Teilstationäre Psychotherapie

Psychotherapeutic day clinics increasingly take over responsibility for the treatment of patients who cannot be cared for satisfactorily, respectively, at all in an inpatient setting. Psychotherapy in a day clinic setting is a treatment in its own right which has progressively established itself between inpatient and outpatient treatment. Empirically raised up to date data prove the efficacy and the efficiency of psychotherapeutic treatment in day clinics. Accordingly, the goal of the present study is to investigate the outcomes of psychotherapeutic treatment in a day clinic with a psychodynamic concept. Since 1996 the psychotherapeutic day clinic Basel empirically assesses the treatment course of all admitted patients. Patients and therapists fill in questionnaires upon admittance, two months into the course of treatment and upon discharge (SCL-90-R, PSKB-Se-R, OPD etc.) Our results indicate that significant improvements of symptoms as well as of socio-communicative competency can be achieved during treatment which remain stable even after discharge (first follow-up three months after discharge). Comparing outcome data of patients treated in full-time inpatient setting and of patients who undergo partial hospitalization we found that outcome was at least equivalent. Additionally we found that the diagnosis of a personality disorder influenced treatment results significantly in some symptom specific spheres.     

Wenn Psychotherapie schadet …

Background

The examination of the negative and harmful effects of psychotherapy has recently moved into the focus of psychotherapy research. The investigation described in the following article specifically analyzes for the first time the contents of complaints by psychotherapy patients and presents a practical category system for classification of the negative effects of psychotherapeutic treatment.

Samples and method

A total of 67 cases of complaints submitted to the Ethics Association (reg. co). Ethics in Psychotherapy during the time period from 18.02.2008 to 27.12.2010 were analyzed with respect to the content in the sense of an inductive categorization and quantitative evaluation.

Results

From the available patient complaints a reliable category system could be elucidated. The violation of therapeutic base variables and violations of sexual limitations were the most common cause of complaints against male therapists whereas for female therapists accusations of violation of medical confidentiality and documentation duty were significantly higher.

Conclusions

The results of this study allow formulation of research recommendations for extended investigation of the negative effects of psychotherapy and reveal options for the development of a targeted risk management.     

Ökonomisierung und Psychotherapie

Former fundamental social structures are disappearing and, especially by the economization and industrialization of medicine, the self-understanding of patients, doctors and hospitals has changed. From these developments psychotherapy gets into a strange area of tension, not only in the society as a whole, but also within medicine: on the one hand psychotherapy is needed more than ever, but on the other hand it finds itself in an outsider position. Thereby, the reality constructions of patients and psychotherapists are affected as well, mostly gradually, so that the consequences for the relationship between psychotherapists and patients escape attention. Dealing with these problems in a considered and transparent manner can avoid damaging the therapeutic work.     

Psychotherapie der Panikstörung

Zusammenfassung Bei der Psychotherapie der Panikstörung ist die Wirksamkeit störungsbezogener verhaltenstherapeutischer Ansätze in zahlreichen randomisierten kontrollierten Studien nachgewiesen; für die Wirksamkeit einer störungsbezogenen psychodynamischen Kurzzeitpsychotherapie (panikfokussierte psychodynamische Psychotherapie, PFPP) gibt es erste empirische Belege. Die theoretische Fundierung der therapeutischen Zugänge und die daraus abgeleiteten Behandlungsprinzipien werden für die beiden Therapieverfahren dargestellt; eine aktuelle Übersicht zu empirischen Wirksamkeitsnachweisen wird gegeben: Schulenübergreifend sind Vorgehensweisen wirksam, die die Auseinandersetzung mit der Paniksymptomatik in den Mittelpunkt stellen. Die Verhaltenstherapie erreicht dies mit der Exposition gegenüber panikbezogenen Körpersensationen und -situationen; in der psychodynamischen Psychotherapie hat sich die aktive Exploration panikbezogener Kognitionen und Emotionen sowie die Deutung der für Patienten mit Panikstörungen typischen ambivalent-abhängigen, konfliktvermeidenden Übertragung bewährt. Die mit der Überwindung der habituellen Vermeidung verbundene Stärkung des Selbstwertgefühls wird als wirksamer Faktor diskutiert.     

Kosteneffektivität ambulanter Psychotherapie

Background

There is a lack of cost-effectiveness analyses (CEA) of psychotherapeutic treatments.

Material and methods

Cost-effectiveness analysis was applied to a sub-sample of 122 psychotherapy outpatients who participated in a large longitudinal study on outpatient psychotherapy (TRANS-OP study). Participants received either psychodynamic psychotherapy (PD, n=69) or cognitive behavioral therapy (CBT, n=53). Effectiveness (change in symptomatic impairment over 2 years) was assessed via the German version of the Outcome Questionnaire (OQ-45.2). Direct health care costs during a 2-year period (psychotherapy and other health care utilizations) were obtained from health insurance claims. Cost-effectiveness analysis methods included incremental cost-effectiveness ratios (ICER) and the net benefit regression approach.

Results

Cost-effectiveness analyses showed no significant differences between the two treatments, neither head-to-head, nor with regard to advantages in certain subgroups of psychotherapy outpatients. A slight dominance of CBT in costs was not maintained after controlling for covariates.

Conclusion

Provided that pivotal covariates such as treatment need are taken into account, cost-effectiveness analyses can contribute to a more equitable distribution of psychotherapeutic resources.     

Psychotherapie von Anpassungsstörungen

In this study we examined the effectiveness of an outpatient client-centered psychotherapy of patients with adjustment disorders (ICD-10 F43.2) limited to twelve sessions in comparison to an untreated control group. The patients of each group (n_treatment= 31 and n_control= 19) had been diagnosed with an adjustment disorder in response to one of the following stressful events: either the loss of an important person or performance deficits at work or university. Compared with the untreated control group the immediate therapy group improved significantly on rating scales and questionnaires. These positive treatment effects proved stable at a 3 months follow-up. Individual treatment gains were also analyzed for clinical and statistical significance. The improvements of the treatment group were significantly greater in all used measures than those of the control group. These improvements were interpreted as an effect of the client-centered treatment which resulted in high individual overall treatment gains and in high effectsizes.     

Psychotherapie als Weg zum Seelen-Enhancement?

Self-optimization is a widespread trend. Psychotherapists often attempt to psychologically explain self-optimization as a manifestation of narcissism. In reality the fact that self-optimization has become a contemporary imperative is only comprehensible against the background of the individualization of living conditions (Beck). In psychotherapy the boundaries between medical treatment of mental illnesses and enhancement of the psyche are increasingly becoming more flexible. By promising to be able to help on the road to a happier and more productive life, to mental well-being or more life satisfaction, psychotherapy joins the self-optimization chorus. Not all attempts at optimization are limited to wanting to improve those features which are inherent to a person: others, such as the transhumanists want to overcome the imperfections of man via technologically upgrading the human nature.     

Interaktionelle Methode und übertragungsfokussierte Psychotherapie

The psychoanalytic interactional therapy proposed by Heigl-Evers and the transference-focused psychotherapy (TFP) suggested by Kernberg are two established methods for the treatment of patients with personality disorders in general, and especially of Borderline patiens. These approaches are often compared with each other due to several important similarities we may consider as specific for those disorders. They include among others the active involvement of the therapist, the use of clarifications and confrontations, a greater attention to the setting of the treatment, and the working in the “here and now.” According to current literature, a more exact analysis of the two procedures and of their development as well as of their implicit metatheories reveal that in spite of the recent rapprochement of interactional therapy to psychoanalysis there are still important theoretical and technical differences between these two treatment methods. This observation is demonstrated here by some typical examples of the particular interventions though without discussing a possible differential effectivity of the two methods. Basically, the two treatments are not fully comparable, because the interactional therapy was developed for groups and TFP was designed for the individual setting. In the final analysis, the “answer” principle of the interpersonal, partly on the neo-psychoanalysis and ego-psychology oriented interactional therapy and the “interpretation” principle of the on object-psychology oriented TFP cannot be considered equivalent. Beside that interactional therapy may bear more risks for becoming pedagogical as TFP does.     

Psychotherapie der Posttraumatischen Belastungsstörung

Zusammenfassung Die Posttraumatische Belastungsst?rung (PTBS) ist ein h?ufiges Krankheitsbild und mit einer Standardtherapie, die die spezifische Problematik der St?rung unberücksichtigt l?sst, nur eingeschr?nkt behandelbar. Der Beitrag geht auf aktuelle diagnostische Kriterien sowie spezifische Risikofaktoren für die Ausbildung chronischer und komplexer PTBS-Symptome ein. Verschiedene Behandlungsans?tze – Konfrontationstherapie, Kognitive Restrukturierung, EMDR, psychodynamische Therapie, angeleitetes Schreiben – werden auf der Basis validierter Therapiestudien vorgestellt. Ausführlicher berücksichtigt werden Behandlungsm?glichkeiten für sexuell traumatisierte Frauen mit chronischer PTBS und komorbiden Beschwerden.      

Psychotherapie oder Psychopharmakotherapie oder Kombinationstherapie?

Current meta-analyses convincingly show the effectiveness of psychotherapy. For many mental disorders psychotherapy is the therapy of choice and superior to an exclusive pharmacotherapy. A psychotherapy is still effective far beyond the end of psychotherapy. Mild and moderate depressive episodes can be successfully treated by psychotherapy alone. A combination treatment is indicated for severe depressive episodes and a chronic course. Cognitive behavior therapy (CBT) is the method of choice for anxiety disorders where CBT can be initiated in order to build up self-efficacy and medication can be omitted at first. A combination treatment is only indicated when the response is insufficient. For obsessive-compulsive disorder with predominantly compulsive behavior CBT with exposure and reaction management is the method of choice. Combination treatment is indicated particularly for predominantly obsessive thoughts and comorbid depression. In posttraumatic stress disorder a trauma-focussed CBT is the method of choice. For posttraumatic stress disorder selective serotonin reuptake inhibitors are indicated only for comorbid disorders. For all disorders benzodiazepines should be prescribed only in justifiable exceptional cases for short-term administration. For individualized differential indications the effects of simultaneous psychopharmacotherapy on the therapeutic process must be taken into consideration.     

Psychotherapie und soziale Unterstützung

Relations between social support as an informal helping system on one hand and psychological intervention on the other are outlined. Starting from an overview of approaches to define and conceptualize social support, common aspects of informal and professional help are derived. These are then illustrated by two intervention contexts which mark the transition between support and psychological intervention. Furthermore, effects of the individuals’ support network on utilization, maintenance, and outcome of psychotherapy are summarized. Finally, interventions to optimize the individual support situation are discussed.     

Station?re Psychotherapie und Medien

Background

According to several studies the application of different media in inpatient psychotherapy and psychiatry has proven to be a useful and effective addition to conventional methods of intervention. This study is the first to catalogue the current spread of media in inpatient treatment as well as the evaluations of media-supported interventions by therapists and patients.

Sample and method

In a representative survey conducted in all psychiatric and psychosomatic clinics in North-Rhine/Westphalia (response: 40 psychologists/doctors and 289 patients from 39 clinics) media equipment, usage of media in different areas, evaluation of and satisfaction with the media usage were measured by a questionnaire which was constructed especially for this purpose.

Results

A widespread usage and acceptance of media could only be found in some areas. The study identified large differences in equipment standards and media usage depending on the type of media, the area of usage and the specific clinic.

Conclusion

Recommendations for the further development and optimization of media usage in inpatient psychotherapy are derived from the results of this study.     

Ambulante Psychotherapie der Substanzstörungen

Background

The revision of the psychotherapy guidelines in 2011 broadened the options for treating substance use disorders (SUD) in outpatient psychotherapy (OP).

Aim

The aims of this study were to answer the following questions: how frequently are SUDs treated in OP? What opinions do psychotherapists (PT) hold concerning the new treatment possibilities?

Material and methods

In this study the frequency of OP for patients with SUD, e.g. harmful use and abuse of as well as dependence on psychotropic substances according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) and the International Statistical Classification of Diseases and Related Health Problems (ICD-10), by private practice PTs as well as their attitude towards the treatment of patients with these diagnoses were investigated. Private practice PTs in five states in East Germany were asked to participate in a postal survey.

Results

Of the 1,382 PTs contacted, 229 (16.6 %) participated in the study. Of the respondents 94.3 % had treated at least one patient with SUD (4-week prevalence including nicotine dependence). These rates ranged from 3.1 % to 26.6 % depending on the substance and diagnosis (SUD as primary reason for treatment). The highest rates of strong affirmation for OP of approximately 20?% were found for disorders related to alcohol, tobacco and medication.

Conclusion

Most PTs treated at least one patient with SUD in OP. However, this particular type of treatment offer should be further extended. Information about the options of treating SUD in OP should be further disseminated and conducting such treatment should be supported by (e.g.) therapist training.     

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.     

Sexuelle Funktionsstörungen und ambulante Psychotherapie

Based on a literature review the following questions are discussed: how prevalent are sexual dysfunctions in the community and in treatment samples (particularly in psychotherapy patients)? How many patients with sexual dysfunctions seek help in outpatient psychotherapy and for how many patients would this kind of treatment be indicated? Data show that only relatively few patients with sexual dysfunctions are being treated in outpatient psychotherapy. Deficits concerning detection and monitoring of sexual dysfunctions and in terms of interdisciplinary treatment are obvious. To find possible reasons for these deficits the multifactorial etiology of sexual dysfunctions, the segmentation of care and also psychological variables characterizing the patient (denial of dysfunction) and the therapist (subjective need for specific training) are discussed. It is proposed that routine use of screening questionnaires for sexual dysfunctions should be introduced and it is described how the diagnostics and treatment implementation for sexual dysfunctions can be effectively integrated into clinical practice. Finally, arguments for a broader representation of research on sexual dysfunction in the field of clinical psychology are presented.     

Psychoanalytisch orientierte Psychotherapie im Maßregelvollzug

The author argues that a psychodynamic approach is needed in forensic psychiatry and describes how it will improve treatment outcome. However, institutional shortcomings and inconsequent application of concepts, such as the lack of object constancy in the therapy, often prevent favorable outcomes. He outlines attitudes and stances that are important for the therapist. In addition, the core conflicts and developmental deficits of the patients are discussed. He finally emphasizes that it is of utmost importance to intensively work through the relationship patterns to early attachment figures.