Previously, three broad categories of silences in therapy contexts were identified: productive, neutral, and obstructive. Empirical studies have shown that obstructive silence is the most common type of silence in adolescent psychotherapy. The present study focused on obstructive silence, aiming to understand psychotherapists’ subjective experiences of such stoppages in the therapeutic process specifically in work with adolescents. Interviews with eight psychodynamically oriented psychotherapists were analyzed using Interpretive Phenomenological Analysis. Six core facets of the phenomenon of obstructive silence emerged. Coming in touch with unconnectedness described the therapists’ understanding of the emergence of obstructive silence, how it was experienced in themselves and in relation to the adolescent patient. Obstructive silence was not experienced as static but as fluctuating between and within therapy sessions. Therapists’ emotional reactions and inner dilemmas in the form of unwanted negative emotions, losing oneself as a therapist, and trying to make sense of what was occurring could be experienced separately, simultaneously or after each other. How the therapists experienced the situation could influence their attempts to reestablish a connection with the adolescent. This process could work in direct association with the understanding of the situation or in interaction with other facets. Attempts to reclaim connectedness could enable paths where the therapeutic process could be resumed or lead back to unconnectedness. The most painful facet of obstructive silence was when the therapists experienced the emotional duality of oscillating between being connected and being unconnected, both with the patients and themselves. In conclusion, obstructive silence was experienced as a multifaceted phenomenon with different origins, functions, and challenges that affected the therapist, the adolescent, and the therapeutic process.

Objectives: The objective of this study was to explore therapists' new-found experiences of what works in successful cases of teletherapy. Design: This was a qualitative study of therapists' experiences, making their implicit knowledge explicit and systematised. Methods: Twelve therapists were recruited via posts on social media and via the interviewers' professional networks. The therapists were interviewed at their office or via Zoom using a semi-structured interview guide. The interviews were analysed using inductive, reflexive thematic analysis. Results: The therapists described a number of interacting favourable factors, together contributing to successful remote treatments. Establishing a good therapeutic relationship and cooperation was a general success factor common to in-person and remote treatments. Specific factors included well-functioning communication technology, co-creating a sense of co-presence, safeguarding therapeutic boundaries adjusted to the remote setting, finding ways of compensating for the loss of several cues available in an in-person setting and the patient being motivated for a remote therapeutic endeavour. Conclusions: In the successful cases, therapists in this study seem to have developed specific skills to counteract the inherent challenges and to benefit from the advantages specific to the remote setting. In the post-pandemic era, when hybrid and remote therapeutic modalities become increasingly common, these specific skills and mechanisms have to be included in psychotherapy training programmes, supervision and continuing education.

Ingress: Subtila band förenar vår frihetssiktande kreativitet med våra narcissistiska och depressiva sidor. Att smärtsamt erkänna Ananke, "nödvändigheten", utgör ett frigörande villkor i konsten liksom i den psykoanalytiska förändringsprocessen.

The aim of the present study was to compare risk factors for death by suicide and sudden violent death (SVD) among young people aged 10–25 years. Two target samples, 63 consecutive cases of youth suicide and 62 cases of SVD, were compared on potential risk factors differentiating the two groups from 104 controls. Data on psychiatric diagnoses, psychosocial factors, adverse childhood experiences, stressful life events, and coping strategies were collected in psychological autopsy interviews. Distinguishing for the suicide group was lower frequency of living in a steady relationship, adult psychiatric care, depression, autism spectrum disorder, being sexually assaulted, higher frequency of recent stressful life events, and lowest levels of adaptive coping. Distinguishing for the SVD group was a predominance of males, lower elementary school results, abuse of psychoactive drugs, being investigated or sentenced for criminal acts, conduct disorder or antisocial personality disorder. Common risk factors for both kinds of premature unnatural death included lower educational level, absence of work or studies, different forms of addiction, child and adolescent psychiatric care, borderline personality disorder, adverse childhood experiences, and less adaptive coping. Accordingly, there is a common ground of vulnerabilities, early adversities, and recent strains in life for both forms of premature death, but also substantial differences between these contrasting lethal developments. Prevention of both suicide and SVD should focus on adverse childhood experiences, learning difficulties, meaningful occupation, more adaptive coping, addiction, and treatment of borderline personality disorder. Suicide prevention should comprise promotion of adaptive stress management skills, depression prevention and treatment, and paying attention to young people with autism. SVD prevention should involve early response to learning difficulties, abuse of psychoactive drugs and delinquent behavior, and treatment of conduct disorder and antisocial personality disorder.

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.

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.

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.”

Psychotherapy has traditionally been delivered in person, but recent technological advances have made it possible to conduct remote treatments. There is currently strong evidence for the efficacy of guided self-help with online support from a therapist, but less is known about video-mediated psychotherapy. The COVID-19 pandemic has however forced many therapists to provide remote treatments. This transition might be especially trying for therapists of children and adolescents, but their experiences are underexplored. This study aimed to investigate their perceptions of video-mediated psychotherapy. Semi-structured interviews were conducted with 16 therapists and analyzed using thematic analysis. The therapists described how they struggled with technical and ethical issues and tried to overcome the loss of their usual therapeutic tools. They were concerned that the online format led to less effective treatments or could have negative effects, even if it might increase care availability. Generally, they felt frustrated, inadequate, and stressed, and experienced less job satisfaction. The therapists concluded that video-mediated sessions might be a good alternative for children and adolescents – provided the therapists themselves could determine for whom and when to offer video sessions. Implications of their experiences are discussed, including how psychotherapy training might have to incorporate issues related to remote psychotherapy.

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.

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.