
==== Front
J Educ Health Promot
J Educ Health Promot
JEHP
J Edu Health Promot
Journal of Education and Health Promotion
2277-9531
2319-6440
Wolters Kluwer - Medknow India

JEHP-13-112
10.4103/jehp.jehp_372_23
Original Article
Tele-psychotherapy for individuals with obsessive-compulsive disorder during the COVID-19 outbreak: A qualitative study
Chaharshughi Batul Tadayon
Izadi Razieh 1
Naghavi Azam 2
PhD Student in Counseling, Faculty of Humanities, Khomeinishar Branch, Islamic Azad University, Khomeinishar, Isfahan, Iran
1 Assistant Professor, Department of Psychology, Safahan Institute of Higher Education, Isfahan, Iran
2 Associate Professor, Department of Counseling, Faculty of Education and Psychology, University of Isfahan, Isfahan, Iran
Address for correspondence: Dr. Razieh Izadi, Assistant Professor, Department of Psychology, Safahan Institute of Higher Education, Isfahan, Iran. E-mail: r.izady@safahan.ac.ir
2024
28 3 2024
13 11215 3 2023
22 5 2023
Copyright: © 2024 Journal of Education and Health Promotion
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
BACKGROUND:

One way of delivering psychological services is tele-psychotherapy, which has attracted significant attention as a viable approach. This study aimed to identify important variables in the application of tele-counseling and psychotherapy for the treatment of patients with obsessive-compulsive disorder (OCD) in Isfahan, Iran.

MATERIALS AND METHODS:

This research employed an exploratory qualitative methodology. The participants of this study consisted of all the clients with OCD and all the psychotherapists in the city of Isfahan. Purposive sampling was employed, and following a series of semi-structured interviews with 35 individuals with OCD and 11 counselors in this area, the sample size reached a saturation point. The data was analyzed by Braun and Clark's thematic analysis method.

RESULTS:

Based on the findings of Braun and Clark's analysis, three primary themes emerged concerning tele-counseling: opportunities, requirements, and challenges.

CONCLUSION:

According to the feedback received from therapists and clients, remote services could offer promising prospects to both groups by providing accessible locations and flexible time management. However, to get the full benefits of teletherapy, therapists should consider certain factors to enhance the therapeutic alliance. Moreover, there are challenges that need to be addressed.

Mental health promotion
obsessive-compulsive disorder
tele-counseling
tele-psychotherapy
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pmcIntroduction

Obsessive-compulsive disorder (OCD) is one of the most debilitating psychological disorders,[1] with a relatively high incidence rate. It affects individuals’ potential, social compatibility, and interpersonal relationships.[2] This condition is characterized by the manifestation of thoughts or behaviors that are deemed obsessive. Obsessive thoughts are mental processes characterized by persistent and repetitive thoughts or mental images, which are deemed inappropriate and obtrusive within the context of the disorder. These thoughts are unrelated to real-life concerns and can cause significant distress to the individual experiencing them. Clients try to ignore, suppress, or neutralize them (mental resistance) while acknowledging that these thoughts, mental images, or impulses are the product of their minds. Obsessive behaviors refer to recurrent actions or cognitive processes that adhere to fixed patterns, and individuals feel compelled to engage in them due to obsessive thoughts. The objective of mental processes is to mitigate or alleviate distress or to prevent a fearful event. The actions mentioned above are not associated with what is intended to be neutralized or are deemed excessively radical.[3]

On the other hand, the prevalence of mental disorders, including stress, anxiety, OCD, and depression has increased with the global spread of COVID-19.[4] The World Health Organization (WHO) recommended various hygiene measures, including wearing masks and gloves and frequent hand and face washing, to prevent infection. However, these measures may pose challenges for individuals with obsessive-compulsive symptoms or a predisposition to such behavior.[5] The pressure and stress caused by COVID-19 have adversely affected people prone to OCD to the extent that their compulsive need for adherence to these hygiene measures disrupts their daily routines.[6] During the pandemic, authorities consistently emphasized the significance of adhering to social distancing protocols and maintaining personal hygiene. Moreover, the results of the studies conducted to investigate the dimensions of OCD during the COVID-19 pandemic reveal that many individuals of different ages have suffered from this mental and behavioral challenge.[7] According to the statistics published by WHO, mental disorders generally were previously following a steadily increasing trend for various reasons. However, since the onset of the COVID-19 pandemic, this trend has taken on an exponential surge[8]; OCD is no exception.

Since implementing social restrictions and mental disorders following the pandemic, online psychotherapy has replaced conventional face-to-face psychotherapy.[9] Before COVID-19, tele-psychotherapy had been growing; it is estimated that 5-21% of the cases were being addressed through teletherapy.[10] However, with the outbreak of COVID-19 followed by mandatory social restrictions, telemental health has become even more popular.[111213] According to a systematic review, telemedicine plays a significant role in the management of diseases. Telemedicine services are available through a diversity of interaction modes and modalities such as “short message service, email and web portals, secure telephone calls or VOIP, video calls, interactive mobile health applications (mHealth), remote patient monitoring, and video conferencing.”[14]

The third wave of psychotherapy has proven successful in treating OCD. Third-wave cognitive behavioral therapies offer a pioneering viewpoint on the treatment of OCD. Focusing on thought processes and how a person relates to thought processes are pivotal in third-wave approaches. Acceptance and commitment therapy is one of the third-wave approaches to managing OCD.[15] This approach emphasizes internal indicators and criteria that an individual uses to stop compulsive behavior.[1316]

Before the pandemic, third-wave therapies, particularly acceptance and commitment therapy, were mainly practiced face-to-face in clinical and research contexts. However, with the onset of COVID-19 and its following restrictions, psychologists have increasingly adopted the practice of tele-psychotherapy.[17] Contradictory to the findings supporting the efficiency of online interventions, some therapists express their doubt, arguing that technology could negatively impact the therapeutic alliance.[1819] These opposing views may affect therapists’ approach to tele-psychotherapy and hinder the ability to create positive virtual therapeutic alliances.[202122] This biased view may arise from the limited availability of resources (literature, training, and practical experience) related to this particular approach and concerns about the therapist's inability to effectively collaborate with clients in a virtual environment.[2324] More recent research also highlights therapists’ inability to comprehend verbal cues and body language and establishing eye contact as impediments to telepsychology.[252627] Despite the concerns surrounding the efficacy of tele-counseling and psychotherapy, it seems that this method will become more widespread in the future; therefore, it is imperative to undertake research on the implementation of such methods. As telemedicine is still in its infancy in Iran, the primary focus of this study was to determine the best way to practice compassion-focused acceptance and commitment teletherapy for clients with OCD and therapists. Moreover, to identify important factors in delivering teletherapy via telephone, the Internet, and online support groups.

Materials and Methods

Study design and setting

This research employed an exploratory qualitative methodology, and the data was analyzed by Braun and Clark's thematic analysis method. The pool of participants included clients with OCD who sought consultation services and psychotropics situated at the counseling centers in Isfahan during the years 2020–2021.

Study participants and sampling

The study's inclusion criteria mandated that participants were within the age range of 18 to 60 years old, had received a diagnosis of OCD from a licensed psychologist or psychotherapist, and had undergone compassion-focused acceptance and commitment teletherapy (via telephone, the Internet, and online support groups). Inclusion criteria required psychotherapists to have a master's degree in counseling or psychology and experience providing OCD clients with compassion-focused acceptance and commitment teletherapy combined with compassion. Out of 35 individuals who received compassion-focused acceptance and commitment teletherapy, 15 reported receiving treatment via telephone, 11 through internet-based means, and nine via online support groups. In addition, 11 psychologists who adhered to the approach above were chosen and subjected to semi-structured interviews. Purposive sampling was employed.

Data collection tool and technique

This study employed semi-structured interviews for the purpose of data collection. Interview instruction was developed under the supervision of experts and as per relevant literature. The explanatory questions were determined through the course of the interview as follows: 1) What was the participant's experience with teletherapy? 2) What were the benefits of teletherapy? 3) What were the drawbacks of teletherapy? 4) How did the participant put trust in the psychologists? The questions for the psychologists included: 1) How did you establish trust? 2) How did you convey your message? In addition to these questions, explanatory questions were asked to gather finer details about the participants’ experience.

To conduct the research, the researcher initially communicated with the authorities, psychologists, and counselors at the specialized OCD treatment center in Isfahan, as well as other centers throughout the city. Following this, the researcher provided an explanation of the research project to the authorities, after which suitable candidates were selected and subsequently interviewed. The interview sessions, which lasted 40–60 min, were transcribed and subsequently analyzed during the data collection procedure. The interviews continued until the saturation point was reached. The accuracy of the data was assessed using four criteria of Lincoln and Guba,[28] namely, dependability, credibility, confirmability, and transferability. The thematic analysis method of Braun and Clark[29] was employed to analyze the content of the interviews. The interviews underwent multiple revisions until they were deconstructed into their most minor and meaningful components: themes. After these revisions, the interviews were scrutinized and categorized based on semantic coherence, and patterns were identified and extracted.

Ethical consideration

The present study has been granted ethical approval by Khomeinishahr Islamic Azad University, with the code of ethics IR.IAU.KHSH.REC.1400.024. All ethical principles have been duly observed and adhered to throughout the course of this research. The study involved the voluntary participation of the participants, who were given the guarantee that their personal details would be kept private.

Results

The results of the thematic analysis of the data yielded three primary themes, including the prospects, requirements, and challenges of teletherapy [Table 1]. Since there was a significant overlap in the viewpoints of therapists and patients, this article presents an overview of the overlapping themes that were raised by the majority of the participants.

Table 1 Qualitative findings

Themes	Category	
Opportunities for teletherapy	1. Accessibility of location
2. Removing the time limit
3. Ensuring confidentiality and privacy
4. Access to therapists in special circumstances
5. Possibility of visits at times of need	
Requirements of teletherapy	1. The ability to establish a therapeutic alliance in teletherapy
2. The ability to effectively convey the message
3. Paying attention to support needs	
Challenges of teletherapy	1. Technical challenges
2. Emotional challenges
3. Physical challenges	

First theme: Opportunities for teletherapy

One of the first points that almost all the participants raised was the accessibility of the location. Participant No. 2 (m. via telephone) stated, “I went to the center in my area, but my visits were unproductive because the therapist there lacked the necessary qualifications and expertise to address my issue. Teletherapy provided me with access to qualified and experienced therapists.” Participant No. 17 (m. via the Internet) mentioned, “Since I had to travel a long distance, teletherapy allowed me to save on my travel costs.” Participant No. 28 (m. online support group) explained, “I used to wake up quick, put clothes on, and enter the session. I logged in to the support group from my bedroom, very convenient.” Similarly, therapist No. 11 stated, “We can assist clients from different cities and countries via teletherapy.”

Removing the time limit is the third point raised in this theme. In this regard, participant No. 17 (m. via the Internet) stated, “Since I have a tight daily schedule, I have to follow up with my therapist in between my break times.” Participant No. 15 (m via telephone) pointed out, “Teletherapy is much more convenient since it allows space for flexible time management. We can contact our therapist whenever we have the time.” In addition, participant No. 34 (m. online support group) said, “We did not have to worry about arriving late. We could stay at home and did not have to commute. And it was good.” In the same regard, therapist No. 5 added, “Teletherapy was an advantage for me since I could easily provide therapy from my office and home during my pregnancy.”

“Ensuring confidentiality and privacy” and the chance of seeking therapy without carrying any stigma are other pros pointed out by the majority of participants. Participant No. 11 (m. via telephone) stated, “Teletherapy was good because I didn't like people to know that I am receiving therapy.” Participant No. 25 (m. via the Internet) admitted, “Since we live in a small town, it would be distressing for me to come across my therapist in a religious ceremony or a football game.” Moreover, participant No. 27 (m. online support group) mentioned, “We had the privilege of turning off our webcam during the online support group.” Furthermore, therapist No. 9 explained, “Teletherapy promotes a greater sense of relaxation and comfort among clients since they are at their own place where they are less anxious. For instance, if their young kid needs their attention, they can go and come right back.”

The fourth point noted by participants was “having access to therapists in special circumstances.” In this regard, participant No. 22 (m. via the Internet) said, “I was terribly afraid of leaving my home because of the corona. I accepted to receive therapy only because teletherapy was available.” Similarly, participant No. 12 (m. via telephone) stated, “I had to travel a long way and due to the Corona situation.... that is why I chose teletherapy.” Participant No. 30 (m. online support group) pointed out, “Members shared their experiences which were totally helpful since we were dealing with the same health issue. The virtual meeting provided us with the opportunity to connect online.” In addition, therapist No. 4 stated, “Teletherapy is equal to face-to-face sessions, especially during the pandemic.”

Finally, the “possibility of visits at times of need” is the last point mentioned in this theme. Participant No. 19 (m. via the Internet), for example, noted, “I had my therapy session when I was at my store because my OCD usually kicks in, in that environment. And it was helpful.” Participant No. 8 (m. via telephone) also said, “I spend a lot of time disinfecting my car on a daily basis, so I had my session when I was in my car to ease the flow of the day.” Therapist No. 9 stated, “Teletherapy helps clients feel more relaxed and comfortable because they are in their own environment, which reduces their anxiety. Additionally, suppose they have a young child who needs their attention. In that case, they can easily attend to them and return to the session.” Similarly, therapist No. 2 pointed out, “Teletherapy offers the opportunity to observe clients in the setting where they encounter difficulties, such as when doing household chores like washing dishes.”

Second Theme: Requirements of Teletherapy

Nearly all respondents identified “the ability to establish a therapeutic alliance in teletherapy” as the primary category. The core skills include attentive listening, providing feedback, and conveying content. Furthermore, the set of skills encompassing qualities such as the therapist's speaking tone, welcoming attitude, openness, flexibility, simple language, look, approval, encouragement, and soothing nature can be referred to as general skills. For instance, participant No. 2 (m via telephone) said, “In our first meetings, my therapist listened to me a lot, and I just kept talking and talking and talking, and it felt terrific because I felt confident that my concerns were taken seriously and that there is at least one person who listens to my words and that he is also a specialist and he can help me....” Participant No. 25 (m. via the Internet) stated, “It was a wonderful feeling when I spoke, and my counselor listened. Moreover, they let me know about their understanding of me. It seemed they deeply understands me as if they are going through the same experience.” In addition, participant No. 33 (m. online group support) pointed out, “The therapists showed a lot of understanding and compassion, which made me feel secure and confident that no one in the group is mocking me.” Moreover, therapist No. 3 stated, “During our first meeting, I always express my desire to see them, and I say, I understand and respect your preference for an audio-only session. However, when you feel comfortable, we can schedule a video meeting.”

The “ability to effectively convey the message” during teletherapy was identified as the second prominent skill by the majority of participants. Participants informed us that using cardboard-drawn shapes and images shown through a monitor or mobile screen serves as a visual cue to aid them in comprehending metaphors. Simultaneously with the counselor and clients’ explanations, the act of drawing, sharing animations related to metaphors, and engaging in exposure exercises and mindfulness exercises were mentioned by the participants as helpful practices during the meeting. In this regard, participant No. 6 (m. via telephone) said, “My consultant says, imagine a kitten which is very cute behind the door, and you hug it and bring it in and look after it.” Likewise, participant No. 22 (m. via the Internet) stated, “Mindfulness exercises are very important to me, and I always do mindfulness exercises with my therapist at the beginning of the session so that I can concentrate.” Similarly, participant No. 30 (m. online support group) pointed out, “The group members exchanged ideas. And with the help of the group leaders and using examples, we would understand the concepts.” Furthermore, therapist No. 3 stated, “The metaphors were selected according to the client's particular mentality and modified to match the client's language in order to increase the clarity of the analogy.”

“Paying attention to support needs” is also recognized as one of the primary factors by the participant. On this subject, participant No. 9 (m. via telephone) commented, “The treatment was greatly motivated by my family, and their support played a crucial role in the process. My mother, in particular, is very encouraging.” Likewise, participant No. 24 (m. via the Internet) said, “When my husband found out about my OCD, he did not try to prevent me from taking a shower, washing, and cleaning too often. He was very helpful and understanding. Now I can comfortably sit down and, with peace of mind, let my husband washes fruits for me, which is great because I could not allow such things before. But now I do not even have problems with my son playing in the park.” Moreover, therapist No. 7 stated, “I have much flexibility when it comes to scheduling sessions, and I make sure to choose a time when the client is least distracted and fully concentrated. I also assure the client that they can reach me anytime.”

Third Theme: Challenges of Teletherapy

Almost all participants brought up the “technical difficulties” involved in providing teletherapy. Poor or disrupted network connections, as well as interruptions in vision or sounds, are prevalent and evident issues. In the same regard, participant No. 34 (m. online support group) stated, “Occasionally, due to network weakness or outages, video or audio, or both, were interrupted or lost, causing the session to end. We would usually lose track of what we were saying before we could call again.” Similarly, participant No. 25 (m. via the Internet) explained, “At one point, I was speaking with great enthusiasm when the connection suddenly dropped. But I kept talking because I did not notice we were disconnected until a few moments later when I finally realized the frozen video of the members.” In addition, therapist No. 10 stated, “On occasions, the video would be repeatedly interrupted, causing us to switch to audio-only for the rest of the meeting.”

Emotional challenges are one of the categories mentioned by many participants. In the same regard, participant No. 33 (m. online support group) mentioned, “I did not join online support group very often because I could not comprehend the emotions and feelings of all the members simultaneously.” Similarly, participant No. 9 (m. via telephone) pointed out, “I perceive the therapist's office as a safer place than my own room, even though I am aware of the fact that my room is in my house.” Furthermore, therapist No. 10 stated, “As we conduct sessions remotely from different locations, it can be challenging to comprehend and empathize with comprehend clients when they are experiencing intense emotions, which could be a cause for concern.”

The third category mentioned by most of the participants was “Physical challenges.” Generally, the absence of nonverbal cues and body language in counseling via telephone and the partial presence of such cues in video-call counseling have caused difficulties in teletherapy. Participant No. 31 (m. online support group) pointed out, “During in-person session body language is very helpful, but in online sessions, it takes longer for me to understand members’ feelings, and sometimes I do not even get them right at all.” Moreover, participant No. 12 (m. via telephone) stated, “I can comfortably get my message across, and there is no shame about it, even though I can't use body language.” In addition, therapist No. 11 stated, “Even though interaction through body language is quite limited in video-call sessions, clients try their best to compensate for it with a higher level of alertness and presence.”

Discussion

In the present study, to discover essential factors in practicing teletherapy (via telephone, the Internet, and online support groups) for OCD clients, we interview 46 participants, including both patients and therapists. The findings of the thematic analysis revealed three primary themes: the opportunities, requirements, and challenges associated with tele-counseling and psychotherapy.

In the first theme derived from the study, the participants highlighted the opportunities for teletherapy. For instance, the two categories of “accessibility of location” and “removing the time limits” enable both clients and therapists to attend the session even when they encounter constraints such as sickness, excessive job demands, or family responsibilities. Similar findings have been confirmed in other studies. For example, research has shown that teletherapy via telephone is a blessing for those who do not have access to the Internet,[25] and demanding work schedules, limited commuting means, and geographical constraints are the reasons that make telephone consulting beneficial.[30] Furthermore, other studies[2627] argue that working with a telephone is very simple and straight, and it does not require complicated means of internet connection. The popularity of this mode of teletherapy can be attributed to its ability to provide individuals with the opportunity to receive therapy in the comfort of their own homes while maintaining confidentiality and privacy and avoiding any associated stigma. In accordance with our findings, it is concluded in another study[2326] that people can enjoy the privacy and comfort of their home or workplace while benefiting from counseling services. Moreover, in another study,[24] participants acknowledged that they perceive tele-psychotherapy as less intimidating and distracting than face-to-face sessions. It is noteworthy to mention that tele-psychotherapy has enabled individuals to receive therapy despite unique or special circumstances, including the COVID-19 pandemic, rigid work schedules, extensive travel time, physical disabilities, and medical and hygiene concerns. Similar findings have been concluded in other scholarly research.[31] Some studies argue that teletherapy allows clients to take their therapist to a location or environment that intensifies their symptoms. Having a more informal setting, this mode of therapy may serve as an icebreaker and facilitate more amicable sessions; however, some might not welcome an informal session or attire.[3233] It appears that the informal setting of a client's home may provide an opportunity for exposure exercises and facilitate a deeper exploration of a broader range of emotions that may not be achievable within the confines of a therapist's office.

The participants pointed out the requirement of teletherapy as the second theme. The ability to establish a therapeutic alliance and effectively convey the message in teletherapy, such as the tone of the therapist, attentive listening, impartiality, getting a sense of comfort from the therapist, facilitating clients’ comprehension of metaphors through visual cues, addressing daily concerns, simultaneously supplementing explanations with illustrations have been deemed crucial for clients. While it is true that such things are essential also during face-to-face counseling, they hold greater significance in teletherapy due to the absence of physical presence and nonverbal cues. Consequently, written content and vocal elements such as rhythm, tone, volume, and speed play a central role in teletherapy. Individuals with OCD appear to experience doubts, hesitations, and a need for reassurance. These symptoms are further intensified during tele-psychotherapy, ultimately disrupting the therapeutic alliance. Contrary to this belief, the remarks made by the participants indicate that the therapeutic alliance is comparably established in tele-psychotherapy as in face-to-face sessions. Of course, this path has some obstacles, but some therapists have displayed their skills and expertise in overcoming such difficulties. In this context, researchers have demonstrated that the establishment and sustenance of therapeutic alliance can occur with equal efficacy in both traditional face-to-face settings and teletherapies. For some clients, establishing a therapeutic alliance may be facilitated in a remote therapy setting. As an example, individuals who have experienced trauma may find it less challenging to confront their profound traumatic experiences in a virtual environment without the physical presence of another individual.[1112] According to a study,[13] individuals admitted they feel a reduction in feelings of loneliness and perceive strong emotional bonds with other members as a result of being part of a group, whether in a face-to-face or virtual context. Consequently, the results of the current study align with those of previous research.

The category of “Paying attention to support needs” was also discussed by the participants. Moreover, the participants pointed out the importance of providing support to clients, recognizing areas of vulnerability, maintaining objectivity, monitoring even the slightest progress in clients, and utilizing reminder text messages. The individuals involved in the study highlighted the significance of the family's contribution to managing obsessions. That is because obsessive thoughts can be highly distressing and persistent, and individuals with OCD require assistance, encouragement, and a noncritical environment to initiate treatment and progress through the process. Support and compassion can serve as an umbrella that fosters a sense of security and fortitude within an individual. Although these concerns may arise in face-to-face counseling, they appear to have a more pronounced impact in the context of tele-psychotherapy. Sending text messages as reminders for counseling sessions can enhance the bond between the counselor and the client, ultimately leading to the growth of the clients.[11]

The third theme of the present study pertains to the challenges of teletherapy. Technical problems and disconnection are inevitable factors that lead to disruptions during sessions and curtail the duration of treatment sessions. Consistent with this research, it has been posited that technical difficulties may impede effective communication, and there is concern that teletherapy may limit patients’ access to verbal, nonverbal, and unconscious modes of communication throughout the course of treatment. Likewise, interruptions in audio and video, as well as limited visibility of the client's body language, can hinder dynamic occupational therapy and the achievement of constant progress.[19]

Individuals diagnosed with OCD may experience preoccupations during therapy sessions regarding the possibility of being overheard by others, which may lead to clients’ unwillingness to or uncertainty about expressing their feelings. Due to the lack of face-to-face interaction and space to clarify these suspicions, clients may not fully realize the nature of the assigned tasks, their intended objectives, and the appropriate methods for executing and reporting them. They might not even find the time to express and clear up their confusion. On the contrary, during an in-person therapy session, clients have the opportunity to talk about their uncertainties, and their therapist can practically demonstrate how to complete their tasks. Moreover, in some cases, people might be unable to afford privacy separate from their household members. This absence of personal space and the inability to seize control of the therapy environment may impede the progress of treatment. The findings align with earlier research[2021] that introduces technological challenges, communication disruptions, and limited control over teletherapy settings as obstacles to providing remote therapy. Of course, therapists are hesitant to offer tele-counseling despite the growing utilization of telehealth. Many therapists have turned away from virtual therapy because of the burdensome licensing process, mandatory telehealth training prerequisites, uncertainty about insurance payments, risk management, and other infrastructure issues. They often presume that in-person therapy is better for clients and should be considered before resorting to virtual therapy.[27]

It is worth mentioning that online support groups face a wider range of difficulties, such as technical problems, time constraints, interpreting body language, keeping up with assignments, resuming interrupted topics, and overall challenges. As supported by studies,[1316] our research state that technical difficulties such as sound disruptions, microphone noise, poor lighting, and background noise are obstacles that online support groups encounter. There is a possibility that some members of online support groups may not be very active, and the facilitator may not notice their participation due to the absence of visual indication. If an individual did not engage in relaxation techniques, they may not have acquired and benefited from this ability. Therefore, the therapist may not be able to see the client to provide additional corrective or educational input.

Conclusion

Based on the results of the present study, it can be inferred that the spread of the coronavirus during the time of research has led to a widespread acceptance of tele-psychotherapy among therapists. This approach enables them to effectively engage with clients, address their concerns, and improve their mental health. Some consultants and clients have acknowledged this issue and can share information through various means, such as phone and virtual platforms. Certain aspects drew clients towards teletherapy, including the ability to remain anonymous, having control over the therapy setting, feeling a sense of rapport with the therapist, convenient access to therapy sessions, affordable fees, and no requirement to travel. It is essential to acknowledge that teletherapies are not without their difficulties and impediments, including technical challenges, disruptive factors, issues of confidentiality and privacy, and overarching challenges. Nevertheless, in the past few years, there has been an increase in the use of teletherapies, which has led to the development of guidelines and regulations aimed at fostering a sense of togetherness and a therapeutic alliance connection in the virtual realm. Therapists who are attentive to the challenges of teletherapies and make an effort to address them using different techniques during treatment are likely to have better outcomes in their interactions with clients.

The study's sampling required participants who have undergone compassion-focused acceptance and commitment therapy; therefore, any generalization drawn from the study should be approached with caution.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgement

We wish to extend our appreciation to the esteemed staff and counselors of the Isfahan counseling centers. It is noteworthy to state that this article has been derived from the PhD thesis in the field of counseling at Khomeini Shahr Islamic Azad University.
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