Westcliff International Journal of Applied Research

Vol. 5, No. 1. Fall 2021

https://doi.org/10.47670/wuwijar202151CDSM

Psychotherapists Working in Private Practice During a Pandemic:

A Literature Review
Christine L. Duquette
Touro University Worldwide

Stephanie M. Morgan
Touro University Worldwide

ABSTRACT

Psychotherapists in private practice provide services to an ever-growing client population. The 2020
novel Corona Virus (COVID-19) pandemic was a catalyst for emerging and exasperated mental health
concerns among the U.S. population. The result was an increase in demand for services and private
practitioners stepping up to meet this growing need. Little is known about the psychotherapists who
embark on independent practice and less is known about the nuances of practicing during a global
pandemic. The aim of this review was to exhaust the literature on private practice psychotherapy and
the practice of psychotherapy during COVID-19, synthesize the findings, report on themes in the
literature, and provide recommendations for future lines of inquiry. Themes from this review included
the impact of COVID-19 on public mental health, telemental health, private practice shifts, and private
practice careers.

Keywords: psychotherapists, private practice, COVID-19, telemental health, pandemic psychotherapy

Psychotherapists Working in Private Practice Many therapists dramatically changed

During a Pandemic: A Literature Review the way they deliver services, and some opted
to transition to private practice following the
Psychotherapists are employed in a onset of the 2020 novel Corona Virus (COVID-
variety of treatment settings and among the top 19) pandemic (Polovoy & Kornak, 2020). The
is a private practice office. Unfortunately, little is reach of COVID-19 extended to all facets of life,
known about those psychotherapists who and people had to pivot in order to
embark on practicing independently, in a private accommodate widespread global change. On
practice setting. The personal, professional, and March 17th, 2020, the Centers for Medicare and
contextual variables that influence the decision Medicaid expanded and relaxed previous
to work independently in private practice have telehealth rules allowing for full telehealth
not been adequately explored. Research services and reducing or eliminating patient
historically centers on the patient, not the cost-sharing in the form of deductibles and co-
practitioner and the modality, nor the course of pays (Inserro, 2020). Other private insurance
professional development. While the study of providers followed suit initiating similar changes
patients, their presenting problems, and the (America's Health Insurance Providers [AHIP],
search for effective treatments are critical to 2021). Taken together, these changes had
evidence-based practice, the practitioner and significant implications for mental health
professional identity are important variables to services, including who needed services, how
consider. services were delivered, where services were
Licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. Page |5
delivered, and how service providers were health, motivation for private practice,
mobilized to meet the needs of a growing client psychotherapy and pandemics, and COVID and
population. Psychotherapists who followed the psychotherapy changes.
previously standard model of in-office and in- The Impact of COVID-19 on Public Mental
person visits (i.e., offices, health care facilities, Health
treatment centers, and myriad other mental
health settings) shifted to providing telehealth, COVID-19 brought on major disruptions
often from their homes (Aafjes-van Doorn et al., in the lives of many individuals and is projected
2020). The pandemic proved to be a call for to result in long-term negative mental health
therapists to meet a growing need for services, outcomes across the globe (Boden et al., 2021;
and yet little is known about how therapists work Lie et al., 20210). Measures taken to respond to
in private practice and even less about how they the pandemic have considerably shifted
prepare for change to support clients during everyday life including routines, occupational
global unrest and pandemics. and academic obligations, and shared spaces in
The dearth of research on practitioners the home; the result has been a complex array
may be influenced by the clinical truism that of stressors with negative impacts on public
practitioners are or should be blank slates for mental health (Javakhishvili et al., 2020; Khan et
their clients. The gaps in the literature include al., 2020; Lewis et al., 2021). The pandemic
motivations for career choice, career created specific issues related to both mental
sustainability, and how private practitioners health and the people who provide mental health
specifically support clients during global crises. services (Lu et al., 2020; Soklaridis et al., 2020).
Additionally, it is difficult to conceptualize roles The outbreak of COVID-19 has resulted in a
and constructs such as psychotherapist, private growing body of research around the
practice, and varying ways of practicing among psychological impact of infection, fear of
innumerable licensure statuses. For the purpose infection, and quarantine. Itrat et al. (2020)
of this review, the term psychotherapist refers to asserted that quarantine has had a clear
an independently licensed masters or doctoral negative impact on public mental health. Lee
level practitioner who provides psychotherapy to (2020) noted that as school was often a conduit
clientele. The terms practitioner, provider, for children and adolescents in need of mental
psychotherapist, and therapist will be used health services, COVID-19 and related school
interchangeably. closures left many children and families abruptly
without necessary services. Taylor et al. (2020)
The aim of this review is to explore the went so far as to coin the term COVID stress
current theoretical and practical understandings syndrome to describe five factors of COVID-
of psychotherapeutic private practice during a related distress, including fear of getting COVID-
global pandemic, synthesize and report on the 19, socioeconomic worries, xenophobia related
overarching themes, and provide to fears of foreigners spreading the virus,
recommendations for future research that may symptoms of traumatic stress, and compulsive
lead to a better understanding of the nuances of checking and hypervigilance.
the role and impact of work done by providers in
this setting, especially during times of rapid The demands of responding to the virus
change and unprecedented crises. The following itself may have diverted resources away from
databases were utilized for this review: mental healthcare (Mauro et al., 2020; van der
Proquest, Google Scholar, EbscoHost, and Miesen et al., 2020). As governments responded
ERIC. In order to be included in this review, to the global threat, restrictions like travel bans,
articles must have been written in English, peer- business and school shutdowns, strict social
reviewed or published from a direct source (eg. distancing, and stay-at-home orders led to an
Insurer or licensing board) and published within uptick in the experience of mental health
the last ten years. The following key terms and symptoms (AJMC, 2021; Rothe et al., 2021).
phrases were used: psychotherapy/ists in These restrictions, in turn, resulted in several
private practice, psychotherapy during COVID, added stressors for many individuals and
therapists in private practice, COVID and mental families, including employment challenges,
income loss, financial difficulties, isolation,

WIJAR. Volume 5, Issue 1. December 2021. Page |6

greater tension between people sharing Administration (SAMHSA) restricted online data
households, stress over the virus itself, and a analysis system (RDAS), the National Survey on
barrage of conflicting information, all adding to Drug Use and Health (NSDUH), and the 2018
an already weighty burden (Davulis et al., 2021). and 2019 Substance Abuse and Mental Health
Javakhishvili et al. (2020) noted that among Data Archive showed that 6.2% of adults
many of the COVID-19 related changes in life reported an unmet need for mental health
circumstances, cultural constructs ranked highly services between 2018 and 2019 (Kaiser Family
and included further stigmatization, Foundation, n.d.). A 2016 report from the U.S.
discrimination and community fragmentation, Department of Health and Human Services
and even the loss of culturally significant examined projections for the supply and demand
mourning rituals. of behavioral health practitioners utilizing an
Stress, anxiety, depression, sleep integrated microsimulation model and found that
disorders, fatigue, boredom, feelings of isolation, shortages were predicted for clinical, counseling,
and anger are among the most reported mental and school psychologists; marriage and family
health systems related to COVID-19 (Davulis et therapists; substance abuse and behavioral
al., 2021; Javed et al., 2020). A July 2020 health disorder counselors; psychiatrists; mental health
tracking poll from the Kaiser Family Foundation and substance abuse social workers; mental
found that many adults reported specific health counselors; and school counselors; and
negative impacts on their mental health related that these predicted shortages exceeded 10,000
to the coronavirus, including sleep issues (36%), full-time employees in each of the various
eating issues (32%), and increases in alcohol positions (U.S. Department of Health and
consumption and/or substance use (12%) Human Services, 2016). These simulations were
(Panchal et al., 2021). Additionally, a National conducted utilizing multiple models, one with a
Health Interview Survey (NHIS) found that from baseline assuming equilibrium with 2013
January to June in 2019, just 11% of adults provider supply and a second scenario
reported symptoms of anxiety or depressive estimating current shortages and projected
disorder, with that number rising to 41.1% in a demand. Neither scenario accounted for a global
January 2020 household survey conducted by pandemic and the demands that might put on
the U.S. Census Bureau (Panchal et al., 2021). both the demand for behavioral health services
A cross-sectional study using data from the and the supply of practitioners (U.S. Department
Centers for Disease Control and Prevention of Health and Human Services, 2016).
National Syndromic Surveillance Program Individuals who had previously
examined nearly 190 million emergency experienced mental health problems reported
department visits finding higher rates of visits worsening symptoms as pandemic stressors
associated with mental health conditions, suicide and other risk factors increased negative mental
attempts, drug overdoses, and child abuse and health outcomes, particularly among already
neglect from mid-March through October 2020 vulnerable populations (Boden et al., 2021).
than the same period in 2019 (Holland et al., Some populations were particularly vulnerable to
2021). The Federal Disaster Distress Helpline, COVID-19 including those with chronic illnesses
run by the Substance Abuse and Mental Health and pre-existing medical conditions, the elderly,
Services Administration and the nonprofit and frontline workers (Davulis et al., 2021).
Vibrant Emotional Health, received a surge in Patients who contracted COVID-19 reported
calls and texts, answering over 25,000 calls and feelings of regret, resentment, isolation,
texts in March of 2020, more than eight times helplessness and new or worsening symptoms
the number of calls and texts from February of depression and anxiety. Even in patients with
2020 (Hopkins & Russell, 2020). no previous history of mental illness, COVID-19
Discussions centering around inequity in was associated with an increase in the onset of
access to and general availability of mental the first presentation of psychiatric symptoms
health services were already taking place prior (Taquet et al., 2021; Tingbo, 2020). Other
to the onset of the pandemic. To this point, a socially disadvantaged populations were
Kaiser Family Foundation analysis of the considered at heightened risk for greater mental
Substance Abuse and Mental Health Services health effects including those with disparities in

WIJAR. Volume 5, Issue 1. December 2021. Page |7

education, income, employment, occupation, Clinicians, supervisors, clinical directors,
age, immigration status, sexual orientation, educators, and those in similar roles were all
cultural/racial background, sex, and gender doing this in tandem with managing their own
(Gibson et al., 2021; Litam & Hipolito-Delgado, personal and professional challenges around the
2021). Preliminary studies suggested that the pandemic.
COVID-19 pandemic is likely associated with Telemental health was already a
rises in reports of stress and anxiety (Ahorsu et modality that some practitioners opted to use
al., 2020; Pierce et al., 2021), symptoms of post- pre-pandemic with studies attesting to its
traumatic stress disorder (PTSD) (Tingbo, usefulness and efficacy (Andersson et al., 2019;
2020), and increased substance use issues Titov et al., 2018; Webb et al., 2017). The
(Rehm et al., 2020). The impacts of quarantine introduction of high-speed Internet and greater
on those individuals with pre-existing mental access to laptops and smartphones has made
illness showed while the symptoms themselves telehealth increasingly feasible (Sammons et al.,
were similar to pre-pandemic, they were much 2020). Still, telehealth coverage before the
more severe (Itrat et al., 2020). pandemic was minimal and limited, with a
Notably, many individuals reported new complex regulatory framework, more of a niche
symptoms and instances of mental health healthcare delivery model in part due to the
impairment, despite having no prior symptoms absence of uniform coverage from insurance
or treatment episodes (Holingue et al., 2020; providers or between states as well as
Rothe et al., 2021). In light of this, there was a adoption/implementation barriers like high
rapid and marked increase in requests to initiate startup costs, shifts in workflow, practitioner buy-
mental health services. Mental health services, in, and patient interest (Weigel et al., 2020).
similar to most other medical services during In March of 2020, soon after the federal
COVID-19, were recommended to be provided government declared a public health
remotely when possible, and so, the majority of emergency, Medicare and Medicaid coverage of
outpatient providers shifted their practices online telehealth was expanded allowing for full
(Punia et al., 2020). Many of the traditional telehealth services and reducing or eliminating
therapeutic or intervention models were not patient deductibles and co-pays (Inserro, 2020).
scalable to meet the increased demand for COVID-19 spurred greater interest in
mental health services (Boden et al., 2021). telemedicine as policymakers, insurers, and
Duan and Zhu (2020) noted that mental health care providers sought out ways to deliver
responses in emergency conditions require services with limited risk of virus transmission
flexibility to meet rapid change and manage any (Weigel et al., 2020; Weineland et al., 2020).
inherent constraints. More people were looking The federal government was instrumental in
for services just as access to services narrowed expanding coverage by allowing Medicare
with the abrupt shift away from in-person beneficiaries from any geographic location to
services. access services from their homes, waiving
Telemental Health HIPAA enforcement for telemedicine, and even
relaxing requirements on the prescription of
Etymologically speaking, the word
controlled substances (Weigel et al., 2020). The
pandemic is related to pandemonium (Szasz,
state governments also had a role in expanding
2020), and pandemonium accurately described
telehealth access and coverage by relaxing
the early days of psychotherapists transitioning
many of the provider licensing requirements,
their practices to telemental health. In the
supervision requirements, and written consents,
immediate aftermath of COVID-19 restrictions,
with some states even mandating telehealth
there was tremendous confusion about how to
reimbursement for fully insured private plans
follow state and federal mandates, stay safe,
(Weigel et al., 2020,).
keep the public safe, deliver services, limit
liability, assure insurance reimbursement of Other private insurance providers
services, maintain the integrity of legal and followed in step initiating similar changes
ethical guidelines, and operate within the law, or (America's Health Insurance Providers [AHIP],
at the very least, within the "spirit" of the law. 2021). The pandemic accelerated the use of

WIJAR. Volume 5, Issue 1. December 2021. Page |8

telemental health making it significantly more that for clinicians with a long history of face-to-
ubiquitous as insurance companies followed face talk therapy, shifting sessions was not a
Medicare/Medicaid in adjusting behavioral simple task. Additionally, with the relationship
health services and expanding coverage of being a significant factor in positive therapeutic
telehealth beyond traditional parameters to meet outcomes (Rogers, 1979), psychotherapists
the increased need and limited access to face- maintained reservations that telemental health
to-face services (Blue Cross Blue Shield, 2020). would impact the rapport-building process and
Taken together, these changes had significant capacity (Cataldo et al., 2021). Boldrini et al.
implications for mental health services including (2020) found that psychotherapist satisfaction
who needed services, how services were with telehealth was influenced by the rate of
delivered, where services were delivered, and interrupted treatments, their previous experience
how service providers were mobilized to meet with telehealth, their beliefs about telehealth with
the needs of a growing client population. their specific theoretical orientation, and the use
Private Practice Shifts of video conferencing over telephone-delivered
Due to the risk of infection transmission services.
from face-to-face psychotherapeutic care, Despite therapist concern about
telehealth was the most recommended solution telehealth and its efficacy, a mounting body of
to offer clients continuation of care and access evidence suggests that telehealth offers
to care providers for those seeking to initiate comparable results to in-person psychotherapy
services (Humer et al., 2020; Markowitz et al., (Lopez et al., 2019; Norwood et al., 2018;
2020; Sampaio et al., 2021). The rapid shift to Simpson & Reid, 2014). Simpson and Reid
telehealth has been described as amounting to (2014) assert that the therapeutic alliance, a
10 years of change taking place over one week critical part of the therapeutic process, can be
(Mueller, 2020). Sammons et al. (2020) noted fostered in psychotherapy via videoconference,
that prior to the pandemic, only 29% of providers as clients rated connection and presence at
were using online platforms for a portion of their least equally as strongly as face-to-face services
practice to current estimates of over 80% of across a number of different diagnostic
providers practicing almost exclusively via groups. Norwood et al. (2018) asserted that
telehealth. Barney et al. (2020) also noted a while there was some indication that the
dramatic surge in telehealth visits at their therapeutic alliance was not as strong in
Adolescent and Young Adult Medicine Clinic, telehealth, that target symptom reduction was
increasing from zero to 97% of patient meetings equivalent. Lopez et al. (2019) found that
in a single month. In fact, researchers practitioners generally have more reservations
contended that COVID-19 presented a turning about the limitations of telehealth than patients
point for the adoption of telemental health, do.
offering a greater catalyst for the rapid Psychotherapists also worried about
implementation of telehealth than decades of telehealth in relation to HIPAA, security and
research promoting the efficacy and economics confidentiality, technical logistics and failures,
of telehealth (Mohr et al., 2018; Pierce et al., regulatory and legal changes, and managing
2021; Wind et al., 2020). insurance and reimbursement (Fernández-
While telehealth can include various Álvarez & Fernández-Álvarez, 2021). As
media platforms and phone systems, Markowitz et al. (2020) explained, telehealth
videoconferencing (e.g., Zoom, Doxy.me) was presented some major technical hurdles like
the most widely utilized medium (Fernández- challenges connecting, frozen screens, delayed
Álvarez & Fernández-Álvarez, 2021; audio, dropped calls, and more, all adding to
Smoktunowicz et al., 2020). Changes in therapist attitudes about telehealth and its
insurance coverage of telehealth opened the efficacy. Thompson-de Benoit and Kramer
door to service continuity but presented (2020) noted that good connectivity, a good
challenges to therapists who were less microphone, adequate lighting, a camera at eye
comfortable with the technology associated with level to enhance eye contact, and limiting
telehealth. Cataldo et al. (2021) acknowledged distractions like notifications and email were
critical to successful teletherapy.

WIJAR. Volume 5, Issue 1. December 2021. Page |9

 Furthermore, some psychotherapists special issues centered entirely on private
expressed fear of managing high-need patients practice and a scant number of articles specific
via telehealth (Cataldo et al., 2021; Cullen et al., to private practice. A review of the more current
2020). For example, suicide risk is often higher available research reveals limited progress in
during a disaster or global threat like COVID-19, this area. While there are some estimations of
and this paired with a lack of face-to-face the various numbers of behavioral health
contact can lead practitioners to feel like they practitioners, there is almost no information on
are inadequately prepared to manage risk how many psychotherapists are in private
(Gunnell et al., 2020). Additionally, some practice, and it was found that most state
diagnoses like severe eating disorders are licensing boards do not maintain easily
managed with regular weighing and other accessible data about how many licensed or
interventions that are not as easily delivered pre-licensed therapists work in private practice
remote without thoughtful and creative (Harrington, 2013). Given the extent to which
adjustments (Matheson et al., 2020). Still, there mental health services are provided in outpatient
is mounting evidence that many serious settings, it is surprising that this data is not
disorders like obsessive-compulsive disorder, further studied and that the decisions leading up
bipolar disorders, suicide ideation, psychosis, to and experiences of maintaining a private
and post-traumatic stress disorder are treatable practice are incredibly underexplored. Even less
via telehealth (Aafjes-van Doorn et al., 2020; is known about practitioners who pursued
DeLuca et al., 2020; De Siqueira et al., 2020; private practice during the global pandemic. The
Hasson-Ohayon & Lysaker, 2020; Mcginn et al., aim of this research is to address these gaps in
2019). the literature.
While therapists reported appreciating Discussion
elements of telehealth, like a reduced commute, Many psychotherapists will go into
they also missed the transitional buffer that private practice during the course of their
working outside of their home provided them careers as an independent practice may offer
and reported greater fatigue and physical autonomy, professional growth, scheduling and
discomfort with telehealth (Markowitz et al., workload flexibility, relief from burnout in
2020). At times, telehealth could offer a window previous employment, and higher compensation.
into a client's life that could not be seen via Unfortunately, very little is known about how
traditional office visits; however, some therapists many clinicians identify as private practitioners
reported this as distracting or disruptive as client and why they choose that role for their work
behavior, pets, children, and family complicated (Harrington, 2013). While private practice can be
sessions (Gabbard, 2021). Additionally, video enticing, there are barriers to establishing a
conferencing seemed to require greater private psychotherapy practice, including startup
attention and focus than face-to-face sessions, costs, commercial office leasing, the
as there is more difficulty in processing complexities of insurance and managed care,
nonverbal cues leading to additional therapist the absence of benefits like healthcare, and the
fatigue (Gabbard, 2021). perceived isolation and lack of support
(Harrington, 2013). COVID-19 led to widespread
Private Practice Careers adoption of telehealth and resulted in shifting
While private practice therapists make attitudes regarding the implementation and
up a substantial percentage of mental health efficacy of telehealth (Békés & Aafjes-van
providers, there is a dearth of literature specific Doorn, 2020). Given that a large percentage of
to this population. Harrington (2013) reviewed a psychotherapeutic services are provided in
decade of noted journals related to major private practice settings and therapists support
licenses in the field of psychotherapy, which clients through a variety of micro and macro
included the American Psychological level issues and crises, it is important to
Association (APA), the National Association of understand career motivations, barriers and
Social Workers (NASW), and The Journal of benefits of independent practice, treatment
Marital & Family Therapy and found that no

WIJAR. Volume 5, Issue 1. December 2021. P a g e | 10

approaches and outcomes, and the experiences https://www.ajmc.com/view/a-timeline-of-
of the providers. covid19-developments-in-2020
Future research could explore the America’s Health Insurance Providers [AHIP].
experiences of private practice therapists during (2021, April 8). Health insurance providers
the COVID-19 pandemic. This may provide respond to Coronavirus (COVID-19).
insight on motivations to start or sustain https://www.ahip.org/health-insurance-providers-
independent practice and the impact of respond-to-coronavirus-covid-19/
supporting clients during a pandemic.
Additionally, a quantitative design could explore Anderson, M. L., Goodman, J., & Schlossberg,
the relationship between variables such as N. K. (2012). Counseling adults in transition:
competency, treatment approach, time in Linking Schlossberg's theory with practice in a
practice, and geography and treatment diverse world (4th ed.). Springer Publishing
outcomes. Finally, educational programs Company.
preparing clinicians to enter the workforce can Andersson, G., Carlbring, P., Titov, N., &
expand their focus on work preparedness and Lindefors, N. (2019). Internet interventions for
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counseling as both separate and overlapping analyses. The Canadian Journal of
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