In 300 Stunden um die Welt

The time frame of psychoanalytic long-term treatment depends on the therapy goals and the means by which these are expected to be reached. A core element for this is the concept of working through. In Freud’s view working through deals with resistance towards the acceptance of an interpretation regarding unconscious conflicts. Also, in classical terms there is a working through of the transference neurosis. Conceptual intertwining with the work on mourning (in terms of libidinal decathexis) brings a difficulty to light, namely the potential danger of misusing long-term treatment and the therapeutic working relationship for avoiding termination and separation. The basic concept of working through can be maintained for patients with non-neurotic disorders as well as regarding modified psychodynamic psychotherapies with fewer sessions and lower session frequency, albeit in consideration of the theory of therapeutic change for each form of treatment; however, a three-fold meaning of working through in contemporary psychoanalysis (i.e. working through of resistances, working through of transference neurosis and the structurally changing inner work of the patient) indicates the need to discuss the necessary duration of long-term treatment neither from a viewpoint of economic efficiency nor from a standpoint of mere professional policy but to base this on the logic of the dynamics of a disorder and the treatment planning.     

Zukunftsperspektiven sexualforensischer Psychotherapie

There is a controversial discussion on to what extent sexual forensic psychotherapy has a positive influence on the legal probation of sexually delinquent people. From this the question arises on how treatment with a perspective for success could be structured. This article assumes that such a perspective can only succeed through close cooperation between science and psychotherapeutic practice. Through the analysis of a methodologically elaborate study, considerations on the motivation and the influence of empirically ascertained risk factors are developed and each placed in relation to scientific and therapeutic practice. In this way various problems are tackled, which range from insufficiently described interventions via too little therapeutic flexibility up to limitations in the scientific evaluation. Finally, possible barriers for the development of such a perspective are discussed and the connection to the so-called risk-need-responsivity (RNR) model is explored.     

Wie können Langzeittherapien mit kürzeren Behandlungen verglichen werden?

Long-term psychotherapy is not recommended in the current guidelines, which are based on the criteria of evidence-based medicine, as there is a lack of confirmation for long-term psychotherapy by efficacy studies. Using the example of psychoanalytic long-term psychotherapy this article describes six dilemmas which impede the realization of efficacy studies for long-term psychotherapy. Finally, basic elements of a study design are proposed, which are considered as being adequate to compare (psychoanalytic) long-term psychotherapy with shorter treatment forms in terms of outcome and cost-effectiveness. The anxiety and personality disorders (APD) study is briefly described as an example of a study realizing the proposed design.     

Pathologisches Glücksspiel und Delinquenz

Pathological gambling is characterized by excessive gambling behavior which influences the life and well-being of a person in a dysfunctional way. It often leads to severe consequences in social and family life, career and material matters. This can also include illegal acts. In the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) excessive gambling was classified under impulse-control disorders but was renamed as gambling disorder (GD) and reclassified under the category “substance-related and addictive disorders” in DSM-5, due to parallels to substance use disorders in the clinical characteristics as well as genetic and neurobiological factors. In Germany, approximately 0.5?% of the adult population suffer from GD. Especially gambling machines are associated with an increased risk of gambling-related problems. Common comorbidities are substance-related and affective disorders. The most important risk factors are young age, male gender, a history of migration, gambling-related problems in the family, unemployment, a low educational level and low household income. Delinquent behavior was not considered to be a sufficiently discriminative factor for GD, although there is a correlation between delinquency and gambling behavior. In addition, those GD subjects who show delinquent behavior also show a specific risk profile. Thus, mental health professionals should be aware of possible psychosocial consequences in GD, such as illegal acts, and this should be addressed in the effective treatment strategies, such as cognitive behavioral therapy. Moreover, it is necessary to improve the access routes for affected people into healthcare system in order to ensure early detection and treatment of the disease.     

LAC-Depressionsstudie

The study on long-term therapy of chronic depression (LAC depression study) is one of the first prospective studies to compare psychoanalytic with cognitive behavioral long-term treatment and also investigates the impact of patient assignment by randomization and preference. This comprehensive multicenter study combines a naturalistic and a randomized controlled approach. The long-term follow-up is based on a broad spectrum of quantitative and qualitative research methods and is expected to contribute to the further development of psychotherapeutic treatment methods in this hard to treat patient group as well as to research on the effectiveness of long-term treatment. The background, design and current state of the assessment are presented. A total of 402 patients with chronic depression were included in the trial and the 1 and 2?year follow-up results are currently being analyzed.     

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.     

Evidenz für psychodynamische Langzeittherapie

Despite continually increasing evidence for the effectiveness of psychodynamic psychotherapy in general, the empirical status of long-term psychodynamic psychotherapy (LTPP) remains controversial. Convincing outcome studies of LTPP were lacking for a long time. This article gives an overview of available systematic reviews addressing the evidence for LTPP. The findings suggest that LTPP can yield large and stable effects across a variety of diagnoses and particularly in complex mental disorders, which even tend to increase after termination of treatment. In comparison to other shorter or less intensive methods of psychotherapy, LTPP has proven to be significantly superior with respect to most outcome domains. First economic analyses suggest that LTPP may be cost-effective in the long run. The comparison of randomized controlled with observational studies revealed no significant differences in outcome; however, the evidence for LTPP is frequently challenged by proponents of other therapeutic approaches or scientific orientations. The criticisms were repeatedly answered and none of the concerns raised by critics identified an issue that would have affected the overall conclusions of the available reviews. Nevertheless, further studies are urgently required to broaden the evidence base for LTPP in order to allow more refined analyses addressing the effects of specific forms of LTPP both in specific disorders and in comparison to specific forms of alternative therapies.     

Kinderpornografie

The quantity and distribution of child abuse material (“child pornography”) has substantially risen since the advent of the internet facilitated access. Due to the international character of the associated delinquency prosecution is confronted with several difficulties. In 2003 the European Union established a framework agreement to legally combat child pornography. The market for child abuse material is profitable, as production is comparably cheap. The number of convictions for relevant crimes varies but is generally still on a high level, even though reporting of relevant contents is decreasing. Providers and users might have switched to less controllable internet platforms. The physical and/or psychological sequelae for victims of child pornography are serious and ongoing. Studies show that compared to hands-on-offenders users of child exploitation material are generally younger, better educated and less often have a criminal record. Some of them (10–25?%) fulfill the diagnostic criteria of pedophilia. A child pornography offender’s risk of committing a hands-on-offence seems to be increasing with the diagnosis of pedophilia and antisocial personality traits. According to existing data, individuals whose only criminal record refers to illegal pornography seem to be at low risk for future offending with child abuse (0.2–6.6?%). Offenders who were already convicted for child abuse have a higher risk for re-offending when consuming (deviant) pornography. Several cognitive behavioral treatment manuals exist, however accurate diagnostic assessment and indication are required.     

Psychotherapie für Straftäter

The legal and administrative framework for psychotherapy of offenders in prisons and secure forensic hospitals is outlined. Established treatment programs for offenders are presented including different variations of standardized cognitive behavioral approaches, e. g. relapse prevention programs (RP), dialectic behavioral therapy (DBT), transference-focused psychotherapy (TFP), and mentalization-based treatment (MBT). The foci of the individual programs as well as their integrative tendencies are described. In psychodynamic therapies cognitive processes are taken into consideration and, vice versa, cognitive-behavioral therapists discover the significance of the therapeutic relationship.     

Fundamental Dilemmas in Contemporary Psychodynamic and Insight-Oriented Psychotherapy

Contemporary psychotherapists are being called on to provide treatment with increased degrees of brevity and efficacy. To meet these demands, the practice of brief psychodynamic psychotherapy has turned to (a) the increased emphasis upon a specific psychodynamic focus for treatment versus the more comprehensive goals of longer-term treatment, and (b) the augmented use of confrontation of psychological defenses versus the enhanced use of emotional support as in more nondirective psychotherapy. Other approaches to insight-oriented psychotherapy that have been influenced by this trend include: client-centered psychotherapy with its focus upon the therapeutic relationship; existential psychotherapy with its focus upon death anxiety; and, the revitalization of interpersonal psychotherapy from its original Sullivanian conceptualization. The clinical dilemmas that limitations of time and restricted therapeutic focus place upon each of these methods of treatment are the central issues of this discussion.     

The piloting of a brief relational psychodynamic protocol (psychodynamic addiction model) for problem gambling and other compulsive addictions: A retrospective analysis

The paper describes a treatment pilot for gambling and compulsive addiction within an NHS problem gambling clinic. The pilot study used a brief relational psychodynamic treatment protocol specifically designed to meet the needs of a group of patients who had not responded to CBT and who had other addictions or co‐morbidities. Seventy‐two (n = 72) patients were offered 12 sessions of therapy by four psychodynamic counsellors. Results were assessed using scores from a pre‐ and post‐treatment patient health questionnaire, the generalised anxiety disorder—7 (GAD‐7) and the Problem Gambling Severity Index (PGSI). Weekly feedback and supervision from counsellors and patients were used to assess the treatment model. The results highlighted that the psychodynamic addiction model was associated with reduced depression (Mean = 14.9; SD: 6.7), anxiety (Mean = 11.5; SD: 5.9), and gambling severity (p < .001), suggesting that a relational psychodynamic treatment is needed for complex patients with compulsive addiction, where CBT had not been successful. These results also highlight the importance of the therapeutic relationship as a critical factor in the treatment of patients with compulsive addiction problems.     

Aktueller Stand der Gruppenpsychotherapieforschung

In view of an increasing importance of group therapies and the intention in healthcare politics to support group treatment, it seems appropriate to provide a review of the current research efforts in this field. In this review, several research traditions are described with a clear focus on the effectiveness of group treatment. Both systematic narrative reviews and recent meta-analyses clearly demonstrate that group treatment of various disorders is equally as effective as individual psychotherapy. Besides outcome research there are other developments in the field, such as the improvement of manualized and focused group therapies even outside cognitive behavioral concepts. Studies related to feedback in groups, specific patient characteristics (especially alexithymia and attachment) as well as the construction of new measures seem to be characteristic for group research during recent years. There is still a need for research related to group dynamics and process aspects of small groups as well as the group leaders and their behavior. In total, research on group psychotherapy has clearly progressed, which justifies the support of this treatment setting.     

Psychopathie,antisoziale Persönlichkeitsstörung und Sexualdelinquenz

In today’s field of forensic psychiatry, psychopathy is seen as a subtype of antisocial personality disorder and includes manipulative behavior, egocentric and arrogant characteristics, high-risk behavior as well as a lack of empathy. Empirical data on the prevalence of psychopathy and antisocial personality disorder among offenders greatly vary depending on the study design and the composition of the sampled population. Offenders who committed both violent and sex offenses seem to have antisocial traits with a higher probability than offenders who committed only violent or only sex offenses. In the context of criminal responsibility and risk assessment for sex offenders, antisocial and psychopathic traits have a negative impact on the prediction of recidivism. Many study results, even though not all, additionally indicate that the combination of psychopathic traits and sexual deviance (i.?e. for example a paraphilic disorder such as sexual sadism) in sex offenders may be associated with a particularly high risk to reoffend. Due to the specific interpersonal characteristics (e.?g., dominant, provocative behavior, exaggerated self-esteem), therapeutic treatment of sex offenders with antisocial and psychopathic traits is often difficult. The regular supervision by the therapist is considered to be crucial to avoid harmful relationship dynamics or distorted perception of the therapist.     

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.     

Tinnitus und das Leiden am Tinnitus

Psychosomatic findings from 287 patients with tinnitus are presented in this article, who were seen by medical psychotherapists specialized in ENT for a period of 15 months. They were assigned to all of the therapeutic methods being offered. As relevant proved to be the neurootological professional competence, especially for recognizing and treating auditory limitations (in 41% of the patients) as well as noticing and treating the psychological comorbidity (in 45.3% of the patients). While neurophysiological and psychophysiological models interpret the subjective tinnitus stress as the failing of habituation, dysfunctional attention processes and assessments, from a psychodynamic view a symptom having pathological significance, such as the suffering from tinnitus (not the tinnitus itself) may develop if the defensive mechanisms are exhausted, a conflict cannot be resolved on the conscious level or traumatic experiences were made. It is recommended that an approach specifically matched with the disturbance is made taking into account both possible psychodynamic causes and sustaining factors in the cognitive behavioral sense, all on an audiologic background.     

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.     

Putting the client in control: The perception of control in the behavioral treatment of anxiety

Traditional explanations of anxiety reduction through behavioral interventions such as extinction, habituation, reciprocal inhibition, and counterconditioning do not adequately account for all instances and aspects of anxiety reduction and clinical methods employed in contemporary behavior therapy. This article examines the role of an additional process — the alterations of perceptions of control — believed to be operative in anxiety reduction. We discuss three targets for establishing control in behavioral treatments of anxiety: (1) control over one's physiological responding while in an anxiety-producing situation, (2) control over the anxiety-producing stimulus or situation itself, and (3) control over the conduct of exposure. These three types of control perceptions are differentially important for different types of anxiety disorders. Implications for the conduct of behavioral treatments and possibilities for increasing client perceptions of control in anxiety treatment programs are outlined. We also recommend that client perceptions of control should be systematically assessed in order to relate them to treatment successes and failures.     

Operationalisierte Basisdokumentation von Gruppenpsychotherapien

It can be assumed that group psychotherapy will play an increasingly more important role for both inpatient and outpatient basic care not only due to health economic considerations. This means that new methods of documentation, quality management and optimization of group-specific therapy processes and results have to be developed. The present system for operationalized basic documentation of group psychotherapy (OBG) is not only meant to be a starting point for research on dynamics and efficacy of group psychotherapy but could also serve as an instrument for standardized documentation of clinical progress, quality assurance and, in combination with the accompanying manual, as an aid for education and further training for psychotherapists. The contents of the documentation system are based on the current state of scientific research and, as far as possible, were implemented irrespective of specific psychotherapeutic approaches referring to particular schools of thought. Particular consideration was given to the practice guidelines for group psychotherapy of the American Group Psychotherapy Association (AGPA) published in 2007. The system structure is based on a model of anatomy and physiology of a group according to Burlingame et al., which ascertains patterns and processes within groups. In addition to general thematic and methodological aspects, several items on group dynamics are included, such as distribution of roles, formation of subgroups, development of group norms, conflict management, interpersonal feedback, self-disclosure, cohesion and other so-called therapeutic factors. Clinical testing in different settings is currently being carried out. Results and further developmental possibilities of the OBG system will be reported soon.     

Integrating Individual and Family Systems Psychotherapy to Treat Borderline Personality Disorder

This paper focuses on two areas. The first is the framework for psychotherapy integration used by Unified Therapy, a psychotherapy approach that is an integration of psychodynamic, cognitive–behavioral, and family systems therapy. The second is the use of this treatment paradigm in the psychotherapy of adults with borderline personality disorder. The theory posits that continuing and recurrent interpersonal behavior patterns within the patient's family of origin serve as behavioral triggers to typical acting-out behaviors. Therapy is geared toward planning strategies to alter these destructive patterns. A case example is presented to demonstrate the use of the therapy's theories and techniques.