N=148), 101 or 68% of participants chose to enter a comment. For descriptive analysis, comments were separated into 231 segments or units for analysis, and the following 10 themes were identified: 1. importance of context, 2. comparison of face-to-face therapy, 3. difficulty with survey, 4. support of video therapy or research, 5. concerns about video therapy, 6. background information, 7. suggestions for improving video therapy, 8. therapy via telephone,

96 9. openness to learning, and 10. clarification of answers.

ANOVA was the intended statistical test for this variable, and a minimum of 52 units was needed for at least three subgroups or themes. Only one theme met this requirement, so further statistical analysis was not possible. The descriptive analysis, however, is presented below and numerically summarized in Table 4.

Table 2 Descriptive Statistics of Additional Comments (N=231) Theme

Frequency

Importance of Context

79

Good for travel or after a move

20

Importance of established relationship

18

Depends on the person or symptoms

12

Good for those living in remote areas

11

Good option if unable to get to office

8

It depends (vaguely stated)

8

Perhaps useful for other types of therapy

1

Comparison of face-to-face therapy

33

Face to face is better or preferable

26

What video therapy specifically lacks

7

Difficulty with survey Difficult to answer questions

30 17

% 34.2%

14.3%

13.0%

97 Wrong questions being asked

8

General dissatisfaction

5

Support of video therapy or research

26

Appreciation of research

15

Video therapy is a good option

8

The use of video therapy will expand

3

Concerns about video therapy

22

Confidentiality

6

More severe cases

5

Quality of interaction

5

Breaking therapeutic ‘rules’

2

Effect of distance and technology

2

Background information

9.5%

20

Level of familiarity with video therapy

12

Experience in educational setting

5

Efforts to support video therapy

3

Suggestions for improving video therapy

7

For the therapeutic dyad

4

For the professional field

3

Therapy via telephone

11.3%

7

Video therapy is better or preferred

5

What video therapy is specifically lacking

2

8.7%

3.0%

3.0%

98 Openness to learning about video therapy

4

Not opposed to video therapy

2

Learn about effectiveness

1

Open if becomes more comfortable

1

Clarification of survey answers

3

Regarding “neutral” responses

2

Regarding terminology

1

1.7%

1.3%

Importance of context.

Of the 231 comment segments, 79 or 34.2% were centered around the feeling that context is critical when thinking about the use of video therapy. Within this theme, there were eight sub-themes that emerged: 21 mentioned that video therapy may be appropriate for use during travel or after a move, 18 mentioned the importance of an established relationship with the patient prior to using video therapy, 12 mentioned that it depends on the person or the symptom that is being addressed (i.e. older people, military families, those in chronic pain, etc.), and 11 mentioned that video therapy may be a good option for those living in remote areas. Eight mentioned it may be useful for those who cannot get to the office due to weather, traffic or some other limitation, and eight were somewhat vague in their indication of when video therapy would be appropriate (i.e. “in unanticipated circumstances” or “it depends”). Finally, one stated it may be useful for other types of therapies “that do not heavily rely on unconscious process.”

99 Comparison of face-to-face therapy.

Of the 231 comment segments, 33 or 14.3% drew some comparison to face-to-face treatment: 26 of those indicated that face-to-face therapy was categorically either a personal preference or objectively superior to video therapy (i.e. “I much prefer face to face therapy” or “Video therapy is better than nothing but not nearly as good as in person therapy.”). The remaining seven comments pointed to something missing from face-toface treatment (“Much is missed particularly in terms of unconscious communication, ability to discern countertransference and/or enactments”).

Difficulty with survey.

Of the 231 comment segments, 30 or 13.0% made a criticism or indicated some difficulty with the survey itself: 17 of those mentioned that the questions were difficult to answer without further context (i.e. “It is hard to answer categorically whether I approve or disapprove of video therapy – it just depends!”). Eight indicated that the survey was asking the “wrong” questions (i.e. “Some of your questions are the wrong ones to ask” or “[The survey] does not get at the significant questions about video therapy”), and the remaining five took some issue with the survey as a whole (i.e. “Your questionnaire jumps around”).

Support of video therapy or research.

Of the 231 comment segments, 26 or 11.3% said something positive or expressed gratitude for conducting this research: 15 of those expressed appreciation for either research in general or the current study (i.e. “I feel research related to telehealth is very

100 important in determining how telehealth can be beneficial” or “Thanks for doing this study”). Eight took the opportunity to reiterate that video therapy is a good option (e.g.

“Necessity is the mother of invention! The technology is helpful and important, in my opinion”). The remaining three comment segments centered around the belief that the trend in the use of video therapy would continue to increase (i.e. “Five years from now I predict that 80% of all therapy will be delivered via video conferencing”).

Concerns about video therapy.

Of the 231 comment segments, 22 or 9.5% mentioned concerns about video therapy.

Of those, six were focused on issues related to confidentiality (“The problems lie with psychoanalysts thinking they are above HIPAA”). Five expressed concerns related to the more severe cases (i.e. “There are limitations with persons diagnosed with severe mental health issues” or “I also worry about my own ability to detect risk with clients via video”). Five were concerned about the quality of patient-therapist interactions (i.e. “It deprives both participants of more affective engagement and the experience of being alone together”). Two mentioned concerns about either patient or therapist breaking the ‘rules’ of treatment (i.e. “eating and texting”). And finally, two mentioned concerns about the effect that distance and technology can have on the dyad (i.e. “Whatever is at the seat of road rage and other ‘anonymous’ persona seems to be activated by the distance in one’s mind while conducting analysis”).

101 Background information.

Of the 231 comment segments, 20 or 8.7% provided some type of background information about themselves: 12 of those made reference to their level of familiarity with video therapy (i.e. “I have never conducted video therapy, so I don’t really have much to say one way or another” or “Most of my video is with patients in China”). Five mentioned something about their educational experience in general or involving technology (i.e. “I’m studying to be a psychoanalyst” or “I teach some courses online”), and three mentioned something about their involvement in the promotion of video therapy (i.e. “I’m working with a national group of LCSW’s to help us access video therapy across state lines”).

Suggestions for improving video therapy.

Of the 231 comment segments, seven or 3.0% offered some suggestion related to video therapy. Four of those were suggestions for the dyad (i.e. “We both talk about what meeting over video is like”), and three were more geared towards what the field can do (i.e. “Medicare should permit video sessions”).

Therapy via telephone.

Of the 231 comment segments, seven or 3.0% made some mention of therapy via telephone. Of those, five stated that they prefer it to video therapy (i.e. “telephone is my preference to provide continuity in treatment”), and two pointed out that the telephone feels more similar to the use of the psychoanalytic couch.

102 Openness to learning about video therapy.

Of the 231 comment segments, four or 1.7% indicated an openness to learning more about video therapy. Of those, two simply expressed they were “not opposed” or would not “rule it out.” One stated, “I would be open to learning more about the effectiveness of video therapy,” and the other stated, “If there was a way for me to feel more relaxed and comfortable while doing a video session, I would be more open to occasionally doing this.”

Clarification of survey answers.

Finally, of the 231 comment segments, three or 1.3% took the opportunity to clarify something about their answers. Two indicated that their “neutral” responses were mostly out of the need for more information, and the other specified that while he or she indicated a primarily “psychodynamic” theoretical orientation, the term “psychoanalytic” is preferred.

Summary of statistical analyses conducted.

The original intent was to conduct nine Pearson’s correlations, eight independentsamples t-tests, and eight ANOVAs. The group of analyses ultimately conducted, however, includes nine Pearson’s correlations, four t-tests, and no ANOVAs. This section summarizes the justifications for those decisions, and they are best understood by working backwards.

103 ANOVAs. Of the eight ANOVAs intended, zero variables met the minimum subgroup sample size requirement of 52 for at least three subgroups. Two variables met the minimum subgroup sample size requirement for a t-test (two groups of 64) and were therefore changed from ANOVA to independent-samples t-test. The remaining variables intended for ANOVA did not meet subgroup sample size requirements for more than one group and were therefore eliminated from further analysis. Simply stated, while eight ANOVAs were intended, none were ultimately conducted. Again, none of these tests were linked to any of the major study hypotheses.

Independent sample t-tests.

Of the eight independent sample t-tests intended, two met the minimum subgroup sample size requirement of 64 for both subgroups and six did not. Those that did not were eliminated from further analysis. For the two that did, independent-samples t-tests were conducted as planned. Between those and the two intended ANOVAs that changed to t-tests, a total of four independent-samples t-tests were ultimately conducted.

Pearson’s correlations.

All nine of the continuous independent variables met the minimum sample size requirement for Pearson’s correlation of 85. Therefore, as planned, a total of nine Pearson’s correlations were conducted.

104 Findings The previous section outlined the 25 independent variables and one dependent variable (with 16 component parts) that were examined. The data collected for those variables allowed for nine Pearson’s correlations and four independent-samples t-tests to be conducted. This section will outline the findings for each of those 13 analyses. A summary of findings organized by direct response to the four research questions and one overarching research question will be presented in the next section.

Pearson’s correlation findings.

To review, the Pearson’s Correlation analysis is designed to describe the relationship between two continuous variables (variables that provide a ratio level of measurement) (Pallant, 2016). It produces a value from -1 to 1, where the sign indicates the direction of the relationship and the absolute value indicates the strength of the relationship (Pallant, 2016). And while the value is subject to interpretation, Pallant (2016) references Cohen (1988), and suggests that a coefficient (“r”) of .10 to .29 is “small,” .30 to .49 is “medium,” and 0.5 to 1.0 is “large” (Pallant, 2016, p. 137).

The results of the nine Pearson’s correlations that were conducted are presented in Table 3. Of the nine independent variables tested, five were found to have statistically significant relationships with attitude towards video therapy (as measured by VTAS score). The two variables that are associated with the two central null hypotheses were both found to have statistically significant relationships with attitudes towards video therapy (as measured by VTAS score) at the .01 level (2-tailed). The Pearson’s correlation coefficient for ‘years of experience providing video therapy’ was .480 (r =

105 .480), and that of ‘familiarity with research related to video therapy’ was .317 (r = .317).

There were also statistically significant relationships (significant at the .05 level (2tailed)) found between ‘attitudes towards video therapy’ (as measured by VTAS score) and ‘gross income 2018’ (r = .212), ‘regular fee’ (r = .191), and ‘clinical sessions per week’ (r = .169).

All of these correlations were positive, meaning that a more positive attitude towards video therapy (as measured by VTAS score) correlated with more years of experience providing video therapy, a greater familiarity with research related to video therapy, a higher income for 2018, a higher regular fee, and more clinical sessions per week.

Table 3 Pearson’s Correlation Findings Pearson’s Correlation Coefficient

Sig. (2-tailed)

146

r = .480**

.000

Familiarity with research related to VT

148

r = .317**

.000

Years in private practice

147

r = .087

.295

Clinical sessions per week

138

r = .169*

.047

Gross income 2018

120

r = .212*

.020

Regular fee

130

r = .191*

.030

Lowest fee accepted

132

r = -.083

.344

Years of experience receiving VT

143

r = .130

.123

Age

147

r = .110

.186

Independent Variable

N

Yrs. of experience providing VT

** Correlation is significant at the 0.01 level (2-tailed) * Correlation is significant at the 0.05 level (2-tailed)

106 Independent-samples t-test findings.

To review, independent-samples t-tests are used to determine if there is a significant difference between two distinct groups as they relate to a dependent continuous variable (Pallant, 2016, p. 244). The “independent-samples” means there is a comparison between two groups, rather than a comparison of two scores for the same group on different occasions (Pallant, 2016). Independent-samples t-tests were used to analyze four of the independent variables against ‘attitudes towards video therapy’ (as measured by VTAS score). One out of the four variables tested (psychoanalyst vs. non-analyst) was found to have a significant difference between subgroups. The results of the four t-tests are discussed below and summarized in Table 4.

Analyst.

An independent-samples t-test was conducted to compare the VTAS scores for psychoanalysts and non-analysts. There was a significant difference in scores for psychoanalysts (M = 54.64, SD = 12.770) and non-analysts (M =48.30, SD = 1.510); t (146) = 3.004, p = .003, two-tailed). The magnitude of the differences in the means (mean difference = 6.339, 95% CI: -2.169 – 10.509) was moderate (eta squared = .06) (Pallant, 2016). In other words, psychoanalysts were found to have a significantly more positive attitude towards video therapy than non-analysts.

Insurance.

An independent-samples t-test was conducted to compare the VTAS scores for clinicians who are part of an insurance panel and those who are not. There was no

107 significant difference in scores for clinicians on an insurance panel (M = 49.69, SD = 12.976) and those that are not (M =53.38, SD = 13.212); t (146) = -1.714, p = .089, twotailed). The magnitude of the differences in the means (mean difference = -3.690, 95% CI: -7.945 – .564) was small (eta squared = .02) (Pallant, 2016).

License.

An independent-samples t-test was conducted to compare the VTAS scores for social workers and psychologists. There was no significant difference in scores for social workers (M = 49.76, SD = 13.419) and psychologists (M = 52.21, SD = 13.430); t (133) = -1.058, p = .292, two-tailed). The magnitude of the differences in the means (mean difference = -2.445, 95% CI: -7.016 – 2.126) was very small (eta squared = .008) (Pallant, 2016).

Location.

An independent-samples t-test was conducted to compare the VTAS scores for clinicians with practices in urban locations and those with practices in non-urban locations. There was no significant difference in scores for ‘urban’ (M = 52.28, SD =12.108) and ‘non-urban’ (M =50.58, SD = 14.406); t (146) = .781, p = .436, two-tailed).

The magnitude of the differences in the means (mean difference = 1.702, 95% CI: -2.605 – 6.009) was very small (eta squared = .004) (Pallant, 2016).

108 Table 4 Independent Sample T-Test Findings Subgroup 1 (N)

Subgroup 2 (N)

t

Sig (2-tailed)

Psychoanalyst (75)

Non-analyst (73)

3.004

.003*

Insurance panel (75)

No insurance panel (73)

-1.714

.089

Social work (67)

Psychology (68)

-1.058

.292

Urban (81)

Non-urban (67)

.781

.436

Note: * indicates a finding significant at the .05 level

Research question findings.

The overarching research question for this study was, “What variables (if any) influence attitudes towards video therapy among clinicians in private practice with a psychodynamic orientation?” There were also four more specific research questions and two null hypotheses. This section will address each of those and then circle back to summarize the findings by addressing this overarching research question.

Question 1.

The first research question read, “What is the frequency and variation of scores on the Video Therapy Attitude Scale (VTAS) for participants in the study?” These answers were found by looking at descriptive statistics of the VTAS. Appendix I presents the frequencies of VTAS scores, and Figure 2 presents them in visual format. The scores ranged from 20 to 78 with a mean score of 51.51 and a standard deviation of 13.179.

109 Question 2.

The second research question read, “What are the variables (i.e., demographic, professional, etc.) that positively correlate with attitudes towards video therapy?” This answer was determined using Pearson’s correlation. Of the nine variables that were examined for a correlational relationship with ‘attitude towards video therapy’ (as measured by VTAS score) five were found to have a significant relationship, and they were all positive. Those variables were ‘years of experience providing video therapy’, ‘familiarity with research related to video therapy’, ‘clinical sessions per week’, ‘gross income 2018’, and ‘regular fee’. Again, specifics related to the Pearson’s correlations can be found in Table 3.

Question 3.

The third research question read, “What are the variables (i.e., demographic, professional, etc.) that negatively correlate with attitudes towards video therapy?” This answer was also found using Pearson’s correlation. Five of the nine variables that were examined for a correlational relationship with VTAS scores or ‘attitude towards video therapy’ were found to have significant relationship, but none of them were a negative correlation. Therefore, to answer research question three, no variables negatively correlate with attitudes towards video therapy.

110 Figure 2 Frequencies of VTAS Scores

Question 4.

The fourth research question read, “What are the variables (i.e. demographic, professional, etc.) that demonstrate a statistically significant difference between subgroups as they relate to VTAS scores?” The answer to this question was found using independent-samples t-tests. Of the four t-tests conducted, one was found to have a statistically significant relationship with ‘attitude towards video therapy’ (as measured by VTAS score). That variable was ‘psychoanalyst’ with subgroups ‘psychoanalyst’ and ‘non-analyst’. Therefore, in response to research question four, only the variable ‘psychoanalyst’ demonstrates a statistically significant difference between subgroups as they relate to VTAS scores.

Central null hypothesis 1.

The first central null hypothesis read, “There will be no statistically significant relationship between clinicians’ years of experience providing video therapy and attitudes

111 towards video therapy.” Again, a Pearson’s correlation was conducted to determine the relationship between clinicians’ years of experience providing video therapy and ‘attitude towards video therapy’ (measured by VTAS score), and a coefficient of .480 was found.

This indicates a relationship significant at the .01 level. Therefore, central null hypotheses 1 was rejected, for there was, in fact, a statistically significant relationship between clinician’s years of experience providing video therapy and attitudes towards video therapy.

Central null hypothesis 2.

The second central null hypothesis read, “There will be no statistically significant relationship between familiarity with research related to video therapy and attitudes towards video therapy.” Once again, a Pearson’s correlation was conducted to determine the relationship between familiarity with research related to video therapy (measured by a slider scale of 0-100) and ‘attitude towards video therapy’ (measured by VTAS score). A Pearson’s correlation coefficient of .317 was found, significant once again at the .01 level. Central null hypothesis 2 was therefore also rejected, for there was found to be a statistically significant relationship between clinicians’ familiarity with research related to video therapy and attitudes towards video therapy.

Overarching research question.

Circling back, the overarching research question read, “What variables (if any) influence attitudes towards video therapy among clinicians in private practice with a psychodynamic orientation?” The answer to this question lies in the statistically

112 significant results of all the analyses combined. For the Pearson’s correlations, significant relationships were found between ‘attitude towards video therapy’ (as measured by VTAS scores) and years of experience providing video therapy, familiarity with research related to video therapy, clinical sessions per week, gross income 2018, and regular fee.

For the independent-samples t-tests, a statistically significant difference was found between psychoanalysts and non-analysts. Therefore, to answer the overarching research question, all six of the variables mentioned here influence attitudes towards video therapy among psychodynamic clinicians in private practice.

Conclusion To summarize, the six main research findings were as follows: 1. There was a positive correlation (significant at the .01 level) between attitudes towards video therapy (as measured by VTAS score) and years of experience providing video therapy (r =.480) (meaning the more positive the attitude, the more years of experience).

2. There was a positive correlation (significant at the .01 level) between attitudes towards video therapy (as measured by VTAS score) and familiarity with research related to video therapy (r = .317) (meaning the more positive the attitude, the more familiar with research).

3. There was a positive correlation (significant at the .05 level) between attitudes towards video therapy (as measured by VTAS score) and gross income 2018 (r = .212.) (meaning the more positive the attitude, the greater the income).

113 4. There was a positive correlation (significant at the .05 level) between attitudes towards video therapy (as measured by VTAS score) and regular fee (r = .191) (meaning the more positive the attitude the higher the fee).

5. There was a positive correlation (significant at the .05 level) between attitudes towards video therapy (as measured by VTAS score) and clinical sessions per week (r = .169) (meaning the more positive the attitude the more hours per week).

6. There was a statistically significant difference between psychoanalysts and nonanalysts when it comes to attitudes towards video therapy (as measured by VTAS score), where psychoanalysts had a more positive attitude towards video therapy than non-analysts (p = .003).

These six findings provide plenty of information for discussion, but the descriptive statistics and ‘non-findings’ or statistically insignificant findings are also of interest. The discussion in the following chapter will therefore discuss the main research findings, as well as points of interest in both the descriptive data and the statistical analyses where significant relationships were not found.

114

Chapter V

Discussion

This study was conducted to address a deficiency in the literature regarding psychodynamic video therapy. The use of video has shown to be effective in other types of treatment (Mallen et al., 2005; Backhaus et al., 2012; Rees & MaClaine, 2015), but there is significant reluctance among the psychodynamic community to thoroughly consider it (Wangberg, 2007). This research was intended to be a preliminary exploration of that reluctance. Much more research will be needed, but as in psychodynamic treatment, an understanding of what the resistance is about may be critical to moving forward. This will be especially important as both newer and more experienced clinicians are grappling with current trends in the use of technology and determining what it means for their own practices.

A quantitative survey research design was utilized to identify what variables (if any) influence clinicians’ attitudes towards video therapy. The survey was posted through professional listservs, social media, and direct email with a resulting sample size of 148 participants. The survey included a tool adapted and developed to measure attitudes towards video therapy (Video Therapy Attitudes Scale (VTAS)), as well as personal and professional demographic questions. Descriptive statistics were run on VTAS scores, all VTAS individual items, and a total of 25 independent variables. Statistical analyses were also conducted to understand the relationship (if any) between attitudes towards video

115 therapy (as measured by VTAS score) and each of the 25 independent variables that met minimum subgroup sample size requirements. This resulted in nine Pearson’s correlations and four independent-samples t-tests. The next section will summarize and interpret the research findings.

Interpretation of Findings The interpretation of findings will include the following three sections: (a) central null hypotheses, (b) exploratory analyses, and (c) descriptive statistics.

Central null hypotheses.

To review, the two central null hypotheses in this study were as follows: 1) There will be no statistically significant relationship between attitudes towards video therapy (as measured by VTAS score) and years of experience providing video therapy, and 2) There will be no statistically significant relationship between attitudes towards video therapy (as measured by VTAS score) and familiarity with research related to video therapy.

The variables ‘years of experience providing video therapy’ and ‘familiarity with research related to video therapy’ were both chosen as central null hypotheses because they are the two variables that most directly relate to video as a modality. Other variables such as ‘age’, ‘professional license’, etc. have more to do with the clinicians themselves.

This means that the relationship between attitudes towards video therapy and the two central variables represent a more informed and somewhat more objective attitude. No attitude can be truly objective, for they are held by human beings with unavoidable biases, but some attitudes are more reliable than others. Someone traveling to a foreign

116 country, for example, may want to consult a friend who has been there or at least read about it. Eye-witness testimonies and empirical reports are accepted in a courtroom, but hearsay is not. Word of mouth can be persuasive (especially when emotions run high), but that does not necessarily make it credible. In this case, direct experience with providing video therapy and familiarity with research related to video therapy were chosen as central variables because, in a similar way, they contribute to a more informed and more reliable attitude.

Both central null hypotheses in this study were rejected, for relationships (significant at the .01 level) were found for each. This means that the more years of experience providing video therapy and the greater the familiarity with research related to video therapy, the more positive the attitude. It also means that the more negative the attitude, the less experience providing video therapy and the less familiar with research related to video therapy. The fact that these correlations were significant at the .01 level means that the confidence in these results is very strong, for there is only a 1% chance the results are due to chance (Statistics Solutions, 2019). Simply stated, clinicians with more positive attitudes towards video therapy are more informed and their attitudes are more reliable.

Exploratory analyses.

The exploratory analyses in this study were also important. The statistically significant findings provided insight into what attitudes are about, and the statistically insignificant findings provided insight into attitudes are not about. As this section will describe, both are of interest and especially compelling when considering further research.

117 Statistically significant findings.

Statistically significant positive correlations (at the standard .05 level) were found between attitudes towards video therapy (as measured by VTAS score) and the following variables: 1) gross income 2018 (r = .212), 2) regular fee (r = .191), and 3) clinical sessions per week (r = .169). This means that the more positive attitude with video therapy, the higher the income, the higher the regular fee, and the more clinical sessions held per week. These three variables are all closely related, and they could be considered some measure of a practice’s success. But because ‘success’ can be defined in a variety of ways, it may be more useful to think about the word ‘thriving’. According to the Merriam-Webster Online Dictionary (2019), a “thriving” practice would be one that is “growing,” “developing” and “flourishing.” The results of this study indicate that attitudes towards video therapy significantly correlate with having a more thriving practice than those with negative attitudes. Are clinicians with more positive attitudes towards video therapy more responsive to the evolving needs of patients (or therapy consumers)? Are they more in touch? Do they have more interest and investment in the future of psychodynamic treatment? These findings raise questions that call for further research, but for now, it is useful and important to know that there is something here to understand.

Additionally, of the four independent-samples t-tests conducted, there was one significant finding. There was a significant difference in scores for psychoanalysts (M = 54.64, SD = 12.770) and non-analysts (M =48.30, SD = 1.510); t (146) = 3.004, p = .003, two-tailed) as they relate to attitudes towards video therapy (as measured by VTAS score). Psychoanalysts had more positive attitudes towards video therapy than non-

118 analysts. This finding may be surprising to many, for one might assume that psychoanalysts are more invested in and more adherent to traditional models of psychoanalytic treatment. However, the results suggest there may be something else at play. The basic difference between psychoanalysts and non-analysts is that psychoanalysts have gone through years of psychoanalytic training, which would presumably translate to a deeper understanding of psychoanalytic treatment. The deeper the understanding of psychoanalytic treatment, then, the more open one is to video as a modality. Why is that? Is there something in the training that suggests or encourages this kind of flexibility? Or, on the contrary, is there something about having gone through psychoanalytic training that makes psychoanalysts more confident in making decisions beyond ‘the book’? Chapter I discussed how the psychodynamic literature seems to be evolving from a more rigid interpretation of the therapeutic frame to one with greater flexibility (Hernandez-Tubert, 2008). Perhaps psychoanalysts are responding and bringing this shift into their practices more than one would imagine. Again, more research is needed to answer these types of questions, but these results give some indication of what questions to ask.

Statistically insignificant findings.

The statistically insignificant findings were also of interest, especially when it came to the variables that yielded more surprising results. For one, there was no statistically significant correlation found between attitudes towards video therapy and age (r = .110).

This may be surprising as age is often assumed to be a relevant factor when considering attitudes towards technology in general. There was also no statistically significant

119 difference found between social workers and psychologists, and that may be surprising because (as discussed in Chapter I) social work is based in an outreach model with a far more flexible conceptualization of the therapeutic frame at its roots. There was no statistically significant difference between those who belong to an insurance panel and those who do not, and yet insurance is considered to be a major deterrent of video therapy. And finally, there was no statistically significant difference between those located in an urban area and those in a non-urban area, and attitudes towards video therapy are therefore not related to therapists’ own need to hold a steady practice in more remote areas.

These results remind professionals to exercise caution when making (or listening to) assumptions about attitudes towards video therapy. Imagine, for instance, a clinician presented with the finding that more positive attitudes towards video therapy correlate with a greater income, higher fee, and more clinical hours per week. If that finding does not align with their existing attitude, it might be easy to deflect and jump to the assumption that those findings have more to do with being located in an urban area. The exploration of that variable, however, found no relationship between attitudes and practice location. Statistically insignificant findings are not necessarily insignificant in their meaning. They are interesting in their own right, but they also lend support to the discussion of results that were found to be statistically significant.

Descriptive statistics.

The descriptive statistics covered a lot of information, and there is a lot that could be gleaned from it. This section will discuss some points of interest that stood out to the

120 researcher, but the data is presented in detail throughout Chapter IV to encourage readers to make their own observations and interpretations as well. The following sections will be included here: (a) VTAS scores, (b) individual VTAS items, (c) independent variables.

VTAS scores.

Once again, VTAS scores ranged from 20 to 78 with a mean score of 51.51 and a SD of 13.179. This means that the group of participants were fairly balanced in terms of their attitude towards video therapy. This is important to note because sometimes results can be misunderstood. The results of the analyses may have lent some support to video therapy, but the sample itself was balanced. In other words, there was not an overrepresentation of clinicians who feel supportive of video therapy.

Individual VTAS items.

The individual VTAS items were interesting in that each one evoked a range of responses. Of the 16 items, there was not one item that did not have at least one participant for each response (“strongly agree,” “agree,” “neutral,” “disagree,” and “strongly disagree”). Simply stated, there were mixed feelings about each item.

Still, there may be something to glean by looking at the mean scores of VTAS items.

Participants scored each item on a Likert scale of 1 to 5 (1= strongly disagree, 5= strongly agree), and the scoring was reversed for negatively stated items (1= strongly agree, 5= strongly disagree). The mean scores ranged from 1.86 to 3.86. Table 5 shows an interpretation of these scores, indicating which statements (based on mean scores) participants generally agreed with, generally disagreed with, and were generally more

121 neutral towards. Mean scores of 2.60 and below were categorized as ‘disagree’ (‘agree’ for reverse scoring), mean scores between 2.61 and 3.39 were categorized as ‘neutral’, and mean scores of 3.40 and above were categorized as ‘agree’ (‘disagree’ for reverse scoring).

Table 5 Interpretation of Mean Scores for VTAS Items #

Item

Mean

Category

9

Using video therapy would help people learn about themselves

3.76

Agree

10

If a friend has personal problems, I might encourage him or her to consider video therapy

2.74

Disagree

11

I would dread trying to understand my patients’ problems through video.

3.63*

Disagree

12

I think it would be worthwhile to discuss patients’ problems through video.

3.53

Agree

13

If video therapy were available at no charge, I think people should consider trying it.

2.99

Neutral

14

I think patients can experience symptom reduction by participating in video therapy.

3.86

Agree

15

I think it is difficult if not impossible to create an adequate holding environment for patients through video.

3.32

Neutral

16

I think patients and therapists can have a strong working alliance through video

3.66

Agree

17

I think any benefits patients might gain from video therapy would take a very long time to emerge.

3.50*

Disagree

122

18

I would have major concerns about protecting patients’ confidentiality through video, even if I remained HIPAA compliant

3.41*

Disagree

19

I think video therapy can be just as effective as face-to-face therapy.

2.48

Disagree

20

I think therapists have an ethical responsibility to consider providing video.

2.57

Neutral

21

I think it is difficult if not impossible to address transference issues with patients through video.

3.51*

Disagree

22

I would be happy to provide video therapy if I had a patient who was specifically asking for it.

3.22

Neutral

23

Even if I could easily bill insurance for video therapy, I still would not provide it.

3.49*

Disagree

24

I think clinicians should meet a patient at least once in person before providing video therapy.

1.86*

Agree

Note: Mean scores of 2.60 and below were categorized as ‘disagree’ (‘agree’ for reverse scoring), mean scores between 2.61 and 3.39 were categorized as ‘neutral’, and mean scores of 3.40 and above were categorized as ‘agree’ (‘disagree’ for reverse scoring). Mean scores with an * indicate that reverse scoring was used for that item.

To summarize this information, participants generally agreed that video therapy can help people learn about themselves, is worthwhile, can result in symptom reduction, can facilitate a strong working alliance, and can address transference issues in the treatment.

Additionally, participants felt they would not dread understanding patients’ problems through video, that benefits would not take long to emerge, they would not have concerns about confidentiality, and that they would provide video therapy if insurance could be easily billed. However, participants generally felt that video therapy is not as effective as

123 face-to-face therapy, that they would not recommend it to a friend, and that they believe patients and therapists should meet at least once before engaging in video therapy.

Again, these means are all fairly close and the more obvious observation is that there are significantly mixed feelings on all of these items. Still, looking at which way these results lean raises some questions. It seems that when it comes to beliefs about what video therapy is capable of, participants agree that it can achieve many of the same individual aspects of what face-to-face treatment achieves. But when it comes an overall assessment of effectiveness or making a recommendation to a friend, the support is not there. What happens in between? What specifically are the deal-breakers for clinicians with more negative attitudes? The additional comments give some insight into these questions, and those will be addressed later in this chapter. But once again, these results provide an indication of where further research is needed.

Independent variables.

Many of the independent variables could not be included in analysis beyond descriptive statistics because the subgroups did not reach minimum sample sizes. But while the information initially sought could not be collected, again, it still offers something to understand and provides direction for further research. Of the 148 total participants, 139 identified as white, 110 identified as female, 125 see mostly adults, and 114 see mostly white patients. 139 offer some type of sliding scale, but 132 do not accept Medicaid, and 99 do not accept Medicare. Again, it is difficult to determine how representative this sample is, but these numbers are not necessarily shocking.

124 They do, however, underscore something discussed in Chapter I that needs to remain at the forefront of discussion. There is not enough diversity among psychodynamic clinicians, and as a whole, they serve an elite segment of the population. They are not accessible enough to everyone. And what does this have to do with attitudes towards video therapy? Other research has shown that clinicians with a psychodynamic orientation have more negative attitudes towards video therapy than others (Wangberg, 2007). So, if psychodynamic clinicians are mostly white, for example, do attitudes have anything to do with this ‘whiteness’? Do white clinicians have more negative attitudes towards video therapy? Do clinicians who serve mostly white patients have more negative attitudes towards video therapy? The current study had hoped to address these questions directly, but perhaps further research that includes other theoretical orientations to achieve a more diverse sample could do so.

Additional comments.

Of the 148 participants who completed the survey, 101 chose to provide an additional comment when given the opportunity. The researcher identified 10 different themes among this data, but the overwhelming message was clear. Most clinicians who commented feel that video therapy is useful in certain contexts or under certain conditions, but it is not as good as face-to face therapy and should therefore only be used when necessary.

This raises several questions. First, in regard to context, if video therapy is useful some of the time, who determines when it is or is not useful? And if it is left to the discretion of individual clinicians, then why is there such a need to categorically

125 (dis)qualify video therapy? There are many decisions therapists and analysts make in practice (i.e. whether or not to make a particular interpretation, whether or not to touch a patient, whether or not to give gifts, where to hold session, etc.), and many would argue context is everything with regard to these as well. So why do members of the professional community seem to be more comfortable leaving those decisions in the hands of individual clinicians than decisions related to video therapy?

Second, in regard to face-to-face treatment, even if it is true, why is there such a pressing need to assert its superiority? Imagine for a moment a clinician with two colleagues. Both are competent and are able to provide good treatment, but the clinician feels colleague A is better than colleague B. If a potential referral were to inquire about treatment with colleague B, would the clinician respond that colleague B should only be consulted if colleague A is not available? Is colleague A the better choice for every potential patient every time? And what purpose does it serve to express that preference anyway? How does it affect the treatment if colleague A is not available and the patient has been told that her new therapist, colleague B, is inferior? Does it not become a selffulfilling prophecy?

This line of questioning leads to even further questions. A future survey might ask clinicians: “Would you rather refer a patient to a colleague you feel is excellent for video therapy or a colleague you feel is mediocre for face-to-face therapy?” Also, it raises the question of what is meant by “better”? A treatment that is able to exist, maintain continuity, and finish to completion is surely “better” than one that is frequently interrupted and/or prematurely terminated. The point is, video therapy is undoubtedly complex, and as with many other aspects of treatment, context may certainly be

126 everything. So again, why the need for blanket statements that condemn video therapy or assert the superiority of face-to-face therapy?

Psychoanalytic interpretation of findings.

To pause for a moment, it may be useful to consider an interpretation of the research results from a psychoanalytic perspective. Suppose the above question were posed less rhetorically: “Why the need for blanket statements that condemn video therapy or assert the superiority of face-to-face therapy?” It was this type of question that inspired this research in the first place. Why do clinicians tend to have such harsh and automatic reactions to video therapy?

Even within a psychoanalytic framework, these questions are subject to a wide range of interpretations. Perhaps, for example, clinicians with negative attitudes towards video therapy experience a need for some idealized form of treatment. Perhaps there is a need to protect oneself from the narcissistic injury of a (perceived) loss of elite status. Perhaps there is some type of anxiety (castration or separation anxiety) about the emergence of something new and different. Perhaps the response is some other transference reaction from the clinician’s own personal history. Or perhaps it is part of an existing relational pattern in the psychoanalytic community as a whole – a pattern of initially rejecting new or innovative ideas. Once again, there are more questions than answers. However, this research has shown that regardless of theoretical viewpoint, negative attitudes towards video therapy (and not positive attitudes) have more to do with the clinicians themselves than with video therapy. There are likely other ideas about why this could be, and further

127 research could contribute to a better understanding of what ideas or interpretations have merit.

Revisiting Assumptions from Chapter I There were several assumptions made in this study by the researcher: 1. The researcher assumed that clinicians hold a set of beliefs or principles that guide their way of conducting treatment.

2. The researcher assumed that clinicians know what video therapy is and have some mental representation of how it is conducted.

3. The researcher assumed that clinicians have a subjective way of thinking or feeling about video therapy.

4. The researcher assumed that one’s subjective way of thinking or feeling about video therapy can be described numerically through the use of a valid and reliable tool.

Summary of Interpretation of Findings To summarize, regarding the two central null hypotheses, positive attitudes towards video therapy positively correlated with more years of experience providing video therapy and greater familiarity with research related to video therapy. These results indicated that clinicians with positive attitudes towards video therapy are more informed and therefore somewhat more objective than those with negative attitudes.

Regarding exploratory analyses, positive attitudes towards video therapy positively correlated with higher incomes, higher regular fees, and more clinical sessions per week.

128 These results indicated that clinicians with more positive attitudes towards video therapy tend to have more thriving private practices than those with negative attitudes.

Additionally, psychoanalysts were shown to have more positive attitudes towards video therapy than non-analysts. These results indicated that clinicians with more positive attitudes towards video therapy have a deeper understanding of psychoanalytic theory and practice.

Regarding descriptive statistics, this sample of psychodynamic clinicians was mostly white women who provide services to mostly white adults. And while it is difficult to determine exactly how representative this sample is of the larger population, in terms of race, it is similar to the membership of APsaA (M. Smaller, personal communication, December 22, 2019). Because previous research has shown psychodynamic clinicians to hold more negative attitudes towards video therapy than those with other backgrounds (Wangberg, 2007), these results encourage exploration into whether or not the lack of diversity in both psychodynamic clinicians and their patients has anything to do with attitudes towards video therapy or not.

And finally, regarding additional comments, many participants agreed video therapy can be useful in certain circumstances or under certain conditions, but it is not as good as face-to-face therapy and should therefore only be used when necessary. These results raised many questions about how decisions about video therapy are made and the need to assert the superiority of face-to-face treatment.

Both the results themselves and the interpretation of results have raised a lot of questions. The next chapter will discuss the implications for practice and solidify

129 suggestions for the direction of future research. It will also address the study’s strengths and limitations and conclude with a research reflection.

130

Chapter VI

Implications and Recommendations This study was designed to better understand the attitudes of psychodynamic clinicians in private practice towards video therapy. There is not nearly enough access to mental health treatment in the United States, and many Americans are not getting the help they need. Video therapy can contribute to a solution, and the field has started to recognize this. Websites have been established to serve hundreds of thousands of consumers online, and many clinicians are using video therapy in their private practices.

Research has shown, however, that clinicians with a psychodynamic orientation hold more negative attitudes towards video therapy than others (Wangberg, 2007). This makes psychodynamic clinicians less accessible to potential patients, limiting resources, and putting the psychodynamic community at risk of becoming antiquated. This study was intended to be an initial exploration of this reluctance in hopes of paving the way for further research.

The literature review in Chapter II looked at the history of video therapy, questions that video therapy raises about psychoanalytic theory, and previous research related to video therapy. In an effort to identify gaps in the literature, it outlines the three questions that typically rise to the forefront when examining a research study: (a) What type of treatment is being used? (b) What is the treatment modality? and (c) What is being

131 measured? Research related to video therapy tends to involve mostly cognitivebehavioral or other types of behavioral treatment, and there is no research that examines psychodynamic video therapy. In terms of treatment modality, studies have looked at video, e-mail, chat, self-guided online programs, etc. What stands out is that video is often thrown into the mix instead of studied on its own. And finally, in terms of measure, most studies focus on efficacy, while some focus on working alliance, and others focus on attitudes. Of the attitudinal studies, some examine the patients’ perspective, while others look at the clinicians’ perspective. Very few studies make any attempt to dig deeper and understand what attitudes are about. After a review of the literature, it became clear that there is a great need for research that looks at psychodynamic therapy via video and attempts to gain a deeper understanding of what attitudes towards video therapy are about.

Chapter III presented the methodology of this study. First, a tool (The Video Therapy Attitudes Scale (VTAS)) was adapted from the Online Counseling Attitudes Scale (OCAS) by Rochlen, Beretvas and Zack (2004), and developed to measure attitudes towards video therapy. A survey was then created that included the embedded VTAS along with personal and professional demographic questions. Purposive sampling was used to recruit psychodynamic clinicians in private practice by posting the survey through professional listservs, social media and direct email. This sampling method resulted in a sample size of 148 participants. Descriptive statistics were run on the VTAS scores, each of the 16 VTAS items, and all 25 independent variables. The hope was to then examine the relationship (if any) between each one of the 25 independent variables and attitudes towards video therapy (as measured by VTAS score). This would have led to nine

132 Pearson’s correlations, eight independent-samples t-tests, and eight ANOVAs. However, due to limited subgroup sample sizes, some variables were not eligible for further statistical analysis. Ultimately, nine Pearson’s correlations, four independent-samples ttests, and no ANOVAs were able to be conducted.

Chapter IV presented the results of the analyses just described. The two central null hypotheses were both rejected, for positive correlations (significant at the .01 level) were found between ‘attitudes towards video therapy’ (as measured by VTAS score) and both years of experience providing video therapy and familiarity with research related to video therapy. Positive correlations (significant at the .05 level) were also found between attitudes towards video therapy and gross income 2018, regular fee, and clinical sessions per week. Finally, psychoanalysts were found to have a significantly more positive attitude towards video therapy than non-analysts. The statistically insignificant findings and descriptive statistics were also of interest, and they were therefore also presented in detail throughout Chapter IV. Chapter V discussed the researcher’s interpretations of statistically significant findings as well as other findings of interest. The results of the two central null hypotheses seemed to indicate that clinicians with a more positive attitude towards video therapy tend to be more informed and that their attitudes may therefore be more reliable. Regarding exploratory analyses, the other statistically significant findings seemed to indicate that clinicians with more positive attitudes towards video therapy tend to have more thriving practices. They also indicated that clinicians with more positive attitudes towards video therapy may have a deeper understanding of psychoanalytic treatment. The descriptive statistics raised questions about the lack of diversity in the community of psychodynamic

133 clinicians and who they serve. Questions about what relationship that homogeneity has (if any) to attitudes towards video therapy were raised. And finally, the analysis of additional comments led to questions about how decisions about video therapy are made and why there is such a strong need to assert the superiority of face-to-face treatment.

Implications for Practice This was not an efficacy study, but the results proved to be supportive of video therapy in many ways. Clinicians with more years of experience providing video therapy and who are more familiar with research related to video therapy were found to hold more positive attitudes towards video therapy. The interpretation of this is that those with more positive attitudes towards video therapy are more informed. Those with more thriving practices and those with a deeper understanding of psychoanalytic treatment tend to have more positive attitudes towards video therapy as well. In other words, the more favorable side of each statistically significant finding was associated with a more positive attitude towards video therapy. It could have been the other way around (a negative correlation), but that was not the case. In other words, there was no finding indicating that those with more negative attitudes towards video therapy may be onto something. There is only, then, more reason to continue with further research, and more reason to encourage the cautiously optimistic use of video therapy.

This general statement has several more specific implications for clinical practice. For one, since more experience with video therapy correlates with a more positive attitude, then clinicians may need to give video therapy a better shot. On the one hand, this result was somewhat predictable because only clinicians with positive attitudes towards video

134 therapy would continue to provide it for so many years. But at the same time, why and at what point have those who tried it stopped? Perhaps it takes more time to move beyond the initial discomfort, to familiarize with the similarities and differences with face-to-face treatment, and to experience the depths that can be reached through video treatment. For individual clinicians trying to decide whether or not to provide video therapy, perhaps this study indicates that they should try it for an extended time before coming to a conclusion.

Second, this study highlights that clinicians may be more familiar with research about practices they already engage in or believe in. This makes sense, for one has limited time and can only educate themselves in so many ways. However, perhaps there is a need for clinicians to stay more abreast of research involving new and emerging trends. How can the field continue to grow and expand if new ideas are not thoroughly considered? How can the field progress if clinicians rely on their own preconceptions? This line of questioning extends beyond the use of video therapy, but video therapy certainly seems to be one area in which clinicians are reluctant to explore beyond what they feel they already know.

Finally, this study also highlights the need for clinicians with more positive attitudes towards video therapy to be more vocal in the professional community. The additional comments made by participants in this study seemed to support the idea of the “hushhush� atmosphere that forward-thinking clinicians feel, as described in Chapter I and in Akhtar’s book (2011). Of the 231 comment segments identified from 101 respondents, only 33 seemed to be from those who support video therapy. This means that many of the clinicians with more positive attitudes towards video therapy chose not to comment, and

135 those with more negative attitudes had more to say. Again, this fits with what the researcher has experienced among professionals in the community, and this needs to change. Newer clinicians or those looking for direction when it comes to the use of technology need to hear from both sides of this debate. More research is needed and will be helpful, but again, clinicians may not read the research if they are not already supportive of video therapy. Therefore, once again, it is important for clinicians to be vocal in other ways as well.

Recommendations for Future Research The results of this study raised many questions, and many recommendations for further research have been mentioned throughout the discussion. However, this section will focus on five central suggestions for further research: 1) VTAS as a tool, 2) further exploration of attitudes, 3) deeper exploration of findings 4) exploratory variables, and 5) diversity of sample.

VTAS as a tool.

The reliability tests run on the Video Therapy Attitudes Scale (VTAS) yielded very strong results (Pallant, 2016). The Pearson’s correlation coefficients (significant at the .01 level) for the split-half method using the pilot study data and final survey data were .950 and .887 respectively. The Chronbach’s alpha using the pilot study data and final survey data were .956 and .940 respectively. The strength of these results indicates that more research is warranted to further validate this tool and continue building upon it for use in further research.

136 Further exploration of attitudes.

The Video Therapy Attitudes Scale (VTAS) was adapted from the Online Counseling Attitudes Scale (OCAS) by Rochlen, Beretvas & Zack (2004). As previously described, many items were added to include aspects of video therapy that, based on the literature, have become important over the last 15 years. The tool was greatly expanded, but this study was still just an initial exploration. Participants in this survey indicated they would have liked to see a longer, more nuanced survey that more adequately addresses the complexity of feelings involved in attitudes towards video therapy. Of course, participants did not necessarily understand that the questions being asked were part of a tool to measure attitudes towards video therapy. What they were really asking for is research that gathers a more elaborate description (as opposed to measure) of attitudes.

There is clearly an eagerness to share more about the nuances of feelings towards video therapy, and therefore, more research in this area should be done.

Deeper exploration of findings.

The results of this study were enlightening, but they also raised more questions. For example, psychoanalysts were found to have significantly more positive attitudes towards video therapy than non-analysts. The researcher interpreted this to mean that a deeper understanding of psychoanalytic treatment leads to a more positive attitude towards video therapy. But why would that be? Again, is there something about analytic training that encourages the flexibility or is there something about having experienced the training that makes psychoanalysts feel more confident in making decisions beyond ‘the book’? This

137 is just one example of a finding that led to more questions, and further research could pursue the answers to new questions raised.

Exploratory variables.

This study sought to examine 25 independent variables to understand the relationship (if any) to attitudes towards video therapy (as measured by VTAS score). Six of those variables yielded statistically significant results, seven did not, and 12 were ultimately ineligible for statistical analysis. Once again, this research was only meant to be a beginning and there are many other variables that could be explored. Future research could explore the variables that were not eligible for analysis, and it could use the VTAS to explore other variables that were not considered for this study at all.

Diversity of sample.

The sample in this study was overwhelmingly white. In order to study the relationship (if any) between race and attitudes towards video therapy, a very concerted effort to recruit clinicians of color would need to be made. A concerted effort would also need to be made to recruit clinicians who see more patients of color. The current study was broad and not able to achieve minimum sample sizes in this area, but the variables are important to explore. If the overwhelming ‘whiteness’ of the psychodynamic community has something to do with the more negative attitudes towards video therapy, it is imperative that be uncovered.

138 Strengths and Limitations of the Study Many of the strengths of this study were also its limitations, and many of the limitations were also its strengths. For one, a major strength was the large number of variables included in this study which allowed for a substantial amount of information to be gathered. This was also a limitation in that the study was designed to be an initial exploration and merely graze the surface in terms of an understanding of psychodynamic clinicians’ attitudes towards video therapy.

As discussed in Chapter III, one limitation of the study was the reliability of the VTAS, as it had been considerably altered from the OCAS and not as vigorously tested.

At the same time, the results of the split-half and the Chronbach’s alpha reliability tests showed the VTAS to be so far a very strong tool. More testing is certainly needed, but one strength of this study turned out to be the beginning of a tool used to measure attitudes towards psychodynamic video therapy that could potentially be used in future research.

Finally, Chapter III also discussed the limitation of this sample. Because purposive sampling was used (as opposed to random sampling), this study is limited in terms of its generalizability. Also, sample size turned out to be a limitation for many of the exploratory variables. Only 13 of the 25 independent variables were ultimately eligible for statistical analysis due to sample size restrictions. Still, a strength of this study was the sample size for variables that were eligible for statistical analysis. The Pearson’s correlations, for example, needed a minimum sample size of 85 and a sample size of up to 148 was reached. This contributed to strong results for the central null hypotheses and some of the other exploratory variables.

139 Research Reflections The purpose of this study was to better understand the attitudes of psychodynamic clinicians towards video therapy. I, the researcher, have had several perplexing encounters with colleagues who seem to have strong negative feelings about video therapy, and I wanted to understand what those feelings were about. I felt genuinely curious because if there is something I have been missing, as a clinician who sees patients via video, I have an ethical responsibility to further educate myself. The way this research process unfolded has been incredibly meaningful to me both professionally and personally.

The results of this research indicated that clinicians with more negative attitudes towards video therapy have less experience providing video therapy, and they are less familiar with research related to video therapy. In other words, negative attitudes and hostile comments are not necessarily substantiated.

Even throughout this research process, I received defensive or hostile comments that were not necessarily substantiated. For example, for the question about income, a participant who did not want to answer wrote “irrelevant” instead of “N/A” or something similar. This example was less hostile than others, but it also clearly illustrates how unsubstantiated comments can be, for income did turn out to be relevant.

Throughout this process I also found myself feeling anxious about what I was finding.

I was anxious about attacks by those who will not like the results and want to ‘shoot the messenger’. Of course, I am aware of my own transference issues around these fantasies, and yet, they are also rooted in some reality. I already experienced some of it in the research process itself, and I anticipate more in the future as I make the results known.

140 Since I entered the psychodynamic community, I have sensed this type of hostility around many matters, not just matters related to video therapy. I wonder about it, and I fear it does not bode well for the future of this field.

I am not the only one who senses this hostility. I am also not the only one who is reluctant to be vocal for fear of attack, and the professional community cannot advance in an atmosphere like this. The needs of patients cannot be met if professionals are afraid to explore new ideas. Freud never wanted psychoanalysis to be stagnant. Technology has seeped into nearly every aspect of life and has significantly changed how people relate to one another. Clinicians who hold onto the notion that an online relationship cannot be as good as a face-to-face relationship will continue to sound more and more removed. Can the blind not relate with the same intimacy and intensity? The deaf? Those with any number of other limitations? Are all people not limited in some way? Video therapy certainly has its limitations, but then, so does every therapy. This research process has been a profound learning experience, for it has shown me the importance of research, and it has taught me to speak up.

This dissertation was defended in March 2020 amidst the COVID-19 pandemic, making the topic of video therapy more relevant than ever. Suddenly nearly every clinician across the globe is being pushed to at least consider using video technology in their practices, and only time will tell what long-term impact that will have on the future of psychoanalysis or psychodynamic therapy. For now, I hope this research can contribute to some peace of mind for both patients and clinicians during these challenging times.

141

Appendix A List of Independent Variables

142 Appendix A List of Independent Variables

1. Type of license 2. Years of experience in private practice 3. Psychoanalyst 4. Level of education 5. Theoretical orientation 6. Practice location 7. Clinical sessions per week 8. Gross income 2018 9. Regular fee 10. Sliding scale 11. Lowest fee 12. Insurance panel 13. Medicaid 14. Medicare 15. Caseload age demographics 16. Caseload racial demographics 17. Years of experience providing video therapy 18. Years of experience receiving video therapy 19. Discomfort with video in general 20. Negative experience

143 21. Familiarity with research related to video therapy 22. Age 23. Race 24. Gender 25. Additional Comments

144

Appendix B The Online Counseling Attitudes Scale (OCAS)

145 Appendix B The Online Counseling Attitudes Scale (OCAS) (Rochlen, Beretvas & Zack, 2004)

Subscale: Discomfort with Online Counseling 1. If I were having a personal problem, seeking help with an online counselor would be the last option I would consider 2.

I would feel uneasy discussing emotional problems with an online counselor.

3. I would dread explaining my problems to an online counselor.

4. I think it would take a major effort for me to schedule an appointment with an online counselor.

5. I would be afraid to discuss stressful events with an online counselor.

Subscale: Value of Online Counseling 6. Using online counseling would help me learn about myself.

7. If a friend had personal problems, I might encourage him or her to consider online counseling.

8. I would confide my personal problems in an online counselor.

9. It could be worthwhile to discuss my personal problems with an online counselor.

10. If online counseling were available at no charge, I would consider trying it.

146

Appendix C Video Therapy Attitudes Scale

147 Appendix C Video Therapy Attitudes Scale (VTAS) Items adapted from the OCAS: 1. Using video therapy would help people learn about themselves 2. If a friend had personal problems, I might encourage him or her to consider video therapy.

3. I would dread trying to understand my patient’s problems through video.

4. I think it would be worthwhile to discuss patients’ problems through video.

5. If video therapy were available at no charge, I think people should consider trying it.

Items Added: 6. I think patients can experience symptom reduction by participating in video therapy.

7. I think it is difficult if not impossible to provide an adequate holding environment for patients through video.

8. I think patients and therapists can have a strong working alliance through video.

9. I think any benefits patients might gain from video therapy would take a very long time to emerge.

10. I would have major concerns about protecting patients’ confidentiality through video, even if I remained HIPAA compliant.

11. I think video therapy can be just as effective as face-to-face therapy.

12. I think therapists have an ethical responsibility to consider providing video therapy.

13. I think it is difficult if not impossible to address transference issues with patients through video.

14. I would be happy to provide video therapy if I had a patient who was specifically asking for it.

15. Even if I could easily bill insurance for video therapy, I still would not provide it.

148

16. I think clinicians should meet a patient at least once in person before providing video therapy.

149

Appendix D Survey

150 Appendix D Survey

Attitudes towards Video Therapy among Clinicians in Private Practice with a Psychodynamic Orientation Thank you for your interest in this survey. This research is being conducted by Kate Smaller, LCSW, M.Ed. as the final step of her doctoral studies at the Institute for Clinical Social Work (ICSW) in Chicago. It has been approved by ICSW's Institutional Review Board (IRB).

The purpose of this study is to gain a better understanding of attitudes towards video therapy among psychodynamic clinicians in private practice with a psychodynamic orientation.

The survey will include questions about your eligibility to participate in the study, your thoughts and feelings about video therapy, your private practice, your familiarity with video therapy, and your personal demographics. There will also be an opportunity for additional comments.

The survey should take approximately 10-15 minutes to complete.

Your participation in this survey is completely voluntary. You should feel free to stop the survey at any time for any reason, and know there will be no negative consequences for deciding not to participate. Also, your answers will be strictly confidential. Once the data has been collected, it will be separated from personal identifiers and stored in a password protected file on a password protected computer.

If you have any questions or concerns, you should feel free to contact the researcher, Kate Smaller, directly at ksmallerlcsw@gmail.com.

1. Would you like to continue?

(By clicking 'yes', you are indicating that you understand the statements above, and are voluntarily choosing to participate in this study.) () Yes () No Questions 2 – 8 are related to your eligibility to participate in this survey.

2. Did you previously participate in the pilot test for this study? () Yes () No

151

3. Which of the following professional licenses do you currently hold? () Social Work () Psychology () Counseling () MD/DO () None of these 4. Is your predominant theoretical orientation ‘psychodynamic’? () Yes () No 5. Are you currently in private practice? () Yes () No 6. Have you been in private practice for at least 5 years? () Yes () No 7. How many years have you been in private practice? _________ 8. Is your private practice based in the United States? () Yes () No

Questions 9-24 are related to your thoughts and feelings about video therapy. For these items, please read each statement carefully and mark your level of agreement or disagreement using the scale provided.

9. Using video therapy would help people learn about themselves () Strongly Agree () Agree () Neutral () Disagree () Strongly disagree

10. If a friend had personal problems, I might encourage him or her to consider video therapy. () Strongly Agree () Agree () Neutral () Disagree () Strongly disagree 11. I would dread trying to understand my patient’s problems through video. () Strongly Agree () Agree () Neutral () Disagree () Strongly disagree

152

12. I think it would be worthwhile to discuss patients’ problems through video. () Strongly Agree () Agree () Neutral () Disagree () Strongly disagree

13. If video therapy were available at no charge, I think people should consider trying it. () Strongly Agree () Agree () Neutral () Disagree () Strongly disagree

14. I think patients can experience symptom reduction by participating in video therapy. () Strongly Agree () Agree () Neutral () Disagree () Strongly disagree 15. I think it is difficult if not impossible to provide an adequate holding environment for patients through video. () Strongly Agree () Agree () Neutral () Disagree () Strongly disagree

16. I think patients and therapists can have a strong working alliance through video. () Strongly Agree () Agree () Neutral () Disagree () Strongly disagree

17. I think any benefits patients might gain from video therapy would take a very long time to emerge. () Strongly Agree () Agree () Neutral () Disagree () Strongly disagree 18. I would have major concerns about protecting patients’ confidentiality through video, even if I remained HIPAA compliant. () Strongly Agree () Agree () Neutral () Disagree () Strongly disagree

19. I think video therapy can be just as effective as face-to-face therapy. () Strongly Agree () Agree () Neutral () Disagree () Strongly disagree

20. I think therapists have an ethical responsibility to consider providing video therapy. () Strongly Agree () Agree () Neutral () Disagree () Strongly disagree

21. I think it is difficult if not impossible to address transference issues with patients through video. () Strongly Agree () Agree () Neutral () Disagree () Strongly disagree

153 22. I would be happy to provide video therapy if I had a patient who was specifically asking for it. () Strongly Agree () Agree () Neutral () Disagree () Strongly disagree

23. Even if I could easily bill insurance for video therapy, I still would not provide it. () Strongly Agree () Agree () Neutral () Disagree () Strongly disagree

24. I think clinicians should meet a patient at least once in person before providing video therapy. () Strongly Agree () Agree () Neutral () Disagree () Strongly disagree Questions 25 – 36 are related to your private practice.

25. Are you a psychoanalyst? () Yes () No 26. What is your highest level of completed education? () MD () PhD () PsyD () MA () Other 27. How would you describe your specific psychodynamic theoretical orientation? () Object Relations () Ego Psychology () Self Psychology () Relational () Eclectic () Other (Please specify: ________ ) 28. How would you describe the physical location of your private practice? () Urban () Suburban () Rural () Other (Please specify: ________ ) 29. On average, how many clinical sessions per week are you currently conducting with patients? ______ 30. What was your gross annual income for your private practice in 2018? _________

154 31. What is your current regular fee? ________ 32. Do you offer a sliding scale of any kind? () No () Yes (please specify the lowest fee you currently accept) ________

33. Do you currently provide any in-network care as a member of any insurance provider’s panel? () Yes () No 34. Do you accept Medicaid? () Yes () No

35. Do you accept Medicare? () Yes () No 36. Which of the following best describes your current caseload? () Mostly adults () Mostly children and/or adolescents () A fairly balanced mixture of adults, children, and/or adolescents 37. Does more than 50% of your current caseload belong to any one particular racial group? () No () Yes (please specify which racial group) _______ Questions 37 – 41 are related to your familiarity with video therapy.

38. Approximately how many years have you provided video therapy as a therapist or analyst? _______ 39. Approximately how many years have you received video therapy as a patient? ______ 40. In general, do you feel uncomfortable or awkward meeting with people over video? () No () Yes (please say more if you like): ________

155 41. Have you ever experienced a particularly negative incident related to video therapy? () No () Yes (please say more if you like): ________ 42. How familiar are you with research related to video therapy? (slider scale (0-100) from “not at all familiar” to “extremely familiar) Questions 42 – 44 are related to your personal demographics.

43. What is your age? ______ 44. Which of the following best describes your racial identity? () White () Hispanic or Latino () Black or African American () Native American or American Indian () Asian or Pacific Islander () Some combination of the above () Other (Please specify: ____) 45. What is your gender? () Male () Female () Other (please specify: _______) 46. Is there anything else you would like to add? _________

156

Appendix E Codebook

157 Appendix E Codebook

SPSS Name

Variable

Q#

Question

Coding Instructions

Measurement Scale

Plan for data analysis

ID

Identification number

NA

NA

Number assigned to each survey

NA

NA

License

Type of license

3

1 = social work 2 = psychology 3 = counseling 4 = MD/DO

Nominal

One-way ANOVA Independent samples

Experience

Years of experience in private practice

7

In years

Ratio

Pearson’s Correlation

Analyst

Psychoanalyst

25

1 = yes 2 = no

Nominal

T-test (Independent-samples)

Education

Level of Education

26

1= MD 2=PhD 3= PsyD 4=MA 5=Other

Nominal

One-way ANOVA Independent samples

Orientation

Theoretical Orientation

27

1 = object relations 2 = ego psychology 3 = self psychology 4 = relational 5 = eclectic 6 = other

Nominal

One-way ANOVA Independent samples

Location

Practice location

28

1 = Urban 2 = Suburban 3 = Rural 4 = Other

Nominal

One-way ANOVA Independent samples

Hours

Clinical sessions per week

29

In # of sessions

Ratio

Pearson’s Correlation

Income

Gross income 2018

30

Which of the following professiona l licenses do you currently hold?

How many years have you been in private practice?

Are you a psychoanal yst?

What is your highest level of completed education?

How would you describe your specific psychodyna mic theoretical orientation?

How would you describe the physical location of your private practice?

On average, how many clinical sessions per week are you currently conducting with patients?

Gross annual income from your private practice in 2018?

In dollars

Ratio

Pearson’s Correlation

158 Fee

Regular fee

31

Sliding

Sliding scale

32

Low

Lowest fee

32 b

Insurance

Insurance panel

33

Medicaid

Medicaid

34

Medicare

Medicare

35

Patient age

Caseload age demographics

36

Patient race

Caseload racial demographics

37

VT provided

Years of experience providing video therapy

38

VT received

Years of experience receiving video therapy

39

What is your current regular fee?

Do you offer a sliding scale of any kind?

Please specify the lowest fee you currently accept.

Do you currently offer any in-network care as a member of any insurance provider’s panel?

Do you accept Medicaid?

Do you accept Medicare?

Which of the following best describes your current caseload?

Does more than 50% of your caseload belong to any one particular racial group? (If so, which group? (write in) Approximat ely how many years have you provided video therapy as a therapist or analyst?

Approximat ely how many years have you received video therapy as a patient?

In dollars

Ratio

Pearson’s Correlation

1 = yes 2 = no

Nominal

T-test (Independent- samples)

In dollars

Ratio

Pearson/s Correlation

1 = yes 2 = no

Nominal

T-test (Independent- samples)

1 = yes 2 = no

Nominal

T-test (Independent-samples)

1 = yes 2 = no

Nominal

T-test Independent samples

1 = mostly adults 2 = mostly children and/or adolescents 3 = a fairly balanced mixture of adults, children and/or adolescents

Nominal

One-way ANOVA Independent samples

1 = yes 2 = no

Nominal

T-test (Independent- samples)

In number of years

Ratio

Pearson’s Correlation

In number of years

Ratio

Pearson’s Correlation

159 Discomfort

Discomfort with video in general

40

Neg

Negative experience

41

Research

Familiarity with research related to video therapy

42

Age

Age

43

Race

Race

44

Gender

Gender

45

Additional

Additional comments

46

VTAS

VTAS score

924

In general, do you feel uncomforta ble or awkward meeting with people over video?

Have you ever experienced an intensely negative incident related to video therapy?

How familiar are you with research related to video therapy?

What is your age?

Which of the following best describes your racial identity?

What is your gender?

Is there anything else you would like to add?

1 = yes 2 = no

Nominal

T-test (Independent- samples)

1 = yes 2 = no

Nominal

T-test (Independent- samples)

Number chosen from scale of 0-100 (Scale labeled Not at all familiar – Somewhat familiar – Extremely familiar)

Ratio

Pearson’s Correlation

In years

Ratio

Pearson’s Correlation

1 = White 2 = Hispanic or Latino 3 = Black or African American 4 = Native American or American Indian 5 = Asian / Pacific Islander 6 = Some combination of the above 7 = Other 1 = Male 2 = Female 3 = Other * Coding to be determined once data is collected and themes are drawn from the write-in answers

Nominal

One-way ANOVA Independent samples

Nominal

One-way ANOVA Independent samples

Nominal

Most likely One-way ANOVA Independent samples

Ratio

*This is the scale/ continuous variable that all other variables will be tested against

Score calculated from VTAS items (# from each of 16 items added; ranges from 16 - 80) 1 = Strongly Agree 2 = Agree 3 = Neutral 4 = Disagree 5 = Strongly Disagree

160

Appendix F Recruiting Post and Direct Email

161 Appendix F Recruiting Post and Direct Email

Subject: Video therapy: What is your attitude? Important study‌ Dear colleagues2, I am conducting dissertation research on attitudes towards video therapy among psychodynamic clinicians in private practice to fulfill the requirements for my Ph.D. at the Institute for Clinical Social Work (ICSW) in Chicago.

If you are a psychodynamic clinician in private practice in the United States and have been for at least 5 years, you could be a great candidate for the study and your input would be greatly valued.

Participation would mean completing an online survey that should take 10-15 minutes of your time. The survey is completely voluntary and confidential. If you are interested, please click on the following link to complete the survey: https://www.surveymonkey.com/r/2GN2YJP Thank you for your time and consideration.

Best, Kate Smaller, LCSW, M.Ed.

2

For direct email, the colleague’s name was inserted

162

Appendix G Subgroup Sample Sizes and Statistical Analysis Determinations

163 Appendix G Subgroup Sample Sizes and Statistical Analysis Determinations Variable

Subgroups

Analysis Intended

Minimum Sample Size

N

Participants Needed

Analysis Conducted

License

Social Work Psychology Counseling MD/DO

ANOVA

52 52 52 52

67 68 1 12

--51 40

T-test

Pearson’s Correlation

85

147

--

Years in private practice

Pearson’s Correlation

Psychoanalyst

Analyst Non-analyst

T-test

64 64

75 73

---

T-test

Level of education

MD PhD PsyD MA Other

ANOVA

52 52 52 52 52

11 59 20 12 46

41 -32 40 6

None

Theoretical orientation

Object Relations Ego Psychology Self Psychology Relational Eclectic Other

ANOVA

52 52 52 52 52 52

26 6 7 43 46 20

26 46 45 9 6 32

None

Practice location

Urban Suburban Rural Other

ANOVA

52 52 52 52

81 53 8 6

--44 46

T-test

Clinical sessions per week

Pearson’s Correlation

85

138

--

Pearson’s Correlation

Gross income 2018

Pearson’s Correlation

85

120

--

Pearson’s Correlation

Regular fee

Pearson’s Correlation

85

130

--

Pearson’s Correlation

T-test

64 64

139 9

-55

None

132

--

Sliding scale

Lowest fee

Yes No

Pearson’s Correlation

85

Pearson’s Correlation

164 Insurance panel

Yes No

T-test

64 64

75 73

---

T-test

Accepts Medicaid

Yes No

T-test

64 64

16 132

48 --

None

Accepts Medicare

Yes No

T-test

64 64

49 99

3 --

None

Caseload age demographics

Adults Children/Adol.

Mixture

ANOVA

52 52 52

125 1 22

-51 30

None

Caseload racial demographics

Yes (homogenous) No (diverse)

T-test

64 64

121 27

-37

None

Years providing video therapy

Pearson’s Correlation

85

146

--

Pearson’s Correlation

Years receiving video therapy

Pearson’s Correlation

85

143

--

Pearson’s Correlation

General discomfort with video

Yes No

T-test

64 64

52 96

12 --

None

Negative experience

Yes No

T-test

64 64

26 122

38 --

None

Familiarity with Research

Pearson’s Correlation

85

148

--

Pearson’s Correlation

Age

Pearson’s Correlation

85

147

--

Pearson’s Correlation

Race*

W H/L B/AA NA/AI A/PI C O

ANOVA

52 52 52 52 52 52 52

139 2 ---3 4

-50 52 52 52 49 48

None

Gender

Male Female Other

ANOVA

52 52 52

38 110 --

26 -52

None

* The abbreviations used for race categories are as follows: W = White; H/L = Hispanic or Latino; B / AA = Black or African American; NA/AI = Native American or American Indian; A/PI = Asian or Pacific Islander; C = Some combination of the above; O = Other.

165

Appendix H Frequencies of Individual VTAS Item Responses

166 Appendix H Frequencies of Individual VTAS Item Responses

60

60

50

50

Frequency

70

#10: If a friend had personal problems, I might encourage him or her to consider video therapy.

40 30 20 10

30 20 0

SA

A

N

D

SD

SA

A

N

D

SD

#11: I would dread trying to understand my patients' problems through video.

#12: I think it would be worthwhile to discuss patients' problems through video.

70 60 50 40 30 20 10 0

60

Frequency

Frequency

40

10

0

50 40 30 20 10 0

SA

A

N

D

SD

SA

A

N

D

SD

#14: I think patients can experience symptom reduction by participating in video therapy.

#13: If video therapy were available at no charge, I think people should consider trying it.

50

80

40

60

Frequency

Frequency

Frequency

#9: Using video therapy would help people learn about themselves.

30 20 10

40 20 0

0 SA

A

N

D

SD

SA

A

N

D

SD

#15: I think it is difficult if not impossible to create an adequate holding environment for patients through video.

#16: I think patients and therapists can have a strong working alliance through video.

60

60

50

50

Frequency

Frequency

167

40 30 20 0

20

0 SA

A

N

D

SD

SA

#17: I think any benefits patients might gain from video therapy would take a very long time to emerge.

A

N

D

SD

#18: I would have major concerns about protecting patients' confidentiality through video, even if i remained HIPAA compliant.

60 50 40 30 20 10 0

Frequency

80 60 40 20 0 SA

A

N

D

SD

SA

#19: I think video therapy can be just as effective as face-to-face therapy.

50

50

40

40

30 20 10

A

N

D

SD

#20: I think therapists have an ethical responsibility to consider providing video therapy.

Frequency

Frequency

30

10

10

Frequency

40

30 20 10

0

0 SA

A

N

D

SD

SA

A

N

D

SD

#21: I think it is difficult if not impossible to address transference issues with patients through video.

#22: I would be happy to provide video therapy if I had a patient who was specifically asking for it.

80

50

60

40

Frequency

Frequency

168

40 20

20 10

0

0 SA

A

N

D

SD

SA

#23: Even if I could easily bill insurance for video therapy, I still would not provide it.

Frequency

40 30 20

A

N

D

SD

#24: I think clinicians should meet a patient at least once in person before providing video therapy.

50

Frequency

30

80 60 40 20

10 0

0 SA

A

N

D

SD

SA

A

N

D

SD

169

Appendix I Statistical Analyses Intended vs. Actually Conducted

170 Appendix I Statistical Analyses Intended vs. Actually Conducted Variable

Intended Analysis

Actual Analysis

Years in private practice

Pearson’s Correlation

Pearson’s Correlation

# Clinical hours per week

Pearson’s Correlation

Pearson’s Correlation

Gross income 2018

Pearson’s Correlation

Pearson’s Correlation

Regular fee

Pearson’s Correlation

Pearson’s Correlation

Lowest fee

Pearson’s Correlation

Pearson’s Correlation

Years providing video therapy

Pearson’s Correlation

Pearson’s Correlation

Years receiving video therapy

Pearson’s Correlation

Pearson’s Correlation

Familiarity with research

Pearson’s Correlation

Pearson’s Correlation

Age

Pearson’s Correlation

Pearson’s Correlation

Psychoanalyst

Independent t-test

Independent t-test

Sliding scale

Independent t-test

None

Insurance panel

Independent t-test

Independent t-test

Medicaid

Independent t-test

None

Medicare

Independent t-test

None

Caseload racial demographics

Independent t-test

None

Discomfort with video

Independent t-test

None

Negative experience

Independent t-test

None

Type of license

AVOVA

Independent t-test

Level of education

AVOVA

None

Theoretical orientation

AVOVA

None

171

Practice location

AVOVA

Independent t-test

Caseload age demographics

AVOVA

None

Race

AVOVA

None

Gender

AVOVA

None

Additional comments

AVOVA

None

172

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