Reflections on the Plague Year
Conducting Psychotherapy Research during the COVID-19 Pandemic
Clinical Impact Statement: The COVID-19 pandemic has had a marked impact on psychotherapy research, as most research institutions have paused or curtailed in-person research and clinical activity. The purpose of this article is to relate experiences the reader may have in common or that may stimulate consultation among researchers as they consider changes in their own research, given the likelihood that the pandemic has introduced lasting changes to the conduct of psychotherapy research.
“I had two important things before me: the one was the carrying on my Business and Shop, which was considerable, and in which was embarked all my Effects in the World; and the other was the Preservation of my Life in so dismal a Calamity as I saw apparently was coming upon the whole City, and which, however great it was, my Fears perhaps, as well as other Peoples, represented to be much greater than it could be.”
--Daniel Defoe, A Journal of the Plague Year, 1722
Marking a full year since the start of the public health emergency and massive social upheaval caused by COVID-19 led me to read Defoe’s A Journal of the Plague Year, an account of the 1655 Great Plague of London. It details a number of parallels with our current pandemic: the tracking of the plague’s spread from parish to parish, the shutting up of homes and public places, the grimness of the rising death count, the weeping and lamentation upon the death of loved ones, and both the public’s fear of the disease and their resistance to government measures to contain its spread. But the passage that’s resonating for me right now is in the epigraph, above. It describes the tension Defoe’s narrator felt between his desire to stay in his community and maintain his saddlery business and his fear of the disease and death he risked by not fleeing the plague-stricken city. In the current pandemic, psychotherapy practitioners and researchers also are driven to sustain our work, and though we have the safe haven of online interactions, the shift to a virtual workspace has presented its own set of challenges, questions about how the pandemic has altered our processes, and speculations about what the new normal will be.
Although much attention has been given to COVID-19’s impact on psychotherapy providers, comparatively little has been written about how the pandemic has affected the conduct of psychotherapy research. Studies that were under way at the start of the pandemic have undergone fundamental changes as COVID-related restrictions at most research institutions have remained in place over the past year. The purpose of this article is to provide examples of adaptations some researchers have made, the challenges encountered in amending study methods, and some potential opportunities stemming from the changes. Several colleagues have generously provided examples from their own experiences in sustaining their research during the COVID-19 year, including study pauses, changes in participant recruitment, the shift to virtual therapy sessions, the impact on data collection and analysis, and the creation of hybrid procedures to enable biomarker data collection.
Most of the colleagues I contacted reported a pause in their research at the start of the pandemic, some because their institution halted in-person research or therapy and others because it took some time to manage the logistics of moving to virtual sessions and data collection. All reported that their institutional review boards were responsive to protocol changes; some experienced a delay but ultimately received approval for COVID-related amendments. The length of time research was paused ranged from no time at all to more than one year. Harold Chui, assistant professor in the educational psychology department at The Chinese University of Hong Kong and member of Division 29’s Research Committee, reported that he was not able to collect data from his clinic from March to December 2020. One Division 29 grant recipient had to request two no-cost extensions because his data collection requires international travel to an area with high COVID case rates, delaying his data collection by at least one year. My current study, a pilot trial of a novel therapy for trauma-related nightmares, was paused for two months by the university’s order that all non-COVID-related research be halted. Once research was allowed to resume, the university and site IRBs quickly approved our COVID-altered protocol. We also are requesting a no-cost extension on our grant to extend our data collection time. Thus, having psychotherapy research activities halted was common among those contacted. Some were able to resume quickly whereas others remain on hold due to pandemic conditions at their study sites.
Impact on Participant Recruitment
For some studies, participant recruitment has been hampered significantly by the pandemic environment. For my study, our most productive approach has been to set up an information table in a high-traffic area of the hospital where research assistants can meet potential participants, provide information about the study, and collect contact information. Our tabling at Walter Reed National Military Medical Center was of course halted at the start of the pandemic because of the public health risk, and the current health protection condition level has precluded our return to in-person recruiting. This has reduced our recruiting numbers substantially and has led us to develop online advertising and recruiting approaches, including use of social media, local intranets, and listservs. In addition to the loss of in-person recruiting, potential participants we contact by text or phone seem more reluctant to follow up after prescreening calls or virtual screening visits, causing further decline in recruiting numbers. One other researcher has had similar difficulties with recruitment, with potential participants seeming less responsive to online recruiting approaches.
Other researchers indicated they had no decrease in recruitment. Joshua Swift, associate professor of clinical psychology at Idaho State University and Division 29 treasurer, reported that he doesn’t believe the pandemic harmed recruitment and perhaps even improved recruiting for their online studies because there were no in-person studies to compete with. Based on these comments, then, one positive impact of the pandemic on participant recruiting is that it has compelled researchers to broaden their approaches to recruitment and that these techniques may have value after the pandemic restrictions are lifted.
Shift to Virtual Sessions
All of the researchers reported shifting to virtual sessions. The availability of Zoom, Google Meet, and other online platforms facilitated the logistics of the change. Clara Hill, professor of counseling psychology at the University of Maryland and president of Division 29, reported no pause in research activity at the Maryland Psychotherapy Clinic and Research Lab, which she attributes to the university switching to Zoom, which enabled their smooth transition to virtual sessions. Other researchers also reported that the shift was relatively smooth. For my study, the change to virtual sessions had some initial glitches, including one participant lacking broadband access in their home and the research team taking some time in figuring out how to smoothly transition the session from a research assistant who does informed consent to the assessor for clinical interviews to the therapist for treatment and then back to the research assistant. We have found that giving each team member an estimated time to stand by and then instant messaging them at the time of transition has worked fairly smoothly.
In addition to mastering the logistics of conducting virtual sessions, developing the therapy relationship virtually is more challenging than it is in person. The therapists and assessors in our study have noted that it can be difficult to read a participant’s facial expressions and body language. The technology also introduces an audio time lag, which can cause participants and therapists to talk over each other or create unintentional, awkward silences. There are occasional signal disruptions, which causes gaps in communication and requires the therapist to ask the participant to repeat themselves. In addition, participants can be distracted when they are in their home by family members, pets, onscreen message notifications, text messages, and other environmental stimuli not present in an in-person therapy setting.
The positive aspects of virtual sessions are, of course, the convenience of not having to travel to the study site and having the capacity to reach a geographically broader pool of participants. In addition, being compelled to conduct psychotherapy research virtually has created a large population of virtual therapy dyads, giving us the opportunity to vastly expand research on virtual therapy process and outcome.
Data Collection and Analysis
Sessions are not the only component of psychotherapy research that have gone virtual; transitioning to online data collection also has forced a steep learning curve. Jenelle Slavin-Mulford, associate professor in the psychological sciences department at Augusta University and chair of Division 29’s research committee, stated that their lab missed several weeks of data collection at the start of the pandemic while they figured out the logistics of transitioning their study online. Because her current study will include data from both in-person and virtual sessions, she says she will need to assess whether and how the virtual sessions are different from the in-person and will have to covary those factors out.
Harold Chui reported that his research team uses Zoom’s recording feature to record sessions for future coding and analysis, and that they are collecting pre- and post-session self-report data via Qualtrics. He also noted that they have had a lot more missing data since the move to online data collection, which will likely extend his data collection period. Joshua Swift stated that he expects his data analysis will be much more complex because the recorded Zoom sessions give a smaller picture of the client (typically just head and shoulders), so that coders can’t view the same amount of detail as they can in recordings of in-person sessions, and this makes it harder to pick up body language and other nuances. In addition, he stated that it’s difficult to tell whether pauses are due to connectivity issues or just natural pauses in the therapist-client interaction. For my own study, we had been using digital audio recorders to record in-person sessions, and after shifting to virtual sessions, we attempted using the same recorders but found that the sound quality was quite poor. We have since switched to using the Google Meet recording feature, which has produced much clearer recordings, making coding and adherence checks go much more quickly.
Given all of the adaptations described thus far, it’s no surprise that managing lab procedures have changed significantly. Jenelle Slavin-Mulford reported that her lab manager had to learn their new online data collection method. Clara Hill stated that the biggest shift in her lab was that therapists had to assume all administrative duties, including giving measures, turning on recording devices, and uploading recordings to the university’s secure system, which has added considerable time to each session. She said they also had to implement a different payment system because they had previously accepted only cash and checks, and since the pandemic have had to set up online payments through the university.
Biomarker Data Collection
An increasing number of psychotherapy studies are integrating biomarker data collection into their protocols, a component that is obviously problematic in a pandemic environment. Two of my colleagues had biomarkers in their protocols when COVID hit. One made the decision to simply halt his study, and the other amended his protocol to omit biosample collection and proceeded with virtual therapy sessions and psychometric data collection. For the pilot trial my team is conducting, we distribute wristband devices for continuous physiologic data collection and collect blood samples at three visits for genetic and inflammatory marker assay. Because these biomarkers are essential to the study, we needed to retain them and so came up with a hybrid of in-person and virtual study visits. The study was originally designed with 10 in-person visits, including screening and follow-up. We have amended it so that six of the visits are now virtual and four are completed in-person in our study offices. These in-person visits are when participants receive or return the wristband devices and give blood samples. To prepare for the visits, all surfaces and equipment are sanitized prior to participant arrival. The research assistant and the participant are masked and meet in person briefly as the research assistant escorts the participant to a laptop in one room and then goes to their own laptop in another room to conduct equipment orientation and administer measures virtually. When these are complete, the therapist enters the video session and conducts the therapy. When the therapy session is complete, the therapist alerts the research assistant, who escorts the participant to the phlebotomy clinic for the blood draw. When the blood draw is complete, the research assistant walks the samples to the lab, where they are centrifuged and stored for later assay. All personnel are masked and observe physical distancing. Although the revised procedures are more burdensome, we’ve been able carry them out fairly smoothly. In one respect, pandemic restrictions have made our procedures a bit easier. With most of the therapists in our suite working from home, the additional office space needed to keep the research assistant and participant separate is always available. It isn’t yet clear when restrictions will be lifted or whether we will return to in-person sessions even if they are lifted, given the convenience that virtual sessions afford. The amended procedures have demonstrated that biomarker collection is possible even under pandemic restrictions.
It’s been a long, strange year. Though our COVID-19 pandemic experiences differ in many ways from the plague year endured by Defoe’s 17th century London saddler, we share the uncertainty wrought by a public health crisis and consequent major changes in how we live and how we do our work. It’s my hope that relating the challenges that I and some of my colleagues encountered during the pandemic year provides a sense of commonality. I also hope that sharing how we adapted our studies may stimulate other researchers to consult with each other when considering how best to adapt their current studies and, as they look to the future, to investigate new topics and constructs that may arise as a result of the pandemic.
Acknowledgments: I would like to express my thanks to Harold Chui, Clara Hill, Jenelle Slavin-Mulford, and Joshua Swift for sharing their pandemic research experiences.
Disclaimer: The opinions and assertions expressed herein are those of the author and do not necessarily reflect the official policy or position of the Uniformed Services University, the Department of Defense, or the Henry Jackson Foundation.
Cite This Article
Spangler, P. (2021). Reflections on the plague year: Conducting psychotherapy research during the COVID-19 pandemic. Psychotherapy Bulletin, 56(2), 18-22.
Defoe, D. (2011). A journal of the plague year. Digireads.com Publishing. (Original work published in 1722).