Many studies are now turning to qualitative methods to provide unique insights into the factors that can lead to better treatment experiences for patients. A greater focus on patient-identified challenges and barriers may inform efforts to improve accessibility, engagement, and outcomes, and to reduce harm. In this systematic review of 10 qualitative studies, Barrett and colleagues integrated qualitative research on adults’ experiences of long-term psychodynamic psychotherapy. Sixty-four findings were organized into five major themes. The first theme was: starting is difficult but eased by acceptance and trust. Patients described various difficulties at the beginning of therapy, driven by a power imbalance and patients feeling diminished by interpretations. However, trust-building emerged as a mechanism of easing these initial uncertainties. Patients valued therapists who demonstrated care and fostered a sense of safety. The second theme was that the process of change can be a bumpy road. Patients reported that making sense of their past facilitated re-evaluation of past events and themselves. They also indicated that the process of change through enhanced mentalizing (understanding themselves and others in terms of mental states such as feelings, desires, and intentions) was key. Adopting new adaptive coping mechanisms was also a significant but challenging aspect of therapy. However, patients indicated that the therapeutic process was frequently emotionally challenging, with progress interspersed with setbacks. The third theme was that group therapy is challenging but an important transition to “real life” practice. Patients reported discomfort with the prospect of group therapy, but they also found it to be an important opportunity to practice new ways of being in a safe context. The fourth theme was: gaining new perspectives as a key outcome. This primarily involved challenging one’s own assumptions and recognizing emotional and cognitive patterns. This theme also included enhancing communication and greater acceptance of others’ perspectives by fostering openness about feelings and intentions, unencumbered by strong emotions. The fifth theme was that ending therapy can be difficult and brings a mix of emotions. Patients reported sadness and ambivalence about ending therapy. And they highlighted the importance of integrating new perspectives gained in therapy into life after treatment. Patients drew on therapy experiences and internalized representations of their therapists (“what would my therapist say about this situation?”) as a source of guidance.
Practice Implications
Patients’ experiences can guide how we start, proceed with, and end therapy. Initial difficulties patients have in therapy can be addressed by providing education on how therapy works and what to expect. Developing a therapeutic alliance (agreeing on goals and process of therapy), combined with a trustworthy, empathetic therapist can also go a long way toward easing patients’ initial concerns about therapy. A good alliance will also provide a buffer to the more challenging aspects of therapy, such as replacing maladaptive coping strategies, altering rigid assumptions, and cultivating self-compassion. Ideally, therapists and patients work toward a positive ending that will allow patients to evoke representations of their therapist during tough times post-treatment.
Malka, M., Sayda, D., Ben-David Sela, T., Moggia, D., Altmann, U., & Zilcha-Mano, S. (2026): It takes two to heal: Trait-like and state-like contributions to the therapeutic bond and their association with therapeutic change, Psychotherapy Research, https://doi.org/10.1080/10503307.2026.2619106.
The director of the Psychotherapy Practice Research Network (PPRNet) is Dr. Giorgio Tasca. Dr. Tasca is an Associate Professor with the School of Psychology, in the Faculty of Social Sciences at the University of Ottawa. His research is centered around psychotherapy process, mechanisms of change, and outcomes, as well as eating disorders.
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PPRNet Clinical summary: Patient Experiences of Long-Term Psychodynamic Therapy
Many studies are now turning to qualitative methods to provide unique insights into the factors that can lead to better treatment experiences for patients. A greater focus on patient-identified challenges and barriers may inform efforts to improve accessibility, engagement, and outcomes, and to reduce harm. In this systematic review of 10 qualitative studies, Barrett and colleagues integrated qualitative research on adults’ experiences of long-term psychodynamic psychotherapy. Sixty-four findings were organized into five major themes. The first theme was: starting is difficult but eased by acceptance and trust. Patients described various difficulties at the beginning of therapy, driven by a power imbalance and patients feeling diminished by interpretations. However, trust-building emerged as a mechanism of easing these initial uncertainties. Patients valued therapists who demonstrated care and fostered a sense of safety. The second theme was that the process of change can be a bumpy road. Patients reported that making sense of their past facilitated re-evaluation of past events and themselves. They also indicated that the process of change through enhanced mentalizing (understanding themselves and others in terms of mental states such as feelings, desires, and intentions) was key. Adopting new adaptive coping mechanisms was also a significant but challenging aspect of therapy. However, patients indicated that the therapeutic process was frequently emotionally challenging, with progress interspersed with setbacks. The third theme was that group therapy is challenging but an important transition to “real life” practice. Patients reported discomfort with the prospect of group therapy, but they also found it to be an important opportunity to practice new ways of being in a safe context. The fourth theme was: gaining new perspectives as a key outcome. This primarily involved challenging one’s own assumptions and recognizing emotional and cognitive patterns. This theme also included enhancing communication and greater acceptance of others’ perspectives by fostering openness about feelings and intentions, unencumbered by strong emotions. The fifth theme was that ending therapy can be difficult and brings a mix of emotions. Patients reported sadness and ambivalence about ending therapy. And they highlighted the importance of integrating new perspectives gained in therapy into life after treatment. Patients drew on therapy experiences and internalized representations of their therapists (“what would my therapist say about this situation?”) as a source of guidance.
Practice ImplicationsPatients’ experiences can guide how we start, proceed with, and end therapy. Initial difficulties patients have in therapy can be addressed by providing education on how therapy works and what to expect. Developing a therapeutic alliance (agreeing on goals and process of therapy), combined with a trustworthy, empathetic therapist can also go a long way toward easing patients’ initial concerns about therapy. A good alliance will also provide a buffer to the more challenging aspects of therapy, such as replacing maladaptive coping strategies, altering rigid assumptions, and cultivating self-compassion. Ideally, therapists and patients work toward a positive ending that will allow patients to evoke representations of their therapist during tough times post-treatment.
By Dr. Giorgio Tasca
The director of the Psychotherapy Practice Research Network (PPRNet) is Dr. Giorgio Tasca. Dr. Tasca is an Associate Professor with the School of Psychology, in the Faculty of Social Sciences at the University of Ottawa. His research is centered around psychotherapy process, mechanisms of change, and outcomes, as well as eating disorders.Also Read