Changes in Clinical Process as a Result of Online Therapy: Findings from a Single Case Study

AIM: This study examined changes in the clinical interaction in a single clinical dyad between sessions conducted in-person and sessions conducted remotely, applying sophisticated linguistic indicators based on Multiple Code Theory and the referential process (Bucci, 2021; Bucci, Maskit, & Murphy, 2016). METHOD: Participants. The participant in this single case study was a male patient in his late 30s, who had been participating in a single case psychotherapy research study at the time of the pandemic. Procedures. Sessions from an ongoing psychotherapy were audio-recorded and transcribed using transcription rules for linguistic analysis. Linguistic indicators, including the Weighted Referential Activity Dictionary (WRAD), was scored and graphed using the Discourse Attributes Analysis Program (DAAP; Maskit, 2014).The sessions included, 8 sessions immediately before, and immediately following the implementation of online work as a result of COVID precautions, and 8 sessions at follow-up, collected several months after the clinical dyad had been working remotely. RESULTS: Findings show that the patient speaks more in post-COVID sessions, but with decreased emotional engagement, as evidenced by WRAD, as compared to pre-COVID sessions. The therapist appears to be working harder to communicate that he is listening as evidenced by an increase in the measure of Non-turn Vocalizations (interjections such as hmm). Thus, it appears that both, patient and therapist, are working harder to remain connected and communicate that they are present. And, yet, despite increased effort, there is a decrease in emotional engagement and connectedness. This pattern remains unaltered at a 7-month follow-up. DISCUSSION: The findings begin to address empirically the subjective experience of many clinicians who have switched to remote treatment. The commonly asked question, Are you there? (Lichtenstein, 2021) is being addressed quite literally during remote work. Notwithstanding what appears to be increased effort, there is a decrease in emotional engagement and connectedness between the dyad. This decrease in connectedness substantiates another common experience reported by therapists commenting on online work: mainly, an increase in fatigue (Seligman, 2021; Weinstein, 2021). With the use of complex linguistic indicators we can detail how clinical work has changed as a result of remote treatment, and how the work can change over time as treatment progresses, and the dyad begins to adjust to a new mode of conducting therapy. Implications for the future of remote therapy will be discussed.