Systemische Therapie bei Störungen des Erwachsenenalters

Background

Systemic therapy is a scientifically acknowledged form of psychotherapy in the US and many European countries, but not yet in Germany.

Method

All randomized (or parallelized) controlled trials (RCT) evaluating systemic couples/family/individual therapy with adult index patients published in English, German or Spanish up to the end of 2004 were identified via data base searches and cross-references in other meta-analyses and reviews. A meta-analysis of the identified RCT was performed.

Results

28 RCT (43 publications) evaluating systemic therapy with adult index patients suffering from clinical disorders (ICD-10) were identified. Systemic therapy is efficacious with regard to substance disorders, mental/social factors interacting with somatic disorders, schizophrenia, depression and eating disorders. The results are stable across follow-up periods of up to 5 years.

Conclusion

According to the criteria of the German Scientific Advisory Board Psychotherapy (Wissenschaftlicher Beirat Psychotherapie) there seems to be good evidence for the efficacy of systemic therapy in at least four fields of application of adult psychotherapy.     

Ambulante Psychotherapie der Substanzstörungen

Background

The revision of the psychotherapy guidelines in 2011 broadened the options for treating substance use disorders (SUD) in outpatient psychotherapy (OP).

Aim

The aims of this study were to answer the following questions: how frequently are SUDs treated in OP? What opinions do psychotherapists (PT) hold concerning the new treatment possibilities?

Material and methods

In this study the frequency of OP for patients with SUD, e.g. harmful use and abuse of as well as dependence on psychotropic substances according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) and the International Statistical Classification of Diseases and Related Health Problems (ICD-10), by private practice PTs as well as their attitude towards the treatment of patients with these diagnoses were investigated. Private practice PTs in five states in East Germany were asked to participate in a postal survey.

Results

Of the 1,382 PTs contacted, 229 (16.6 %) participated in the study. Of the respondents 94.3 % had treated at least one patient with SUD (4-week prevalence including nicotine dependence). These rates ranged from 3.1 % to 26.6 % depending on the substance and diagnosis (SUD as primary reason for treatment). The highest rates of strong affirmation for OP of approximately 20?% were found for disorders related to alcohol, tobacco and medication.

Conclusion

Most PTs treated at least one patient with SUD in OP. However, this particular type of treatment offer should be further extended. Information about the options of treating SUD in OP should be further disseminated and conducting such treatment should be supported by (e.g.) therapist training.     

Aus vier mach zwei

Background

The diagnostic and statistical manual of mental disorders 5 (DSM-5) includes a revision of the DSM-IV criteria for somatoform disorders. The aim of the current work was to investigate whether (a) patients with DSM-IV diagnoses of somatization disorder, pain disorder and hypochondriasis and (b) whether patients categorized as having the DSM-5 somatic symptom disorder and illness anxiety disorder differ with respect to illness anxiety and cognition regarding somatic symptoms.

Material and methods

The data from 269 inpatients from the psychosomatic clinic Schön Klinik Bad Bramstedt were used. Somatoform disorders were diagnosed using the German version of the structured clinical interview for DSM-IV (SCID).

Results

Patients with a DSM-IV diagnosis of hypochondriasis differed in illness anxiety and catastrophizing interpretation of somatic symptoms compared to patients with other somatoform disorders. Patients with illness anxiety disorder differed in the catastrophizing interpretation of physical symptoms, autonomic sensations, bodily weakness and intolerance of physical complaints compared to patients with somatic symptom disorder.

Conclusion

The present results indicate that illness anxiety and a catastrophizing interpretation of somatic symptoms play a fundamental role in patients with somatoform disorders. Therefore, psychotherapy should address illness anxiety and health-related concerns in all patients with somatoform disorders.     

Gegenübertragung im stationären Therapie-Setting

Background

Countertransference is seen as an instrument of research into a patient’s unconscious and is therapeutically useful in furthering psychodynamic work. For inpatient psychodynamic psychotherapy, where patients are treated by a team of psychotherapists, countertransference is much more complex and makes consideration and integration of different countertransference feelings necessary. Using the first German translation of the countertransference questionnaire (CTQ, Zittel Conclin and Westen, the countertransference questionnaire, 2005) an attempt was made to identify differences in countertransference phenomena in a team of psychotherapists and to show the impact countertransference has on therapy outcome.

Materials and methods

A total of t multiprofessional teams of psychotherapists (15 physicians, 5 psychologists and 9 body and art therapy psychotherapists) took part in the study and completed the CTQ for 137 patients (100 female, 37 male) at the beginning and at the end of inpatient psychotherapy. In addition, the patients completed two questionnaires, the Symptom Check List Revised 90-R (SCL-90) for the severity of symptoms and the Assessment of DSM-IV Personality Disorders Questionnaire (ADP-IV) for personality disorders.

Results

Body and art therapy psychotherapists expressed more positive, protective and involved countertransference feelings whereas psychotherapists for single and group therapy expressed more aggressive and hopeless feelings. Countertransference has an impact on therapy outcome and feelings of a lack of interest, aggression and resignation at the beginning of therapy can point to a poor outcome. Patients with personality disorders activate more negative countertransference reactions than patients without personality disorders but at the same time they may also evoke parent-like feelings of protection.

Conclusions

Using the CTQ it is possible to differentiate countertransference phenomena in a team of psychotherapists treating inpatients with psychodynamic psychotherapy. The timely perception and integration of countertransference feelings has a positive influence on the therapeutic process and therapy outcome.     

Erfahrungsorientiertes Lernen in der Psychotherapie

Background

Based on principles of experiential learning, psychophysical exposure (PPE) on a tightrope course offers a promising intervention in the treatment of patients with mental disorders. A PPE program conducted on a hospital tightrope course is presented as an adjunct in inpatient psychotherapy.

Methods

The acceptance and effectiveness of the PPE were evaluated in a prospective controlled naturalistic study. A total of 155 patients, who were exposed at least once during their inpatient therapy, were compared with 92 control patients, who did not participate in the tightrope course. The main outcome criteria were self-reported depressive symptoms, state anxiety, locus of control, self-efficacy, and trait anxiety.

Results

The PPE was highly accepted by the participants. Patients who attended the tightrope courses showed greater improvement in the outcome criteria than patients who received inpatient treatment as usual. Particularly better effects were found on the personality variables.

Conclusions

Psychophysical exposure can successfully and effectively be integrated into a psychosomatic inpatient treatment program. Methodological limitations of the study, especially threats to internal validity, are discussed.     

Scham und Familienbeziehungen bei Bulimie

Background

Empirical studies show a relationship between family factors and disturbed eating behavior. Feelings of shame are associated with a higher level of eating disorder symptoms and with family relations perceived as being dysfunctional. Thus shame can be understood as a mediator of the relationship between dysfunctional family relations and eating disorder symptoms.

Material and methods

For 69 female patients, including 55 with bulimia nervosa and 14 with eating disorder not otherwise specified (EDNOS) between 14 and 22 years of age, who participated in a comparative study of psychotherapy outcome, eating disorder symptoms (EDI, EDE-Q), general psychiatric symptoms severity (SCL-90R), level of shame (TESE-KJ) and perceived family relations (FB-A) were measured at the beginning of psychotherapy.

Results

The higher the feeling of shame the more dysfunctional the perceived family relationships were and the more the eating disorders and general symptoms severity were reported. Shame was a partial mediator of the relationship between family functionality and symptoms.

Discussion

Feelings of shame could originate in dysfunctional family relationships but could also evoke more negative perceptions of interpersonal relationships. The direction of causality could not be proven in the correlative design; nevertheless, shame contributes to an understanding of the mechanisms between dysfunctional family relationships and eating disorder symptoms.     

Trauma und sexuelle Störungen

Background

Sexual disorders are common among patients with traumatic childhood experiences, especially when they were exposed to sexual abuse. Despite the fact that trauma-associated sexual disorders imply serious consequences for the persons concerned, to date the topic has not found much consideration in the research and clinical contexts.

Material and methods

This study investigated the prevalence and relationships of sexual disorders and experiences of sexual abuse in 189 patients (81?% women, 19?% men) with complex posttraumatic stress disorder. All participants completed the Interview zur Diagnostik der komplexen posttraumatischen Belastungsstörung (I-kPTBS, interview on diagnostics of complex posttraumatic stress disorder) and the traumatic antecedents questionnaire (TAQ).

Results

At least one sexual disorder was found in 77.2?% of the participants. In both sexes hyposexual disorders were more common than hypersexual disorders. Women showed more hyposexual disorders than men and men showed more hypersexual disorders than women. Of the participants 50.8?% reported experiences of sexual abuse and women were more often affected than men. The presence of hyposexual disorders was clearly associated with the existence of experiences of child sexual abuse.

Conclusion

There is a need for research on and effective treatment concepts for trauma-associated sexual disorders. The development of new therapeutic approaches should be realized in interdisciplinary cooperation.     

Suchttherapie bei abhängigen Ärzten

Background

International studies indicate an increased incidence of substance abuse disorders among physicians. This article investigates specific variables in the work field and describes existing treatment programs.

Patients and methods

In a cross-sectional study 107 physicians with and 468 without substance abuse disorders were compared. Two highly developed treatment programs in Germany and Canada are described.

Results

The high work-load associated with the medical work environment leads to reduced performance and social isolation. Treatment programs for addicted physicians work with the concept of ?help before restriction“. The abstinence rate of the 5-year Canadian program is over 90%.

Conclusions

As a form of prevention, medical students should be systematically informed about work-related stress in the medical profession. Structured treatment programs should be implemented nationwide. The expert team ?Risk of addiction in physicians“ of the German Addiction Foundation, whose members are authors of this article, may be a small step in this direction.     

Werden Psychotherapeuten,Psychiater oder die Psychotherapie stigmatisiert?

Background

In the last decades much has been found out about the stigmatization of persons with mental illnesses. Recently, a potential stigmatization of psychologists, psychiatrists and psychotherapy has been debated.

Aim

The question should be answered whether there is any scientific evidence for stigmatization of psychologists, psychiatrists and psychotherapy by using the conceptualization of stigma as brought forward by Link and Phelan (Ann Rev Sociol 2001; 27:363–385).

Material and methods

For the systematic literature search in 2013 a databank search was carried out in Web of Science using the search terms stigma or discrimination or stereotypes or prejudice AND psychiatrist or psychotherapist or psychotherapy or mental health professional. A total of 2013 publications were identified which were systematically arranged according to the title and abstract with respect to the relevance for the question whether psychotherapy or associated professional groups are stigmatized. Only four of the articles were considered to be relevant. After advice from experts six further relevant articles could be found which did not appear in the databank search.

Results

The review found evidence for both positive and negative stereotypes but not for other components of the stigmatization process.

Conclusion

At present there is no evidence for a stigma related to psychotherapy or to the professions of psychotherapists and psychiatrists.     

Schizophrene Patienten der forensischen Psychiatrie im Vergleich zu schizophrenen Patienten der Allgemeinpsychiatrie

Background

The number of schizophrenic patients admitted to forensic hospitals according to section 63 of the German Criminal Code has increased continuously over the past years. Some researchers assume that these forensic patients form a group of patients with very complex mental disorders, a number of risk factors and insufficient pretreatment in general psychiatry. This study aimed to identify differences regarding the history of treatment of forensic and general psychiatric patients diagnosed with schizophrenia.

Method

The matched samples included 72 male patients from forensic wards and 72 male patients from general psychiatric institutions diagnosed with schizophrenia. The history of psychiatric treatment was reconstructed by interviewing the patients as well as outpatient psychiatrists and patients’ legal custodians and by analyzing patient medical records.

Results

In contrast to the general psychiatric patients, prior to admission forensic patients were less integrated into psychiatric care and showed a lower rate of treatment compliance. They also showed a higher rate of previous compulsory treatment because of aggressive behavior towards other persons as well as higher rates of treatment difficulties and violent behavior during previous inpatient treatment. Furthermore, forensic patients had a higher number of previous criminal convictions and had been convicted more often for violent offences. With regard to other relevant risk factors (e.g. comorbid substance abuse disorder, age, education, conduct disorder, antisocial personality disorder, previous exposure to violent and abusive behavior) the two patient groups were, however, comparable.

Conclusions

Regarding schizophrenic patients with comorbid substance abuse disorders, previous violent delinquency and violent behavior during previous inpatient treatment, an intensive outpatient aftercare should be arranged before they are discharged from general psychiatric institutions.     

Kreuzvalidierung der Kurzform des Kindheitsfragebogens

Objectives

Existing questionnaires about parent-child relationships usually assess love and control only. The childhood questionnaire (CQ) offers a more differentiating alternative.

Methods

In a sample of approximately 1,400 patients and more than 500 controls the CQ was reduced from 22 to 11 scales and the number of items of each scale was shortened to 5.

Results

The shortened scales of the CQ also showed good reliability and item characteristics, as well as plausible intercorrelations.

Conclusion

By the use of 66 out of the former 128 items, the shortened version of the CQ assesses three further important dimensions in the parent-child relationship of adults towards their parents in childhood besides love and control: punishment, ambition and role reversal. Beside this, parental separation, divorce and job status as well as various parameters of the socio-economic status (e.g. educational, occupational and financial) of the parents can be assessed.     

Familienfunktionalität und Therapieerfolg

Background

Even though it is a treatment standard of child psychotherapy to involve the parents, hardly any research has been carried out about the impact of family functioning on treatment outcome. Aims of the present study were to investigate the change in and the prognostic power of family functioning on treatment outcome of short-term psychodynamic psychotherapy in children and adolescents.

Patients and methods

The sample consisted of 54 children and adolescents undergoing outpatient short-term psychodynamic psychotherapy. To assess family functioning, their parents were asked to complete the Family Assessment Measure (FAM).

Results

Patients from families with high levels of functioning in task accomplishment, communication and affective expression were more often treated successfully. Improvement in levels of functioning in role performance, emotionality and control were only found in the group of successfully treated patients.

Conclusion

Family functioning is a decisive factor in the differential indication of psychotherapeutic treatment in children and adolescents.     

Mangelnde Eignung bei angehenden Psychotherapeuten

Background

Psychotherapy research has shown that some therapists have systematically more negative outcomes than their colleagues. Many attempts have been made to answer the question of whether these unsuccessful therapists have specific features but as yet no consensus has been reached. Particularly in the field of psychotherapy training this issue has rarely been discussed.

Aims

This study focused on the following questions: how many trainees are incompetent, what characteristics do they have and how to deal with them? How are trainees selected?

Material and methods

In a research expertise on psychotherapy training for the German Ministry of Health, directors of training institutions were interviewed and 129 responses were analyzed using, for example content analysis.

Results

A total of 4–5?% of trainees were judged as being not sufficiently competent to become a psychotherapist. Relevant criteria were mainly the lack of personal and interpersonal competencies.

Conclusions

Future psychotherapy training should focus more and earlier on recognizing and intervening regarding incompetence in the given areas.     

Wenn Psychotherapie schadet …

Background

The examination of the negative and harmful effects of psychotherapy has recently moved into the focus of psychotherapy research. The investigation described in the following article specifically analyzes for the first time the contents of complaints by psychotherapy patients and presents a practical category system for classification of the negative effects of psychotherapeutic treatment.

Samples and method

A total of 67 cases of complaints submitted to the Ethics Association (reg. co). Ethics in Psychotherapy during the time period from 18.02.2008 to 27.12.2010 were analyzed with respect to the content in the sense of an inductive categorization and quantitative evaluation.

Results

From the available patient complaints a reliable category system could be elucidated. The violation of therapeutic base variables and violations of sexual limitations were the most common cause of complaints against male therapists whereas for female therapists accusations of violation of medical confidentiality and documentation duty were significantly higher.

Conclusions

The results of this study allow formulation of research recommendations for extended investigation of the negative effects of psychotherapy and reveal options for the development of a targeted risk management.     

Simulationspatienten in der Psychotherapieausbildung

Background

The development of therapeutic skills is an essential therapist-related variable that deserves special attention in the context of the currently increasingly discussed topic of therapeutic failures and discontinuation of therapy.

Aim

The study investigated whether the use of simulated patients (SP) in the training of psychotherapists can lead to an increase in therapeutic skills.

Material and methods

The use of SP (16 teaching units) was tested in a pre-post comparison with 29 training participants for child and adolescent therapy and analyzed from three perspectives: from the perspective of the SP, the training of participants and rater.

Results

The work with SP in psychotherapy training leads to a significant increase in therapeutic skills; however, it requires further research to see if this teaching method is more effective than other approaches to teaching, whether it contributes to long-term changes in therapeutic skills and to what extent the results can be transferred to other therapeutic contexts (except exploration).     

Kosteneffektivität ambulanter Psychotherapie

Background

There is a lack of cost-effectiveness analyses (CEA) of psychotherapeutic treatments.

Material and methods

Cost-effectiveness analysis was applied to a sub-sample of 122 psychotherapy outpatients who participated in a large longitudinal study on outpatient psychotherapy (TRANS-OP study). Participants received either psychodynamic psychotherapy (PD, n=69) or cognitive behavioral therapy (CBT, n=53). Effectiveness (change in symptomatic impairment over 2 years) was assessed via the German version of the Outcome Questionnaire (OQ-45.2). Direct health care costs during a 2-year period (psychotherapy and other health care utilizations) were obtained from health insurance claims. Cost-effectiveness analysis methods included incremental cost-effectiveness ratios (ICER) and the net benefit regression approach.

Results

Cost-effectiveness analyses showed no significant differences between the two treatments, neither head-to-head, nor with regard to advantages in certain subgroups of psychotherapy outpatients. A slight dominance of CBT in costs was not maintained after controlling for covariates.

Conclusion

Provided that pivotal covariates such as treatment need are taken into account, cost-effectiveness analyses can contribute to a more equitable distribution of psychotherapeutic resources.     

Station?re Psychotherapie und Medien

Background

According to several studies the application of different media in inpatient psychotherapy and psychiatry has proven to be a useful and effective addition to conventional methods of intervention. This study is the first to catalogue the current spread of media in inpatient treatment as well as the evaluations of media-supported interventions by therapists and patients.

Sample and method

In a representative survey conducted in all psychiatric and psychosomatic clinics in North-Rhine/Westphalia (response: 40 psychologists/doctors and 289 patients from 39 clinics) media equipment, usage of media in different areas, evaluation of and satisfaction with the media usage were measured by a questionnaire which was constructed especially for this purpose.

Results

A widespread usage and acceptance of media could only be found in some areas. The study identified large differences in equipment standards and media usage depending on the type of media, the area of usage and the specific clinic.

Conclusion

Recommendations for the further development and optimization of media usage in inpatient psychotherapy are derived from the results of this study.     

Direktausbildung Psychotherapie an der medizinischen Fakultät

Background

There is ongoing political discussion at the Federal Ministry of Health that a university entrance diploma should allow psychotherapy to be studied directly: Graduation leads to a licensure that qualifies for further specialization, e.g. in cognitive behavioral therapy (CBT) or psychodynamic psychotherapy analog to medical specialization. As psychotherapy has its roots in both psychology and in medicine, the question is raised which faculty should be the future home of direct psychotherapy schools.

Material and methods

A theoretical model curriculum of psychosomatic psychotherapy is proposed. Its structure which is oriented to the established structure of medical training and its contents are described. It is argued that the proposed model in the tradition of psychosomatic medicine is suitable to meet ongoing changes in the structure of psychotherapeutic care due to new challenges in the field of public health.

Conclusion

The study of psychotherapy should be associated with chairs in clinical psychology and psychosomatic medicine in order to maintain and further develop the variety and quality which psychotherapy has gained in Germany.     

Ressourcenaktivierung bei Patienten

Background

Starting from Klaus Grawe’s draft of a general psychotherapy, the patient’s resources and resource-activating interventions have received increasing attention in empirical research.

Objective

The effectiveness of standardized writing instructions for the activation of patients’ resources before participating in internet chat aftercare groups for psychosomatic patients was examined.

Method

In a randomized controlled trial writing instruction for the activation of patients’ resources was given in 52 out of 102 internet chat aftercare sessions. The effects of this minimal intervention on the patients’ activity and the number of positive emotion words expressed during the chat session were examined. Additionally, the effects on patients’ self-esteem, attachment, orientation, control and well-being after the group sessions were assessed.

Results

Patients reported higher levels of self-esteem, orientation, control and well-being after chat sessions with a resource-activating intervention. No differences between intervention and control groups were detected on the text-based variables activity and number of positive emotion words.

Conclusions

Standardized minimal interventions for the activation of patients’ resources seem to be promising for enhancing the effectiveness of therapeutic Internet chat groups.