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

Abstract

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.

New skills for distance regulation: Therapists’ experiences of remote psychotherapy following the COVID-19 pandemic.

“…However, some patients seemed to be more comfortable with remote sessions, allowing them to open up more in therapy and opening new areas for therapeutic work (cf., the online disinhibition effect; Suler, 2004). The physical distance allowed some patient–therapist dyads to get closer, potentially strengthening the therapeutic alliance and facilitating tailored interventions (cf., Aafjes-van Doorn, Békés, & Luo, 2021; Chen et al, 2021; Mercadal Rotger and Cabré, 2022; Simpson et al, 2021; Werbart et al, 2022). Thus, the therapists felt that different patients, and potentially different therapists too, had different needs when it comes to distance and closeness in the therapeutic relationship.…”

“…What factors are perceived by therapists to be important for their patients’ positive as well as negative long-term experiences of remote therapy? The present study is a part of a larger research project focusing on both patients’ and therapists’ experiences (Ahlström et al, 2022; Erlandsson et al, 2022; Werbart et al, 2022). We regard the qualitative methodology of inductive experiential thematic analysis (TA) as the method of choice for approaching how the participants experience and make sense of the clinical phenomenon in focus (Braun & Clarke, 2013; cf., Larkin et al, 2006).…”

“…Furthermore, patients and therapists could have different views of the therapeutic relationship and of what worked in telepsychotherapy (Cataldo et al, 2021; Probst et al, 2021), and the therapists could find the remote work to be more challenging than did patients (Thomas et al, 2021). Therapists without previous experience of online therapy and those with more negative preconceptions might feel more uncomfortable with the transition (Aafjes-van Doorn, Békés, & Prout, 2021; Ahlström et al, 2022; Békés & Aafjes-van Doorn, 2023; Isaacs Russell, 2021; Khan et al, 2022; Reilly et al, 2022; Werbart et al, 2022). The therapists’ attitudes toward and familiarity with the communication technology, as well as their experienced technical difficulties were associated with their view of the therapeutic relationship and seemed to affect the effectiveness of remote therapy (Aafjes-van Doorn, Békés, & Prout, 2021; Mancinelli et al, 2021; Rathenau et al, 2022).…”

Psychoanalysts’ work throughout the COVID-19 pandemic: An empirical study on teleanalysis during the Italian lockdown.

“…However, some perplexities may remain, and despite the potential benefits of online psychotherapy, especially during this specific period of time (e.g., Simpson et al, 2021), many therapists are worried about being less able to communicate their empathy, to build therapeutic alliance (Roesler, 2017), or worry about the impact of technical glitches, insufficient confidence with internet, and confidentiality issues (Titzler et al, 2018). Research has also shown that the transition to internet-based therapy, after an initial face-to-face phase, may be experienced as something that does not allow for specific rituals and boundaries of psychoanalysis to survive in the online setting (Werbart et al, 2022). These concerns seem to be influenced by therapists’ past experiences, such as psychotherapy modality, clinical experience, and previous online psychotherapy experience (Békés & Aafjes-van Doorn, 2020).…”

“…PSYCHOANALYSIS AND THE PANDEMIC (Werbart et al, 2022). These concerns seem to be influenced by therapists' past experiences, such as psychotherapy modality, clinical experience, and previous online psychotherapy experience (Békés & Aafjes-van Doorn, 2020).…”