3.2.6. Psychotherapeutic Relationship

A major category mentioned by *n* = 159 (73.3%) respondents is the "psychotherapeutic relationship". It includes as subcategories various aspects related to the quality and intensity of the therapeutic relationship. The four subcategories are illustrated in Figure 7.

*N* = 98 (45.2%) respondents described that the therapeutic relationship was strengthened or even intensified by the fact that patients experienced that their therapists were there for them even in the crisis and that psychotherapies were continued in the remote setting. Respondents stated that patients were very "*grateful*", "*happy*", "*relieved*", "*unburdened*" or reacted "*positively*". For example, respondent 28 voiced:

*"I offered all my clients to use the new forms immediately after the announcement of the ÖBVP (the Austrian Federal Association for Psychotherapy, which informed psychotherapists that sessions were to be held remotely if possible), and this was received with "gratitude" or "relief ". Some were afraid/worried about having to "go through the crisis alone". The quick provision of alternatives certainly had a positive influence on the relationship ("She doesn't leave me alone", "She is also there for me in the general crisis")"*

Repeatedly, the shared experience of the crisis was considered as uniting, as was the fact that patients, as well as therapists, were in lockdown, attended the sessions from home and sometimes both were navigating (technical) "uncharted territory". For example, respondent 42 described:

*"Conversations were more personal because of Corona—in the sense that you share the lockdown situation. We are more or less in the same boat, and have similar difficulties (small apartments, bad WiFi, no childcare—so children who "barge in", etc.)—these are things you simply catch through Corona, because especially in the beginning everything was new, untested, spontaneous, complicated by external circumstances. (* ... *) It was also more personal because of the way of communication: the patient is sitting comfortably at home, with a cup of coffee or tea, in familiar surroundings, without makeup and in her sweatpants, and she is just happy to be able to have contact with someone, due to Corona. This changes the nature of the conversation. I, as a therapist, of course tried to have a professional ambiance, yet I was also at home and in a similar situation"*

In addition, many respondents described how relational closeness and intimacy were generated in remote contact. They used adjectives such as "*open*", "*confidential*", "*personal*", "*holding*", "*trusting*", "*strengthening*", "*reliable*", "*intense*", "*consolidated*", "*stable*", "*cooperative*", "*deepened*", "*connected*", "*secure*" and "*intimate*" to describe their and their patient's relational experience. Sometimes the closeness in remote contact was described as a "special" or "different" kind of closeness than that in face-to-face contact.

In this context, *n* = 23 (10.6%) respondents observed that in the remote setting, the atmosphere was more relaxed, and there was less negative transference in the therapeutic relationship. They attributed this to the spatial separation and to the fact that patients were at home in their safe environment.

In contrast, *n* = 86 (39.6%) respondents mentioned that they experienced less closeness in the psychotherapeutic relationship during remote sessions. "*Superficial*", "*difficult*", "*distant*", "*impersonal*", "*noncommittal*", "*flattened*", "*fragile*", "*lonely*", "*alienated*", "*cold*", "*businesslike*", "*less palpable*", "*less immediate*", "*foreign*", "*uncertain*" and "*reserved*" were adjectives used to describe relational experiences in remote sessions. In many cases, this was attributed to the fact that the other person is more difficult to "grasp" emotionally in remote contact and that atmospheric information is lost. Respondent 11 described this as a "*lack of relational immediacy*", and respondent 30 stated, "*I felt like I couldn't grasp the patient as well. It was more difficult to assess the client's emotional situation to the same extent as in a face-to-face conversation".* Respondent 138, in turn, commented "*on the relationship level, it was no longer possible to "tune in" as usual*", and respondent 154 elaborated by stating, "*establishing a presence in the relationship, being empathically accurate and empathizing at the moment and being congruent/immediately involved is more difficult, as a result of which the flow of the relationship often falters".*

In this context, *n* = 33 (15.2%) respondents observed that the holding function is impaired in the remote setting, i.e., respondents see their ability to emotionally support patients in crises, to provide support in difficult situations or to work through difficult issues therapeutically as limited.

Female psychotherapists expressed strengthening of the relationship more frequently than their male colleagues (49% vs. 32%; χ<sup>2</sup> (1) = 4.544; *p* = 0.033). For the other three subcategories, no differences were observed between male and female therapists (*p* ≥ 0.112).
