Long-term Psychotherapy Research Articles

Clinical Recommendations for Addressing Impasses in Long-Term Psychotherapy

Many clients benefit from psychotherapy sessions that extend across months or years. However, there is a risk for therapeutic impasse in long-term psychotherapy in which the work can become repetitive or with limited gains over time. The current paper provides five transtheoretical principles to increase the impetus in long-term therapy. The five principles include: planful spontaneity, habitual creativity, pushing the limits of the therapeutic alliance, guided discovery, and specific broad goals. The therapist is encouraged to share responsibility for creative flexibility with the client in each session, including within the therapeutic alliance and the real relationship. The therapist can use a series of questions to promote a process of guided discovery. A clear focus on principles of psychology and goals that reflect maintenance of gains, development of strengths, and promotion of enrichment can ensure that the therapy continues to produce change over the length of the relationship.

Identification of Dynamic Patterns of Personal Positions in a Patient Diagnosed With Borderline Personality Disorder and the Therapist During Change Episodes of the Psychotherapy.

Personal positions and voices of a patient diagnosed with borderline personality disorder (BPD) and the therapist during long-term psychotherapy were studied aiming to find differences in the patterns formed in these aspects of subjectivity according to the level of elaboration of the change episodes achieved by the patient. This case study considered a stage of qualitative analysis where change episodes of the patient were traced through the Change Episodes Model. Later, through the Model of Analysis of Discursive Positioning in Psychotherapy (MAPP), the voices and personal positions of the patient and her therapist were identified in each of the change episodes. In the stage of quantitative analysis, dynamic patterns in the voices and personal positions were established, accounting for hypothetical attractors using the Space State Grid (SSG) technique in each of the three different levels of subjective elaboration that constitute the change episodes. The results established differentiated dynamic patterns in the change episodes, coherent with the patient’s change process, and formation of propositive/reflective specific patterns as the patient evolved in the three different levels of subjective elaboration. The above suggests that a subjective transformation process is displayed, and this is manifested in the different voices and personal positions that emerged as the change episodes evolve. The identified dynamic patterns can be considered nonlinear and emergent subjective exchanges between the patient and the therapist throughout the psychotherapy.

The interplay between agency and therapeutic bond in predicting symptom severity in long-term psychotherapy.

This study investigated the interplay between agency and therapeutic bond in predicting patient symptoms in outpatient psychotherapy. A total of N = 731 patients provided measurements of agency (Therapeutic Agency Inventory; TAI), therapeutic bond (bond subscale of Working Alliance Inventory-Short Form Revised [WAI-SR]), and symptoms (Symptom Checklist Short Form [SCL-K11]) every fifth session of long-term treatment for up to 60 sessions. When investigated in separate models, both more agency and a stronger therapeutic bond predicted symptom improvement. However, within-person changes and between-person differences in agency predicted symptom improvement over and above the effects of therapeutic bond. Multilevel response surface analysis was used to further investigate the interplay between agency and therapeutic bond. When both agency and therapeutic bond levels were high, symptoms improved the most. When agency and therapeutic bond ratings differed, symptom ratings were significantly lower when agency exceeded therapeutic bond levels than when therapeutic bond ratings exceeded agency. Findings suggest that both agency and therapeutic bond are important treatment factors, but outcome could be improved when a strong therapeutic bond is combined with an equally strong sense of agency that empowers patients to pursue changes in their lives. When a strong therapeutic bond is present, but the patient feels less agentic, therapists may want to foster agency to improve outcomes. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The Effectiveness of 6 versus 12 Months of Dialectical Behavior Therapy for Borderline Personality Disorder: A Noninferiority Randomized Clinical Trial

Introduction: Evidence-based psychotherapies for borderline personality disorder (BPD) are lengthy, posing a barrier to their access. Brief psychotherapy may achieve comparable outcomes to long-term psychotherapy for BPD. Evidence is needed regarding the comparative effectiveness of short- versus long-term psychotherapy for BPD. Objective: The aim was to determine if 6 months of Dialectical Behavior Therapy (DBT) is noninferior to 12 months of DBT in terms of clinical effectiveness. Methods: This two-arm, single-blinded, randomized controlled noninferiority trial with suicidal or self-harming patients with BPD was conducted at two sites in Canada. Participants (N = 240, M (SD)_age = 28.27 (8.62), 79% females) were randomized to receive either 6 (DBT-6) or 12 months (DBT-12) of comprehensive DBT. Masked assessors obtained measures of clinical effectiveness at baseline and every 3 months, ending at month 24. DBT-6 and DBT-12 were outpatient treatments consisting of weekly individual therapy sessions, weekly DBT skills training group sessions, telephone consultation as needed, and weekly therapist consultation team meetings. Results: The noninferiority hypothesis was supported for the primary outcome, total self-harm (6 months: margin = −1.94, M_diff [95% CI] = 0.16 [−0.14, 0.46]; 12 months: margin = −1.47, M_diff [95% CI] = 0.04 [−0.17, 0.23]; 24 months: margin = −1.25, M_diff [95% CI] = 0.12 [−0.02, 0.36]). Results also supported noninferiority of DBT-6 for general psychopathology and coping skills at 24 months. Furthermore, DBT-6 participants showed more rapid reductions in BPD symptoms and general psychopathology. There were no between-group differences in dropout rates. Conclusions: The noninferiority of a briefer yet comprehensive treatment for BPD has potential to reduce barriers to treatment access.

A case of dissociative identity disorder and attention deficit hyperactivity disorder comorbidity

IntroductionDissociative identity disorder(DID) is characterized by the existence of two or more distinct identities which involve changes in consciousness, emotion, memory, and behavior. It is associated with childhood traumatic experiences and other psychiatric disorders. Comorbidity in DID can lead to complex clinical presentations, poor treatment responses. Thus, it is crucial to identify patients with comorbidity and take them into the treatment plan.ObjectivesWe aim to report a case of DID and Attention-Deficit/Hyperactivity Disorder(ADHD) comorbidity.MethodsA case report is presented alongside a review of the relevant literature regarding “dissociative identity disorder” and “attention deficit hyperactivity disorder”.ResultsWe describe the case of a 39-year-old woman with DID, onsetting at age 25, who had consistently responded poorly to long-term psychotherapy and pharmacological treatment. She presented with anxiety, distinct personality states, alterations in memory, consciousness and behavior problems in functioning, and high Dissociative Experiences Scale(DES) scores. Throughout the interviews, we noticed that she had limited attention, excess movements. After a detailed evaluation, diagnosis of ADHD is established, using the Diagnostic Interview for ADHD(DIVA) and ADHD Self-Reporting Scale(ASRS). Methylphenidate was prescribed in addition to previous medication. İmprovement in the severity of both ADHD and DID symptoms was presented with lower scores in DES and ASRS after the introduction of methylphenidate with progressive dose adjusting till 60mg/day.ConclusionsAlthough previous studies demonstrated ADHD symptoms are related to dissociation, there is no well-established strategy for this. We believe that this case report provides a better approach to the comorbidity of ADHD and DID.DisclosureNo significant relationships.

Dynamic Patterns in the Voices of a Patient Diagnosed with Borderline Personality Disorder, and the Therapist throughout Long-Term Psychotherapy

This case study identified the subjective change in a patient diagnosed with Borderline Personality Disorder (BPD) by analyzing the dynamic patterns that emerged during discursive interaction with her therapist during a successful long-term psychotherapy. A qualitative analysis was conducted by applying the Model of Analysis of Discursive Positioning in Psychotherapy (MAPP), tracking voices and the personal positions of the patient and therapist in all sessions. Subsequently, dynamic patterns were identified and the hypothetical attractors were defined (i.e., the most stable patterns in the interaction of voices) using the Space State Grid (SSG) technique. Five sessions (representing the initial, middle and final stages) were selected to describe the trajectory of the patient’s subjective change. These sessions highlight the presence of different attractors and depict the intersubjective interaction that developed during the process. The results suggest a process of subjective transformation from a monological to a dialogical dimension, a change supported by therapeutic interaction based on propositional and reflective discursive aspects; a transition from a state of dissociation of the patient to a reorganization of her subjectivity. The most relevant characteristics of this process as an emergent quality of psychotherapy and its relation to the patient’s positive outcomes are discussed.

Where Is My Mother? Childhood Trauma and the Configuration of the Self

ABSTRACT In this account of a long-term psychoanalytic psychotherapy, a confluence of childhood traumatogenic factors in interaction with the patient’s unconscious fantasy life resulted in dramatic permutations and distortions in the patient’s self- organization. From a different but related perspective, the psychic repercussions of an incompletely mourned and internalized maternal object are also explored. The prevailing psychic script or narrative, deeply embedded and nearly intractable, revolved around the patient’s conscious and unconscious conviction of mortal sin and guilt in response to her mother’s death – imposing on her the penalty of “a life for a life.” During the course of treatment, the patient’s investment in becoming a good mother became a powerful incentive for the recovery of previously inaccessible experience, facilitating a gradual movement toward psychic integration. While the primary transference at the outset of treatment was the therapist’s nonexistence, replicating the patient’s experience of abandonment-obliteration, the development of the therapeutic relationship was essential to the gradual assimilation of dissociated traumatic experience and the enlivenment of the unrepresented maternal object.

Ego Impairment Index (EII-2) as a predictor of outcome in short- and long-term psychotherapy during a 5-year follow-up.

ObjectiveThis study examined the predictive ability of the Rorschach‐based Ego Impairment Index (EII‐2) on outcome of psychotherapy in different types and durations of therapy.MethodA total of 326 outpatients suffering from depressive or anxiety disorders were randomized into receiving solution‐focused (n = 97), short‐term psychodynamic (n = 101), or long‐term psychodynamic psychotherapy (n = 128). Psychotherapy outcome assessments during the 5‐year follow‐up period covered psychiatric symptoms, social functioning, and work ability.ResultsLower EII‐2 values, which indicate less problematic ego functioning, were found to predict faster improvement in both short‐term therapies as compared to long‐term psychotherapy.ConclusionThe results provide preliminary support for the utility of EII‐2 as a complementary measure to interview‐based methods for selecting between short‐ and long‐term therapies.

A Short-Term Training Clinic Model for Dialectical Behavior Therapy (DBT) in Treating Borderline Personality Disorder (BPD): The Case of "Jane"

Dialectical Behavioral Therapy (DBT) is an evidence-based, long-term psychotherapy initially developed to treat Borderline Personality Disorder (BPD) patients and/or highly suicidal individuals. DBT involves four components: tailored individual therapy, phone coaching from the individual therapist, structured group skills training, and therapist supervision by participation in a "consultation team." While manualized, DBT is a multifaceted and flexibly applied treatment that balances interventions both for acceptance and maintenance (e.g., validating the patient in the present), and for change and progression (e.g., encouraging the patient to try on new, more healthy attitudes, emotions, and behaviors). The Dialectical Behavioral Therapy Clinic at Rutgers University (DBT-RU) is a research and training clinic that adapts the DBT Manual to provide short-term (6-months long), comprehensive DBT for community adults presenting with BPD and associated problems. The present project reports an example of the DBT-RU model in action, including the decision-making processes involved, by presenting the case of "Jane," for whom I was the therapist. At the beginning of therapy Jane was a 32-year-old, heterosexual, Caucasian, single mother of a 7-year-old son; and she worked as a medical technician. Her presenting problems met the full DSM-5 criteria for BPD. Her symptoms, following DSM-5 numbering, included: 1) frantic efforts to avoid abandonment; (2) recurrent unstable and intense relationships; (3) identity disturbance (in self and religious beliefs); (4) impulsivity; (6) affective instability; (7) chronic feelings of emptiness; and (8) inappropriate, intense anger. In addition, she reported past suicidal ideation that was "very strong." In line with Jane’s intense and challenging presenting problems, the process of therapy was complex with many starts and stops. However, over the course of therapy she showed important, substantial improvement, as reflected by both quantitative measures and qualitative indicators. To aid the reader in following the complex organization of this case study, an outline of it is presented in Appendix 1.

What patient characteristics predict treatment success or failure in short- and long-term psychotherapies?

Background Patient factors make a strong contribution to psychotherapy outcome. Pre-treatment patient characteristics – demographic, pathology and personal – may either facilitate achievement of recovery and lasting benefits or constitute a risk for different kinds of treatment failure. Methods A narrative review focused on evaluating the role of pre-treatment patient characteristics on the success or failure of short- and long-term psychotherapy for mood and anxiety disorders. Success was conceptualized as significant improvement or recovery and failure as non-improvement, deterioration, or non-attendance/dropout. Results There is no consistent evidence of demographic variables as predictors of treatment failure, except for lower socioeconomic status, being male and ethnic minority status for therapy non-attendance. Patients’ pathology, i.e. severity of psychiatric symptoms, greater functional impairment, personality disorder and other comorbidities, have been shown to be mostly associated with lesser recovery across different types of disorders, especially in short-term therapies, but it does not consistently predict treatment failure. Some pre-treatment personal characteristics (e.g. secure attachment style) and capacities (e.g. motivation, self-observing capacity and good overall psychological suitability) mostly increase the likelihood of therapy success whereas some vulnerabilities and poor psychological suitability, or overall complexity (i.e. combination of demographic, clinical and personality factors), increase the risk of poor outcome mostly in short-term but not in long-term therapy, or moderate dropout. Likewise, the subsequent match between therapy type and patient’s pre-treatment expectations and preferences may account for different aspects of treatment failure. Conclusions The relative importance of pre-treatment patient characteristics on treatment failure is not known. Meta-analyses on this issue are needed.

The Experience of Psychotherapy in Greek Women with Breast Cancer: An Interpretative Phenomenological Study

Βreast cancer is amongst the most frequently occurring types of cancer amongst women worldwide. The present qualitative study explored experiences of long-term psychotherapy among women with breast cancer attending psychodynamic psychotherapy at an outpatient service specializing at providing psychotherapeutic interventions for cancer patients, in Greece. The sample was purposeful and comprised of six women who participated in individual interviews, consisting of questions framed in an open way to explore their lived experiences in the context of therapy. The research data was analyzed using Interpretative Phenomenological Analysis and produced five group experiential themes (superordinate themes) namely 1) the experience of breast cancer 2) psychosomatic aspects of cancer 3) psychotherapy as a process of self-awareness and growth 4) the process of change and 5) the therapist-client relationship. Participant women seemed to experience psychotherapy as a positive, even though challenging journey, that integrated past, present and future promoting post-illness and post-recovery well-being, and allowing for the exploration of different needs that surpass the event of the disease itself. Given the complex experiences and different needs of women with cancer, it seems important for further qualitative research to explore the experiences of patients in psychotherapy in different cultural contexts, and taking into account different theoretical orientations in order to offer appropriate therapeutic interventions.

La tanière et le territoire : esquisse d’une topo-analyse des troubles du comportement alimentaire

ObjectivesClinical and phenomenological exploration of the manner in which patients with eating disorders inhabit their dwellings. MethodsDiscussion of a series of four adult patients treated in long-term psychotherapy. ResultsWe describe two distinct, interrelated modes of dwelling: the den and the territory. The territory is the parental home, where the patients grew up; the den is the current place of living. The territory is an arena of rivalry and conflicts with parents and siblings. Patients have a strong attachment to the territory, exerting a sharp surveillance through frequent inspection visits, with violent reactions to changes happening in the house. Even in their absence, they haunt the territory. In contrast, the den is a place where they disappear, severing all links with the outside world and abandoning themselves to binge eating. The den is an escape from the demands of social relationships, painfully experienced as intrusions or the threat of desertion. ConclusionsEating disorders, because they are related to fundamental difficulties in the processes of emancipation, result in specific, altered modes of dwelling. These alterations are mutually reinforcing, and can be understood as pathological solutions developed in response to difficulties in the emancipation process. Systematic, empirical studies would help to shed more light on modes of dwelling in eating disorders. These aspects of the patients’ experience should be included in clinical care.

Implementation of a Care Manager Organization and Its Association with Health Care Contacts and Psychotherapy: A Register-Based Study of Real-Life Outcomes at Primary Health Care Centers in Sweden.

BackgroundA care manager organization, based on a collaborative care model, was implemented in the primary health care service in Region Västra Götaland, Sweden, to improve the care of persons with common mental disorders (CMDs). We aimed to investigate the association between the care manager organization and number of health care contacts, and the extent of psychotherapy among female and male patients with CMD compared to primary health care centers (PHCCs) offering usual care, in the introductory year of implementation with one year follow-up.MethodsThis register-based study included all PHCCs in the region, which were analyzed in two groups depending on their care manager status. The study periods were 2015.09.01–2016.08.31 (first year) and 2016.09.01–2017.08.31 (second year). Data on health care contacts and psychotherapy per PHCC were obtained from a health care register. The mean number and proportion of visits to different health care professionals, and the proportion of patients with short-term versus long-term psychotherapy were measured. A linear mixed-effects model for cross-sectional and longitudinal analysis was implemented as well as a generalized linear regression model for possible interaction effects of PHCC characteristic on care manager status and outcomes.ResultsPHCCs with a care manager organization had more nurse contacts (p = 0.001 for both year 1 and year 2) compared to PHCCs with usual care. PHCCs with usual care had a significantly lower proportion of visits to psychotherapists and a higher proportion of both female and male patients receiving short-term psychotherapy (1–5 sessions vs ≥6) over time and compared to PHCCs with a care manager organization.ConclusionWith a care manager organization, nurse contacts increased at the PHCCs. However, this did not negatively influence the visits to a general practitioner and to psychotherapists. This evaluation showed that the care manager organization at PHCC level implies higher accessibility and sustainability of care for up to two years after implementation.

A service evaluation of short-term mentalisation based treatment for personality disorder.

People with personality disorder experience long waiting times for access to psychological treatments, resulting from a limited availability of long-term psychotherapies and a paucity of evidence-based brief interventions. Mentalisation-based treatment (MBT) is an efficacious therapeutic modality for personality disorder, but little is known about its viability as a short-term treatment. We aimed to evaluate mental health, client satisfaction and psychological functioning outcomes before and after a 10-week group MBT programme as part of a stepped-care out-patient personality disorder service. We examined routinely collected pre-post treatment outcomes from 176 individuals (73% female) aged 20-63 years, attending a dedicated out-patient personality disorder service, who completed MBT treatment. Participants completed assessments examining mentalising capacity, client satisfaction, emotional reactivity, psychiatric symptom distress and social functioning. Post-MBT outcomes suggested increased mentalising capacity (mean difference 5.1, 95% CI 3.4-6.8, P < 0.001) and increased client satisfaction with care (mean difference 4.3, 95% CI 3.3-5.2, P < 0.001). Post-MBT emotional reactivity (mean difference -6.3, 95% CI -8.4 to -4.3, P < 0.001), psychiatric symptom distress (mean difference -5.2, 95% CI -6.8 to -3.7, P < 0.001) and impaired social functioning (mean difference -0.7, 95% CI -1.2 to -0.3, P = 0.002) were significantly lower than pre-treatment. Improved mentalising capacity predicted improvements in emotional reactivity (β = -0.56, P < 0.001) and social functioning (β = -0.35, P < 0.001). Short-term MBT as a low-intensity treatment for personality disorder was associated with positive pre-post treatment changes in social and psychological functioning. MBT as deployed in this out-patient service expands access to personality disorder treatment.

Insight and Outcome in Long-Term Psychotherapies of Depression

Objectives: In different therapeutic approaches, insight is acknowledged as an important part of patient's therapeutic change process. We examined whether the level of insight (1) differs between psychoanalytic (PA), psychodynamic (PD) and cognitive-behavioral therapy (CBT), and (2) predicts long-term symptomatic outcome. Methods: A completer sample of 67 depressed patients from the Munich Psychotherapy Study was analyzed. Symptoms were assessed with Beck Depression Inventory (BDI) and Symptom Checklist-Revised (SCL-90-R) at pre-treatment and three-year follow-up. Insight was assessed from 242 sessions of mid-therapy phase with the Experiencing Scale. Results: The general level of insight was higher in PA as compared to CBT, and associated with lower depressive symptoms (BDI) across all three therapeutic modalities at three-year follow-up. Insight was unrelated to general distress (SCL-90-R). Exploratory analyses suggested that patients treated with PA showed higher levels of insight especially in high quality sessions (assessed by therapist). Patients for whom the extent of insight was positively linked to session quality, suffered from more depressive symptoms at three-year follow-up than patients gaining insight when session quality was low. Conclusion: Insight differs between PA and CBT and may be a common change mechanism in long-term psychotherapies.

Intraindividual dynamics between alliance and symptom severity in long-term psychotherapy: Why time matters.

Objective: The association between alliance and therapy outcome is one of the most investigated factors in psychotherapy research. However, even studies using advanced methods estimate effects over a specific time period (interval) between measurement occasions. Thus, it remains unknown how the magnitude and direction of effects depend on the considered time interval, resulting in limited comparability across studies. The current study examines the influence of time on the within-person relationship between alliance and symptom severity. Method: Alliance (WAI-SR) and symptom severity (SCL-K11) were assessed every fifth session in N = 650 patients receiving up to 100 weekly sessions (mode = 55; M = 41.03; SD = 27.23) of individual psychotherapy in a German outpatient clinic. Bivariate continuous-time (CT) structural equation modeling (SEM) was used to estimate within-person cross- and auto-effects. Results: Analysis revealed significant reciprocal within-person cross-effects with stronger relative effects of SCL-K11 on WAI-SR (a₂₁) than vice versa (a₁₂). CT analysis showed that both cross-lagged effects increased for longer time intervals with strongest effects for time intervals of about 40 sessions (a₂₁ = -.47; a₁₂ = -.19). Conclusions: Alliance and symptom severity showed a reciprocal relationship. Expanding current evidence, our analysis showed how the magnitude of these effects depends on the considered time interval. Applying CT-SEM on longitudinal data of the alliance outcome association complements current cross-lagged panel analysis and allows to compare results of studies which are based on different time intervals between measurement occasions. Methodological, theoretical, and clinical implications are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Psychoanalytic psychotherapy in Denmark: development, implementation in the public health service and present status

The history of psychoanalysis and psychodynamic psychotherapy in Denmark is briefly described. An important element in developing the psychodynamic thinking in the public mental health service took place in the 1970s where several British psychoanalysts and group analysts helped Danish therapists and analysts starting regular courses in psychoanalytic psychotherapy that were attended by a few hundred psychologists and psychiatrists. The implementation of psychodynamic thinking and practice in the Mental Health System followed over the next two decades, although the Danish welfare system did not economically support patients referred to psychoanalysis, long-term or intensive psychoanalytic psychotherapy. At the new millennium, opposition to psychoanalysis and psychodynamic thinking made it difficult to sustain the relative high level of involvement of psychodynamic practice in both mental health institutions and private practice. The reasons for this are suggested as well as comments on the future.

Enduring the chaos. Psychoanalytical psychotherapy in Poland

The article describes the place of psychoanalytic psychotherapy in the public health care system and private practice in Poland today. Because no systematic research has been previously conducted on this topic, and as a result, we lack sufficient data for a comprehensive overview, the authors have chosen to focus their attention on the conditions under which psychoanalytic psychotherapists conduct their work. In order to provide the reader with a better understanding of the contextual issues involved, we begin by describing key moments in the history of Poland that were of significance for psychoanalysis and the functioning of the country’s health care system, taking into special consideration the effects of successive reforms of this system. Based on the authors’ observations, theoretical reflection and practices rooted in psychoanalysis are experiencing a Renaissance in the Polish psychotherapeutic community, despite the fact that the Polish health care system does little to promote the practice of long-term psychotherapy.

Sharing Experiences and Positive Outcomes From Working as a Psychoanalytic Psychotherapist During COVID-19

In early 2020, COVID-19 began disrupting working life across the globe, with remote working and social distancing becoming the norm for many industries. This called for radical changes in psychotherapeutic practices in Australia and internationally, challenging the long-accepted face-to-face therapeutic model. COVID-19 also introduced new anxieties for patients and practitioners alike. In this paper, I draw on my own personal experiences and, through a series of case studies, explore how moving to remote working during COVID-19 actually provided unexpected and positive therapeutic outcomes. Firstly, I discuss how unexpectantly working remotely with a young girl in long-term psychotherapy helped her to return from her “psychic retreat”. Secondly, I look at how a father who was working remotely at home during COVID-19 was more available to his anorectic daughter. Thirdly, I describe how students who were undertaking infant observations were able to continue these intimate mother/caregiver and baby observations remotely, and how crucial these were to the observed family.

Moving Forward While Standing Still: A Case of Mental Health Advocacy Evolving in the Time of COVID-19.

There have been shifts over time in the value placed on long-term psychotherapeutic modalities even though they can be life-saving. For example, the province of Ontario in Canada has been dealing with a government proposal put forward in 2019 to limit the length of psychotherapy treatment. In response, stakeholders from numerous groups came together to advocate for the importance of continuing unrestricted access to long-term psychotherapy. Approaches to this advocacy then had to unexpectedly adapt to the Coronavirus Disease 2019 (COVID-19) pandemic that came to the forefront in 2020 and will continue to develop in response to this changing landscape.