Psychotherapierichtlinien: seit 40 Jahren Bewährung in der Praxis

Looking back at 40 years application of psychotherapy guidelines, a positive balance can be drawn. Benchmarks of the guidelines are the biopsychosocial conception of psychic disturbances requiring treatment and the congruent expertise procedure. The latter is considered by many psychotherapists as unreasonable and by the health insurances as not effective enough because of a rejection quota of only 5%. Nevertheless, it proved to be useful in historical, therapeutic and textual aspects. The biopsychosocial conception of psychic disturbances according to the psychotherapy guidelines is an important counterbalance to the objectifying view and evaluation of psychic processes. This concept implies also a complementary view of the ill compared to somatic medicine which allows a better comprehension and understanding of the individual suffering. The most important modification in the psychotherapy guidelines was the inclusion of behavior therapy as the guideline therapy. It succeeded in surpassing the hallmark of (higher) effectivity by offering shorter therapies and objectifiable verification, as an important complementary object-view into psychic processes. Meanwhile, however, this object-view threatens to displace the ?subject-view“ of the psychotherapy guidelines, especially supported by new developments in evidence-based medicine.     

The peer supervisory group for psychoanalytic therapists

The recent interest in peer supervisory groups for psychoanalytic therapists raises important questions regarding both psychoanalytic training and group process. The present paper explores these issues and suggests that there exists a continuum from case-centered peer supervisory groups to process-centered peer supervisory groups. Transference and countertransference and the recognition of parallel processes in psychotherapy supervision are examined in their relation to the supervisory group experience. The authors suggest that the model a therapist employs regarding the role of countertransference will most likely influence the kind of peer supervisory group that s/he will choose. Further, there are specific techniques, as well as experiences, which may foster alteration of the group's psychic organization. Illustrative case examples are provided throughout.     

Medikalisierung sozialer Prozesse

Medicalization of social processes increasingly more involves societal areas and leads to the extension of disease concepts and the creation of new diseases. In this article the disciplines in psychiatry and psychotherapy will be discussed with reference to the trends towards medicalization. Particular attention is paid to the diagnostic models and their critical implementation. The interaction between societal conditions, the medical healthcare model and the individual will be presented and discussed with respect to their influence on medicalization and psychopathologization. Furthermore, the importance will be shown by which the increasing societal openness for psychic phenomena and the influence of mass media on the medicalization process becomes incorporated. At the individual level societal-typical psychological characteristics which have an influence on the readiness of individuals to experience themselves as sick and socially deficient will be elucidated. The pathologization and chronification processes are exemplified using the case of unemployment and the psychological sequelae, such as on the term burnout. Finally, approaches of a societal-critical medical and psychotherapeutic science and practice will be sketched.     

The Analyst’s Private Space: Spontaneity,Ritual, Psychotherapeutic Action,and Self-Care

The contemplation, containing, and linking that circulate within the analyst’s private space are positioned as key to states of psychic equivalence (the melding of psychic reality and material reality) and to sustained states of unknowing, which are held to be necessary for analytic work and fantastic spontaneity. These modes of practice are considered as they relate to rituals that promote the analyst’s self care. An account of a psychotherapy with a 5-year-old electively mute girl is offered to illustrate the work undertaken in the analyst’s private space, as he seeks to build and sustain potential space and the possibilities borne through play.     

Newly Discovered Lands: An Experience of Psychotherapy Training Within ANZAP

In Australia, training in psychoanalytic psychotherapy differs greatly from psychological training. Within the Australian and New Zealand Association of Adult Psychotherapy, the training process allows for a more comfortable mix of art and science, as well as clinical theory. It is also experiential and has a deeply relational style. This article elaborates on the breadth and depth of newly discovered psychic landscapes that result from this particular psychodynamic training. The aim is to illuminate how the training enables the trainee to empathize and converse with clients for transformations to occur.     

Comparison of Dreams in Individual and Group Psychotherapy

This article gives specific reasons and evidence why group psychotherapy is the treatment of choice for addictions. Utilizing object relations theory and the self-psychology of Kohut, the authors present a model of group psychotherapy that combines these perspectives with those of Yalom's interactional group psychotherapy. Agreeing with Kohut and other object relation theorists, the authors view addiction as a condition that is the result of a person's misguided attempts at self-repair because of deficits in psychic structure. Vulnerability of self is the consequence of developmental failures and deprivation. Substance abuse only exacerbates this condition leading to exaggerated difficulty in regulation of affect, self-care, and characterological pathology. Abstinence is usually required as the first step in arresting this process and establishing a treatment regimen that will allow the vulnerabilities of the self to be altered and restored. This article suggests that this recovery and treatment process is best accomplished in a group therapy setting that is conducted within the guidelines of the principles of object relations theory and a modified version of Yalom's interactional group therapy format.     

IDENTITY FORMATION DIFFICULTIES IN IMMIGRANT ADOLESCENTS: THREE CASES FROM GERMANY

Adolescence is a period of instability caused by biological changes and restructuring of the personality. An immigration background renders the process of identity formation even more difficult or fragile, with an additional burden coming from persecution and harassment. Three case studies of mentally disturbed adolescents with different immigration backgrounds illustrate the problems in diagnosis and psychotherapy. All three cases share a common feature—the particular influence of the native country on the psychic disorder of the adolescent, be it a suitable target of narcissistic self-aggrandizement, a reactivated metaphor of the past or a deposited conflict. I point out and discuss the danger of diagnostic colonization and activation of perpetrator-victim constellations—such as the Nazi past in the present. Offering a transcultural transitional space as a container yields a therapeutic approach to the different worlds of these borderland adolescents.     

Clinical Implications for the Expressions of Self and Identity in Adolescent Psychotherapy: Case Studies of a Vampiress and a Gangster

Self and identity are examined as significant complementary processes in the psychoanalytic psychotherapy of two adolescent patients. The distinction between these processes is underscored as emergent from neuropsychological developmental changes while being expressed within a shared unconscious process. These cases examined how the analyst and patients fostered their co-constructed potential space for therapeutic transformation. Each patient had adopted compensatory identities in response to profound psychic conflict. The treatments explored the function of their identities as objectified processes to cope with psychic trauma while also addressing an essential respect for the subjectivity of self as a vehicle for psychological truth.     

Thoughts on autism with special reference to a paper by melanie klein

The article begins with a brief exploration of the various aspects of adolescent's psychic qualities as these are described in Greek mythology. It is argued that myths are an integral part of the way that adolescence is perceived and myths play an important role in adolescents' psychic and external world, as well as in their mythological thinking. Connections are made with the attraction towards the creation of myths about adolescence in ancient and contemporary societies. Three clinical vignettes from adolescents' psychoanalytic psychotherapy are presented in an effort to support the idea of the value and importance of mythology in adolescence in the clinical practice. Through the clinical material, we try to explore how psychic and developmental disturbances, which might lead to psychopathology, are reflected in family and personal myths and also in the mythological thinking of adolescents.     

Welche Rolle spielt die Diagnostik in der systemischen Psychotherapie?

Diagnostic procedures in systemic psychotherapy are bound to raise questions: These procedures are indebted to a medical model which is pathology- and deficit-oriented and which requires that diagnosis precedes therapy. Yet diagnostic procedures in systemic psychotherapy are mainly geared to assessing the psychic and social domains rather than the domain of medicine proper. The article takes up some of the issues and problems deriving from this state of affairs.     

The Preoedipal Development of the Critical Superego and Its Manifestations in Psychoanalytic Group Psychotherapy

Alexithymia is a psychic dysfunction in which symbolic thinking and fantasy are reduced, somatization is common, feelings are poorly communicated, empathy is impaired, and intimate interpersonal relations are difficult to maintain. Individuals with significant alexithymia may have a variety of psychiatric disorders but their psychotherapy should always be informed by an awareness of their alexithymia. This paper reviews the concept and details the most efficient means of psychotherapy for alexithymic patients. Ideal treatment for such patients maximizes their opportunities to learn while protecting their self-esteem and minimizing nonproductive stress. Such treatment involves concurrent individual and group psychotherapy. Clinical material is presented and specific therapeutic maneuvers are explored.     

ICD-10-Diagnosen in der psychotherapeutischen Praxis

An evaluation of the ICD-10 manual (Chapter V) reveals severe shortcomings of this diagnostic instrument concerning outdoor psychotherapy. It is well known that ICD diagnoses are restricted to symptoms and deficits of psychic functions; this restriction contradicts the definitions of psychic diseases as stated by the German “Psychotherapie – Richtlinien”. In Germany, third-party-payment is bound to therapies taking etological aspects into account. It doesn't make sense that the diagnostic system abandons any etiological foundation, making no difference between neurobiological, psychological and psycho-reactive factors fostering psychic diseases. The diagnostic principle of the co-morbidity impairs the therapist's diagnostic and therapeutic capacity to synthetize different phenomena to a common gestalt. Moreover, the new diagnostic category “personality disorder” is ill-defined and doesn't allow any conclusion of therapeutic relevance. The ICD-10 manual is maybe a suitable instrument in a research context, but its usefulness to promote quality assurance in outdoor psychotherapy is considerably restricted.     

Working with and ‘seeing through’ the sexual transference in the psychotherapy of an adolescent boy

This paper explores the challenges and developmental opportunities of working with the sexual transference in psychotherapy with adolescents. Psychoanalytic contributions investigating the nature of adolescent sexuality and the developmental move from a narcissistic organisation to a capacity to form intimate relationships are reviewed, and the question of what happens when there is a lack of containment in infancy is addressed. The way in which unintegrated sexual impulses and phantasies can invade the therapeutic relationship is further discussed through the account of the weekly psychotherapy of a 16-year-old boy who formed a powerful sexual transference to his female therapist. The paper highlights how working through the sexual transference enabled this young man to face his developmental paralysis and begin to use the therapy as an opportunity for psychic growth.     

Ambulante Psychotherapie bei Kindern und Jugendlichen

This paper presents the results of a study of the state of outpatient psychotherapy of children and juveniles in Germany after the PTG came into force. A total of 180 psychotherapists were questioned on certain issues. One result was that patients have to wait 4.5 months for psychotherapy and that every second patient asking for a diagnostic interview and possible treatment was refused.Of those who were given a diagnostic interview 43% were not taken into treatment, although disturbances were diagnosed such as addiction, bodily disabilities with psychic complications, enuresis/encopresis, anorexia nervosa, psychosomatic illnesses, developmental arrests which would normally demand psychotherapeutic treatment. Furthermore only 25% of those children and juveniles who Löcherbach et al. (2000, S.59 f.) considered needing and wanting psychotherapeutic treatment were actually in a G IV psychotherapy.Apart from this the possibility of getting psychotherapy as well as the kind of psychotherapy proved to be dependent on the kind of medical insurance. Differing payments by the insurance companies caused longer waiting times for patients and determined the choice of psychotherapy by the psychotherapists.     

Disintegration of the self and the regeneration of ‘psychic skin’ in the treatment of traumatized refugees

This paper presents a tentative understanding of the characteristics of the extreme traumas, elsewhere called ‘complex PTSD’, that some refugees and asylum‐seekers bring into therapy. It suggests that these kinds of traumas suffered during adulthood may involve a disintegration of the self and a loss of ‘psychic skin’. This conceptualization is derived from the treatment of a refugee who survived multiple extreme traumas and with whom efforts were made in therapy to identify a complex methodology making use of supplementary therapeutic tools in addition to individual psychotherapy. The case demonstrates how the disintegration of self implies not only a deep somato‐psychic dissociation, but also a loss of intrapsychic and interpersonal space. In the treatment this was worked through via repetition of the victim‐aggressor dynamics at multiple levels. In the end, the therapeutic context was structured like a set of concentric layers, creating a ‘bandage’ over the patient's wounds whilst his ‘psychic skin’ was able to regenerate. The conditions triggered by extreme traumas in refugees challenge some of the cornerstones of individual psychoanalytic technique, as well as the idea that individual therapy may be thought of as existing in an environmental vacuum.     

促进当事人的改变：基于治疗性最近发展区的视角

作为心理治疗的有效区域,治疗性最近发展区是指当事人当前适应问题经验的能力和通过治疗师的协助能够达成的潜在能力之间的距离。早期的同化模型理论更注重对心理治疗改变过程的描述,治疗性最近发展区理论则能够进一步解释治疗师在不同阶段的帮助策略。在研究上,治疗性最近发展区理论建立在非传统的方法论基础上,通过不断累积个案的质性研究,帮助治疗师理解和解释不同咨询效果的互动过程,并使理论得到持续发展;在临床上,治疗性最近发展区为理解心理治疗过程中倒退现象提供了新视角,并能够有效指导在治疗过程中采取挑战性还是支持性策略。未来研究可从临床上探索经验丰富的治疗师的实践智慧,也可选取较大跨度的治疗对话序列,对不同流派的特点,从不同参与者的视角出发进行研究,进而深化对心理治疗过程机制的理解。     

Truth and falsity in group

The universal tension and juxtaposition between truth seeking and truth evasion are explored in a contemporary relational context, drawing on Bion 's later ideas on group. Bion's key idea of "psi," or psychic evasiveness, refocuses group theory, supplementing intra- and inter-psychic perspectives with sociopolitical analysis. To some extent the psychotherapy group exists as a political "Establishment" and thus corresponds to psi. Using three illustrative case examples, the nature and nurture of truth evasion is considered, along with the purposes it serves and the forms it may take. The therapist must maintain a disruptive-creative influence on group process, but like other group members, he or she instead may accept and promote falsity. Whereas the therapist ensures the integrity of the culture, the members, and not solely the therapist, break up old relational patterns and experiment with new ones. Dynamic, evolving groups aid the leader in life-affirming truth-seeking, eventually challenging establishment tendencies and exposing falsity.     

The embodied analyst: from Freud and Reich to relationality

This paper presents the impact of clinical supervision on once-weekly psychoanalytically-informed training psychotherapy. The development of Oedipus complex theory is presented, culminating in Britton's work on the triangular space that opens up by working through the complex. The geometry of psychic space is described to highlight the importance of supervision, especially when training in therapy. The theme of spiders and cobwebs emerging from the clinical material provides a powerful metaphor for the tensions in psychic space. In the course of this training, the trainee therapist was at times less able to benefit fully from supervision, and thus the third position partially collapsed. Vignettes from anonymised clinical work are presented in the three ‘phases’ of this therapeutic process, illustrating the impact of the presence – and relative absence – of supervision.     

Précarité psychique et dispositifs d'intervention clinique

The author tries to analyze the characteristics of the situations of psychic precariousness, which appear in a more manifest manner in the social field but which also exist in various fields. In these situations, an archaic conflictuality dominates, the psychical reality is covered by various "material realities". When the subjectivation process of the suffering is failing, the much primitive sufferings act through institutions and require to be located and contained by an attention or linking work. These situations cannot be treated like situations of psychotherapy: the request, the symptom and the framework are not sufficiently identified. It is then necessary to stress the offer of attention, the indices of the suffering and the device. The clinician must thus fight against the crushing of psychic temporality for maintaining the attention to the other. The devices are thus in an anticipation of the suffering and of the request, their characteristics are the qualities to be sufficiently "attractive" and attentive to the present situation and to be leaning on the other registers of reality (social, medical, educational, legal etc.).