Between Presence and Distance: Patients’ Experiences of Therapist Connection in Internet Administrated Psychodynamic Therapy for Somatic Symptom Disorder

Abstract

Psychodynamic therapies emphasize the healing potential of emotional awareness and relational presence. In online therapy, the therapist’s presence becomes transformed - mediated by written words and digital distance. This exploratory qualitative study examined how participants with Somatic Symptom Disorder (SSD) experienced therapist presence versus absence in Internet-based Emotional Awareness and Expression Therapy (I-EAET), an online psychodynamic treatment designed to help patients engage with avoided emotions linked to physical symptoms. Semi-structured interviews were conducted with ten participants who had completed either a guided or unguided version of I-EAET as part of a randomized controlled trial. Data were analysed using reflexive thematic analysis. The participants described that therapist contact was experienced as both supportive and limited: written guidance provided containment, motivation, and validation, but there was an absence of immediacy and emotional resonance. Working without a therapist was described as fostering autonomy and self-reflection, yet often evoked feelings of isolation. Across conditions, participants described a movement between dependence and independence, containment and solitude. Clinical implications include tailoring the level of therapist involvement to patients’ relational needs and emotion-regulation capacities.