Psychotherapie der Psychosen

In this paper the psychotherapy of patients with schizophrenic, schizoaffective and affective psychoses is outlined. Psychoanalytic, cognitive-behavioural and systemic approaches and their theoretical concepts as well as the therapeutic techniques are de- scribed. The settings of individual, group and family therapy are also presented. A survey of the types of psychoanalytic therapy with their eldest historic roots is given with the development of the various psychodynamic concepts for schizophrenic and affective psychoses including schizoaffective psycho-ses. The different kinds of psychotherapy are compared to each other with respect to the aims. Finally this paper deals with the effectiveness of the therapies and discusses the pros and cons of relatively short randomised controlled trials compared with long term psychotherapies without control groups.     

Systemische Therapien bei Menschen mit psychotischen Verhaltens- und Erlebnisweisen

Systemic therapy for persons who have been diagnosed as having schizophrenic or schizoaffective psychosis has been practiced since the 1950s, not everywhere and routinely but in many psychiatric hospitals and outpatient clinics with a strong psychosocial orientation. Evidence of the effectiveness is well documented in randomized controlled studies. This article describes three systemic approaches in which the authors are actively involved: (1) systemic constructivist family therapy developed in Heidelberg for outpatient contexts, (2) need-adapted treatment and open dialogue developed in northern Europe that has gained access to psychiatric clinics through regional training within integrated care projects and (3) the concept of systemic therapeutic methods of acute psychiatric treatment (SYMPA) a systemic family-oriented inpatient treatment.     

Bipolarity, monopolarity and "dichotomous functional decay" as principles of differential diagnosis and "functional pathology" of endogenous psychoses

On the basis of Leonhard's Classification of the endogenous psychoses an attempt is made to trace the phenomenology of the monopolar and bipolar affective psychoses as well as Leonhard's "unsystematic schizophrenias" to three different functional anomalies. The differential diagnosis between the "cycloid psychoses" and the "unsystematic schizophrenias" as well as the problem of the so-called schizoaffective psychoses connected with them, is of particular interest. The arrangement to "functional areas" seems to be suitable.     

Serum creatinphosphokinase (CPK) in endogenic psychoses]

Creatinphosphokinase (CPK) was determined in 141 patients with manic-depressive and schizophrenic psychoses. In general endogenic psychoses of the manic and depressive type as well as chronic schizophrenias show normal CPK values. In acute cases of paranoid-halluzinatory schizophrenias normal values are predominant. In catatonic schizophrenias, as a rule, clearly increased enzyme activities are found. Thise increased values suggest a postulated somatic disease as a cause of the psychosis. Thus, the determination of CPK provides a useful aid in the diagnosis and control of the course of catatonic schizophrenic.     

Determination of fucokinase activity in the blood of schizophrenic patients

An investigation was conducted into whether dopamine induces an alteration in the fucolysation of glycoproteins, starting from the dopamine hypothesis of schizophrenia and taking the fucokinase activity determined in erythrocytes of schizophrenic patients as parameter. As with patients with "schizoaffective psychosis" and those with manic-depressive disorders, who were likewise examined, it was found that the enzyme activity of schizophrenic patients was no different than that found in the blood of a control group.     

Features of Families with Major Affective Disorders

This article reports the authors' observations on 22 families in which a young adult member has been diagnosed as manic-depressive, and on 11 families in which a member has been diagnosed as suffering from major schizoaffective disorder. All families could be described as extremely rigid and bound-up systems. Many of them were characterized by a "restrictive parental complementarity" and reciprocal delegation, and they shared certain cognitive features and assumptions. "Manic-depressive" families showed similarities as well as differences when compared with families in which there were schizophrenic and serious psychosomatic disorders.     

Studies of higher nervous activity in functional psychoses

Psychiatric illnesses can be conceived of as experiments of nature, providing a variety of pathopsychological mechanisms which may elucidate normal psychological processes. Clinically the reactive psychoses are predominantly psychogenic reaction types. They present disturbances of higher nervous activity, similar to those of the neuroses. The unconditional reflex activity is practically as in normal controls, and the most outstanding finding was the large effect of psychodynamic complex structures. This is a physiological parallel to the clinical manifestations with great concern over experienced mental trauma. In the manic-depressive psychoses the most characteristic feature is a marked disturbance of unconditional reflex activity. This factor may be an important physiological mechanism underlying the more biological than psychodynamic reaction type and partly explain the changes of mood and associated interferences with sleep, body weight, sexual activity, aggression and other instinctual and vegetative functions. Schizophrenic psychoses also present changes of unconditional reflex activity, predominantly in the direction of inhibition of response. In addition there are severe dissociations within and between the three levels of unconditional reflexes and the two signaling systems. It is suggested that schizophrenia represents a functional maladaptation, which can be explained from the principles of autokinesis and schizokinesis established by Gantt in animal experiments. Prognostic models based on experimentally established impairment of performances were shown to predict long-term risks of schizophrenic defects just as well as models based on constellations of clinical symptoms. I would predict that psychophysiology and experimental psychology will become increasingly more important for establishing diagnosis and prognosis in the functional psychoses. The data of this article point toward a basis for a prophylactic psychiatry.     

Beyond Bipolar Thinking: Patterns of Conflict as a Focus for Diagnosis and Intervention

Most family typologies in the history of family therapy organized the observation according to bipolar scales. The implied assumption of such models is that the attribution of the one observational characteristic is inevitably bound to the negation of its opposite characteristic. This article presents a formal observational schema that has the possibility to grasp contradictory, conflicting characteristics. Using this schema, one can develop a clinically relevant family typology, making distinctions between different patterns of interaction by which conflicts and antagonistic tendencies in families are organized. Clinical observation and experience suggests that one can distinguish families with members with psychosomatic, manic-depressive, and schizophrenic symptoms by the way they overcome conflicts and ambivalence.     

Psychosis and multiple family group therapy

Despite the growing evidence base for the effectiveness of family intervention in the treatment of individuals suffering from a psychotic disorder, in practice only relatively few mental health teams use family approaches when treating and managing those with schizophrenia or other psychoses. This paper describes a pragmatic model, which may be used in addition to other ongoing treatments, such as medication, CBT or single family therapy. It was developed jointly by clinicians and service users over the past few years. It consists of regular multiple family group work, with six to eight families attending simultaneously, and aims to involve families directly in the treatment, rehabilitation and recovery of their members suffering from psychotic disorder.     

Need-adapted treatment of schizophrenic processes: The essential role of family-centered therapy meetings

Need-adapted treatment is a psychotherapeutically oriented approach to psychoses that has been planned and is implemented individually in each case, combining different activities so that they meet the needs of each patient as well as the people making up her or his personal interactional network (usually the family). A systemic initial intervention, carried out as a conjoint session of the patient, the family members, and a team of 3–4 staff members is an essential part of this approach. The name therapy meeting was given to these sessions because of their notable therapeutic significance. Therapy meetings are often continued during the later phases of treatment to follow up the course of treatment and to reassess the therapeutic plans.     

Psychodynamik und Psychotherapie psychotischer St?rungen

This article gives a review of the options for psychodynamic treatment of patients with psychoses. The various settings for individual treatment as well as group and family therapy will be presented with a special emphasis on modified analytical long-term therapy. For a psychodynamic understanding, which is the basis for this treatment, the most important psychoanalytical models for psychotic disorders will be presented. In addition the current empirical results of non-explicit psychodynamic-oriented research will be referred to, which emphasize the significance of traumatic events in the early phases of life and the importance of narrative elements, whereby the psychodynamic approach experiences both complementation and confirmation.     

ABSTRACTS OF LITERATURE

This paper describes the family dynamics of the identified patient with manic-depressive illness. Method included chart review of 53 families in which the identified patient had bipolar, manic-depressive illness; of these 57, 43 were married. Of these 43, eight participated in two, sequential, post-hospital, psychotherapy groups. Clinical observations noted were: (a) the threat of recurring mania, (b) hostility between spouses, (c) massive denial, (d) symbiosis and dependency, (e) weak or absent father. Therapy implications were discussed.     

What we say we do: results of the 1997 UK Association of Family Therapy Members Survey

This study represents the first UK national survey of family therapists and systemic practitioners. The aim was to provide demographic information of systemic practitioners/family therapists and also to describe their clinical practice. The sampling frame used was the UK Association of Family Therapy membership list and all members were sent a postal questionnaire. The response rate was 33% with 495 out of 1500 questionnaires returned. Among the major findings were: systemic practitioners/family therapists are most likely to work for an NHS trust, to use family therapy techniques/systemic ideas predominantly, and to treat a broad range of client issues. They are also most likely to work with families, and therapy is relatively short term (five to eight sessions) regardless of whether they treat families, couples or individuals. Most family therapists/systemic practitioners use some measure of outcome, although frequently this will be feedback from clients. Supervision is sought by the majority of AFT members. In spite of some methodological limitations, the study provides interesting insights into the training and practice of UK family therapists and systemic practitioners which appears to differ in some respects from our American colleagues. It also provides a baseline for future surveys, making it possible to describe the developments of family therapy and systemic practice in this country.     

'We are the stuff that dreams are made on': the use of dreams in systemic therapy

This paper considers the place that dream material has occupied in therapy, and particularly family therapy. A rationale will be given for the inclusion of this source of information by systemic therapists. The use of dreams in systemic therapy with individuals, couples and families is described. Dreams are divided into five main categories: those that precipitate therapy, provide hypotheses, as memories, relationship dreams, and those that reflect the process of change. Each category is described and illustrated with relevant clinical material. The paper concludes with a method for working with dreams that is congruent with a systemic perspective applicable to individual, conjoint or family therapy sessions.     

Pattern of familial psychoses--systematic and unsystematic schizophrenia and cycloid psychoses]

604 cases were examined, 309 of which were systematic schizophrenics, 191 were unsystematic schizophrenics and 104 cycloid psychotics. With the systematic schizophrenics the average period spent in hospital amounted to 16.9 years, with the unsystematic schizophrenics 13.8 years, with the cycloid psychotics 8.2 years. The systematic schizophrenics were discharged from hospital on average 1.5 times, the unsystematic 2.3 times, the cycloid psychotics 4.1 times. Of the systematic schizophrenics, 37.5% were never discharged after their first admittance to hospital, of the unsystematic 25.7%, of the cycloid psychotics 9.6%. Bipolar fluctuations were detected in 1.6% of the systematic schizophrenics, 49.7% of the unsystematic and 78.8% of the cycloid psychotics. 15.9% of the systematic schizophrenics had occurrences of psychoses in their family compared to 50.8% of the unsystematic and 22.1% of the cycloid psychotics. The systematic schizophrenics had 17.5% of their family ill, the unsystematic 69.6%, the cycloid psychotics 25.0%. Of the parents of the systematic schizophrenics 2.3% were ill, of the parents of the unsystematic schizophrenics 11.6%, of the parents of the cycloid psychotics 5.0%. Of the brothers and sisters of the systematic schizophrenics 2.4% were ill, of the unsystematic schizophrenics 10.9%, of the cycloid psychotics 3.0%. These variations in the pattern and occurrence of psychoses in the family seem to prove that the three groups of endogenous psychoses are genetically separable. There are also differentiating features inside the groups. Periodic catatonia in particular is characterized by the great number of psychotics in the family.     

Family Therapy in Chinese Culture and Context: Lessons from Supervising Therapists-in-Training in China

Systemic family therapy as an essential paradigm for treating couples and families has gone global since its initial rise to popularity. According to researchers, China has signaled a strong desire for training in systemic family therapy. Even though this mode of mental health service is a foreign import to China, the surge in interest for Western psychotherapy for individuals and families grows by leaps and bounds. However there has been evolving conversations about the transportability of systemic family therapy from the West to the East. Using a qualitative focus group format, this study explored the experiences of sixteen Chinese couple and family therapists on their perspectives in adapting systemic family therapy concepts to the local Chinese context. Results reveal the interplay between the systems of the changing Chinese family structure and of the application of family therapy models that originated from the West must work harmoniously in order to enhance the goodness of the familial system within the evolving Chinese society in the 21st century.     

Outcome studies of family therapy in child and adolescent depression

There is surprisingly little good-quality evidence for the effectiveness of family systemic interventions with child and adolescent depression given the prevalence of depression and the demonstrated association with a range of family factors. What studies there are suggest the possibility of family therapy being an effective intervention but more research is needed before firm conclusions may be drawn. Family interventions may be more effective in children than in adolescents and where other family members are depressed. It is possible that family interventions continue to bring about improvement in symptoms after cessation of treatment. What research there is evaluates older structural models of therapy: there is a real need for more evaluation of newer models of practice.     

Family Therapy Training and Workforce Planning

There is a strong argument for further developing family therapy as a profession within the NHS, using the mechanisms for workforce planning at regional and national levels. Family therapy can be a full-time occupation, as a profession and a secondary activity, as systemic practice. There is ambivalence about professionalism within the field and at different levels of society. This article outlines areas of tension between family therapy and government policies which focus on evidence-based practice. Full integration into the NHS is possible through the career structure which links family therapy with clinical psychology, adult and child psychotherapy, and provides a model for linking workforce planning with education. There are risks of family therapy becoming marginalized in the future, as a profession or as systemic practice, unless it connects better with workforce planning.     

The Efficacy of Systemic Therapy for Childhood and Adolescent Externalizing Disorders: A Systematic Review of 47 RCT

Systemic (family) therapy is a widely used psychotherapy approach. However, most systematic efficacy reviews have focused solely on “family‐based treatment” rather than on the theoretic orientation “systemic therapy.” We systematically review trials on the efficacy of systemic therapy for the treatment of childhood and adolescent externalizing disorders. All randomized (or matched) controlled trials (RCT) evaluating systemic/systems‐oriented therapy in various forms (family, individual, group, multi‐family group therapy) with child or adolescent index patients (0–17 years) suffering from mental disorders were identified by data base searches and cross‐references. Inclusion criteria were as follows: index patient diagnosed with a DSM‐ or ICD‐listed mental disorder, and trial published in any language up to the end of 2011. The RCTs were analyzed for their research methodology, interventions applied, and results (postintervention; follow‐up). A total of 47 trials from the United States, Europe, and China, published in English, German, and Mandarin, were identified. A total of 42 of them showed systemic therapy to be efficacious for the treatment of attention deficit hyperactivity disorders, conduct disorders, and substance use disorders. Results were stable across follow‐up periods of up to 14 years. There is a sound evidence base for the efficacy of systemic therapy for children and adolescents (and their families) diagnosed with externalizing disorders.