Brauchen wir Richtlinien oder Leitlinien für psychotherapeutische Behandlungen?

In many countries, psychotherapy is increasingly influenced by standards of scientifically evaluated methods and disorder-specific approaches. Referring to the definitions of the Scientific Council for Psychotherapy in Germany (WBP) concerning the differentiation of modalities, methods and techniques, this article points out that clear distinctions between modalities and methods are increasingly vanishing; instead, the tendency, especially within behavior therapy, to integrate all scientifically based methods and techniques is prevailing. This trend runs parallel with a development away from ?disorder-specific“ to a ?disorder-oriented“ approach. Facing the fact that technical aspects explain a relatively small proportion of outcome variance in psychotherapy, research related to the quality of psychotherapists is recommended. In addition, ?empirically validated psychotherapists“ should receive guidelines instead of rules of action.     

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.     

Passt oder passt nicht?

Differential indication in psychotherapy should be a process of decision making, that takes multiple factors into account, and not just the assignment of a particular disorder to the adequate therapeutic method. Unspecific characteristics of the patient, instead of disorder-specific features, as well as personality characteristics of the therapist having therapeutic relevance are important factors either. In this way decisions for an indication then turn into the crucial question of matching between patient and therapist. The receptivity of the patient is a central component. As a result of successful maching, the therapeutic relationship will improve which has a positive influence on the outcome of psychotherapy. According to the generic model of psychotherapy 4 levels of the decision-making process are defined. They serve as orientation for a differential indication taking into account both persons and methods. The realization of this indication model in in-patient treatment has some preconditions. Obligatory is the availability of a variety of therapists differing in therapeutic methods and personal characteristics. The mostly applied principles of matching decisions are listed in tabular form and illustrated by a case report.     

How central is the alliance in psychotherapy? A multilevel longitudinal meta-analysis

Prior meta-analyses have found a moderate but robust relationship between alliance and outcome across a broad spectrum of treatments, presenting concerns, contexts, and measurements. However, there continues to be a lively debate about the therapeutic role of the alliance, particularly in treatments that are tested using randomized clinical trial (RCT) designs. The purpose of this present study was to examine whether research design, type of treatment, or author's allegiance variables, alone or in combination, moderate the relationship between alliance and outcome. Multilevel longitudinal analysis was used to investigate the following moderators of the alliance-outcome correlation: (a) research design (RCT or other), (b) use of disorder-specific manuals, (c) specificity of outcomes, (d) cognitive and/or behavioral therapy (CBT) or other types of treatments, (e) researcher allegiance, and (f) time of alliance assessment. RCT, disorder-specific manual use, specificity of primary and secondary outcomes, and CBT did not moderate the alliance-outcome correlation. Early alliance-outcome correlations were slightly higher in studies conducted by investigators with specific interest in alliance than were those in studies conducted by researchers without such an allegiance. Over the course of therapy, these initial differences disappeared. Apart from this trend, none of the variables previously proposed as potential moderators or mediators of the alliance-outcome relation, alone or in combination, were found to have a mediating impact.     

Therapy with Refugee Families: What Is a “Good” Conversation?

This article addresses the question of what is a “good” conversation by analyzing “poor” conversations. During a project on family therapy with refugee families, we often experienced what we labeled as “poor” conversations. We present examples of a variety of such conversations, which we then analyze with reference to therapeutic maps and central concerns of the therapists. We describe four patterns of therapist/client relationships that emerged from this analysis. The main focus of our discussion is to clarify when “poor” conversations may be an important part of the therapeutic process, and when and how they should be avoided. We believe that the issues we raise are central to therapeutic work in general and not just to therapy with refugee families.     

EXPLICATING THE IMPLICIT: THE LOCAL LEVEL AND THE MICROPROCESS OF CHANGE IN THE ANALYTIC SITUATION

This paper proposes a method of examining the micro-events of the analytic process that borrows heavily from developmental research. The increasing importance of illuminating the microprocess of interaction to understanding the process of change in analytic treatment is emphasised. A set of constructs and terminology is proposed for the study of the moment-to-moment interactive process in psychoanalytic therapy referred to as the local level. A theory of therapeutic action based on 'local-level' process is then explicated. Its central element involves a step-by-step process of 'fitting together', which leads to changes in implicit knowing through alteration of emotional procedures.     

Phylo- and ontogenetic fears and the expectation of danger: differences between spider- and flight-phobic subjects in cognitive and physiological responses to disorder-specific stimuli

To compare specific phobias with an assumed phylogenetic or ontogenetic origin in responses to fear-relevant (FR) stimuli, 17 spider- and 17 flight-phobic participants were exposed to pictures of spiders, flight accidents, or mushrooms randomly followed by either a startling noise or nothing else. While both groups showed a disorder-specific expectancy bias, only spider-phobic participants exhibited a disorder-specific covariation bias. Spider-phobic participants also showed enhanced skin conductance responses (SCRs), event-related brain potentials (ERPs), and startle responses triggered by disorder-specific FR pictures while flight-phobic participants showed only disorder-specific enhanced SCRs. In sum, our direct comparison between ontogenetic and phylogenetic phobias revealed that the former is characterized by biased and enhanced responses triggered by disorder-specific FR stimuli presumably based on a biological preparedness.     

Can research influence clinical practice?1

After briefly reviewing the unfavourable reception accorded empirical research by parts of the psychoanalytic community, as well as some of the benefits to clinical practice of analysts being involved in research activities, the author examines whether the findings of process and outcome research in psychotherapy and psychoanalysis can help identify the most appropriate forms of intervention for producing therapeutic change, given the specific condition of the patient and the relationship that the individual establishes with the analyst. He argues that research findings can influence clinical practice on various levels and in different areas, and goes on to examine a number of related issues: the specificity of therapeutic interventions versus the relevance of common curative factors; the dyadic conception of technique and ways of understanding the therapeutic action of the treatment alliance; and the strategic or heuristic conception in psychoanalytic therapy. Finally, the author presents clinical material with the aim of illustrating how the knowledge acquired through research can be applied to psychoanalytic treatment.     

Prospects for prenatal gene therapy in disorders causing mental retardation

Advances in understanding the genetics and pathogenesis of disease and in prenatal diagnosis have lead to an exploration of ways to intervene earlier and earlier in the disease process. The possibility of prenatal gene therapy for severe genetic and developmental disorders has sparked new research and debate as to its feasibility, reliability, and ethics as a therapeutic option. Recent animal studies have demonstrated the feasibility of introducing a vector into the developing fetus. The optimal timing and best mode of delivery, however, have yet to be defined. Whether or not this research should be pursued also has been the subject of recent bioethical debates. There is additional concern with the possibility of in utero gene transfer inducing mutagenesis and subsequent tumor formation. This review will provide a summary of the current state of knowledge in the field of prenatal gene therapy and possible directions for the future research.     

Therapeutic action in psychoanalytic therapy with toddlers and parents

Psychotherapy with toddlers and parents can focus on promoting attachment, facilitating development and improving interactions. Some techniques provide guidance to the parents, whereas others interpret to them their unconscious fantasies or ‘ghosts’ contributing to the child’s disorder. A recent paper introduced a psychoanalytically oriented technique, which emphasised the therapist’s interaction with the child in the presence of the parent(s). The child was addressed about his/her unconscious motivations in the session and the feelings towards the therapist. Also, the parent’s transference onto the therapist was seen as a vehicle that might further the therapeutic process and was accordingly addressed. The present paper analyses the therapeutic action in such treatments. Whereas work with the parents resembles that of ordinary psychodynamic therapy, therapeutic action is more difficult to conceptualise regarding the toddler, whose understanding of verbal interpretations and the therapist’s dialogues with the parent is more limited than that of an adult. However, a clinical vignette demonstrates a toddler’s precise and swift reactions to communications from mother or therapist. The paper investigates evidence from neuroscience and psychological research as to which communicative channels – beyond words – toddlers might perceive and comprehend. In addition, it is claimed that the countertransference is key to explaining how the therapist understands such communication.     

Hypotheses are dialogues: sharing hypotheses with clients

The use of systemic hypotheses in therapy has been criticized on the ground that it promotes the expert position of the therapist and tends to underplay the role of the client in the therapeutic process. In this article, we propose to view the systemic hypothesis as a collaborative action, involving the dialogue between therapists and clients. This interactive hypothesis is created by the very interaction of all participants in the therapeutic dialogue, and as such it may be considered a dialogue in itself. The article articulates a way of hypothesizing that is consistent with both systemic and dialogic premises, and presents some examples of the process in action.     

Abh?ngigkeitserkrankungen und Pers?nlichkeitsst?rungen

Substance use disorders and personality disorders often co-occur in clinical treatment. In this review the association between substance use disorders and personality disorders is described and discussed. Clinical and neurobiological data as well as psychodynamic concepts are included to focus on the therapeutic implications for patients with these comorbidities. The consumption of substances often begins as a kind of self-medication. Patients suffering from severe personality disorders need these substance effects to avoid severe destructive affects and to regulate their self-esteem. Patients with chronic substance dependence often show changes in brain structure. In the dependency stage of addiction clinical symptoms can make the diagnosis of a specific personality disorder very difficult. The treatments can be classified by the severity of substance use disorders and personality disorders. Substance misuse can be treated with psychotherapy. In substance dependence, specific forms of addiction therapy should be included. In patients with the frequent comorbidity of substance use disorders and severe personality disorders, disorder-specific treatment can be used with good results.     

Die therapeutische Beziehung

The therapeutic relationship is deserving of special consideration. Both knowledge of the widely varying aspects of proposals in terms of possible relationship regulation and acquisition of the different forms of therapeutic relationship management are crucial for therapeutic success. Impact factors are used in the psychotherapeutic process (resource activation, problem activation, problem identification and problem solving), which are predominantly used in rapid succession or even simultaneously. This is also true of the relationship proposals intended and deployed by the therapist, which can also be conceptualised on the basis of impact factors. It has been shown that a single relationship quality can have very different mechanisms of action (e.g. on problem updating and identification). Successful therapeutic relationship regulation is characterized by high flexibility on the part of the therapist, who is able to move between the poles of understanding/confirmation, guidance/support and leadership/control. A good therapeutic relationship in terms of effecting an improvement in the patient is characterized according to the therapist’s flexibility as regards what he/she can offer in the relationship, a flexibility which can no longer be squarely attributed to one therapy discipline alone. In order to take the significance of the therapeutic relationship into account, the training and specific skills required for this need to be taught during training and supervision. A prerequisite to this, in addition to a sound theoretical training in the relevant aspects of relationship regulation, is relationship regulation skills in terms of both concept and own practical experience.     

Dilemmas in kinship care: negotiating entitlements in therapy

This paper considers how ideological dilemmas that arise in therapy can be analysed usefully for therapeutic practice. The focus is on the particular situation of kinship care families where family or friends are caring for children without birth parents being present. In the process of family members negotiating the entitlement to care and to be cared for, multiple possibilities about family constructions and authorities throw up many dilemmas for therapists and families. Based on the author's research study with kinship care families, a method for linking discourse theory and therapeutic practice through the use of discourse analysis and positioning theory is explored, with reference to the hierarchical method of the Co‐ordinated Management of Meaning model. The paper contends that a consideration of ideological dilemmas in conversation is a core part of any therapeutic encounter, which needs to be recognized and considered in order that those involved in therapy may reflect on several possible futures and so open up the space for future decision‐making.     

Psychoanalytic psychotherapy in paediatric liaison: a diagnostic and therapeutic tool

Paediatric liaison work requires an appreciation of the interweaving of the different factors involved when a child has physical symptoms. Psychoanalytic psychotherapy is usually viewed simply as a potential treatment option. This paper argues that its use is both therapeutic and diagnostic and that it should be valued for this breadth of contribution. The therapeutic process is conducted in a way that can promote an understanding of the child and their context and thus enhance the ability 9 to meet the child's needs by all involved in their care. This can be achieved without sacrificing the degree of privacy that the psychotherapist/patient relationship requires. Material is presented from the psychotherapy of a child who had an hereditary condition which moved unexpectedly into a terminal 2 phase after psychotherapy was started. Examples are given to illustrate the importance of the understanding gained from therapy and how, through an integrative process, it was used to assist the overall 4 care. The material also describes the potential diagnostic use of information from psychotherapy when this is formulated by consideration of conscious and unconscious mechanisms alongside mental state phenomenology. This has implications for the relationships between disciplines and for their training requirements.     

Portrait of the therapist as a shaman

What follows will show that an understanding of the nature and purpose of shamanism contains a number of insights that bring to light some important, but often obfuscated, aspects of Western therapeutic practices. the point of departure of the argument is the theory of shamanism developed by the inventor of structural anthropology: Claude Lévi-Strauss. It will be argued, in particular, that his theory of shamanism provides a key to the therapeutic action of symbols upon the body as well as to the broader social function of therapy in general.     

Patterns of psychotherapy development: A mixed-method analysis using assimilation indices

Understanding how assimilation develops is essential in promoting personal change. By attending to signs or indices of assimilation in the speech of clients, therapists can use this process to assess how the therapy is developing and to tailor intervention. The system of assimilation indices was developed to use assimilation to understand the process of change. This system signals five sub-processes of assimilation: external distress, pain, noticing, decentring, and action. This study consisted of a longitudinal mixed-method analysis, following a multiple cases embedded design. The system of assimilation indices was applied to the recordings of nine psychotherapies and contrasted with both the outcome of the therapy and the perspectives of the therapists and clients about their therapy process. The results show that the system of indices is useful in understanding multiple pathways for assimilation. The system of indices is seen as a useful tool for understanding assimilation and as having clinical value in anticipating challenges to the success of the therapy. This study also shows how the indices are sensitive to the nuances in the change process observed in clinical settings.     

Placement of responsibility and moral reasoning in couple therapy

Within the past two decades there has been a growing awareness of the importance of moral and ethical judgements in family and couple therapy. In this article we provide a detailed analysis of placements of responsibility related to blame in one couple therapy session. We suggest that it is important to study therapeutic interaction in situ , when searching for an understanding of moral reasoning in couple therapy and an ethical evaluation of the practice. A detailed analysis of discursive tools used by clients and therapists makes it possible to look at moral reasoning in action as it unfolds within the flow of therapeutic conversation. The findings are discussed in relation to two discourses of moral justification: autonomy and relationality. The principle guiding the therapists' actions in the studied conversation could be called 'relational autonomy'.     

Systemic family therapy can be manualized: research process and findings

Determining the efficacy of therapeutic interventions is becoming an increasing political and ethical necessity. Comparative therapeutic outcome trials are most powerful when there is a precise specification, or manualization, of the forms that therapies took. Manuals have begun to be developed for structural/behavioural family therapy and couple therapy. The development of these manuals is often reliant on experts' self-report, rather than a systematic analysis of the therapeutic process as it happens. This can limit their validity and applicability to standard clinical practice. In addition, no manuals exist which reflect less structured forms of family therapy aimed at incorporating systemic, postmodern and narrative frameworks. The feasibility of producing a workable manual that reflects the fluidity of such practices has been questioned.
A research project to systematically create and test such a manual is reported. Multiple data sources and research methods, primarily qualitative, were applied to generate a rich specification of the therapy. In reporting these results the contents of various aspects of the final manual are indicated. Procedures to ensure that the prescribed practice is consistent with a widely used approach to systemic family therapy are also described.
The manual will be an important tool for outcome research and therapeutic practice. The account of the research process should be helpful to researchers engaged in constructing a manual for other models of family therapy based on a rigorous analysis of actual practice. The manual itself is available for use by outcome researchers who wish to evaluate this widely used form of systemic family therapy.     

Holding in mind: Theory and practice of seeing children in groups

ABSTRACT The authors will describe their therapy group for children in a Child and Family Consultation Centre. They will discuss the rationale for this treatment. An account will be given of the group processes with special reference to different feelings as they emerge in the transference relationships. Issues concerning the dynamics of co-therapy will be addressed. The work on the ‘reflective function’ by Fonagy and Target, which the authors think is an important contribution to understanding the therapeutic process in the group, will be discussed.

What literature there is on group therapy for children suggests that it is an effective form of treatment. This article describes the way in which the children's issues come alive in group therapy and in this way can be addressed quickly, in comparison with individual therapy where the process is sometimes slower. It will be emphasized that structure and boundaries are essential for containment of children so that psychoanalytic reflectiveness can take place. This reflectiveness includes understanding of the group process as well as the inner world of the child.