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.     

“… der Phantasieschlüssel bewährt sich“

In operationalized psychodynamic diagnostics (OPD) imagination is seen as a psychic resource (aspect of self) and as such integrated in the widely known thought system contrasting (inner) self-reflexivity and (outer) reality. In order to make better use of and profit by this resource therapeutically, the power of the imagination to generate structure needs to be conceptually included. The author proposes adding a further dual system comprising the imaginative and the rational to this known polarity of imagination and reality, thus widening the therapeutic scope through the dynamic versatility of the imagination. This system could also become part of future concepts of structural competences of the psyche.     

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.     

Psychodynamische Diagnostik

The paper describes the development and objectives of psychoanalytic diagnostics. It shows that one of the key tasks of psychoanalytic/psychodynamic interviews is to initiate the doctor-patient relationship and that the patient’s motivation for treatment is to be examined and promoted in the interview. Different sources of information for the interview are then described; following a presentation of various systematic approaches of psychodynamic diagnostics, the principles of biographic history-taking are also explained. Modern psychodynamic diagnostics provides complex access to the patient, covering both elements of open interviewing and more exploratory approaches. Options for integrating these various methodological approaches are highlighted. Finally, more recent approaches in psychodynamic diagnostics that have a stronger relation to treatment planning are presented. These include the Structural Interview developed by Kernberg and Operationalised Psychodynamic Diagnostics (OPD).     

Assessing the Level of Structural Integration Using Operationalized Psychodynamic Diagnosis (OPD): Implications for DSM-5

A key ingredient in the current proposal of the DSM-5 Work Group on Personality and Personality Disorders is the assessment of overall severity of impairment in personality functioning: the Levels of Personality Functioning Scale (LPFS). The aim of this article is to contribute a conceptual and empirical discussion of the LPFS from the perspective of the Operationalized Psychodynamic Diagnosis (OPD) system (OPD Task Force, 2008 ). First, we introduce the OPD Levels of Structural Integration Axis (OPD-LSIA), a measure of individual differences in severity of personality dysfunction that is rooted in psychodynamic theory. We show that the OPD-LSIA is reliable, valid, and highly associated with observer ratings of personality disorders. In the second part, we present results from an OPD expert consensus study exploring potential limitations of the current LPFS item set from the perspective of the OPD-LSIA. We conclude with highlighting implications for future revisions of the DSM-5 proposal.     

Angstzustände bei Patienten mit schweren Persönlichkeitsstörungen

States of anxiety are very common problems in patients with severe personality disorders. All phenomena of anxiety can be observed. In this connection a continuum of the severity of impairment of structural personality organisation can be postulated. In many cases proper anxiety disorders exist as comorbid disorders. Anxiety is esteemed to be the central affective problem of borderline patients. In spite of these relations, states of anxiety in patients with personality disorders are often underdiagnosed or misdiagnosed. For the treatment of neurotic anxiety disorders (for example panic disorders), there exist disorder-specific therapy manuals that proceed from behavioural as well as psychodynamic perspectives. Nevertheless, for the treatment of anxiety states in personality disordered patients, the techniques that focus heavily on symptomatology appear often contraindicated. In our opinion, treatment of these typically severe anxieties must be contained within a therapeutic framework, which essentially takes into account the personality organisation of this group of patients. Such treatment makes special demands on the therapist for working with transference and countertransference processes. From a disorder-specific psychodynamic perspective recommendations are given for psychotherapy.     

Strukturniveau,Abwehr und Merkmale von Träumen

Attempts were made early on to associate certain human characteristics with dreams. The psychoanalytical notion of structure encompasses a fully differentiated construct, which in particular is characterized by basic mental capabilities. The structural level of a person derived from this reflects their ability for communicative exchange and dealing with themselves as well as with social partners.Within the framework of the project “Affectivity, relationship and mental disorder” operationalized psychodynamic diagnostic (OPD) interviews were carried out, from which the reports of dreams were evaluated for this investigation using the dream generation model of Moser and von Zeppelin. The aim was to investigate associations between features of dreams and the structural level. A total of four different indicators of structure were investigated, e.g. number of personality disorders, OPD-2 structural level, inventory of personality organization (IPO) and the defence maturity quotient, with reference to the association with dream characteristics according to Moser and von Zeppelin.In this investigation only a few associations between dream characteristics and structural level could be identified. The clearest was the association between the degree of maturity of defence and the dream characteristics. Dreams from persons with a more mature defence appeared more complex and livelier. Dreams from persons with a good structural integration according to OPD-2 are also characterized by more “animation” than dreams from less structured persons. The dreams from persons with a moderate structural level do not show any significant differences to those with low structural integration.The results are first and foremost critically discussed with reference to the methods.     

Psycho-educational group treatment for the severely and persistently mentally ill: how much leader training is necessary?

Psycho-educational groups (PEGs) have been shown to be a particularly effective form of treatment for patients classified under the rubric of severely and persistently mentally ill (SPMI). However, recent surveys suggest that certain professionals, such as nurses and clinical psychologists, called on to conduct these groups may have limited to no training. This study tested three methods (self-instructional, workshop, and workshop plus clinical supervision) designed to provide on-the-job training to practicing clinicians. Specifically, training was based on two manuals; one that operationalized the basic knowledge and skills needed to run an effective PEG and the second being a commonly used PEG program for symptom management targeted at SPMI patients. Eight nurses from four adult units at a state psychiatric hospital initially received self-instructional or workshop training and then conducted a 12-session symptom management PEG composed of four to five SPMI patients (e.g., schizophrenia, schizoaffective or major depression disorders). In a second wave of additional training, nurses received workshop training or clinical supervision and then conducted a second PEG. Differences between training methods were assessed by nurse- and patient-completed measures that tapped the knowledge and skills emphasized in the symptom management and PEG (nurses only) manuals. Results indicated limited support for the superiority of the workshop method on the nurse measures alone. Implications for training working professionals in group treatments and assessing outcomes with chronic SPMI patients are discussed.     

Aneignung der Suchterkrankung

Addiction develops on the basis of a psychic disorder but acquires relative autonomy. Therefore, psychodynamic therapy of addiction needs its own theoretical foundation and specific diagnostic instruments. The process of the subjective acceptance of the addiction by the addict himself is introduced as an important concept. The continuum of acceptance is differentiated into three levels: defense, acceptance, and compensation. It is argued that a specific diagnosis of acceptance connected with the system of Operationalized Psychodynamic Diagnostics (OPD) can contribute to a more differentiated therapy of addiction. A rating scale for the measurement of the acceptance of addiction is proposed. It defines the three levels mentioned above, divides each into two sub-levels and lists specific items. Questions of application are discussed. Clinical experience indicates that the application of the scale together with the OPD instruments improves the planning of addiction therapy.     

Group psychodynamic counselling with final-year undergraduates in clinical psychology: A clinical methodology to reinforce academic identity and psychological well-being

Educational institutions should ensure that students develop a professional identity, as well as safeguarding their well-being and activating awareness and change processes. The aim of this study was to assess the efficacy of group psychodynamic counselling as a means of reinforcing academic identity – considered the forerunner of professional identity – and psychological well-being in a group of final-year undergraduates studying clinical psychology. Thirty-three final-year-students of clinical psychology who participated in six group psychodynamic counselling sessions were compared with sixteen final-year students of clinical psychology who had never participated in an intervention of this kind. The results suggested that group psychodynamic counselling made students feel more capable of managing their lives and more open to new experiences as well as encouraging them to perceive their relationships as more positive and satisfying, to believe that their life is meaningful, and to achieve greater self-acceptance. The in-depth exploration also prompted students to consider their commitment to their choice of career. Group psychodynamic counselling also reinforced students’ educational choice, as the likelihood of students becoming less committed to this choice was reduced after the intervention. Thus, the study confirmed the efficacy of group psychodynamic counselling as a means of reinforcing both academic identity and promoting well-being and demonstrated that it is a tool clinical psychologists and university teachers could use to activate self-reflection and change within educational settings.     

Experimentation with Group Techniques with Ego-Disturbed Mothers

Abstract

Psycho–educational groups (PEGs) have been shown to be a particularly effective form of treatment for patients classified under the rubric of severely and persistently mentally ill (SPMI). However, recent surveys suggest that certain professionals, such as nurses and clinical psychologists, called on to conduct these groups may have limited to no training. This study tested three methods (self–instructional, workshop, and workshop plus clinical supervision) designed to provide on-the-job training to practicing clinicians. Specifically, training was based on two manuals; one that operationalized the basic knowledge and skills needed to run an effective PEG and the second being a commonly used PEG program for symptom management targeted at SPMI patients. Eight nurses from four adult units at a state psychiatric hospital initially received self–instructional or workshop training and then conducted a 12–session symptom management PEG composed of four to five SPMI patients (e.g., schizophrenia, schizoaffective or major depression disorders). In a second wave of additional training, nurses received workshop training or clinical supervision and then conducted a second PEG. Differences between training methods were assessed by nurse– and patient–completed measures that tapped the knowledge and skills emphasized in the symptom management and PEG (nurses only) manuals. Results indicated limited support for the superiority of the workshop method on the nurse measures alone. Implications for training working professionals in group treatments and assessing outcomes with chronic SPMI patients are discussed.     

Understanding negative hallucination: toward a developmental classification of disturbances in reality awareness

Negative hallucinations are explored from a psychodynamic viewpoint in four cases of neurosis. Next, shifting to the level of clinical theory, negative hallucinations are contrasted with five better-studied disturbances in reality awareness. It is noted that all six function as screen phenomena, and all occur in everyday contexts. These and other phenomenological issues lead to an assertion that negative hallucinations are regressive perceptual phenomena, similar in form to both preconscious perceptions and infantile amnesia. Finally, developmental considerations are used to derive a coherent hierarchy of disturbances in reality awareness.     

Ambivalenz in der psychiatrischen Organisation

For the past 100 years Bleuler??s ambivalence terminology has been applied to many aspects of the psychiatric treatment of patients, particularly in the realm of diagnostics and therapy. It has, however, been adopted in an approach mainly limited to psychopathological phenomena. This article discusses whether advanced concepts of ambivalence can facilitate the analysis of current challenges and problems of institutional psychiatry, placing them in a new light. It describes a wide range of psychiatry-specific ambivalence experiences by investigating the field of activity of individual therapists as well as of interdisciplinary therapeutic teams. Particular attention is given to an ambivalence-oriented perspective of clinic management taking uncertainty and complexity into consideration. In such different contexts modern ambivalence concepts give way to a psychodynamic understanding of clinical areas of conflict, thus extending the possibilities of multimodal therapy. When dealing with complex leadership and planning tasks, sensibility and tolerance towards ambivalence phenomena and conflicts prove to be unusual but valuable problem solving resources.     

Charakterpathologie – Persönlichkeitsorganisationen – Strukturniveaus

Following the recent development of special treatment for people with defective ego structures, the diagnosis of ego structures has become highly relevant. Four models, developed during the last 40 years for the differentiation of particular levels of the ego structure are presented: the classification of character pathology (Kernberg 1966), the personality organisations (Kernberg 1977 and 1996), the structure axis of the OPD (Operationalized Psychodynamic Diagnosis 1996) and the personality organisations of the STIPO (2006). Because the levels of character pathology, the personality organisations as well as the structural levels of the OPD are widely used and the last two often even in parallel, it is worthwhile comparing them concerning their strengths, weaknesses and compatibility. It turns out that especially the categories between the neurotic and the borderline personality organisation (Kernberg 1977) show significant differences. The fact that the OPD as well as the STIPO pay much more attention to these levels as the models of personality organisations also do, is to be considered because of its great clinical significance as an advantageous innovation. In addition, both instruments offer the possibility to assign different structural levels to particular dimensions and, due to their operationalization, assure comparability and allow change measurement.     

Operationalisierte Psychodynamische Diagnostik des Kindes- und Jugendalters

There are only a few studies focusing on the mental structure and its change in children and adolescents with psychiatric disorders. This study aimed at investigating change in the mental structure of children and adolescents over time. At intake 60 inpatients were interviewed with the operationalized psychodynamic diagnostic interview for children and adolescents (OPD-CA). After an average of 27 months 25 patients agreed on participating in the follow-up study. The OPD-CA was conducted again and the Kiddie-Sads present and lifetime version (Kiddie-Sads-PL) as well as parent-based ratings child behaviour checklist (CBCL) and strength and difficulties questionnaire (SDQ) were applied. A consensus rating of the OPD-CA was attained by three researchers well experienced with the use of the OPD-CA. The level of structural integration improved significantly, in particular in the dimensions “control” and “communication skills”. There were no significant changes in the dimension “self-perception/object-perception”. The improvement was also observable in parent-report questionnaires. This study makes a contribution to the idea that changes in the mental structure of children and adolescents can be shown and measured with the OPD-CA.     

Does Economic Development Affect Life Satisfaction? A Spatial–Temporal Contextual Analysis in China

Social context affects people’s life satisfaction because it provides a natural reference for evaluating their own socioeconomic standing. Given their reference role, social contexts operationalized by space versus time may have very different implications. Our hypothesis is that spatial variation in economic development has little impact on life satisfaction as individuals living in different locales are unlikely to experience this variation personally, but that short-term temporal changes in economic development, on the other hand, do have an impact, as individuals in a given locale experience these changes directly. These two very different implications of spatial versus temporal social contexts are tested with an analysis of repeated survey data in 60 counties of China from 2005 to 2010. The results show that life satisfaction does not vary much with regional differences in economic development but responds positively to the local level of economic development over time. That is, the contextual effects of economic development vary greatly depending on how social context is operationalized. Temporal context matters far more than regional context where individuals’ life satisfaction is concerned.     

An approach to supervision in health care settings

This article describes a flexible approach to supervision which allows for the fact that integration may mean different things to different people under different circumstances. In the health contexts described the clinical mix which was found most helpful in the supervisory work combined psychodynamic, Jungian and humanistic perspectives. The application of this particular mix of clinical techniques is demonstrated with reference to the work with two supervisees. It is felt that the methods employed are consistent with the current notions of difference in counselling and psychotherapy.