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.     

Theme-focused family therapy: the inner emotional world of the family

This paper is an account of a method of family work developed for social workers in social services departments which allows them to work with the emotional impact on children and adults of traumatic events in family life. Theme-focused family therapy has been designed to meet the needs of the families and also to enable social workers and their supervisors to develop both psychodynamic and systemic perspectives m their work with families. It is a staged approach, moving from individual work to a structured family interview through to a series of theme-focused family sessions. It is phased in this way both to facilitate the development of a therapeutic attachment between social worker and family and to take account of the crises that can interrupt planned work in social services departments. Theme-focused family therapy is carried out in partnership with families, and gives children a voice and a leading role in the therapeutic process. The approach is illustrated with a case example.     

Integrated Group Psychotherapy Program [IGGP] for Multi-Diagnosed Clients

This article describes a group therapy–centered program geared toward the treatment of individuals with co-occurring disorders, including addictive disorders, borderline personality disorder and other mental health issues which involve difficulties with emotion regulation. Group therapy plays a vital role in their recovery. Over 18 years, the author has developed a treatment model that offers an integrative approach to group therapy and individual treatment encompassing psychodynamic and other empirically based therapies, especially dialectical behavior therapy (DBT). Its value lies in its therapeutic effectiveness with hard to reach clients, in its practice-based evidence, its team-building and management approach, its training component and its capacity for replication.     

Gender: A critical factor in a couples group

Couples group therapy should be considered as a primary treatment for marital couples whose dysfunctional interaction is rigidified and chronic. A gender-linked perspective for treatment is developed which expands a psychodynamic approach underscoring power as one of the central issues in marital conflict. Clinical vignettes from couples groups illustrate this model. A gender orientation facilitates the psychodynamic group process, decreases unrealistic expectations of the spouse, and encourages greater acceptance of male/female and individual differences. In this setting, individuals are able to develop new and more functional modes of interaction with their spouses, which generate an increased sense of empowerment.Excerpts from this paper were presented at the American Family Therapy Association meeting in Montreal, 1988.The authors gratefully acknowledge the helpful comments of Henry Grunebaum, M.D., and Fred Sander, M.D.     

Treating work inhibition in group psychotherapy

Work Inhibition, defined as an impaired ability to pursue one's career goals, may be treated by combined individual and group therapy. The author presents a method for assessing the degree of work difficulty, a psychodynamic understanding of the problem, and an approach to treatment. He proposes that helping the patient work more actively in group will generalize to the workplace and reduce inhibition. A clinical illustration is provided.     

Network therapy for addiction: bringing family and peer support into office practice

Network therapy was developed as a specialized type of combined individual and group therapy to ensure greater success in the office-based treatment of addicted patients by using both psychodynamic and cognitive-behavioral approaches to individual therapy while engaging the patient in a group support network composed of family members and peers. This article outlines the role of group cohesiveness as a vehicle for engaging patients in this treatment; the patient's family and peers are used as a therapeutic network, joining the patient and therapist at intervals in therapy sessions. This network is managed by the therapist to provide cohesiveness and support, to undermine denial, and to promote compliance with treatment. The author presents applications of the network technique designed to sustain abstinence and describes means of stabilizing the patient's involvement. Some specific techniques discussed include ambulatory detoxification, disulfiram and naltrexone administration, relapse prevention, and contingency contracting. Also discussed are recent research on the use of psychiatric residents and counselors for treatment, and use of the Internet in dissemination.     

Integrative Family Therapy

This paper describes an integrative approach to marital and family therapy in which psychodynamic (particularly object relations), family systems, and behavioral (particularly cognitive–behavioral) theory are blended in a flexible and tailored therapeutic approach. Human personality in its most significant contexts is a consistent focus. Background factors in the development to the approach and illustrative case materials are included.     

Using psychodynamic concepts in strategic family therapy: A suicidal adolescent case

This paper describes the treatment of a suicidal adolescent with strategic family therapy. The cotherapists conceptualized the case psychoanalytically and systemically. They propose that their understanding of psychodynamics enhanced their ability to tailor their interventions to the family's unique style and capacities. Rather than dismiss psychodynamic concepts as irrelevant to strategic family therapy, they maintain that an appreciation of individual members' ego strengths, defenses, affects, and unacknowledged impulses leads to the construction of more effective metaphors and a set of interventions more isomorphic to family patterns.     

Time-Limited Dynamic Psychotherapy as a Model for Short-Term Inpatient Groups

The present article proposes a method, practiced by the author, to adapt time-limited dynamic psychotherapy (TLDP), a short-term individual psychodynamic therapy, for use with inpatient psychotherapy groups. Characteristics of TLDP which suggest the usefulness of such an adaptation, including short-term duration, specific treatment focus, rapid conceptualizations and broad selection of patients, and emphasis on the here-and-now in therapy, are discussed. The general approach to treatment, a supportive stance that involves an identification of maladaptive interpersonal issues, and then working on these issues without directly confronting the patients, is described. Specific therapeutic techniques for common inpatient group situations are also discussed.     

Family therapy without the family: a framework for systemic practice

This paper contrasts the basic tenets of systemic thinking with some guiding principles of the psychodynamic approach, and outlines specific techniques which family therapists can use when seeing individuals. It is argued that a useful systemic framework can be maintained if the therapist aims to keep the therapy system 'open' for relevant others to join at any time.     

Integrating family therapy in adolescent depression: an ethical stance

Adolescent depression, particularly where suicidal behaviour is involved, is a complex and pressing mental health problem and demanding for families, therapists and services alike. This article reviews the evidence-based literature for adolescent depression including family therapy approaches. It suggests an integrative treatment approach that includes individual psychological treatment like CBT, medication where required and a family therapy intervention is supported by the literature. The focus of the latter is psychoeducation, building resilience and hope, enhancing communication, reducing relational conflict between parents and adolescents and addressing attachment and relationship issues. A systemic framework for integrating family therapy in the evidence- based treatment of adolescent depression is described. This is based on an ethic of hospitality towards different languages of therapy, which is illustrated by a detailed example from family therapy practice.     

Psychodynamic group therapy for male survivors of sexual abuse

The group therapy literature on male sexual abuse is very preliminary and concerned solely with short-term support models. This paper describes a long-term psychodynamic therapy group for male survivors that has been running successfully in a clinic setting for almost three years. This combined group and individual treatment approach presupposes the selection of men who are capable of using group process to explore basic personality and relationship problems. With sexually abused men, certain treatment issues are paramount. These concern the safety of group boundaries, power and control, facilitating intimacy, handling shame and guilt, and the effects of trauma. Special attention is given to the gender-related dynamics and conflicts that occur in a group of male survivors with a male leader.     

Combined therapy with borderline and narcissistic inpatients at the cassel hospital

An account is given here of a rather unorthodox approach to psychodynamic therapy with Borderline patients in part of the therapeutic community at the Cassel Hospital. ‘Combined therapy’ here refers to the setting in which one therapist sees patients in groups and individual sessions concurrently. The paper demonstrates the manner in which this approach brings to the fore the massive destructiveness and rage which so often lies at the core of these patients' difficulties. This is done by describing the development of the group over its first nine months. The therapist comes to be split in the patient's perception, the group sessions representing separation in all its most hated aspects rather than as a prerequisite for differentiation and growth. The resultant rage and destructiveness threaten to render the group unworkable and dangerous. The individual sessions, by contrast, represent a fantasy of being regressed and at one with the ideal mother. It is my belief that these difficulties can be contained only within a therapeutic community. The strength of this approach lies in the vivid reconstruction of a central conflict for these patients and corresponding potential for working through difficulties in the area of separation and individuation. It is also particularly effective in bringing the therapeutic community alive within the therapy. The discussion attempts to address some of the complex theoretical issues raised by the transformation of the transference in both settings which occurs when they are used together and with the same therapist.     

Manualisierte psycho- dynamisch-interaktionelle Gruppentherapie

20–40% of the patients in general practices, as well as in different departments in hospitals, suffer from somatoform diseases. 70% of these patients have pain as their main complaint. The present treatment manual is the first disease-specific, psychodynamically oriented group-treatment for these patients. Compared to other psychodynamic treatment settings this therapy is a short and cost-effective approach to treat these patients. It is based on a so-called psychodynamic-interactional group psychotherapy and focuses on disease-specific parts of the problem, as well as on psychic and interpersonal problems resulting from adverse childhood experiences. Over a period of six months 7 to 9 patients are treated in 40 group therapy sessions. Two weekly meetings are held during the first four months and one weekly session is held during the last two months. The concept contains psycho-educational elements, the discussion and formulation of individual treatment goals as well as work with a psychodynamic and relationship- oriented treatment focus. The efficacy of this concept is planned to be evaluated in a randomised, controlled clinical trial, including two treatment conditions and one control condition. One of the two treatment conditions is, beneath the concept already discussed, a cognitive behavioural group therapy.     

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.     

Are psychodynamic and psychoanalytic therapies effective?: A review of empirical data

There is a need for empirical outcome research in psychodynamic and psychoanalytic therapy. However, both the approach of empirically supported therapies (EST) and the procedures of evidence‐based medicine (EBM) have severe limitations making randomised controlled trials (RCTs) an absolute standard. After a critical discussion of this approach, the author reviews the empirical evidence for the efficacy of psychodynamic psychotherapy in specific psychiatric disorders. The review aims to identify for which psychiatric disorders RCTs of specific models of psychodynamic psychotherapy are available and for which they are lacking, thus providing a basis for planning further research. In addition, results of process research of psychodynamic psychotherapy are presented. As the methodology of RCTs is not appropriate for psychoanalytic therapy, effectiveness studies of psychoanalytic therapy are reviewed as well. Studies of psychodynamic psychotherapy published between 1960 and 2004 were identifed by a computerised search using Medline, PsycINFO and Current Contents. In addition, textbooks and journal articles were used. Twenty‐two RCTs were identifed of which 64% had not been included in the 1998 report by Chambless and Hollon. According to the results, for the following psychiatric disorders at least one RCT providing evidence for the efficacy of psychodynamic psychotherapy was identifed: depressive disorders (4 RCTs), anxiety disorders (1 RCT), post‐traumatic stress disorder (1 RCT), somatoform disorder (4 RCTs), bulimia nervosa (3 RCTs), anorexia nervosa (2 RCTs), borderline personality disorder (2 RCTs), Cluster C personality disorder (1 RCT), and substance‐related disorders (4 RCTs). According to results of process research, outcome in psychodynamic psychotherapy is related to the competent delivery of therapeutic techniques and to the development of a therapeutic alliance. With regard to psychoanalytic therapy, controlled quasi‐experimental effectiveness studies provide evidence that psychoanalytic therapy is (1) more effective than no treatment or treatment as usual, and (2) more effective than shorter forms of psychodynamic therapy. Conclusions are drawn for future research.     

Psychoanalytisch-orientierte Fokaltherapie der sozialen Phobie

Although psychodynamic therapy is one of the most frequently applied forms of psychotherapy to treat anxiety disorders in clinical practice, evidence for the efficacy of psychodynamic therapy in anxiety disorders is unsatisfactory. This is especially true with regard to randomized controlled trials of psychodynamic psychotherapy in anxiety disorders. Psychodynamically oriented treatment manuals for anxiety disorders presently exist for generalized anxiety disorder and panic disorder. For social phobia (or social anxiety disorder), however, no manual for psychodynamic treatment has yet been published. Social phobia is a very frequent mental disorder characterized by an early onset, a chronic course, severe psychosocial impairments and high socio-economic costs and at the same time in spite of these facts one of the mental disorders which are scarcely diagnosed and treated. In this article, a manual for a 30-session (5 exploratory and 25 therapy sessions) short-term psychodynamic treatment of social phobia is presented. The treatment is based on Luborsky’s supportive-expressive (SE) therapy. In the first part, the general principles of SE therapy are presented. In the second part, a manual specifically adapted to the treatment of social phobia is described. This manual includes specific additional treatment elements that have clinically proved to be useful in the therapy of social phobia. The treatment manual is presently used in a large-scale randomized controlled multi-center study comparing short-term psychodynamic psychotherapy and cognitive-behavioral therapy in the treatment of social phobia.     

Theorietreue und Variationen

Interventional techniques can be integrated into inpatient group psychotherapy. Our approach is not meant to be a wild eclecticism but an empirically founded interventional repertoire that contains psychoanalytical, depth psychological, behavioral and hypnotic therapeutic interventions. A “uniform solution” for an integrative therapy is not possible. A tension between theory conformity and variations remains inherent to psychotherapy for a multitude of reasons. An interventional repertoire is illustrated by case examples which use operationalized psychodynamic diagnostics (OPD). The results must be appraised within the time frame of inpatient treatment. The conception in guideline psychotherapy that the individual approaches cannot be mixed because they would lose their effectiveness, does not correspond to our experiences. The chances and risks of switching interventions must be considered.     

Multiple Overt Incest as Family Defense Against Loss

A case report of father-daughter incest is presented that illustrates the way in which overt incest can function as a multi-determined familial defense against separation and loss. The case is further distinguished by: (a) multiple incest and (b) family therapy — an approach infrequently described in the literature on this problem. The authors have adopted the psychodynamic view that incest expresses the collective psychopathology of all the family members as well as their common adaptational capacities. Specifically, we have attempted to demonstrate that separation anxiety was a shared dread in this family and that incest defended against this painful prospect.     

Playing Together: DIR and Child Psychodynamic Therapy

ABSTRACT

This article describes the integration of the developmental, individual difference, relationship model (DIR) and relational child psychodynamic therapy. DIR is an effective treatment for many children with uneven development, not only for those on the autistic spectrum. The importance for child psychodynamic therapists to understand individual differences, as delineated by occupational and speech/language therapists, and to include parents within the treatment will be discussed throughout this article and in a particular case. An understanding of individual differences makes psychoanalytic formulations, especially about the body, more accessible and actionable. Overlooking the contribution of individual differences to a child’s play and development has consequences for progress in treatment. Together, DIR and child psychodynamic therapy can most effectively integrate “psyche” and “soma” (Winnicott, 1949). The child psychodynamic therapist’s particular expertise, in such areas as countertransference enactments and unconscious meaning, crucially contributes to this integration.