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Table 2 Qualitative analysis of patient statements: citations related to categories 1 to 4

From: Day clinic and inpatient psychotherapy of depression (DIP-D): qualitative results from a randomized controlled study

1. Therapeutic aspects (266)
D.1.1. Start of therapy (29)
 “At first it was quite difficult. The first two weeks… yes, the whole “arrival-thing,” I just did not know what to do with myself and I wasn’t confident enough yet to approach people .” (1.2)
 “At first I was very insecure… just the insecurity of being in a group , especially in the mornings and evenings during these mood scale exercises, which totally confused me at first.” (1.18)
 “Let’s put it this way: I’m not a group person . So the individual therapy sessions were really important and meaningful for me. In the group session, I just had the problem that my fellow patients didn’t know why I’m here. Accordingly, I couldn’t open up in the way I might have needed to. “ (1.13)
I.1.1. Start of therapy (20)
 “Actually, you spend most of the time in therapy with them and so it’s always a bit easier to open up to them, because of that. I found that in general, in any case… so for some day-patients, I often thought that they should be inpatients really… I’ve definitely noticed that the people who were inpatients got along far better among themselves compared to the day patients. You really noticed this. You are much more open with each other and you can talk about some things more easily.” (2.2)
 “During the therapy, it was very strange to start with. In the beginning, you had a week of time to yourself . The intention was, probably, that you get to know the other patients, especially fellow patients, and to have time to yourself. It was very depressing . Because I was in a strange environment, had nothing to do and was supposed to just potter around with myself . That was very weird because usually, in everyday life, I’m always here and there and I was always on the move together with someone else. And here: this calmness.” (2.9)
 “So for the first few weeks it was hard for me to become part of the group .” (2.17)
D.1.2. Experience of therapy (61)
“I found it incredibly helpful to talk about it and it was a relief, when I realized, it all become a little clearer. I was able to explain things to myself or I could change things.” (1.8)
 “Yes, I had a very close relationship to one of my therapists. I felt very well understood and well taken care of there.” (1.1)
 “Already after the first week, I noticed that I felt comfortable and that it was a place, somehow, where I could feel safe .” (1.18)
“The routine was good for me and the task of working on myself . At the time, I already noticed that it helps me.” (1.8)
 “Really, everything was exhausting, I think. This was the first time that I ever had to really talk, because, usually, I never talk about problems . And there, you just had to talk, you had to join in, you had to accept this and that. I found that all just very tiring,” (1.17)
I.1.2. Experience of therapy (98)
 “…We’re all going through the same stuff, really. Everyone has their own problems, that’s for sure, but you can simply learn a lot from the others, also from the older ones. And many opened my eyes . So, I guess, the other patients were the best therapy! Definitely.” (2.9)
 “It was all these conversations. Although they upset me, but afterwards it always felt better . I had a much clearer view of things.” (2.16)
 “… I was glad that I was an inpatient. I wouldn’t have been able to guarantee that I would’ve come every day. And so I just knew that breakfast was at seven-thirty. It put a little pressure on me . This was beneficial for me.” (2.5)
 “So I thought it was really hard work. After some therapies, I felt really knackered.” (2.12)
D.1.3. Involvement of current conflicts at home in therapy (21)
 “… and if I had difficulties or problems or other things, that I was able to work with them and discuss them right on the very next day. That was very helpful, really very helpful.” (1.6)
 “And it is this being able to use things, that you could use things, you’d learned right away . And not learn stuff for eight weeks and then blast people around you with change.” (1.7)
 “It was also important to see for myself: “Look, you can really do this . I am able to go to work or therapy in the morning and evening and come home again.” (1.5)
I.1.3. The clinic -a safe haven (37)
 “I was also glad that I was away from home. That I was simply out of the whole surroundings and was in a protected environment, where it really was about me for once . Because I have not taken care of myself for 40 years. But now I had eight weeks of time to realize that I also exist. And I’m not under this pressure to come back home in the evening to feed my family, to do the ironing and washing etc. And especially with my boys at home, it was also important that they used the time to learn to be more independent.” (2.15)
 “I found being inpatient was actually much better than being the other, because you are completely away from home . That is, you are actually worry - free . You have nothing to worry about. Your head is free to focus on yourself . That was something that really helped me an awful lot.” (2.7)
 “And that is, what I think is valuable in inpatient treatment. That you are able to get that necessary distance from home .” (2.6)
 “So, I just think that the reference to normal, everyday life was a bit too small .” (2.4)
2. Experience of the patient group (322)
D.2.1. Learning through interactions (19)
 “And then I simply noticed that here you can really say what you think. That you won’t be judged or demonized for it. I had the feeling of being accepted just as I am . With all the “ifs and buts” and that simply felt incredibly good.” (1.18)
 “It was positive feedback , and that of course brought about a sense of self - worth again … For example, that people said that it was pleasant talking to me. I guess, I just have, for example, a rather bizarre sense of humor and made people laugh from time to time. They simply thought that was great. My self - esteem has gone up .” (1.14)
 “I came in here, and I just started trying everything out with my fears that I otherwise wouldn’t have dared to do. I felt very comfortable and held by my group.” (1.7)
I.2.1. Learning through interaction (19)
 “I then realized that everybody didn’t want to harm me all the time and I started regaining confidence . It definitely helped that you had to deal with the other patients.” (2.2)
“The feedback that I received. How I come across to people . Because it was always so horrible for me feeling rejected so often.” (2.7)
 “Before therapy, I often felt out of place. I couldn’t carry a conversation anymore and was already thinking, “Oh God, I’m a hermit. I can’t even talk to people anymore.” That made me socially retreat more and more. And here I realized: People like being with you! They like having a chat with you; they are interested in what you have to say. That was a really nice feeling. Because I always thought no one likes hanging out with me . I have nothing to offer, nothing interesting to tell. There’s nothing there, what I could give. And here, I just started seeing it again: there is something there! It was simply hidden or whatever you’d call it.” (2.12)
D.2.2. Sharing experiences (29)
 “There were quite a few discussions, which helped me a lot. Just seeing, there are other perfectly normal people, like me, who are dealing with the same problems. Somehow, this has helped me the most.” (1.2)
 “Here you are able to talk and that really helped me, because they understand you here . Because everyone is dealing with pretty much the same somehow. Here you can talk about stuff you can’t talk about outside or at work .” (1.4)
 “Patients lift each other up a bit, and you can support each other and always find good conversations.” (1.3)
I.2.2. Sharing experiences (34)
 “Outside, you always have to explain so much and here, a few words were enough and you’re understood. That was something special. Nowhere else is like that. A whole load of people, who understand you without you having to say a lot of words. ” (2.12)
 “When we sat together in the evening… and just talked about experiences… you could really benefit from the others’ experiences .” (2.6)
“The ton of time you spend with the other patients after the end of the day’s work. So, really the exchange actually takes place then, when the day patients are gone . That’s when it really begins.” (2.15)
 “It was nice because there was always somebody there, if one was not feeling too good , with whom you could always talk. You did not have to plan anything; that was just great. If you felt the need to, you simply went and joined people somewhere.” (2.12)
D.2.3. Group cohesion and sense of belonging (78)
 “This sense of community , it was there in a way. As I knew it in the past, like it always used to feel.” (1.8)
 “I mean, I was made to feel very welcome and also welcomed other people after a certain time.” (1.4)
 “It was simply a kind of an outsider feeling . The others are there to stay and spend the evening together and get to know each other better and I have to go back home at 4 o’clock . I’m missing out on something. They are having a good time and I’m home alone… the feeling of being a second - class patient and only a guest . Also not really being part of the community of inpatients….” (1.11)
 “It just really dawned on me. Really, just the thought: “This isn’t helping! It can’t help like this” And:” I don’t belong to the group ” that popped up again and again.” (1.11).
 “It was just this feeling of being a stepchild when you’re only a day clinic patient.” (1.11)
I.2.3. Group coherence and sense of belonging (93)
 “It created a great sense of community and gave me a lot of information and input. For me, that was really the best part. ” (2.15)
 “As I said, the contact with the other patients was much, much more intense . I wouldn’t want to miss that, really. This sense of togetherness, this feeling of solidarity, I would really have missed it. I’d have felt more like a patient, and this way it felt more like a family .” (2.16)
 “So, for me it was an essential part of therapy (…) if I imagine, I’d have had to go home at 4 o’clock, a large part of the actual therapy would have been missing. Exchanging experiences is incredibly valuable. To be able to interact with others, but not to have to. Or just joining the others while they were chatting, was immensely valuable. The day clinic would not have been an option for me.” (2.13)
 “Then I had the exact same problem which I normally have, I felt excluded from the group of other patients, I felt isolated, I couldn’t get a connection , and it was then that I noticed that this was a general problem and not only to do with the work.” (2.1)
D.2.4. Stress experience (26)
 “I was a day patient and that was a bit much for me. So many people from morning to night and you always have to talk straight away.” (1.9)
 “In the beginning, when I came here, it was so that everyone was talking about their illness and I didn’t want to hear anything about illnesses. It was like it for the first two weeks: “Illness, illness, illness!” (1.4)
 “I was quite content in some cases that I had some distance to my fellow patients . That I was able to hear and see something else, too.” (1.16)
I.2.4. Stress experience (24)
“But also the feeling of being exposed to some patients whilst staying as an inpatient.” (2.1)
 “Yes, it was very exhausting never really being alone , never really being able to be just for myself. Then also the change to being an inpatient here; that was difficult.” (2.8)
 “Negative was that sometimes you could not cope with their problems . This sometimes was very stressful and I often took stories very much to heart. I then, sometimes, spent too much time on some people, and later thought, “Oh God, you shouldn’t have done that, that was too much again! You’ve exceeded your own limits again. ” (2.19)
3. Social contacts outside of therapy (120)
D.3.1. Support and improvement of social contacts/Positive interaction of social contacts (31)
 “Simply to spend the evening at home with friends or maintaining social contacts. One’s not totally removed and has to fit in again in the end. That really helped me.” (1.11)
 “Actually good. I also noticed that my relationship improved again when I come home in the evening. That this had a positive effect. My partner also said that in the couple therapy session that I am now more relaxed and balanced. It really had a positive effect.” (1.18)
 “I thought it would actually be better to shield yourself completely, but then I realized through several therapy sessions that it was quite good also to talk to my family about such problems. This also improved things a lot .” (1.2)
I.3.1. Support and improvement of social contacts/Positive interaction of social contacts (42)
 “So contact was actually pretty good . I’ve done a lot with friends during the stay and I was even visited by my mother and my little brother once. Yes, that was positive.” (2.4)
 “We also had a family therapy session. This […] and everything, that really helped me a lot, looking back. I get along with my parents much better . We can now argue and I feel much better after, than before my stay, I’d say.” (2.19)
 “With my friends far too little… but I’m just a very giving person . I don’t want to alienate myself. It makes you think, “Oh, after all this time! Hopefully, they haven’t forgotten me.” (2.9)
D.3.2. Social withdrawal (18)
 “Now and again it was too much . If I had, for example, talked about something that had really pulled me down, I just wanted to come home and fall into my bed… but I could generally distance myself quite well from things. F or example, I just didn’t answer the phone or something or I said, “I ‘m not well today, I’ll call you tomorrow, or so.” (1.7)
 “There was almost nothing, because I came home and was so tired that I often went to sleep at six or seven o’ clock. Especially, in regards to my boyfriend, I then started feeling really guilty, because then we really had no more time together .” (1.14)
 “With my husband, there were always problems and that really got me down every time . That’s why I avoided contact with him.” (1.3)
 “It actually really hindered therapy . It threw me back severely. It didn’t help me progress, let’s put it that way. Everything moved very slowly because of it.” (1.3)
I.3.2. Social withdrawal (29)
  I had no contact . Apart from the fact that people knew that I was in the clinic, it’s like this: you get in and it’s like being on another planet. All at once, one is completely free of everything. You don’t have to worry about shopping or other things. It’s like being “beamed away.” And you’re not even interested in the outside world . That’s how it seemed to me, anyway.” (2.13)
 “On the weekends, when I was at home, I didn’t want to see anyone…. There is only a limited amount of time and people start hogging you. I want to have the weekend to be able to sort things in my head and not have to talk about it.” (2.15)
 “Because it was really important for me to get the necessary distance from home .” (2.6)
4. Treatment discharge and going back to everyday life (503)
D.4.1. Leaving the unit in the evening (9)
 “That’s what I wrote on the questionnaire on Friday, that I find the transition from here to home really hard .” (1.4)
 “… I did see it that way and also missed it somehow. As I said, it was not important to be here over night, so that I had slept here. But simply this: The others were still together, they sat together in the kitchen, or just went into town together or watched TV together in the evenings, etc. And in the morning they then talked about it! Well, for myself I found it was sometimes like being excluded and demarked from the group .” (1.13)
I.4.1. Visiting home on the weekends (9)
 “… in the early days of therapy I was glad when weekends were over and I could go back again . I was counting the minutes on Sunday morning until I could go back again. I just didn’t feel comfortable here.” (2.16)
 “I never had the desire to go home . On Saturday mornings I always felt sick. I couldn’t eat breakfast because I knew I had to go home. I always delayed going for a further 1 h and would really have rather just stayed. And Sunday evening I was always happy when I stood in front of the door . I told my friends. “I’m going home again,” It just slipped out. It was home for me. My friends called and asked me, “Where are you?” and I said. “I’m on my way home” and that’s when it struck me first and I thought, “Oh my God!” (2.16)
 “If I was at home on Saturday and Sunday, I was happy again on Sunday evening when I saw my people. But then they eventually left and you couldn’t go to see your mates in the clinic any longer. My friends, acquaintances, the “protective” feel around the whole thing. ” (2.14)
D.4.2. Discharge from treatment (29)
 “So, I’m a total opponent of the day clinic, but at the moment I’m thinking it might have been the better option for me (patient laughs). It’s easier to cut that umbilical cord . I mean, on the one hand I haven’t felt as attached to the other patients as I did last time because you just don’t spend as much time together.” (1.11)
  For me, it was very difficult to leave the hospital on the whole . Also, because the other patients and the thought of how it all is being back.” (1.2)
 “And also, this sense of security you have being in the clinic stops at four o’clock …. It’s just not the same protected feeling, which one usually has for eight or ten weeks. That has made things easier. Simply keeping up your social contacts outside.” (1.11)
I.4.2. Discharge from treatment (27)
 “So I just felt that the reference to normal, everyday life was a bit too small . If I had still been going to school, I would have thought it would have been great if you could have something like a day’s trial. Have a day in school or a day in work. And that then discuss everything with the therapist.” (2.4)
 “This feeling of being sheltered was gone … it really is the case that you’re exposed to all sorts of things: the thoughtfulness is no longer there ! Everyone’s understanding is gone and the worries are different, too! It’s no longer about “feeling good” or whatever, but it’s all about: “making it” and other problems. That’s a shock at first and exhausting. A change that one has to come to terms with first. This is quite a big difference.” (2.10)
 “For me, not at all. Because I thought, “When I’m out, I have to live my life.” Yes, I want to live my life . It scared me that whilst I was there, people were discharged and then came back every day. They just could not let go . Then I thought, “No, you cannot do that. This is not life . “We had one who came back every night. Every evening! He crept in every evening.” (2.16)
D.4.3. Going back to everyday life (208)
 “Well, the routine is missing , simply, having to get up in the morning and to go there. Now, it doesn’t matter. I just start the day without having a plan.” (1.17)
 “But now I realize, I haven’t used everything I’ve learned from the first week or therapy, but I realize that the potential is definitely there. And that it’s not a problem to do that for me .” (1.8)
 “I could do my household chores; redecorate the apartment, decorating and cooking food again… all the fun in things has just come back again . The enjoyment is just there again!” (1.7)
 “Before I was in the clinic, my therapist had already told me that I should get in contact with her again straight after discharge. So that we could continue my outpatient treatment again. So, I knew that I had at least one contact . And I also get on quite well with my GP. He really supports me.” (1.13)
I.4.3. Going back to everyday life (221)
 “It was just as it had been before: I was at my computer a lot and in bed. I fell right back into my old behaviors .” (2.2)
 “Actually quite positive. During my period of depression I was totally unmotivated and was doing nothing really and now you can really notice it, I’m more active, looking for an apartment, for a job and so on. So, quite positive actually . I’m even making plans for the next day again. That’s positive.” (2.9)
 “So, perhaps instructions to the effect: “ Communicate your needs ” This is such a nice topic. I’m certainly doing more of that now. But I’m also not so much… well, this feeling of being disappointed- I don’t have it as much anymore. Well, a certain indifference and a certain positive distance to other people is now there.” (2.13)
 “Because I was always out and about, not really. That was perhaps an advantage. I always went out and didn’t hide in my shell . I went to see my friends and family as often as I could. Maybe that’s why I didn’t find it so hard now.” (2.9)