Die verbale Aktivit?t in therapeutischen Dialogen

The discourse in psychotherapeutic treatment is less specific than usually expected so the question arises whether different therapy methods are different in the style of communication. In this study the verbal activity and other characteristics of the discourse of therapist and patient for sessions from two psychoanalytic, two psychodynamic and two cognitive behavior therapies were compared. Psychoanalytic therapists were found to talk the least and behavior therapists the most. Patients talk nearly the same amount in all therapies. As therapists of psychoanalytic treatment talk less than behavior therapists the percentage of patient talking is highest in psychoanalytic therapy. Further formal characteristics: statements are the most frequent form of intervention in behavior therapy (51?%), followed by psychodynamic (36?%) and psychoanalytic therapy (27?%). The most frequent form of intervention in psychodynamic and psychoanalytic therapy is listening, whereas it is only a small part of communication in behavior therapy. Questions are asked most often in behavior therapy. Hence there are significant differences which correspond to the theory of treatment, between the three methods in discourse behavior on a single case level.     

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.     

Indikation zur strukturbezogenen Psychotherapie

The distinction of conflict processing and structure promoting psychotherapeutic approaches in the psychodynamic field is now common knowledge and has now been incorporated into the guideline comments. The differentiation of treatment presupposes theoretical knowledge of the dynamics of conflict and structure and corresponding thorough initial diagnostics. Based on these foundations an appropriate focus of therapy can be agreed with the patient and the therapy target can be set. This focussed working towards a joint target is especially important for psychodynamic psychotherapeutic treatment, which is of limited duration. The actively accompanying therapeutic process differs from older assumptions that positive developments on the foundation of a therapeutic relationship occur quasi automatically but possibly need a long time. Aspects of the treatment technique and the therapeutic attitude, estimation of the therapeutic development and typical age-related modifications in adolescents and older persons are discussed.     

Methods and mechanisms in the efficacy of psychodynamic psychotherapy

Comments on the original article, "The efficacy of psychodynamic psychotherapy," by J. Shedler (see record 2010-02208-012). Shedler summarized a large body of research that shows psychodynamic therapy to have a substantial effect size, comparable to that for many empirically supported treatments. This is an important finding, in part refuting the concerns raised by Bornstein (2001, 2002) regarding the future of psychodynamic approaches had there been no substantial changes in how practitioners and researchers approached the science to demonstrate efficacy. Further, Shedler showed that the efficacy of psychoanalytic psychotherapy is due to therapeutic methods commonly employed in cognitive behavior therapy (CBT), one of the most frequently cited empirically supported approaches for a wide range of psychological conditions. From a methodological perspective, there are some important limitations to the claim of psychodynamic psychotherapy's comparable efficacy to other empirically supported approaches.     

The use of self-disclosure among Swedish psychotherapists

Although self-disclosure, when handled with discretion, is often seen as an important intervention in many psychotherapy orientations, including psychodynamic as well as humanistic and cognitive-behavioral approaches, many psychotherapists seem reluctant to use it. The frequency and type of those interventions from psychotherapists of different orientations is less well known. In this study, a random sample of Swedish psychotherapists was asked about their use of different types of self-disclosing information. The results showed that therapists with CBT orientation told their clients more about their training and about their personal ways of handling affective-relational issues. It was apparent that the trend toward more use of self-disclosure in relational psychodynamic treatment has not been accepted among a large number of psychodynamic and psychoanalytic psychotherapists in Sweden. It is recommended that psychotherapists inform their clients more about their training and in appropriate ways share more with their clients about their own relational experiences. Doing so may help enhance clients’ hope and their ability to address their ongoing difficulties.     

Are Psychiatric Residents Still Interested in Psychoanalysis? A Brief Report

In spite of the efficacy of the psychodynamic psychotherapies, the number of young psychiatric residents interested in psychodynamic therapies is decreasing. Our psychoanalytical group, Genden (Genève-Denver), explored the possible reasons for psychiatric residents' hesitation to get psychoanalytic training. Five psychoanalytical psychotherapists met weekly for a year in order to debate that question, focusing on personal feedbacks from all of our 100 residents in psychiatry working with us for at least 4 years. Following the residents' responses, our focus group proposed ten commonsense feedbacks for psychoanalysts regarding stimulating young psychiatric residents' interest in psychoanalytic approaches.     

Childhood Sexual Abuse

Abstract

Childhood sexual abuse is a problem that leads to serious psychological disturbances evidenced through the symptoms of post-traumatic stress disorder (PTSD). This article discusses the treatment of sexual abuse survivors within a psychoanalytic framework. Different theoretical perspectives including classical Freudian, ego-psychological, object-relational and self-psychological are presented. Several relational treatment models, including feminist psychodynamic approaches, are offered. Themes include the importance of developing a strong therapeutic alliance and analyzing transference responses.     

The emerging dialogue between psychoanalysis and neuroscience: neuroimaging perspectives

Current progress in the cognitive neurosciences is highly relevant to the development of psychoanalytic theory and practice. Neuroscience is today becoming mature enough to provide empirical biological approaches for the investigation of psychoanalytic models and observations. The current state of functional neuroimaging techniques is reviewed, selected paradigms and findings relevant to psychotherapy research are presented, and ways to pursue the dialogue between psychoanalysts and neuroscientists are discussed, as are some related obstacles and pitfalls. The emerging dialogue between psychoanalysts and neuroscientists may help not only to reestablish a solid position of psychodynamic theory and treatment in contemporary medicine, but also to bridge the division between "psychological" and "somatic" treatments, and gain important insights into the mind-brain relationship.     

Minding the gap between positivism and hermeneutics in psychoanalytic research

Two quite different cultures are to be found within psychoanalysis, one more clinical in orientation, more focused on meaning and interpretation, and relying primarily on the traditional case study method, the other more research-oriented, focused on cause-and-effect relationships, and relying primarily on methods borrowed from the natural and social sciences. The history of this divide is reviewed and arguments, pro and con, about the potential contributions of specific types of empirical investigation are discussed. Increasingly, it seems, criticisms concerning the scientific status of psychoanalysis are being responded to by empirical research. This has contributed to a growing recognition within the scientific community of the credibility of aspects of psychoanalytic theories and of the effectiveness of psychodynamic treatment. However, some segments of the psychoanalytic community are concerned that this increase in the quantity and quality of empirical research on psychoanalytic concepts risks creating an empirical one-sidedness, while other segments are concerned that not engaging in systematic empirical research can lead to intellectual isolation, fragmentation, stagnation, and orthodoxy. To counter this polarizing tendency, a recommendation is made for methodological pluralism. Adopting this stance could contribute to an enriched understanding of the clinical process and to the development of new research methodologies to investigate complex psychodynamic hypotheses, thus bridging the gap between the two psychoanalytic cultures, as well as the gap between research and clinical practice.     

Psychodynamic Conceptualization and Treatment of Suicidal Patients

This paper discusses psychodynamic perspectives to the conceptualization and treatment of suicidal patients. A review of psychoanalytic and psychodynamic conceptualizations is provided, along with representative case examples of these phenomena. Empirical studies are also reviewed, noting how recent research provides some meaningful insight into the object relations of suicidal patients. Finally, treatment issues are discussed, including comments about transference, dreams, and countertransference. It is concluded that a psychodynamic model is of value when treating patients with suicidal ideation and impulses.     

Chapter 4 Interpretation in Short-Term Therapy

Abstract

There is much theoretical and clinical literature on the role of interpretation in psychoanalysis, psychoanalytic psychotherapy, and brief dynamic psychotherapy, but little supporting research data. Using 112 audiotaped sessions from 38 patients in supportive-expressive time-limited treatment, the present study hypothesized that therapists would modify the object and temporal content and frequency of their interpretations in relation to the level of patient functioning. The results did not support this hypothesis. Therapists were not less active with more interpretations for higher functioning patients, nor were they more active with fewer interpretations for lower functioning patients. Therapists were more active and made more genetic interpretations with married patients, regardless of level of patient functioning. The findings are discussed in terms of their implications for supportive-expressive psychodynamic therapy.     

The psychoanalytic perspective of adolescent homosexuality: a review

Psychoanalytic theory asserts that adolescent homosexuality is the result of unresolved infantile conflict experienced during the Oedipal and pre-Oedipal periods, in which inadequate object relations and identifications with parents predispose the individual to homosexuality in adolescence. Classical psychoanalytic thought emphasizes the importance of drives and defenses in the formation of homosexuality, while more contemporary approaches understand adolescent homosexuality from a psychosocial and early developmental perspective. In addition to childhood predispositions, the various developmental tasks of adolescence influence the degree and course of homosexuality. This article notes the different types of homosexuality that emerge in adolescence which are influenced by different psychodynamic conditions in each stage of adolescence. Changing developmental roles in relation to individuation, object relations, identification, and identity formation are a few of the factors that contribute to adolescent homosexuality.     

The Protective Skin of the Analyst’s Case Formulation: Commentary on Paper by Tom Wooldridge

The contours of every psychoanalytic process are shaped by its case formulation. This discussion of Tom Wooldridge’s paper (this issue) of the long-term, psychodynamic treatment of a patient with severe anorexia provides opportunity to demonstrate that formulation derives from aspects of the clinician’s clinical education and personal growth. Wooldridge’s metaphor of the containing functions of the entropic body is extended to include particular paternal functions that an analyst provides his patient and that are suggested in the dialogue of this clinical material. Psychoanalytic case formulation distinguishes it from other aspects of an integrated treatment plan for eating disorder patients; in particular, clinician and patient discover important metaphors and elaborations of personal history that assist in recovery. Thinking through a case from different lenses provides real gratification for the psychoanalyst and a bulwark to assist in potentially life-saving work because of its protective and enriching functions. Drawing upon the metaphors Wooldridge expands upon such as secondary skin formations and the entropic body, I suggest that clinicians who work in the field of eating disorders could draw great benefit from learning more about what psychoanalytic case formulation offers patients. Detailed, evocative case examples such as the one Tom Wooldridge puts forward may be one way to reach this important audience because they bring to life many of the unique features of contemporary psychoanalysis.     

From the Couch to the Street: Applications of Psychoanalysis to Work with Individuals Who Are Homeless and Mentally Ill

Current-day psychiatric treatment of severely disturbed populations tends to focus on the biological, behavioral, and social dimensions of rehabilitation. This paper addresses the relative neglect of the complex psychodynamic and interpersonal aspects of treatment of individuals who are homeless and mentally ill by presenting two clinical cases that are discussed from various psychoanalytic frames of reference. Based on their clinical experiences, the authors conclude that psychoanalysis offers valuable frameworks to guide the treatment process and the structure of the treatment setting for individuals who are homeless and suffering from severe psychiatric illness.     

Process‐orientated psychoanalytic work in initial interviews and the importance of the opening scene

From the very first moment of the initial interview to the end of a long course of psychoanalysis, the unconscious exchange between analysand and analyst, and the analysis of the relationship between transference and countertransference, are at the heart of psychoanalytic work. Drawing on initial interviews with a psychosomatically and depressively ill student, a psychoanalytic understanding of initial encounters is worked out. The opening scene of the first interview already condenses the central psychopathology – a clinging to the primary object because it was never securely experienced as present by the patient. The author outlines the development of some psychoanalytic theories concerning the initial interview and demonstrates their specific importance as background knowledge for the clinical situation in the following domains: the ‘diagnostic position’, the ‘therapeutic position’, the ‘opening scene’, the ‘countertransference’ and the ‘analyst's free‐floating introspectiveness’. More recent investigations refer to ‘process qualities’ of the analytic relationship, such as ‘synchronization’ and ‘self‐efficacy’. The latter seeks to describe after how much time between the interview sessions constructive or destructive inner processes gain ground in the patient and what significance this may have for the decision about the treatment that follows. All these factors combined can lead to establishing a differential process‐orientated indication that also takes account of the fact that being confronted with the fear of unconscious processes of exchange is specific to the psychoanalytic profession.     

Can psychiatry residents be attracted to analytic training? A survey of five residency programs

In the face of fewer psychiatrist applicants for psychoanalytic training, determining the interest of current psychiatric residents in psychoanalysis and psychodynamic psychiatry is a pressing concern. To gauge this interest, an anonymous online survey was sent to residents from five psychiatry residency programs in the Midwest and South. Seventy-five residents responded, for a return rate of 42%. The data suggest that residents value psychoanalytic concepts and most plan to incorporate the practice of psychodynamic psychotherapy into their careers after graduation; however, residents have little confidence in their level of skill and the adequacy of their training. While 46% express interest in further psychodynamic psychotherapy training, only 22% express interest in psychoanalytic training. Most cite the cost and time involved as reasons they would not pursue further training. This study demonstrates that psychiatric residents have strong interest in and respect for psychodynamic psychotherapy and psychoanalysis. The data suggest that psychiatric residents are a viable pool of applicants for psychoanalytic training, especially if barriers to training can be reduced and creative ways for psychoanalysts to engage residents can be fostered.     

Werkzeugkasten des psychodynamischen Psychosetherapeuten

The authors describe the modification of the classical psychoanalytic treatment technique, which was developed in the past decades to treat people with schizophrenic psychosis. The technique which can be used in modified psychoanalytic as well as other psychodynamic settings, was adjusted to the specific problems which occur in the psychotherapy of patients with schizophrenia. This specific modified psychotherapy deals with a paradigmatic experience in the therapeutic relationship to reduce traumatic fear and to overcome interpersonal and intrapsychic dilemmas. This modification increases the possibility to reconstruct the personal history of the psychosis in a dialogical process together with the patient.     

Behandlungsleitlinie Persönlichkeitsstörungen

The S2 guidelines for the treatment of personality disorders (PD) are summarized. In the diagnostic assessment of personality disorders a clinical interview should be supplemented by (semi-) structured clinical interviews and self-report measures for the categorical and dimensional assessment of PDs. The results of the assessment process should be communicated to the patient based on a psycho-educational framework. The diagnosis should always be linked to the patient’s individual history. Psychotherapy is the treatment of choice for personality disorders. A detailed analysis of the patient’s problems as well as the definition of a hierarchy of treatment goals are part of the process of treatment planning. For three PDs empirical evidence for treatment approaches is available: (1) dialectical behavior therapy, mentalization-based therapy, schema focused therapy and transference focused therapy all proved beneficial in the treatment of borderline personality disorder. Cognitive-behavior therapy proved helpful in the treatment of (2) dissociative personality disorder and (3) avoidant personality disorder. There is limited evidence for interpersonal therapy and psychodynamic therapies in the treatment of avoidant personality disorder.     

Indikation zu Psychoanalyse und analytischer Psychotherapie

Based on the diagnostic process in the initial interview, which is an intersubjective encounter, the various developmental steps for establishment of the indications for psychoanalysis are presented. Freud and his followers, who were initially oriented to the psychiatric diagnosis, were later oriented to the criteria of approachability, analysability and in particular on the aptitude for psychoanalysis. The criterion of aptitude was not only elaborated from the perspective of Ego psychology but was also relevant for all high frequency non-terminated psychoanalyses which followed the basic psychoanalytical principles of “afocality”. This has so far characterized the standard procedure of all psychoanalytic schools. Due to the experiences of psychoanalysts with early disturbed, structurally Ego-disturbed neuroses and personality disorders, the extent of lability of the mental structure and by turning to countertransference analysis, the person of the psychoanalyst become more important for the assessment of the indications. In Germany the integration of psychotherapy, which is financially supported by healthcare insurance, ultimately leads to differential indication assessments between high frequency psychoanalysis or analytical psychotherapy, modified psychoanalytical psychotherapy and less frequent psychodynamic procedures.