Clinical Psychology and the COVID-19 Pandemic: A Mixed Methods Survey Among Members of the European Association of Clinical Psychology and Psychological Treatment (EACLIPT)

Background: The COVID-19 pandemic has affected people globally both physically and psychologically. The increased demands for mental health interventions provided by clinical psychologists, psychotherapists and mental health care professionals, as well as the rapid change in work setting (e.g., from face-to-face to video therapy) has proven challenging. The current study investigates European clinical psychologists and psychotherapists’ views on the changes and impact on mental health care that occurred due to the COVID-19 pandemic. It further aims to explore individual and organizational processes that assist clinical psychologists’ and psychotherapists’ in their new working conditions, and understand their needs and priorities. Method: Members of the European Association of Clinical Psychology and Psychological Treatment (EACLIPT) were invited (N = 698) to participate in a survey with closed and open questions covering their experiences during the first wave of the pandemic from June to September 2020. Participants (n = 92) from 19 European countries, mostly employed in universities or hospitals, completed the online survey. Results: Results of qualitative and quantitative analyses showed that clinical psychologists and psychotherapists throughout the first wave of the COVID-19 pandemic managed to continue to provide treatments for patients who were experiencing emotional distress. The challenges (e.g., maintaining a working relationship through video treatment) and opportunities (e.g., more flexible working hours) of working through this time were identified. Conclusions: Recommendations for mental health policies and professional organizations are identified, such as clear guidelines regarding data security and workshops on conducting video therapy.

• Rapid change in psychotherapy delivery occurred due to the COVID-19 pandemic.
• Clinical psychologists and psychotherapists report challenges (e.g., reluctance among patients) and opportunities, resulting from changes to the work environment.• Data security is crucial as well as access to treatment via video therapy.
• National policy and organizational guidance is crucial to support clinical psychologists and psychotherapists in their work.
Health care services globally have faced unprecedented challenges due to the COVID-19 pandemic.Alongside the physical health consequences of the COVID-19 virus, mental health problems are also increasing, with reported increases for anxiety, depression, psychological distress and sleeping problems (Bohlken et al., 2020;Liu, Heinzel, Haucke, & Heinz, 2021;Rajkumar, 2020;Salari et al., 2020;Vindegaard & Benros, 2020;Xiong et al., 2020).Furthermore, there has been an estimated additional 53.2 million cases of major depressive disorder and an estimated additional 76.2 million cases of anxiety disorders globally (Santomauro et al., 2021).As a consequence, mental healthcare needs to be prioritized and clinical psychologists and psychotherapists1 play an important role in the prevention and treatment of these adverse consequences of the COVID-19 pandemic.However, as yet little is known about how well clinicians and services have adapted to the increased demand and additional challenges presented by the COVID-19 pandemic, and what might be done to improve mental health care for those who have suffered psychologically as a consequence of the COVID-19 pandemic.
Clinical psychologists and psychotherapists had to find rapid alternatives to face-toface treatment such as telephone-based or video therapy (Békés & Aafjes-van Doorn, 2020;Humer, Stippl, et al., 2020), or in-person sessions whilst adhering to their COV ID-19 national containment measures from the start of the pandemic.Prior studies have shown that the implementation of changes to service delivery can take an average of sixteen years to implement in a health care system (Rogers et al., 2017).In contrast, during the pandemic, change in service delivery was rapid and unexpected, and there was little supervision or guidance available for clinicians (e.g., Boldrini et al., 2020;Probst, Stippl, & Pieh, 2020).Moreover, the pandemic itself led to significantly higher stress levels in clinical psychologists and psychotherapists, especially in younger and less experienced professionals (Aafjes-van Doorn et al., 2020;Probst, Humer, Stippl, & Pieh, 2020).Additionally, fear of infection and other issues related to the pandemic itself were also reported by clinical psychologists and psychotherapists (Humer, Pieh, et al., 2020).
In the midst of such rapid and unforeseen changes to practice, several reassuring and thought-provoking phenomena have been observed.For instance, preliminary evidence showed video therapy to be more effective than previously expected (Humer, Stippl, et al., 2020).Interestingly, the ability to adapt to conducting therapy via video is related to the individual clinical psychologists' and psychotherapists' attitudes and is influenced by their past experiences with video therapy (Békés & Aafjes-van Doorn, 2020).Further, challenges have been reported by mental health professionals regarding the lack of inter personal interactions, feelings of isolation and other technical issues whilst conducting therapy online (McBeath et al., 2020).The aforementioned studies provide an interest ing, yet heterogeneous, picture of the impact of the COVID-19 pandemic on mental health professionals.However, most of the studies used closed questions and quantitative methods (e.g., Békés & Aafjes-van Doorn, 2020;Boldrini et al., 2020), thus limiting the possibility for participants to provide their own insight into offering psychotherapy during a global pandemic.
Professional organizations and other commissions have taken the initiative to provide the public and mental health care professionals with information regarding COVID-19 (e.g., UK 2 , Germany 3 , Austria 4 , Belgium 5 ).However, it is also important for mental health care professionals who work 'on the ground' to share their experiences, in order for organizations to find ways to best support their clinicians.The current survey aimed to gather information 'from the field' to gain an understanding of the experiences of clinical psychologists and psychotherapists working during the COVID-19 pandemic, across different European countries.Members of the European Association of Clinical Psychology and Psychological Treatment (EACLIPT) were consulted; EACLIPT is an association that aims to foster research, education and dissemination of scientifically evaluated findings on clinical psychology and psychotherapy.The current study seeks to provide a first European wide insight into the perceived changes to clinical practice and research of clinical psychologists and psychotherapists, as well as the barriers and opportunities, in order to improve support to people as part of the response to the COVID-19 pandemic.The study also aims to gather information to highlight helpful ways for clinical psychologists and psychotherapists to approach, prioritize and manage their work in the context of the pandemic.Finally, it aims to provide information on how organizations and organizational bodies (such as EACLIPT) can best adapt to pandemic related changes.

Figure 1
Country of Origin of Participants Note.Please note that n = 6 participants chose to not comment on their country of origin.

Procedure and Measures
Socio-demographic information was collected using nine closed questions (e.g., country of origin, place of work and most commonly presenting patient need during the pandem ic).Five open questions were used to gain information on perceived changes in the work place, challenges and opportunities during the crisis, the effect of COVID-19 safety measures on their practice, and other implications.The survey was open for completion between 25 th May 2020 and 1 st September 2020.The last response that was included was submitted on 19 th August 2020.

Quantitative and Qualitative Analysis
The six phases of thematic analysis (Nowell, Norris, White, & Moules, 2017) were fol lowed by the first two authors (J.A. and S.G), including familiarization with the data (Phase 1), generating initial codes (Phase 2), searching for themes (Phase 3), reviewing themes (Phase 4), defining and naming themes (Phase 5) and producing the report (Phase 6).The third author (J.B.) supervised their work and checked the data during Phase 4, in order to review the themes that had been generated.This enabled research bias to be evaluated and the interpretation of the data to be confirmed.The first two authors screened the answers independently in Phases 1, 2, and 3 and formed their own categories, which were then compared and agreed on and a list of themes per question was finalized.Themes were then listed in terms of frequency for each question.The authors were each based in different countries, therefore all meetings took place over remote platforms.
Regarding the overall process, reflexivity is considered as a key aspect of the thematic analysis process (Nowell et al., 2017).Therefore, the first two authors kept their own reflexive journal to document the logistics and methodological considerations as well as their own personal reflections.The precise analysis was then conducted in line of the six step technique by Braun and Clarke (2006).

Results
The results have been analyzed according to the six-phase method by Braun and Clarke (2006) i.e., familiarization with the data, generation of initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report.Data are organized and summarized in the results section and the interpretation regarding signifi cance and implications follows in the discussion.

Changes in Patients Seeking Help
Based on the question that asked if participants were seeing more or less patients, the number of patient contacts (i.e., number of patients seen by a clinician) seemed to remain relatively stable during the first wave of the COVID-19 pandemic, as reported by 42% of the participants who indicated no change in the number of patient contacts.Nonetheless, almost 40% reported to see less patients, while 17% reported to see more patients.
Further, 78.8% reported that patients displayed similar psychological problems as they did prior to the COVID-19 pandemic.However, 48.3% also reported that their patients seemed to be more distressed compared to one year before, whereas 28.7% reported no change in their patients' distress.The most frequently reported patients' clinical issues encompassed anxiety (86%), depression (82%), loss of social contacts and isolation (each 39%) (see Figure 2).
In terms of clinicians' working practices, most responders reported that COVID-19 had changed their work routines (73.6%), mostly in ways that they perceived to be undesirable.Note.Please note that not all patients were seen in standard psychotherapeutic environments which is why alternative topics are listed as the presenting problem.This refers to other medical conditions, neuropsychological testing and other non-identified topics.

Qualitative Results
The overarching themes that were identified in the data were: changes to clinical prac tice; changes to other work activities and contexts; the challenges and opportunities; the effect of COVID-19 measures on clinical practice and further reflections.Within these themes, the following categories were found including: Changes to working practices such as online working; psychotherapists reflections on the changes and an exploration of what could be improved and, implications for clinical practice and organizations.

Perceived Changes in Clinical Practice
Perceived changes in clinical practice were mostly in regards to working online, e.g., conducting video therapy, and working from home.Further, several participants reported changes in treatment frequencies (more/less patients, more sessions per patient), hygiene measures (such as wearing face masks, social distancing in assessments), challenges in providing treatment while wearing personal protective equipment (such as face masks), redeployment and logistical difficulties if patients were not able to use online platforms.
Citation regarding hygiene measures: "every patient has to wash first his hands, more disinfection, mouth-nose-protection, plexiglass for breath protection, safety distance, and more time and space are needed between the appointments for disinfection" Citation regarding personal protective equipment: "Wearing masks, me and patient, which is very disturbing while there is no emotional expression." Some participants also reflected on patients' concerns regarding treatment, such as more anxiety and individual differences in motivation to access online treatment.Further, therapists' concerns were also mentioned (e.g., if their hygiene procedure is correct).
Citation regarding therapists' concerns: "the first thought in every step is 'how correct is my procedure?'" Overall, changes in patient contact (i.e., less appointments, fewer face-to-face contact, more support for patients) were named.

Perceived Changes to Other Work Activities and Contexts
Not all participants were necessarily working in clinical practice, and changes in research and teaching were also reported.Participants noted that procedures in the work environ ment were modified according to COVID-19 safety measures, often leading to a lack of contact between colleagues.
In an additional question, general aspects of the working environment were covered.Here, once again digitalization was mentioned as a central change, as not only video therapy but also remote meetings with colleagues that had been introduced.Citation regarding digitalization: "No face to face clinics, therefore replying on phone and video contact.Working in isolation more and away from my team to do working from home." Some participants reported that there was an increasing lack of contact between collea gues due to the increasing division in teams as a result of remote working.
In answers to this question, participants also highlight the adherence to hygiene measures in the work environment such as social distancing, wearing masks and more cleaning.Several participants mentioned that they were mainly working from home and some were holding therapy sessions outside.Additionally, two participants were engaged in extra activities regarding COVID-19 (i.e., at a phone support line).Three participants said that there were significant changes to their research, such as delays in recruitment, or needing to stop research entirely.

Challenges and Opportunities in the COVID-19 Pandemic Era
The challenges and opportunities that participants reported were wide ranging, and there was not always a clear distinction between what constituted a challenge or an opportunity (e.g., only replying "tele-therapy"), and sometimes different participants reported the same issue as a challenge, whereas others saw it as an opportunity.There were several participants who listed an opportunity that arose as a result of the COV ID-19 pandemic and also at the same time reported it as a challenge of working during the COVID-19 pandemic (e.g., no commute vs. constant working from home).

Change in Work Logistics -
The change to a predominantly technology-based work practice appeared to be either a challenge or an opportunity for participants.While several participants reported problems regarding technical knowledge and support or in ternet connection issues, as well as lack of equipment (such as laptops), remote working was also perceived by some as an opportunity to improve their own technology skills.

Citation regarding technical factors: "videocalls are more tiring, but effective"
A similar pattern of both challenges and opportunities emerged for working logistics: additional childcare, the need to develop new work-related rituals and a higher strain of videocalls were mentioned, as well as no time between meetings.However, several positive aspects were also mentioned, such as less need to travel, more flexibility at work, and the opportunity to access patients who may not have had the possibility to receive treatment otherwise.Some also felt that video therapy works very well, and some had been able to further develop their self-care strategies.
Citation regarding working logistics: "The main challenge was man aging childcare alongside working while the nurseries were closed." Citation regarding working logistics: "working from home so less MDT [multidisciplinary teams] working, not being able to provide a service for those with sensory impairments primarily hearing loss, increased competing demands on my time, my own response to COVID and lockdown and depleted resources over time.New ways of working do include being able to offer video or remote access to appointments not requiring people to travel and being able to support people who are shielding" Citation regarding working logistics: "I had to develop new rituals at the end of the work day, digital work exhausts me more than working from the office" Clinical Issues -Interestingly, the therapy-related factors also included both challenges and opportunities.Interventions for some mental health problems appeared to be more challenging to deliver online (e.g., depression, trauma) compared to the pre-pandemic face-to-face settings (e.g., difficulty in finding new options to increase activity, more insecurity in trauma treatment due to a lack of stabilizing measures).Furthermore, par ticipants reported that they were at a greater physical distance to patients during faceto-face interactions, whereas online sessions provided less opportunity for non-verbal feedback and therapeutic engagement.Participants reported having to spend more time preparing for sessions, and there were concerns about a lack of consent and choice of therapy modality for patients.Conversely, less cancellations were noticed.Additionally, participants were able to receive contextual information about their patients by seeing their environment.
Citation regarding therapy-related factors: "Less cancellations and non-attendance at sessions.Harder developing rapport and doing ther apy without the same transference or cues."

Citation regarding therapy-related factors: "video sessions allow for less non-verbal feedback/assessment (negative for diagnosis and treat ment recommendation); video sessions allow impression of the patient's home environment (important context information and opportunity for the patient to illustrate problems that occur at home = positive)"
Citation regarding therapy-related factors: "Reachability was better for some, but worse for others, especially mothers (closed schools) and women in abusive relationships (often had to talk in their car)" Team and Organizational Factors -Several factors were portrayed as rather chal lenging, as participants reported difficulties regarding social factors at work, such as a worsening of team cohesion, staff absence, staff conflicts and social isolation.Although some found this to be a positive as they could decide who they spent time with.

Citation regarding social factors: "prevent social isolation also in my staff without forcing collaborators back to work"
Furthermore, a number of organizational factors were mentioned.For example, the rapid change of regulations (e.g., weekly changes) and the lack of guidelines and unified standards were reported to make working processes even more difficult.

Citation regarding organizational factors: "Trying to keep up with the constant information changes, rapid decision making and trying to look after myself too"
Alongside organizational factors, data security issues were also mentioned.This often highlighted the problem of patient confidentiality and keeping data safely stored while working from home.
Finally, participants reported difficulty adapting to new ways of working initially, however this appeared to develop into a new and practiced working routine over time.

Effects of the COVID-19 Pandemic Measures on Clinical Practice
Participants mainly focused on the effects of COVID-19 emergency measures on their clinical practice.The general restrictions of contact, i.e., lockdown, social distancing, restricted entrance to buildings and building closures were mentioned by half of all par ticipants.These were often brought into close relation to other themes such as increased psychopathology in patients.
Citation regarding general restrictions: "Restrictions concerning cer tain hours for meeting the patients."

Citation regarding general restrictions: "Full Lock-down, both in ef fect on my work directly and how it seeps into clients' existing strug gles"
Another topic mentioned was the effect of wearing masks.

Citation on wearing masks: "Mask wearing -conceals the faces of both client and counselor, lack of nonverbal cues"
Additionally, effects of hygiene measures on treatment were often mentioned, such as wearing protective clothing, opening windows during sessions, no face-to face contacts and short-notice cancellations due to patient concerns about showing COVID-19 symp toms.

Citation regarding hygiene measures: "Wearing protection clothingit is necessary and important but it makes work harder"
Both general restrictions issued by the state and individual restrictions in the workplace had a significant effect on participants and their work, such as closure of nurseries, Clinical Psychology in Europe 2023, Vol.5(1), Article e8109 https://doi.org/10.32872/cpe.8109quarantine, shielding, and loss of freedom as well as concerns around travelling on public transport.

Citation regarding individual restrictions: "Closure of nurseries -hav ing to provide childcare between a working couple means a massive reduction in available working time. "
Participants also reported on the effects on patients, such as changes in psychological symptoms and less motivation to seek help or engage in online sessions.
Citation regarding effects on patients: "People with mental health conditions hold their breath: that is do not seek help because they are afraid to get COVID-19 and because there is a pause in social life" Citation regarding effects on patients: "COVID-19 measures, at least in Italy, did not help in containing the viruses, as people were terrified by the official information, so did not ask for help or did not dare to go to hospitals, and were hampered from going to parks."

Further Reflections
Participants shared a variety of interesting insights into prospective changes concerning both mental health professionals and government policies.
One major theme was the wish to collect, share and discuss their experiences of using video therapy.This included both concerns (e.g., regarding effectiveness and data security), and desire for specific training in psychotherapy delivered online.Participants also shared that they had a new understanding of the importance of being connected to their colleagues.
Citation regarding sharing with colleagues: "More practice in online therapy, share data concern effectiveness of online therapy versus on said therapy"

Citation regarding sharing with colleagues: "I think it would be a good idea to set up a section in Clinical Psychology in Europe [journal of the EACLIPT] and invite practicing clinical psychologists to describe their experience with new forms of work. I would be motivated by such an opportunity to contribute, and I would also learn from the experience of colleagues. "
In terms of policy implications, it was argued that the importance of mental health should be further promoted at national levels, particularly given the collective impact on mental health.A greater flexibility (e.g., introducing video therapy into health insurance plans) and the possibility of choosing the most suitable treatment modality (e.g., face to face or video) were two major points raised by respondents.Furthermore, the effects of the current pandemic on both research (e.g., regarding long-term effects on mental health), and the healthcare system was mentioned, including implications for research funding.Finally, government policy implications regarding the implementation of policy guidelines, such as closure of nurseries and schools, resulted in a dilemma for many parents who are having to work from home while caring for children.
Citation regarding political implications: "Research funding being so FAST and associated huge number of reviews; being on funding panels.Existing research in NHS stopped due to redeployment." Citation regarding political implications: "Acknowledgement of the impact of COVID-19 on the mental health of the population should be acknowledged at a national/international level.Awareness needs to be raised in governments and there needs to be a way to address the increased level of distress that the population will undoubtedly experience." Citation regarding political implications: "Productivity whilst work ing from home is understood although not overtly acknowledged to be more limited when children to be cared for at home too which creates unnecessary guilt when torn between roles.Some managers (not mine) did not stand up to look after staff by leading and issuing clear guidance." Several participants pointed out that there will be long-term consequences of the COV ID-19 pandemic on mental health.

Discussion
The current study demonstrates that the COVID-19 pandemic brought about unprece dented changes in clinical practice for clinical psychologists and psychotherapists across EACLIPT members in Europe.Changes to the clinical practice of psychologists and psychotherapists were sudden, for example the digitalization of therapy, which was at odds with previous attempts to implement digital mental health approaches in healthcare (Mohr, Riper, & Schueller, 2018).Some opinions and evidence have suggested that this has been a 'black swan' moment, where the COVID-19 pandemic has led to a rapid change in how mental health care is provided, including more opportunities for online working (Wind, Rijkeboer, Andersson, & Riper, 2020), also in low-and middle-income countries (Fu et al., 2020).Additionally, the current study showed that clinical psychol ogists and psychotherapists managed to provide treatment throughout the COVID-19 pandemic, despite the additional challenges of working in this context, to patients who were perceived to be experiencing a greater level of distress.Although challenges were clearly identified in the current study, participants also identified opportunities from working through the pandemic, such as reduction in commuting time, increased work flexibility and accessibility for patients.
Despite such a significant change in working context for clinical psychologists and psychotherapists, only one previous study looked at the impact of the pandemic on clinical psychologists and psychotherapists and also used a mixed-methods analysis of qualitative and quantitative data (McBeath et al., 2020).In that study, clinical psycholo gists and psychotherapists who were mostly based in the UK, were recruited via social media and, similar to our results, found that clinical psychologists and psychotherapists were able to cope with the rapidly changing work, and managed immediate problems with imagination and engagement.They also described a significant change of psycho therapeutic treatment, especially in relation to video therapy.

Digitalization
Even though clinical psychologists and psychotherapists have not yet reached a con sensus regarding whether they plan to continue using video therapy in the long run (Aafjes-van Doorn et al., 2020), the opportunities conferred via video therapy are clearly shown, both in the current study and other research (e.g., Humer, Stippl, et al., 2020).More than ten years ago, Simpson (2009) pointed out the opportunities and challenges of video therapy, naming the lack of research regarding efficacy as one major research goal.Simpson (2009) also pointed out that efficacy might be strongly related to patient and therapist's personality and interpersonal style, as well as therapist skills and experience in the use of technology.A pilot project with university students (Simpson, Guerrini, & Rochford, 2015) and the analysis of the recent, COVID-19 induced changes (Simpson et al., 2021) clearly points out the potential of video therapy if used correctly.It seems likely that the pandemic has shaped therapists' attitudes towards technology and led to a more positive view of it now they are more experienced in conducting treatment remotely, even if prior to COVID-19 they would not have elected to do so (Aafjes-van Doorn et al., 2020).As the success is highly dependent on therapists' overall attitudes and self-con fidence regarding technology and remote therapy (e.g., Aafjes-van Doorn et al., 2020), training courses and supervision in this regard is essential.As Simpson (2009) already pointed out, some barriers that prevent access to psychotherapy and counselling might be tackled with video therapy such as geographical distance between major cities and remote and rural communities, and a lack of adequate or affordable transport between them.Furthermore, video therapy can be used by patients who are immobile (Connolly, Miller, Lindsay, & Bauer, 2020).It might also encourage patients to engage who are indecisive about treatment and worry about stigma.Finally, most studies overall tend to conclude that video therapy will not be the new standard medium for psychotherapy (e.g., Aafjes-van Doorn et al., 2020;Connolly et al., 2020), but a useful addition under certain circumstances and considering specific adaptations such as providing a rationale for video therapy, maintaining therapeutic boundaries and finding a new way of risk management (for an overview see Simpson et al., 2021; for an exemplary analysis of pa tients with Borderline Personality Disorder see Ventura Wurman, Lee, Bateman, Fonagy, & Nolte, 2021).

Conducting Therapy With Personal Protective Equipment (PPE)
While the changes to working as a result of video therapy clearly brought opportunities, conducting therapy in person while using protective equipment such as face masks pre sented significant challenges.Clinical psychologists and psychotherapists who conducted face-to-face treatment during the pandemic mostly wore face masks and thus covered more than half of their face.Thus, while the disadvantage of video therapy is erased (e.g., no technological difficulties), others might appear: it has been argued both in our study and previous opinion pieces (e.g., Hüfner, Hofer, & Sperner-Unterweger, 2020) that emotions are harder to read if someone is wearing a face mask, which can then cause difficulties in the patient-therapist relationship.Interestingly, initial evidence from basic research has shown mixed findings.Some found that emotions are harder to read when the conversational partner wears a face mask (Grundmann, Epstude, & Scheibe, 2021), while others found in a longitudinal design that participants change which cues they use to detect an emotion, suggesting they adjust to the presence of masks (Barrick, Thornton, & Tamir, 2021).One study of school-aged children who are currently constantly interact ing while wearing masks concludes that masks pose a challenge but, in combination with other contextual cues, are unlikely to dramatically impair social interactions (Ruba & Pollak, 2020).Translating these findings to the clinical context, one can assume that psychotherapy with masks is somewhat more challenging than without masks, but could still lead to a good patient-therapist relationship and successful treatment outcomes.However, more research on the effects of masks on psychotherapy is necessary.

Restriction of Contact
It is important to acknowledge that clinical psychologists and psychotherapists have not only experienced a significant change in their working logistics, but also in their everyday life outside of work -similar to their patients and all other citizens.As some participants have highlighted, social support at work was less available and the team cohesion diminished, thus personal and work resources were limited.Furthermore, additional tasks added to stress (e.g., working from home without a proper place to work; child and other family care etc.).These factors indicate the importance of social support among the clinical psychologists' and psychotherapists' community in difficult times, and the importance of leadership from professional and governmental organizations.

Reflections for EACLIPT
It has been an unprecedented working environment for clinical psychologists and psy chotherapists during the COVID-19 pandemic.Clinical psychologists and psychothera pists were required to adapt their approach to work at very short notice during the first wave of the COVID-19 pandemic.However, survey respondents reported that they managed to convert working logistics efficiently and have been providing much needed care for patients ever since, even though the examination of the efficacy of treatment still needs more research.This was often done on an individual basis or by smaller groups of colleagues.An important next step is to collect, share and discuss experiences of, and develop guidelines for, video or phone therapy or intervention.This has been done locally (e.g., UK, Simpson, Richardson, Pietrabissa, Castelnuovo, & Reid, 2021.However, the EACLIPT as an organization has provided a position statement and a summary of national statements on what is needed for both patients and clinical psychologists and psychotherapists as well as future research endeavors regarding mental health 6 by integrating perspectives from a wide range of clinical psychologists and psychotherapists across multiple countries.

Reflections for Government Policy and Other Institutions
Although the sample of the current survey was limited to EACLIPT members, arguably, this data could be useful to inform the policies of government and other institutions, as the views of clinical psychologists and psychological therapists are represented from across a broad range of occupationals settings, across multiple European countries.The current findings emphasize the importance of including mental health issues in current policy considerations on how to manage the pandemic in the longer term.The long-term effects on mental health as a result of the COVID-19 pandemic are still not clear (e.g., de Figueiredo et al., 2021).Based on previous research on epidemics, further symptom increases in the upcoming one to three years are expected in anxiety, anger, depression, post-traumatic stress symptoms, alcohol abuse, and behavioural changes such as avoid ing crowded places and cautious hand washing (e.g., Kathirvel, 2020).This needs to be considered both in research (e.g., which factors could lead to mental health problems in the long run, de Figueiredo et al., 2021) and in health care (e.g., further flexible inclusion of video therapy into health insurance plans; enlarging mental health treatment provi sion; Kathirvel, 2020).In addition, the uptake of video therapy by clinical psychologists and psychotherapists during the COVID-19 pandemic offers the opportunity to take part 6) https://www.eaclipt.org/?tab=5 in treatment long distance (the therapist in one country, the patient in another) which calls for cross-border guidelines.

Limitations and Implications
The current study was implemented during the first wave of the COVID-19 pandemic, from May to September 2020.The pandemic is still ongoing and, thus, the situation is continually changing.To keep the questionnaire as short as possible to encourage participants to complete the survey, we did not include detailed information on the sociodemographic background and we did not ask for detailed numbers and facts, e.g.re garding the number of patient contacts before and during the pandemic.We rather opted to assess the personal estimation of change, which relies on the therapist's perception of the number of patient contacts and could include inaccuracies.Additionally, we are aware that only a small number of members completed the survey (i.e., 13% of EACLIPT members) and, thus, the results have to be considered in light of a rather limited and selective sample.However, our results provide a qualitative and quantitative picture of the first abrupt changes to the work of clinical psychologists and psychotherapists as a result of the COVID-19 pandemic.
Furthermore, in the current study, responses to open questions were often quite short, which at times limited the scope of interpretation.However, many answers poin ted to similar conclusions as shown above.
The current study highlights the tremendous challenges that both patients and clin ical psychologists and psychotherapists have experienced during the pandemic.Conse quently, there are calls for specific training for therapists and clear guidelines regarding the use of technology, data security and solutions to the psychotherapeutic challenges of delivering therapy remotely.However, more research (such as the follow-up to this survey that is underway) is necessary to identify the long-term effects of the COVID-19 pandemic on both patients and clinical psychologists and psychotherapists, and to com prehensively influence policy and future healthcare considerations.