Psychotherapy For Patients Research Articles

Who seeks psychodynamic psychotherapy in community-based practices? Patient characteristics examined in a large sample of applications for reimbursement of psychotherapy in Germany

This study examined the demographic characteristics of patients using outpatient psychodynamic psychotherapy and compared them to the general population. A second aim was to explore clinical and biographical features of the users. We extracted data from a random sample of 983 applications for reimbursement of psychodynamic psychotherapy in community-based practices in Germany. These applications contain information for the health insurer but also additional written reports for an expert reviewer. Census data for comparison were obtained from the Federal Statistical Office of Germany. Men, older people, and migrants were underrepresented, while the unemployed were overrepresented compared to the general population. A third of the reports described a patient’s experience of physical and/or sexual violence. Twenty-six percent of the reports mentioned that the parents had separated, and a third of these patients were younger than 5 years at that time. Suicidal ideation was reported for a fifth of the patients. About 5% were reported to present with self-harming behaviour and 14% with violence towards others. It was mentioned that the patients were consuming dangerous amounts of alcohol in 9%. The most frequent diagnosis group was affective disorders, followed by neurotic disorders, whereas only few had a substance use diagnosis or a psychotic disorder. In summary, men, migrants, older people, and patients with substance abuse and psychotic disorders are likely underrepresented in outpatient psychotherapy in Germany, indicating unequal access to mental health care despite the universal coverage of its costs. Patients in outpatient psychodynamic psychotherapy often present with severe clinical problems.

Inpatient psychotherapy of depressive disorders: options and challenges

The psychotherapy of depressive disorders has become established as acentral component of inpatient treatment in psychiatric and psychosomatic hospitals and furthermore constitutes an important component of the residency training in Germany; however, the number of studies examining the effectiveness and efficacy is limited. This narrative review summarizes the current state of research on inpatient psychotherapy for depressive disorders. The results of meta-analyses as well as practice-based observational studies from routine treatment in Germany, disorder-specific special programs, and side effects of inpatient psychotherapy are summarized. The number of studies on the efficacy of inpatient psychotherapy of depressive disorders is overall low. The main finding of the largest recent meta-analysis indicates that psychotherapy in clinics and other facilities has asignificant effect on depressive symptoms, with small to moderate effect sizes in randomized controlled studies. The effects are mostly maintained even after 9-15months follow-up. An observational study from routine treatment with avery large sample size reported large pre-post and pre-follow-up effect sizes. It additionally revealed factors that appear to be difficult to change during inpatient psychotherapy, negatively affect treatment success and could be specifically addressed in future trials. Special programs, such as inpatient Interpersonal Psychotherapy (IPT) and the inpatient Cognitive Behavioral Analysis System of Psychotherapy (CBASP) indicate acceptance and efficacy/effectiveness in an initial randomized controlled (IPT) study and in observational (CBASP) studies. Side effects of inpatient psychotherapy were reported by 60-94% of patients with depressive disorders, whereby a perceived dependence on the therapist or the therapeutic setting was identified as afrequent side effect. Overall, the results of the narrative review reveal that inpatient psychotherapy appears to be meaningful and effective for many patients with depressive disorders. Specific side effects, cost-effectiveness, and the question of differential indications (what works for whom?) should be further investigated.

Evidence-based inpatient psychotherapy of bipolar disorders

Although psychotherapy is an important pillar in the treatment of bipolar disorders, alongside pharmacotherapy, non-drug and complementary procedures, there is no up to date evidence synthesis for inpatient psychotherapeutic treatment and work with caregivers. To review and evaluate the current study situation on evidence-based inpatient psychotherapy for bipolar disorders. 1.Summary of the evidence for inpatient psychotherapy in adolescents and adults with bipolar disorders from current review articles and guidelines (German S3 guidelines, Australian, Canadian, and British NICE guidelines). 2.Systematic literature search (PRISMA) in Cochrane trials and Medline (via PubMed). 2a.Identification of original articles using the following search term: "bipolar fft" OR "bipolar ipsrt" OR "bipolar cbt" OR "bipolar cognitive remediation" OR "bipolar psychotherapy inpatient". 2b.Screening of n = 942 publications on the following inclusion criteria: randomized controlled efficacy trials, inpatient treatment/recruitment in the inpatient setting, adolescent or adult patients with bipolar disorder or caregivers. The guidelines recommend acombination of pharmacotherapy and psychotherapy for the treatment of patients with bipolar disorders (so far no evidence-based presentation of inpatient psychotherapy). The results from reviews and original papers are heterogeneous. Recently described evidence-based psychotherapeutic approaches for inpatient treatment are family focused therapy (FFT), interpersonal and social rhythm therapy (IPSRT) and psychoeducation. Although the current evidence is heterogeneous and further systematic studies are necessary, the results indicate that psychotherapy should be started or initiated in the inpatient setting with inclusion of caregivers.

Evidence-based inpatient psychotherapy in borderline personality disorder

Borderline personality disorder (BPD) is frequent (prevalence in Germany between 0.7% and 4.5%) [11] and is associated with ahigh level of psychological stress and frequent emergency inpatient admissions. The provision of disorder-specific outpatient psychotherapy is still insufficient also in Germany. This article provides an overview of the available data on the effectiveness of inpatient psychotherapy for BPD. Aqualitative review on the effectiveness and therapy outcome predictors was conducted based on aliterature search in PubMed. Overall, very few randomized controlled trials are available; in contrast uncontrolled studies are predominant. Most evidence is available for dialectical behavior therapy (DBT) but other approaches, including psychodynamic procedures, have also been studied. The currently available data suggest an efficacy of inpatient psychotherapy for BPD; however, randomized trials with larger samples and sufficient representation including male patients are largely lacking. There is also no substantial direct evidence for the superiority of inpatient compared to outpatient psychotherapy.

Can students in simulation portray a psychotherapy patient authentically with a detailed role-script? Results of a randomized-controlled study.

Can students in simulation portray a psychotherapy patient authentically with a detailed role-script? Results of a randomized-controlled study.

Current evidence for various inpatient psychotherapy programs in the treatment of psychoses-A narrative review article

The analysis of the efficacy of evidence-based psychotherapy for patients with psychotic disorders has mostly been carried out in the outpatient field. In the inpatient field the efficacy is sometimes difficult to assess due to different healthcare systems. The aim of this narrative review is to summarize international guidelines and meta-analyses on the efficacy of inpatient psychotherapeutic treatment strategies for patients with psychotic disorders. Based on this, recommendations for disorder-specific ward concepts for acute and postacute fields are formulated. The German S3 guidelines, international guidelines, current meta-analyses and primary studies on psychological interventions in the treatment of psychotic disorders were included. Based on the results, recommendations for the inpatient psychotherapeutic treatment in various phases of treatment were formulated (acute phase and postacute phase). In the acute phase a combination of cognitive behavioral therapy (CBTp) in the individual setting and family interventions in the group setting as well as metacognitive training (MCT acute) is effective and recommended. In the postacute phase, in addition to individual and group CBTp and family interventions, psychoeducation, social skills training and cognitive remediation have been shown to be effective and are recommended. The suggested recommendations for concrete interventions in various treatment phases and the evidence base are critically discussed and recommendations for the structure of wards are presented.

A Psychodynamic Study on Premature Termination of Therapy Sessions

Objectives: In this study, the author compared the psychodynamics of three patient groups before the termination of individual psychotherapy to understand how the patients differed in related themes and their dysfunction levels, conflicts and modes of conflict processing, defense immaturity level, and disintegration levels of some aspects of the psychodynamic structure. Methods: I used detailed process notes of 97 adult psychotherapy patients treated by a psychotherapist in a Taiwan psychiatric hospital. The study patients were divided into three groups: the treatment completers, premature terminators with prior information (informers), and premature terminators without prior information (non-informers), according to their completion of the treatment protocol and offering premature termination (PT) information in advance. I also used the core scheme of Operationalized Psychodynamic Diagosis-2 to evaluate the psychodynamics of the last two sessions before ending therapy. Results: Three groups of patients were not different in primary relational themes and total dysfunctional level of relations, also in conflict significance and mode of conflict processing. The completers and informers were not different in conflict types, but the completers presented themselves higher frequency of “individuation-dependency” conflict and a lower frequency of “Oedipal” and “un-notable” conflicts than noninformers. The completers showed less disintegrated “internal communication” and “external world communication” than informers and noninformers. Conclusion: Premature terminators less communicated internally and externally with the therapist than therapy completers, and non-informers depend less on dyad therapeutic relationships than informers and completers. Psychodynamics represented in preterminate therapy sessions can provide insight into predicting patients' inclination to PT with or without advance information that is difficult to detect in another way.

The therapeutic effects of the therapists’ ability to pass their patients’ tests in psychotherapy

Introduction According to Control-Mastery Theory (CMT)—a cognitive-dynamic relational theory of mental functioning, psychopathology, and psychotherapy—patients come to therapy with an unconscious plan to disprove their pathogenic beliefs and achieve adaptive goals. One of the primary ways patients work to disconfirm their pathogenic beliefs is by testing them within the therapeutic relationship. Objectives: The present study aimed to replicate and expand the results of previous studies suggesting that therapists’ responses that disconfirmed patient’s pathogenic beliefs were predictive of patients’ within-session progress. Moreover, we wanted to investigate whether these interventions correlated with the therapeutic alliance. Methods: Transcriptions of 81 sessions from five brief psychodynamic psychotherapies were assessed by 11 independent raters. For each case, the patient’s plan was formulated and tests identified, the accuracy of the therapist’s responses to these tests was rated, and the impact of the therapist’s interventions on the patient’s subsequent communications and their relationship with the therapeutic alliance was measured. Results: The results supported the central hypothesis of the CMT that when the therapist’s interventions passed the patient’s tests, the patient showed signs of improvement. Moreover, the ability of the therapist to pass the patient’s tests correlated with the therapeutic alliance. Conclusions: The clinical implications and the limitations of these findings are discussed, together with the relevance of a good case formulation for clinicians’ optimal responsiveness.

Determinants of quality of life improvements in anxiety and depressive disorders-A longitudinal study of inpatient psychotherapy.

Quality of life (QoL) is substantially impaired in patients with anxiety disorders (AD) and depressive disorders (DD) and improvements in symptom burden after psychotherapy are not always paralleled by similar improvements in QoL. So far, little is known about treatment outcome in terms of QoL and predictors of QoL improvements following inpatient psychotherapy with a focus on cognitive behavior therapy (CBT). The current study aimed at investigating the relationship between changes in symptoms and QoL across different life domains. Additionally, predictors of a positive treatment outcome were evaluated. 122 patients with AD and/or DD undergoing an 8-weeks inpatient CBT program completed self-report measures of psychopathological symptoms and QoL at pre- and post-treatment. Mixed effects models were used to investigate changes, a confirmatory factor analysis was applied to analyze the latent factor structure of the anxiety sensitivity index and binary logistic regression analyses were performed for predictors of QoL improvements. Patients showed moderate to strong decreases in anxious and depressive symptoms and moderate to strong improvements in general QoL, particularly in the psychological and physical QoL subdomains. Changes in symptom burden correlated most strongly with psychological and physical QoL. In addition, poor QoL before treatment and low levels of specific anxiety sensitivity symptoms (items 1 and 5) significantly predicted improvement in QoL. Patients with poor QoL who are not as inhibited to openly express their anxious feelings particularly benefit from inpatient psychotherapy (individual and group) to improve their QoL. In contrast, our research suggests that patients who are too anxious to openly express their nervousness should receive additional social skills training, more focused treatment to build sufficient self-confidence to better engage in the treatment program.

The role of face masks within in-patient psychotherapy: Results of a survey among inpatients and healthcare professionals.

Face-to-face medical and psychotherapeutic treatments during the Corona pandemic often involve patients and health care providers wearing face masks. We performed a pilot survey assessing the subjective experience of wearing face masks during psychotherapy sessions regarding (i) feasibility, (ii) psychotherapeutic treatment and (iii) communication, emotion and working alliance in patients and healthcare professionals. A total of n = 62 inpatients (RR = 95.4%) and n = 33 healthcare professionals (RR = 86.8%) at an academic department of Psychosomatic Medicine and Psychotherapy participated in this survey anonymously. The items of the questionnaire were created by the interprofessional expert team and were based on existing instruments: (i) the Therapeutic Relationship Questionnaire and (ii) the German translation of Yalom's Questionnaire on Experiencing in Group Psychotherapy. The majority of patients rate their psychotherapy as highly profitable despite the mask. In individual therapy, face masks seem to have a rather low impact on subjective experience of psychotherapy and the relationship to the psychotherapist. Most patients reported using alternative facial expressions and expressions. In the interactional group therapy, masks were rather hindering. On the healthcare professional side, there were more frequent negative associations of face masks in relation to (i) experiencing connectedness with colleagues, (ii) forming relationships, and (iii) therapeutic treatment. Information should be given to patients about the possible effects of face masks on the recognition of emotions, possible misinterpretations and compensation possibilities through alternative stimuli (e.g., eye area) and they should be encouraged to ask for further information. Especially in group therapy, with patients from other cultural backgrounds and in cases of need for help (e.g., hearing impairment) or complex disorders, appropriate non-verbal gestures and body language should be used to match the intended emotional expression.

The Effectiveness of an Intensive Inpatient Psychotherapy Program for Chronic Depression: A naturalistic comparison with wait list

BackgroundPatients with chronic depression (CD) typically have an early symptom onset, more psychiatric comorbidities, more treatment attempts, and more frequent and longer inpatient hospitalizations than patients with major depressive disorders. The main purpose of this study was to investigate the effectiveness of an intensive inpatient psychotherapy program for patients with chronic depression (CD). The primary research question was whether two intensive psychodynamic inpatient treatments, affect phobia therapy (APT) and VITA, were superior to an outpatient wait list condition, receiving treatment as usual (TAU), at completion of treatment. To investigate if a potential difference between the intensive treatment and the wait list control group was dependent on a specific psychotherapeutic model, the study contrasted two therapies with similar intensity, but different theoretical rationales.MethodsTwo hundred eighty patients with CD were included in a naturalistic study. Patients were assessed at four time points; assessment, start of therapy, end of therapy and 1-year follow-up. Three comparisons were performed with patients matched across groups; Intensive inpatient treatment program (APT + VITA) vs wait list during treatment, APT vs VITA during treatment and APT vs VITA during follow-up. The outcome measure was the BDI-II.ResultsIntensive inpatient treatment program vs. wait list showed a significant difference in favor of the intensive treatment. No significant differences were found between APT and VITA during therapy or follow-up; but both groups had large effect sizes during treatment, which were maintained during follow-up.ConclusionsThe intensive inpatient psychotherapy program showed superior effect on chronic depression over an outpatient wait list condition receiving treatment as usual (TAU), but no significant differences were found between the two intensive inpatient psychodynamic treatments. The results provide support for the effectiveness of an intensive inpatient psychotherapy program in treatment of chronic and severe disorders, such as CD, which could be of benefit for policymakers and the health care sector as they are allocating recourses efficiently.Trial registrationThis study has been retrospectively registered on ClinicalTrials.gov (NCT05221567) on February 3rd, 2022.

Mitochondrial DNA as a marker for treatment-response in post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a serious mental health condition thought to be mediated by a dysregulated stress response system. Stress, especially chronic stress, affects mitochondrial activity and their efficiency in duplicating their genomes. Human cells contain numerous mitochondria that harbor multiple copies of their own genome, which consist of a mixture of wild type and variant mtDNA - a condition known as mitochondrial heteroplasmy. Number of mitochondrial genomes in a cell and the degree of heteroplasmy may serve as an indicator of mitochondrial allostatic load. Changes in mtDNA copy number and the proportion of variant mtDNA may be related to mental disorders and symptom severity, suggesting an involvement of mitochondrial dysfunction also in PTSD. Therefore, we examined number and composition of mitochondrial DNA before and after six weeks of inpatient psychotherapy treatment in a cohort of 60 female PTSD patients. We extracted DNA from isolated monocytes before and after inpatient treatment and quantified cellular mtDNA using multiplex qPCR. We hypothesized that treatment would lead to changes in cellular mtDNA levels and that change in mtDNA level would be associated with PTSD symptom severity and treatment response. It could be shown that mtDNA copy number and the ratio of variant mtDNA decreased during therapy, however, this change did not correlate with treatment response. Our results suggest that inpatient treatment can reduce signs of mitochondrial allostatic load, which could have beneficial effects on mental health. The quantification of mtDNA and the determination of cellular heteroplasmy could represent valuable biomarkers for the molecular characterization of mental disorders in the future.

Suicidal ideation and attempts in adults seeking outpatient psychodynamic psychotherapy.

Suicide is an important cause of death in patients with mental health disorders, but little is known about the occurrence of suicidal ideation and attempts in outpatient psychotherapy patients. The aim of this study was to identify the proportion of patients with and correlates of suicidal ideation and attempts in community-based psychotherapy practices. Using 983 applications for reimbursement of psychotherapy from individual patients, reports about suicidal thoughts and suicide attempts were extracted along with demographic, biographic and clinical data. Multivariate logistic regression analysis was used to identify correlates of suicidal ideation and attempts by calculating odds ratios (ORs). Among the patients, 19% presented with suicidal thoughts (11% currently and 8% in the past) and 6% with suicide attempts. Important correlates of suicidal thoughts were male gender (OR 1.7), lower education (OR 1.8), early retirement (OR 2.9), death of a parent when younger than 5 years old (OR 3.3), violence experienced from various people (OR 2.1), self-harm behaviour (OR 7.9) and alcohol misuse (OR 1.7). Suicide attempts were associated with male gender (OR 5.6), lower education (OR 4.2), violence experienced from partner (OR 2.5) or from various people (OR 9.5) and self-harm behaviour (OR 15.0). These results show that the proportion of suicidal patients seeking outpatient psychotherapy is high. It should therefore be a central topic in clinical training. Biographic data such as the loss of a parent at an early age or experiencing violence are associated with who is at increased risk and should be explored in detail.

Like a rolling stone: Psychotherapy without (episodic) memory.

People with profound amnesia still retain the capacity to learn about the emotional value of experiences, which is crucial in developing and sustaining interpersonal relationships. In a 2017 paper, we demonstrated for the first time (with patient JL) that transferential feelings develop across the therapeutic process, despite profound episodic memory impairment after medial temporal lesions. This paper reports a second case (GA) of a profoundly amnesic patient in psychotherapy, this time after lesions to the anterior fornix. The work with GA opens issues such as the differences and similarities to the previous case, counter-transference phenomena, and the effects of hyperphagia. The findings make it clear that many phenomena are common to both GA and JL, such as forgetfulness, various types of repetition, the importance of the therapeutic alliance, and the ability to make therapeutic gain. However, there were differences between the cases, for example as regards confabulation, which may relate to either pre-morbid personality or lesion site. The paper also discusses the way in which patients of this type bear the very status of psychotherapeutic work with profoundly amnesic patients. Where others have seen barriers and in principle problems in working with such patients, we see many opportunities.

Passing patients' tests-But how? An analysis of therapists' helping skills in response to patient testing.

According to control mastery theory, patients in psychotherapy try to master their problems by disconfirming their pathogenic beliefs. This can be done by testing the therapist. So far, there is hardly any evidence on what concrete interventions or statements of therapists are specifically helpful in passing those tests. In our study, we analyzed the verbal utterances of therapists in test situations to determine whether there is a difference in statements used for passing or failing tests. A total of 168 session transcripts of 21 patients were selected from a total of six therapists, two each in psychoanalytic therapy, psychodynamic therapy, and cognitive behavioral therapy. Test situations were identified, and therapist responses were coded using the helping skills system. There were significant differences in the therapists' reactions to test situations. In particular, closed questions, approval, interpretation, and reflection of the patients' feelings by therapists were associated with a high probability of passing tests. These findings can especially support therapists-in-training to obtain an orientation on how to deal with their patients' test situations that may be perceived as challenging and are important for therapy success while respecting the individuality of their patients. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Personality functioning and physical health

Objectives: Considering direct and indirect evidence of associations between deficits in personality functioning and high somatic morbidity, our exploratory study determined whether and, if so, which physical illnesses may be associated with impairments in personality functioning. Method: A large sample of diagnostically heterogeneous psychotherapy inpatients (N = 5401) was assessed with the short version of the Structural Questionnaire of the Operationalized Psychodynamic Diagnosis (OPD-SQS) and the Work Ability Index (WAI). In addition, discharge diagnoses were recorded. For a subsample (N = 2582), levels of personality functioning were assessed by their therapists according to the OPD system. Results: While consistent associations were found between personality functioning and neurological, urogenital, dermatological, and musculoskeletal disorders, findings on possible associations with other disorders revealed inconsistencies. The number of diseases as surrogate marker for disease burden was significantly associated with several indicators of personality functioning. Conclusions: Our results suggest associations between impairments in personality functioning and poor physical health. We discuss potential mechanisms as well as clinical implications.

The in-session discourse of unresolved/disorganized psychotherapy patients: An exploratory study of an attachment classification.

The Unresolved/disorganized (U/d) attachment classification has generated considerable interest among clinicians. This is in part based on its empirical associations with adult mental health, parenting practices, and treatment outcomes. Despite decades of theorizing, however, we have little empirical information regarding how patients with a U/d classification assigned by accredited coders actually behave or speak in psychotherapy sessions. Here, we take a step towards bridging this gap by reporting our observations of the psychotherapy session transcripts of 40 outpatients who were independently classified as U/d on the Adult Attachment Interview (AAI), the gold standard measure of adult attachment research. These patients were extracted from a larger sample of 181 and compared to others without a U/d classification. In this paper, we discuss two different discourse styles associated with a U/d classification. Some U/d patients did not seem to sufficiently elicit the therapist’s endorsement of what they said. For example, they did not justify their claims with examples or explanations, or did not consider others’ intentions or experiences. Other U/d patients were credible, but left the listener uncertain as to the underlying point of their discourse, for example, by glaringly omitting the consequences of their experiences, or interrupting their narratives mid-way. In the discussion, we place these observations in the context of recent thinking on attachment and epistemic trust, and discuss how this study may form the basis for future quantitative studies of psychotherapy.

Auditing Practices of the Medical Service Regarding Hospitalizations of Patients With a Secondary Diagnosis of Obesity.

It has been observed that the Medical Service (Medizinischer Dienst, an auditing body of the German statutory health insurance system) is more likely to audit the bill for a hospitalization in a psychosomatic clinic if the patient carries a secondary diagnosis of obesity. In an exploratory study, we retrospectively analyzed 771 datasets collected in 2019 as part of the standard documentation of acute psychosomatic hospitalizations. In 2019, the Medical Service audited bills for psychosomatic hospital - izations much more often in obese than in non-obese patients (odds ratio [OR] 2.499; 95% confidence interval [1.69; 3.69]). This was accounted for by a very high audit rate for patients with a secondary diagnosis of grade 3 obesity (OR = 3.972 [2.30; 6.86]). The audit categories "quality of coding" and "possible incorrect admission" were examined. Treatments of markedly obese inpatients that incurred greater expenses presumably led to a higher hospitalization audit rate as an automatic consequence of the auditing algorithms used. An unintentional statistical discrimination arose from the unjustified linkage of the audit category "quality of coding" of the secondary diagnosis (obesity) with the audit category "possible incorrect admission" with regard to the main diagnosis. Similar effects may be occurring with economically relevant secondary diagnoses in other areas of medicine as well.

Toward a More Comprehensive Understanding of Pathogenic Beliefs: Theory and Clinical Implications

According to Control-Mastery Theory, an integrative cognitive-dynamic theory of mental functioning, psychopathology, and psychotherapy process, functional psychopathology derives from pathogenic beliefs. Pathogenic beliefs associates a healthy and adaptive goal to a danger, are generally developed during the developmental period to adapt to traumas and are unconsciously tested by patients in psychotherapy to be disproved. We propose the existence of pathogenic beliefs that are mainly encoded as bodily tensions, sensations, emotions, intensions, mental images and expectations, and only secondarily or not at all as words. These non-verbal pathogenic beliefs painfully affect patients’ bodily states, emotions and behaviours without the patients being able to understand the reasons of their own sensations, reactions and actions. In order to disprove these non-verbal pathogenic beliefs in therapy, it is not enough that clinician help their patients make them explicit; clinicians have also to adapt their overall attitude, non-verbal and paraverbal communications, and to adjust the setting, the nuances and the “atmosphere” of the therapeutic relationship according to the specific developmental traumas that gave rise to these beliefs, the goals thwarted by them and to how the patient test them. The disconfirmation of pre-verbal pathogenic beliefs may also be facilitated by psychotherapy techniques that address the problems of patients on a bodily level. In order to disprove preverbal pathogenic beliefs, an embodied corrective emotional experience is needed.

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.