The meaning and feeling of the time and space between psychotherapy sessions and everyday life: Client experiences of transitions.

OBJECTIVE: To explore how clients in psychodynamic or psychoanalytic psychotherapy, conducted in the traditional in-person setting, experience the transitions in time and space between psychotherapy sessions and everyday life. METHOD: Twelve semi-structured interviews were analyzed with inductive experiential thematic analysis, focusing on how the participants experience and make sense of the phenomenon in focus. RESULTS: The participants described therapy as a sheltered space where they could be open, vulnerable, receptive, and present. Approaching and leaving psychotherapy sessions, the participants established different behavioral patterns and routines dealing with their anxieties and resistances. In this in-between area, the participants could handle interconnections and differences between therapy and everyday life. Participants stressed the clinical impact of transitions: transitions affect both therapy and everyday life; disturbed transitions have an adverse impact; transitions are insufficiently addressed in therapy. CONCLUSION: Transitions between therapy and life appear to be an essential but seldom recognized part of the therapy process beyond the borders of therapy sessions. Implications of these findings for psychotherapy training and practice are discussed, and a tentative transtheoretical framework for further research is proposed.

Understanding psychoanalytic work online and back to the couch in the wake of the COVID-19 pandemic: an investigation among Italian psychoanalysts.

Background: Worldwide, psychotherapists' clinical experience went through rapid developments with transition to teletherapy during the COVID-19 pandemic. Literature on the use of remote psychoanalysis was not conclusive, leaving the issue of the consequences of the necessary setting alternation open. This study aimed to investigate the psychoanalysts' experiences of shifting to remote work and then returning to in-person setting, considering the effect of the patients' attachment styles and personality configurations. Method: Seventy-one analysts of the Italian Psychoanalytic Society were asked to fill out an online survey about patients who found the transition easier and patients who found it more difficult. General questions on therapeutic work, ISTS (Interpretive and Supportive Technique Scale) for interpretive and supportive aspects of technique, WAI-S-TR (Working Alliance Inventory-Short Revised-Therapist) for therapeutic alliance, RQ (Relationship Questionnaire) for attachment style, and PMAI (Prototype Matching of Anaclitic-Introjective Personality Configuration) for personality configurations were administered. Results: All of the analysts chose to continue the treatment using audio-visual tools. Patients with difficult transitions had a significantly higher frequency of insecure attachment and a higher score on RQ Dismissing scale than patients with easy transitions. No significant differences were found between the two groups in personality configurations, psychotherapeutic alliance, and psychotherapeutic technique. Moreover, a higher level of therapeutic alliance was positively correlated to RQ Secure scale and was negatively correlated to RQ Dismissing scale. Patients with easy transition both to remote work and back to in-person setting had higher scores of therapeutic alliances than those with difficult transition both to remote work and back to in-person setting. Conclusion: Online psychoanalytic therapy was widely used during the COVID-19 pandemic. Patients with insecure attachment styles had greater difficulties in adapting to setting alternations, thus confirming that insecure attachment is a vulnerability factor not only for psychopathological problems but also for a well-functioning therapeutic collaboration. Patient's personality configuration did not influence their adaptation to the setting alternation. The supportive and interpretive styles did not undergo significant changes in the transition from in-person setting to remote setting and vice versa, thus suggesting a continuity in the analysts' "internal setting."

It turned into something else: patients' long-term experiences of transitions to or from telepsychotherapy during the COVID-19 pandemic.

Introduction: The shift from in-person therapy to telepsychotherapy during the COVID-19 pandemic was unprepared for, sudden, and inevitable. This study explored patients' long-term experiences of transitions to telepsychotherapy and back to the office. Methods: Data were collected approximately two years after the declaration of COVID-19 as a pandemic. Eleven patients were interviewed (nine women and two men, aged 28 to 56, six in psychodynamic psychotherapy, five in CBT). Treatments switched between in-person and video/telephone sessions. Interview transcripts were analyzed applying the qualitative methodology of inductive thematic analysis. Results: (1) The patients experienced the process in telepsychotherapy as impeded. Interventions were difficult to understand and lost impact. Routines surrounding the therapy sessions were lost. Conversations were less serious and lost direction. (2) Understanding was made more difficult when the nuances of non-verbal communication were lost. (3) The emotional relationship was altered. Remote therapy was perceived as something different from regular therapy, and once back in the therapy room, the patients felt that therapy started anew. The emotional presence was experienced as weakened, but some of the patients found expressing their feelings easier in the absence of bodily co-presence. According to the patients, in-person presence contributed to their security and trust, whereas they felt that the therapists were different when working remotely, behaving in a more easygoing and familiar way, as well as more solution-focused, supportive and unprofessional, less understanding and less therapeutic. Despite this, (4) telepsychotherapy also gave the patients an opportunity to take therapy with them into their everyday lives. Discussion: The results suggest that in the long run, remote psychotherapy was seen as a good enough alternative when needed. The present study indicates that format alternations have an impact on which interventions can be implemented, which can have important implications for psychotherapy training and supervision in an era when telepsychotherapy is becoming increasingly common.

How much time does psychoanalysis take? The duration of psychoanalytic treatments from Freud's cases to the Swedish clinical practice of today.

The starting point for this paper is Freud's thinking about the length of psychoanalysis and the conditions for ending it. His psychoanalytic treatments were intense, but varied greatly in length. Freud's assertion that deep psychological changes take time is still topical; however, the length of time has gradually increased. Available documentation from psychoanalytic training institutes, and findings from empirical studies, indicate that the mean length of psychoanalysis ranges from between three to seven years, and varies between different countries and periods. A recent survey among Swedish psychoanalysts found a mean length of 5.7 years and a wide variation in length from 1.5 to 12 years. Discussions in a seminar group on endings and the qualitative follow-up survey showed that a unique combination of factors determined the duration of psychoanalysis in each individual case. We briefly review the potential determinants of the treatment length and the different meanings of time in open-ended psychoanalytic treatments. To conclude, we stress the need for systematic clinical and empirical studies of determinants and the underlying processes behind the different lengths of psychoanalyses.

Loss of Rituals, Boundaries, and Relationship: Patient Experiences of Transition to Telepsychotherapy Following the Onset of COVID-19 Pandemic.

Telepsychotherapy is an increasingly common way of conducting psychotherapy. Previous research has shown that patients usually have positive experiences of online therapy, however, with large individual differences. The aim of this study was to explore patients' experiences of transition from in-person psychotherapy sessions to telepsychotherapy during the COVID-19 pandemic, as well as variation in the experiences with regard to the patients' personality orientation. Seven psychotherapy patients in Sweden were interviewed and the transcripts were analyzed using thematic analysis. Additionally, the participants were asked to rate their dissatisfaction/satisfaction with the transition, how hindering/helpful the transition was, and how unsafe/safe they felt after the transition in comparison to before. Personality orientation on relatedness or self-definition was assessed applying a self-assessment instrument (Prototype Matching of Anaclitic-Introjective Personality Configuration; PMAI). The participants experienced telepsychotherapy as qualitatively different from in-person psychotherapy. They reported several essential losses: the rituals surrounding therapy sessions were lost, including the transitional time and space between their every-day life and the therapy sessions, less therapeutic work was done, the therapists could lose their therapeutic stance, the sense of rapport was impaired, and the patients felt less open and emotionally available. On the other hand, some patients could feel freer online. As six of the participants had an anaclitic personality orientation, the present study could especially contribute to the understanding of how patients with strong affiliative needs and fear of abandonment experience the transition to meeting their therapists via communication technology. The participants' self-ratings showed that they were only marginally dissatisfied with the transition and experienced the transition as slightly hindering, whereas they felt rather safe after the transition, indicating low concordance between qualitative and quantitative evaluations. New studies are needed to explore the introjective patients' experiences of the transition. An essential topic is also to collect evidence and to test how the impaired sense of rapport when using communication technology can be remedied by adequate, patient-tailored interventions, a topic that has to be included in psychotherapy education and training.

Am I Really Bipolar? Personal Accounts of the Experience of Being Diagnosed With Bipolar II Disorder.

Bipolar disorder (BD) is a complex and chronic mental illness with highs and lows beyond the ordinary, which induces a significant risk of suicide. The aim of this study was to explore the experience of being diagnosed with BD and the impact that receiving a correct diagnosis had had on life situations and relationships with others. Semi-structured qualitative interviews were conducted with seven people diagnosed with BD. The results showed that the primary treatment all participants had received or were currently receiving was pharmacotherapy, typically without any psychological component. A major concern that arose was delayed diagnosis, leading to inadequate treatment, and lack of knowledge among professionals about non-typical forms of BD. Moreover, the experiences of others' reactions were multifold, though generally surprisingly positive. Generally, the participants had learned to recognize, understand and tackle early symptoms of both hypomanic and depressive episodes to avoid developing a full-blown acute episode. This study highlights the crucial importance of a collaborative relationship between the clinician and the patient.

Love, Work, and Striving for the Self in Balance: Anaclitic and Introjective Patients' Experiences of Change in Psychoanalysis.

One of the most famous quotations credited to Freud is that, when asked what he thought a psychologically healthy person should be able to do, he said: "to love and to work." A central goal in psychoanalytic treatment is to bring about changes in basic, mostly unconscious, mental structures. The aim of this study was to investigate, applying an inductive thematic analysis, the experiences anaclitic and introjective patients have had of change after psychoanalysis with regard to the domains Love and Relationships and Work and Achievements. Analyzing patient interviews, we identified a third domain of experienced changes, The Self, which refers to increased self-understanding, self-acceptance, and self-care rather than an improved dynamic balance between love and work. All patients experienced several positive changes in their lives during and after psychoanalysis. We also found distinctive patterns that appear to be closely linked to the patients' initial personality orientation with regard to relationships and achievements. Generally, the patients described symmetrical, but opposite, change processes within the two specific domains of Love and Work. For the anaclitic patients, this indicated a movement inward in the domain of Love (from an excessive preoccupation with issues of their relationship with others toward more distinct self-boundaries and increased agency) and outward in the domain of Work (from unenterprising toward becoming more outgoing and daring). For the introjective patients, this pointed to a reverse movement outward in the domain of Love (from an excessive preoccupation with issues of autonomy toward increased responsiveness to others and desire to be establish close, mutual relationships) and inward in the domain of Work (from an excessive orientation on achievements toward increased becoming more grounded in their own feelings, needs, and desires). In conclusion, patients in both groups have experienced a reduced preoccupation with issues related to their initially predominant personality dimension (relatedness or self-definition) and increased receptivity to needs typical for the complementary dimension. These changes seem to be mediated by changes in the domain of The Self. Our study suggests the clinical relevance of focusing the therapeutic work on fostering a better and more dynamic balance between love and work, relatedness, or self-definition.

Successful and Less Successful Psychotherapies Compared: Three Therapists and Their Six Contrasting Cases.

Despite the general effectiveness of bona fide psychotherapies, the number of patients who deteriorate or fail to improve is still problematic. Furthermore, there is an increased awareness in the field that the therapists' individual skills make a significant contribution to the variance in outcome. While some therapists are generally more successful than others, most therapists have experienced both therapeutic success and failure in different cases. The aim of this case-series study was to deepen our understanding of what matters for the therapists' success in some cases, whereas other patients do not improve. How do the patients and their therapists make sense of and reflect on their therapy experiences in most successful and unsuccessful cases? Are there any distinctive features experienced by the participants at the outset of treatment? To explore these issues, we applied a mixed-method design. Trying to keep the therapist factor constant, we selected contrasting cases from the caseloads of three therapists, following the criterion of reliable and clinically significant symptom reduction or non-improvement at termination. Transcripts of 12 patient interviews and 12 therapist interviews (at baseline and at termination) were analyzed, applying inductive thematic analysis and the multiple-case comparison method. The comparisons within the three therapists' caseloads revealed that in the successful cases the patient and the therapist shared a common understanding of the presenting problems and the goals of therapy and experienced the therapeutic relationship as both supportive and challenging. Furthermore, the therapists adjusted their way of working to their patients' needs. In non-improved cases, the participants presented diverging views of the therapeutic process and outcome. The therapists described difficulties in the therapeutic collaboration but not how they dealt with obstacles. They tended to disregard their own role in the interactions and to explain difficulties as being caused by the nature of their patients' problems. This could indicate that the therapists had difficulty in reflecting on their own contributions, accepting feedback from their patients, and adjusting their work accordingly. These within-therapist differences indicate that taking a "third position" is most needed and seems to be most difficult, when early signs of a lack of therapeutic progress appear.

"The Skin is the Cradle of the Soul": Didier Anzieu on the Skin-Ego, Boundaries, and Boundlessness.

Didier Anzieu's notion of the skin-ego builds on a long psychoanalytic tradition that began with Freud's idea that the ego is first and foremost a body ego, a projection in the psyche of the surface of the body, or, in other words, the idea that psychic phenomena are always embodied. An interface, a container for the ego, but also its origin: thus did Anzieu conceptualize the skin's psychic function. The baby's fantasy of having a common skin with the mother is the concrete starting point for a development that, through the prohibition on touching, leads to the experience of being a separate and individual person. Psychoanalytic work with severe mental disorders makes it necessary to investigate deficiencies in the skin-ego's containing function before the patient's psychic contents can be explored. In the psychoanalytic situation, the analyst's words replace tactile contact and thereby contribute to healing injuries to the skin-ego. The clinical implications of Anzieu's theoretical model are illustrated by examples from psychoanalyses of children and adults. The close connection between touch, psychic envelopes, and thinking opens a wider perspective on the necessity of setting limits to violence, against both nature and human beings.

"It was hard work every session": Therapists' view of successful psychoanalytic treatments.

OBJECTIVE: To explore therapists' experiences of the therapeutic process in successful cases of psychoanalytic psychotherapy. METHOD: A two-stage, mixed-method design was used. Sixteen successful cases were drawn from a sample of 92 young adults in psychoanalytic psychotherapy according to Jacobson's criteria for reliable and clinically significant improvement. Therapist interviews at baseline and termination were analyzed applying Inductive Thematic Analysis. RESULTS: Three core themes emerged: Being Particularly Motivated to be This Patient's Therapist, Maintaining a Safe and Attentive Therapeutic Position, and Assiduous Work Every Session. The therapists experienced positive feelings towards the patient from the outset of treatment and described active, relational work that included paying attention to incongruities in the patient's self-presentation and being mindful of patient's avoidant behavior. The therapist's motivation and attentive position made it possible to balance support and challenge in the therapeutic relationship. CONCLUSIONS: Successful therapeutic work presupposes positive expectations, an active therapeutic stance and assiduous work session-by-session. Therapist expertise may involve the ability to mobilize and work effectively with patient-specific resources and obstacles from the beginning of treatment. In addition to identifying the characteristics and actions of effective therapists, research should also focus on processes emerging within effective therapeutic dyads. Clinical or methodological significance of this article: Our study indicates several factors that seem to characterize therapist expertise and can inform psychotherapy training. Successful therapeutic work presupposes positive expectations, an active therapeutic stance, courage to challenge the patient, and assiduous work session-by-session. Therapist expertise may involve the ability to mobilize and work effectively with patient-specific resources and obstacles from the beginning of treatment. In addition to identifying the characteristics and actions of effective therapists, research should also focus on processes emerging within effective therapeutic dyads.

"It was like having half of the patient in therapy": Therapists of nonimproved patients looking back on their work.

Objective: To explore therapists' experiences of therapeutic process in psychoanalytic psychotherapy with nonimproved young adults. Method: Eight nonimproved cases were identified according to the criterion of reliable and clinically significant change in self-rated symptoms. Transcripts of therapist interviews (8 at baseline and 8 at termination) were analyzed applying grounded-theory methodology. Results: A tentative conceptual process model was constructed around the core category Having Half of the Patient in Therapy. Initially, the therapists experienced collaboration as stimulating, at the same time as the therapeutic relationship was marked by distance. At termination negative processes predominated: the patient reacted with aversion to closeness and the therapist experienced struggle and loss of control in therapy. The therapists described therapy outcome as favorable in form of increased insight and mitigated problems, while core problems remained. Conclusions: This split picture was interpreted as a sign of a pseudo-process emerging when the therapist one-sidedly allied herself with the patient's capable and seemingly well-functioning parts. The therapists' experiences could be compared to the nonimproved patients' "spinning one's wheels" in therapy. The therapists seem not to have succeeded in adjusting their technique to their patients' core problems, despite attempts to meta-communicate.

Matching Patient and Therapist Anaclitic-Introjective Personality Configurations Matters for Psychotherapy Outcomes.

Decades of psychotherapy research suggest that patient-therapist match accounts for outcome beyond single patient or therapist variables. This study examines the associations between different patterns of patient-therapist matching (in terms of orientation on relatedness or self-definition) and outcomes at termination of psychoanalytic psychotherapy with young adults. Thirty-three patients and their therapists were classified as predominately anaclitic or introjective at baseline. Patients in the convergent patient-therapist dyads (both anaclitic or both introjective) showed significantly greater symptom reduction and increased developmental levels of representations of mother than patients in the complementary dyads (opposite personality configurations). Moreover, convergent patient-therapist match was connected with larger effect sizes on all outcome measures and lower proportion of non-improved patients. These findings suggest the importance of the therapists' early adjusting their orientation on relatedness or self-definition to their patients' predominant personality configuration in order to enhance treatment outcomes.

Correction to: Matching Patient and Therapist Anaclitic-Introjective Personality Configurations Matters for Psychotherapy Outcomes.

[This corrects the article DOI: 10.1007/s10879-018-9389-8.].

Changes in the Anaclitic-Introjective Personality Configurations Following Psychoanalytic Psychotherapy with Young Adults.

Treatment goals in psychoanalytic psychotherapy often include changes in underlying psychological structures, rather than only symptom reduction. This study examines changes in the anaclitic-introjective personality configurations following psychoanalytic psychotherapy with young adults in relation to outcomes. Thirty-three patients were interviewed pretreatment and at termination using the Object Relations Inventory (ORI). Prototype Matching of Anaclitic-Introjective Personality Configuration (PMAI) was applied to the ORI material by two independent judges (intraclass correlation coefficient=0.73). The patients were classified pretreatment as predominately anaclitic (n=13) or introjective (n=20). Outcome measures included the Symptom Checklist-90-R (SCL-90) and Differentiation-Relatedness scale (D-R) pretreatment, at termination, at the 1.5-year and three-year follow-up. Both groups improved post-treatment in terms of symptoms and developmental levels of representations of self, mother, and father. No significant differences between the anaclitic and the introjective group were found in this respect, and could not be expected due to the low power (0.27). The anaclitic group showed better balance between relatedness and self-definition post-treatment, while this improvement was not significant in the introjective group. Further and larger studies are needed to draw more far-reaching conclusions about the relations between changes in personality configurations over the course of treatment and the treatment efficacy. The clinical implications of this approach to underlying dynamic psychological structures are discussed.

Changes in Self-Representations Following Psychoanalytic Psychotherapy for Young Adults: A Comparative Typology.

Changes in dynamic psychological structures are often a treatment goal in psychotherapy. The present study aimed at creating a typology of self-representations among young women and men in psychoanalytic psychotherapy, to study longitudinal changes in self-representations, and to compare self-representations in the clinical sample with those of a nonclinical group. Twenty-five women and sixteen men were interviewed according to Blatt's Object Relations Inventory pretreatment, at termination, and at a 1.5-year follow-up. In the comparison group, eleven women and nine men were interviewed at baseline, 1.5 years, and three years later. Typologies of the 123 self-descriptions in the clinical group and 60 in the nonclinical group were constructed by means of ideal-type analysis for men and women separately. Clusters of self-representations could be depicted on a two-dimensional matrix with the axes Relatedness-Self-definition and Integration-Nonintegration. In most cases, the self-descriptions changed over time in terms of belonging to different ideal-type clusters. In the clinical group, there was a movement toward increased integration in self-representations, but above all toward a better balance between relatedness and self-definition. The changes continued after termination, paralleled by reduced symptoms, improved functioning, and higher developmental levels of representations. No corresponding tendency could be observed in the nonclinical group.

Shame and Gender Differences in Paths to Youth Suicide: Parents' Perspective.

Risk factors, suicidal behavior, and help-seeking patterns differ between young women and men. We constructed a generic conceptual model of the processes underlying youth suicide, grounded in 78 interviews with parents in 52 consecutive cases of suicide (19 women, 33 men) identified at forensic medical autopsy and compared by sex. We found different forms of shame hidden behind gender-specific masks, as well as gender differences in their paths to suicide. Several interacting factors formed negative feedback loops. Finding no way out, the young persons looked for an "emergency exit." Signs and preparations could be observed at different times but recognized only in retrospect. Typically, the young persons and their parents asked for professional help but did not receive the help they needed. We discuss parents' experiences from the theoretical perspective on gender identity and developmental breakdown. Giving voice to the parents' tacit knowledge can contribute to better prevention and treatment.

Secure attachment to therapist, alliance, and outcome in psychoanalytic psychotherapy with young adults.

Using a novel approach to assess attachment to therapist from patient narratives (Patient Attachment to Therapist Rating Scale; PAT-RS), we investigated the relationships between secure attachment to therapist, patient-rated alliance, and outcome in a sample of 70 young adults treated with psychoanalytic psychotherapy. A series of linear mixed-effects models, controlling for length of therapy and therapist effects, indicated that secure attachment to therapist at termination was associated with improvement in symptoms, global functioning, and interpersonal problems. After controlling for the alliance, these relationships were maintained in terms of symptoms and global functioning. Further, for the follow-up period, we found a suppression effect indicating that secure attachment to therapist predicted continued improvement in global functioning, whereas the alliance predicted deterioration when both variables were modeled together. Although limited by the correlational design, this study suggests that the development of a secure attachment to therapist is associated with treatment gains as well as predictive of posttreatment improvement in functioning. Future research should investigate the temporal development of attachment to therapist and its interaction with alliance and outcome more closely. To ensure differentiation from patient-rated alliance, observer-based measurement of attachment to therapist should be considered.

"Spinning one's wheels": Nonimproved patients view their psychotherapy.

OBJECTIVE: To explore psychotherapy experiences among nonimproved young adults in psychoanalytic psychotherapy. METHOD: A two-stage, mixed-method design was used. Twenty patients in the clinical range at pretreatment were identified as either with reliable deterioration or with no reliable change at termination. Interviews at termination and 3-year follow-up were analyzed with grounded theory methodology. RESULTS: "Spinning One's Wheels" emerged as a core category. The patients described the therapeutic relationship as distanced and artificial. While they saw active components in therapy and their own activities in life as beneficial, therapy itself was experienced as overly focused on problem insight and past history. CONCLUSIONS: When the therapist does not contribute to the achievement of the patient's treatment goals--even when the patient gains some benefit--the patient does not fully profit from the therapy.

Dropout revisited: patient- and therapist-initiated discontinuation of psychotherapy as a function of organizational instability.

OBJECTIVE: To explore the association between the stability or instability of services' organizational structure and patient- and therapist-initiated discontinuation of therapy in routine mental health. METHOD: Three groups, comprising altogether 750 cases in routine mental health care in eight different clinics, were included: cases with patient-initiated discontinuation, therapist-initiated discontinuation, and patients remaining in treatment. Multilevel multinomial regression was used to estimate three models: An initial, unconditional intercept-only model, another one including patient variables, and a final model with significant patient and therapist variables including the organizational stability of the therapists' clinic. RESULTS: High between-therapist variability was noted. Odds ratios and significance tests indicated a strong association of organizational instability with patient-initiated premature termination in particular. CONCLUSIONS: The question of how organizational factors influence the treatment results needs further research. Future studies have to be designed in ways that permit clinically meaningful subdivision of the patients' and the therapists' decisions for premature termination.