Understanding Therapist Heterogeneity in the Post-Pandemic Use of Video-Based Psychotherapy: A Person-Centered Longitudinal Analysis of German Outpatient Psychotherapists (Preprint)

BACKGROUND Video-based psychotherapy (VBT) became an essential modality during the COVID-19 pandemic, enabling continuity of outpatient care despite social distancing measures. While adoption surged during the pandemic, little is known about how usage and attitudes evolved after restrictions were lifted. Understanding patterns of sustained use and the factors influencing acceptance can guide targeted implementation strategies. OBJECTIVE This study examines changes in VBT usage, attitudes, and determinants among German outpatient psychotherapists before, during, and one year after the pandemic restrictions. Specifically, it assessed (1) frequency and purposes of use, (2) changes in perceived effectiveness and therapeutic factors, (3) determinants of acceptance and continued use, and (4) attitudinal profiles of psychotherapists based on a person-centered clustering approach. METHODS A longitudinal partially repeated cross-sectional survey was conducted among German outpatient psychotherapists (N=296) during the pandemic (T1:2020/ 2021) and one year after restrictions were lifted (T3:2023). Measures included VBT usage frequency, perceived effectiveness, therapeutic change mechanisms based on Grawe’s model, and determinants from the Unified Theory of Acceptance and Use of Technology for therapists (UTAUT-T). Sociodemographic, practice characteristics, regulatory perceptions, and digital affinity were recorded. Analyses combined longitudinal comparisons, theory-based regression modeling, and person-centered clustering to examine changes in VBT usage, attitudes, and acceptance. Descriptive statistics and non-parametric tests assessed temporal changes in usage, perceived effectiveness, and therapeutic factors. Based on the UTAUT-T framework, multiple linear regressions identified determinants of behavioral intention and actual use. Cluster analysis (hierarchical and k-means) classified psychotherapists into attitudinal profiles, which were compared using ANOVA and chi-square tests. RESULTS Out of the 296 outpatient psychotherapists surveyed, 202/296 (68.2%) reported using VBT post-pandemic. Usage rose from 13/296 (4.4%) pre-pandemic to 240/296 (81.1%) during the pandemic and declined post-pandemically but remained above pre-pandemic levels, Q(2)=357.2, P<.001. Longitudinal data (117 therapists) showed balanced inflow and outflow of users (15, 12.8% new users; 14, 12.0% discontinuers; χ²(1)=0.0, P=1.000). Active users reported 50.7 (SD 57.4) VBT sessions with 10.9 (SD 11.3) patients annually, corresponding to 5.7% (SD 6.4) of caseload. VBT was rated less effective than face-to-face therapy (Wilcoxon, P<.001), with non-users assigning significantly lower ratings than users (U=5638.00, P<.001). Predictors of intention to use included Therapy Quality Expectation (β=.513, P<.001) and Ease of Use (β=.213, P<.001). Logistic regression showed that prior use (OR=.25, P<.001), perceived effectiveness (OR=.36, P=.001), professional internet use (OR=.48, P=.029), and regulatory awareness (OR=.30, P<.001) significantly predicted post-pandemic usage. A three-cluster solution based on UTAUT-T dimensions revealed Tech-Savvy Optimists (high acceptance and use, 92.6% users), Cautious Neutrals (moderate acceptance and use, 79.2% users), and Skeptical Traditionalists (low acceptance and use, 11.9% users). Cluster profiles differed significantly in VBT usage intensity, digital affinity, therapeutic orientation, pandemic usage, awareness of and perceived restrictions by regulations, and perceptions of Grawe’s therapeutic factors. CONCLUSIONS Post-pandemic VBT adoption among German outpatient psychotherapists remains heterogeneous, shaped by distinct attitudinal profiles that reflect deeper professional value orientations. Implementation strategies should be tailored to profile-specific needs, consider professional identity, and ensure regulatory clarity. These findings point to the central role of person-technology fit in sustaining digital innovations in psychotherapy. However, sustained implementation has boundaries; not all therapists will adopt VBT, even under favorable conditions, and some may view face-to-face therapy as more compatible with their values.