In this study, a purposive sample of nine inpatients was selected from Wuhan Mental Health Center, the largest psychiatric hospital in south-central China, between June to December 2019. The inclusion criteria were adult inpatients who had been diagnosed with both the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mood/anxiety disorders and personality disorders and were willing to participate in this study. In addition to traditional psychopharmacological treatments, these patients received individual psychotherapy twice a week and group psychotherapy once a day, with typical hospitalizations lasting around 3 months due to the complexity of their conditions. The exclusion criteria were patients in the acute phase of mood disorders and those with comorbid thought disorders. Of the nine patients, six were male and three were female, with an average age of 36 years (range: 24 to 58 years). The most common Axis I diagnosis was major depression (n = 5). The subtypes of personality disorders that the nine patients suffered from were borderline personality disorder (n = 3), paranoid personality disorder (n = 2), narcissistic personality disorder (n = 2), and avoidant personality disorder (n = 2). The relevant information is shown in Table 1.

The interview outline for this study is shown in Table 2. This outline was developed according to Greenberg’s theory of three dimensions of significant events, which was further informed by the Helpful Aspects of Therapy (HAT) scale [26] and the empirical taxonomy of helpful and nonhelpful events in brief counseling interviews [27]. In-depth, semi-structured interviews with patients were conducted in a one-on-one and face-to-face manner, with talk time ranging from 30 minutes to 60 minutes.

Table 2. Interview outline.

1. In your opinion, what is a significant event? (Connotation, extension)

2. During your hospitalization, what events were most significant to you personally? (The events can be positive or negative, and it can happen to different people such as therapists, nurses, psychiatrists, fellow patients, etc.)

3. Please carefully recall the situation at that time, how did the event happen? Who said or did what? How did each person respond to the other? How did the event end? Evaluate the extent to which the actions/responses of these people had an impact on you.

How much did this event help or hinder you? Please follow the scale below to assess this:

4. Describe your experience during the event:

A. How do you feel?

B. What were you thinking at the time?

C. What were you doing or trying to do?

5. Describe why this event was significant? What did you gain from it?

6. From now on, what are the strongest thoughts and feelings that this event has brought to your mind?

7. Describe what kind of changes and impacts may be brought to you in the future as a result of this event? Include both immediate impact (within 1 month) and subsequent impact (1 month later).

8. Apart from the above, is there anything else you would like to add?

Before the formal study, the ethics committee of Wuhan Mental Health Center approved the research proposal. The researcher and the participant engaged in a thorough informed consent discussion. Every step was executed following the patient’s consent and the signing of a written informed consent form. This included the interview process, audio recording of the interview, and the notation of key information including the patient’s non-verbal behaviors, insights derived, and associations made during the interview. It was mandatory that participants comprehended the purpose of the research and potential risks. Feedback to research subjects was also provided once the results were obtained, with consideration of the subjects’ perspectives and evaluations of the research findings. Furthermore, all individuals involved in the execution of this study consistently adhered to the ethical standards pertinent to the research.

After collecting the audio recordings, they were transcribed into verbatim scripts and coded by both researchers. Grounded Theory was used to code and analyze the information obtained by rooting in the data and working from the bottom up, and a log of coding and analysis was kept.

For data analysis, verbatim transcripts and memos were imported into Nvivo 11.0 (version 11.0, QSR International Pty Ltd, Melbourne, Victoria, Australia) for systematic coding using a three-stage Grounded Theory approach: Open Coding, Axial Coding, and Selective Coding [28]. The two coders, both experienced psychotherapists, first re-familiarized themselves with the interview context by reviewing the transcripts and audio recordings. Discrepancies in coding were resolved through discussion or, if unresolved, a third coder was consulted.

The therapist-patient interaction in individual psychotherapy for patients with personality disorders is a central component in the hospitalization process, where the patient’s projections, conflicts, and relational dynamics manifest. This interaction creates a controlled environment, allowing patients to express, manage, and reflect on emotions and behaviors, fostering self-awareness. The therapeutic process can be divided into three main phases: the therapist’s ‘giving’, the interaction itself, and the patient’s response. The patient-therapist interaction presents the basic unitary process, as shown in Fig. 1.

Fig. 1.

Basic unit of therapist-patient interaction.

The therapist’s ‘giving’ includes both ‘explicit’ and ‘implicit’ forms. Explicit giving involves direct verbal communication, such as explanations and guidance, helping patients to understand their symptoms and recognize underlying psychological issues. Implicit giving uses indirect methods, such as metaphors or non-verbal cues, to support self-awareness and provide empathic understanding. P1 mentioned that the therapist made ‘a very rich body movement, just a gesture like this (making a gesture with both hands: placing both hands palm up in front of his abdomen and raising his hands upwards). It’s giving me a cue. This is important to me!’ Patients often perceive implicit giving as more impactful, feeling acknowledged and supported in ways they may not have experienced in their daily lives. This creates a foundational support system, with the therapist sometimes becoming a significant figure in the patient’s life.

Patient responses to the therapist’s input can be active or passive. Active acceptance reflects a willingness to internalize insights and make changes, while passive acceptance may occur when patients comply due to the therapist’s authority, despite reservations. The interaction process itself may be harmonious or conflictual. Harmonious interactions occur when therapist and patient roles are naturally complementary, fostering trust and receptivity. Conflictual interactions arise from differing perspectives or unresolved transference, where unexpressed emotions are projected onto the therapist. These dynamic interactions reveal the complex layers of therapist-patient relationships, highlighting the critical role of relational attunement and patient receptivity in therapeutic effectiveness.

In the hospital environment, close daily interactions among patients serve as a primary form of interpersonal activity, both during and outside of treatment. Through shared activities—such as chatting, playing cards, singing, and participating in group therapy—patients not only fulfill their social needs but also learn to navigate interpersonal relationships, fostering personal growth. These interactions span cognitive, emotional, and behavioral dimensions, supporting patients’ psychological development within a structured community.

This peer interaction establishes a mutual support system where patients empathize and understand each other more readily, as noted by P2: ‘In the hospital, you may have a similar situation with some of the same patients, and you will understand each other a little’. Emotional contagion is also evident, where patients’ emotions impact each other within and beyond therapy sessions. P4 described how other patients’ experiences, such as personal or family issues, easily trigger their own emotional responses, reflecting a shared emotional vulnerability and reciprocal influence that enhances connection and empathy.

This dynamic of shared understanding, emotional resonance, and mutual support within patient interactions highlights the therapeutic value of peer relationships in a hospital setting, creating an environment conducive to emotional validation and psychological resilience.

The hospital environment serves as a structured, stable container that supports patients with a safe space for exploration, self-reflection, and socialization. It offers a unique interpersonal context where patients can observe and compare themselves with others who share similar struggles, fostering mutual support and empathy. This environment allows patients to feel less isolated, as expressed by P8, who noted that seeing others with similar challenges provided a sense of connection. Likewise, P2 highlighted the opportunity to engage with diverse perspectives, fostering a sense of belonging and facilitating self-awareness through relational dynamics and comparisons with peers. P2 also said ‘I think I’ll get to know what a lot of people think. There could be opportunities to find out! … Everyone has their own unique way of getting along’.

The structured nature of the hospital environment promotes exposure and reflection on personal issues, which can lead to insights and growth. For instance, patients experience a supportive yet controlled environment that contrasts with the outside world, bringing a sense of protection, belonging, and control. However, this contained setting also brings challenges, such as the temporary isolation from the external environment, which can be both relieving and restrictive. Long-term hospitalization may induce social detachment, as patients become increasingly aware of their ‘maladjustment’ when removed from everyday social contexts.

Finally, the hospital environment is marked by both stability and change, as patients navigate the departure of old friends and the arrival of new ones, which can disrupt the social dynamics they rely on. The regulated, sometimes coercive nature of hospital routines, such as assigned therapists and room arrangements, reinforces adaptation to structure and authority. As P3 and P1 described, they learned to adjust to aspects of the environment that were initially uncomfortable. Ultimately, the hospital becomes a ‘corrective environmental experience’, providing a balanced environment for restructuring psychological and relational patterns within a protective, transitional space between family and society.

The interaction between patients and medication encompasses both biochemical and psychological dimensions. Medication provides direct symptomatic relief, notably improving sleep quality, emotional state, and reducing mental stress, as noted by P8, who described feeling like a ‘new person’ after receiving specific injections. While relief from somatic symptoms, especially improved sleep, is prominent, the psychological impact of medication evolves as patients’ perceptions of it shift alongside their engagement with psychotherapy.

Patients’ views on medication and psychotherapy often move from initial differentiation to eventual integration. Initially, patients may prioritize medication over psychotherapy, viewing them as separate treatments. For instance, P1 described initially focusing on medication’s calming effects without engaging deeply with psychotherapy. Over time, patients begin to see medication as foundational, supporting psychotherapy’s effectiveness. P3, for example, stated ‘I feel that medication helps me to reach a certain state, and then the psychotherapy helps me to reach a better state. But without medicine as that foundation, psychotherapy could be in vain’. He recognized that medication creates a baseline for mental stability, enabling deeper therapeutic work. This shift often involves a process where initial idealization of medication wanes as patients recognize its limitations, leading them to appreciate the combined role of both treatment modalities.

The psychological meaning of medication also relates closely to the therapeutic relationship, where attention and trust play key roles. Patients may express dissatisfaction or frustration if they feel that their medication needs and somatic discomforts are inadequately addressed by their therapists. As P1 described, unmet expectations regarding medication management led to feelings of mistrust, reflecting how the medication experience is intertwined with the patient’s perception of care and attunement within the therapeutic relationship. This complex interplay highlights how medication, beyond symptom relief, influences patient trust and engagement in therapy, shaping the broader therapeutic experience.

In individual therapy, the therapist serves as a ‘container’, holding the fragmented and confusing aspects of the patient’s experience and facilitating their clarification and re-identification. Within the context of hospitalization, however, the entire environment functions as a larger container, wherein the patient projects and navigates identifications with the various elements of this broader system. To support this process, it is essential to establish boundaries through rules, therapeutic contracts, and other structured settings, enabling the patient to gradually comprehend, adjust to, and derive a sense of security and authenticity from these parameters. More critically, the hospital environment—acting as a holding space—provides patients with a unique opportunity to confront and work through their symptoms, ultimately fostering the rediscovery of their true selves.

Fagin believes the inpatient ward represents the only constancy, a safe place able to contain and hold [33]. Gabay and Ben-Asher [34] further suggest that ‘in the context of hospitalization, patients anticipate that healthcare providers will hold and manage their pain, grasp its significance, and recognize the urgency of their crisis’. They emphasize that ‘providers who contain the emotional and cognitive experiences of patients contribute significantly to an enriched understanding of patients’ internal processes, emotions, and thought patterns [34]’. This act of containment fosters a therapeutic setting in which patients feel validated and supported, facilitating emotional recovery and self-awareness.

Jiang and Tong [35] propose that patients reconstruct their internal object relations during hospitalization, and that the conflicts that occurred in their family life are reenacted in their relationships with health care workers and fellow patients. The inpatient setting, however, offers a constructive context for these compulsive repetitions to be fully identified and explored therapeutically, providing patients with opportunities to address their conflicts. This therapeutic environment encourages patients to learn both to love and to accept love, fostering new or reconstructed means of finding contentment in their lives [35]. According to Tong [36], the therapeutic environment within hospital is structured to address patient needs through containing, structuring, involvement, support, and affirmation.

As patients 2 and 4 said, ‘the interpersonal relationship among fellow patients is the main interpersonal relationship during the hospitalization process’. Xu et al. [37] referred to this interaction between patients as the ‘inter-patient relationship’ and stated that this inter-patient relationship has an impact on the mental state of patients in hospital through direct communication of different depths and indirect comparison and judgment (with patients).

Turner et al. [38] identified peer support as a powerful tool for empowerment, fostering a sense of hope, connection, and engagement. Their findings highlight how peer support contributes to increased self-acceptance, meaningful social roles and relationships, and strengthened self-determination. Additionally, self-awareness is often facilitated through both direct comparison and alternative learning with fellow patients. In a related study, Bloch et al. [39] examined therapeutic factors in group therapy, identifying key elements such as self-disclosure, interaction, acceptance (or group cohesiveness), insight, alternative learning, and altruistic behaviors as primary contributors to patient healing. These factors emerge naturally in the interactions among group members, illustrating the therapeutic potential embedded within a supportive group dynamic. During hospitalization, patients engage in various interactions within a relatively safe and therapeutic environment, where they are encouraged to communicate and share genuine experiences. This environment fosters mutual understanding, support, and acceptance among patients, which contributes to a cohesive, warm, and supportive atmosphere. Moreover, when the patient’s conflict or maladaptive patterns enact in the interaction of the patients’ peers, group therapy provides an opportunity for meaningful expression, where therapeutic intervention and interpretation can facilitate personal growth and behavioral change.

Pharmacotherapy and psychotherapy engage with patients on distinct yet intersecting levels. Biochemically, medication directly interacts with the patient’s body, but also carries psychological meanings and effects, such as the placebo effect, and the expression of transference and counter-transference, often conveyed through the therapeutic use of drugs. Konstantinidou and Evans [40] found that in different therapeutic contexts, pharmacological and psychotherapeutic treatments for patients with personality disorders are frequently compartmentalized, with pharmacological and psychotherapeutic approaches standing in contrast to one another. This compartmentalization often creates a confrontation between the practical and psychological dimensions of treatment: which treatment is more effective? This situation can also potentially lead to patient splitting and enactment [40]. Norcross and Goldfried [41] argue that the effectiveness of medication often needs to be discussed in psychotherapy as well, and that the side effects of medication may become a focal point for fluctuations in the patient’s symptoms, which has an impact on the progress of psychotherapy. However, medication and psychotherapy may interact in surprising ways to bring about change. For example, medication may make patients more sensitive to psychotherapy, but may also contribute to the initiation and maintenance of new behaviors [41]. Beitman et al. [42] examined the perspectives of pharmacists, non-medical psychotherapists, and patients, analyzing this ‘triangle’ of pharmacotherapy and psychotherapy. They found that collaborative arrangements between psychotherapists and pharmacotherapists significantly contribute to the effective alleviation of patients’ symptoms. They propose that the basic principle in establishing this triangle is for each therapist to refrain from commenting on the other’s treatment approach. Ideally, the patient, along with both therapists, should meet to clarify the treatment plan collectively. Each therapist must initially explain their distinct role to minimize patient confusion and foster a strong therapeutic alliance. At the beginning of treatment, therapists should also articulate how psychotherapy and pharmacotherapy integrate to benefit the patient. Therefore, in-depth exploration of the combined effects of pharmacotherapy and psychotherapy from an integrative perspective is essential. Such an exploration would not only help to reveal how the two treatments complement each other at different levels, but also provide an important basis for developing more individualized and effective treatment plans.