Lost and Found in Psychotherapy During COVID-19.

The authors discuss the loss of the traditional setting for psychotherapy caused by the COVID-19 pandemic, a natural experiment lasting 2 years, and the finding of new channels of communication for therapy using video and telephone platforms as well as outdoor therapy spaces. The manuscript explores the experience of both patients and therapists with these new channels and investigates how the external features of the therapy frame can be subjectively experienced by different people and within different therapeutic relationships. Through patient surveys, case vignettes, and discussions with colleagues, the authors conclude that for a large group of psychotherapy patients the new channels worked as well as and sometimes even better than the old in-person appointments and that an occasional in-person "booster" session can strengthen the therapeutic alliance of ongoing teletherapy.

Flexibility in Treatment: A Trial of Walking Psychotherapy.

Flexibility in the psychotherapeutic frame of treatment arises from many sources, from the general to the personal, and can take several forms. This article looks at walking while conducting psychotherapy with patients and explores the ways in which flexibility in treatment can enhance the alliance, how walking side by side brings the body into focus with its implications for transference and countertransference, and how associations to landscape evoke past memories and access emotions. Issues relating to self-disclosure and boundaries, as well as patient responses to the psychotherapist's personally driven request to consider walking during psychotherapy are addressed. Since writing this article, the coronavirus pandemic has swept across the world and required psychotherapists everywhere to bend the frame of treatment and meet with patients virtually-by phone or video conference-to maintain social distancing and prevent the spread of infection. The hardships posed by this shift in treatment frame combine with benefits not dissimilar to those found with psychotherapy while walking.

Race in Supervision: Let's Talk About It.

Addressing race and racial trauma within psychotherapy supervision is increasingly important in psychiatry training. A therapist's ability to discuss race and racial trauma in psychotherapy supervision increases the likelihood that these topics will be explored as they arise in the therapeutic setting. The authors discuss the contextual and sociocultural dynamics that contributed to their own avoidance of race and racial trauma within the supervisory relationship. The authors examine the features that eventually led to a robust discussion of race and culture within the supervisory setting and identify salient themes that occurred during three phases of the conversation about race: pre-dialogue, the conversation, and after the conversation. These themes include building an alliance, supercompetence, avoidance, shared vulnerability, "if I speak on this, I own it," closeness versus distance, and speaking up. This article reviews the key literature in the field of psychiatry and psychology that has shaped how we understand race and racial trauma and concludes with guidelines for supervisors on how to facilitate talking about race in supervision.

Learning through the lens: ethical considerations in videotaping psychotherapy.

Psychiatry training programs have begun to use technology to enhance psychotherapy teaching. Videotaped interviews provide a window into the psychotherapeutic exchange, demystifying the process and capturing verbal and nonverbal interactions, facial expression, and tone of voice-which can illustrate therapeutic elements such as the alliance and resistance. The process of videotaping psychotherapeutic interviews, however, introduces issues related to consent, ethics, and the dynamics of therapy. By examining two cases in which residents asked their patients to videotape a session for didactic purposes and encountered divergent outcomes, we explore the ethical issues unique to providing informed consent for videotaping psychotherapy. Informed consent must be given verbally and in writing. Verbal consent must include discussion of the risks and benefits of therapy. The discussion must also include the risks inherent in memorializing sensitive material on an external device, with disclosure of the logistics of how data will be stored, who will view the recorded material, and when it will be destroyed. Therapists should be aware of the coercive power inherent in the physician-patient relationship and should individualize each informed consent procedure with this knowledge in mind. Despite these potential pitfalls, videotaping sessions provides a wealth of information about both patients and therapists that can improve psychotherapy teaching and supervision, and indirectly improve patient care.

Transfer of care of psychotherapy patients: implications for psychiatry training.

Transfers of care occur routinely in medical training, but the transfer of psychotherapy patients has received relatively little attention. This article discusses important issues concerning these transfers, using case examples and findings from a survey of the experience of psychiatry residents transitioning psychotherapy patients. Residents have difficulty telling patients they are leaving and often delay doing so. Because feelings of closeness and attachment can develop in long-term therapeutic relationships, residents describe feeling guilty, uncertain, anxious, sad, and occasionally relieved as they prepare their patients for transfer. Outgoing residents can feel anxious when recognizing and addressing their patients' and their own positive feelings. Incoming residents experience discomfort at being compared to the previous therapist and often encounter the patient's negative feelings at the transfer and the loss of the previous therapy. Teaching about the two poles of transfer of care is recommended to better understand and respond to this transition for both patient and therapist. This should include addressing the stresses involved and recommendations for management.

When mothers leave their children behind.

Psychiatry has studied the effect on children of separation from their mothers or primary caregivers, but has not given equal attention to the effect on mothers of separation from their children. This article examines the current literature on separation from the mother's perspective. Following a review of the literature on mothers' attachment behaviors, as evidenced by separation from their very young children due to ordinary circumstances, attention will turn to specific populations of mothers enduring separation from their children in situations of hardship: mothers with mental illness, homeless mothers, mothers in prison, and two groups of working mothers-immigrant mothers and deployed navy mothers. Separation can be experienced as temporary, bringing on anxiety, or may involve a mother's choice between her child's safety and her own wish to keep the child near her, causing a conflict in the mother's feelings. In other situations, separation may be involuntary and long-lasting, inducing symptoms of depression, despair, and grief, all of which are characteristic of loss. The particular conditions of the separation-such as choice, control, and ongoing communication between mother and child-can mitigate the impact of the separation and transform it from a total to a partial loss. Three clinical cases of mothers forced to separate from their children in extreme circumstances are examined, with recommendations for treatment.