Vom Sinn des Verfahrenskonzepts und der Verfahrensvielfalt ­ und warum das Baukasten-System in der Psychotherapie nicht funktioniert.

Why the concept of distinct psychotherapeutic approaches is indispensable - and why the tool box concept of psychotherapy cannot work Background: In Germany, the official psychotherapy guidelines are oriented towards the model of distinct psychotherapeutic approaches. Within the German health care system this also applies to the training in psychotherapy. Some critics, however, are presently pleading in favour of abolishing the model of distinct psychotherapeutic approaches, which also implies to abolish the concept of the so called "Richtlinienverfahren" in Germany - approaches of psychotherapy which proved to be efficacious and whose costs are reimbursed by the insurance companies. Objective: The arguments put forward such as the heterogeneity of the approaches as well as the proposed alternatives, for example, an "integrative" model of both mental disorders and psychotherapeutic treatment are critically discussed. Results: Both the arguments and proposed alternatives are found to be not convincing, neither from a scientific nor from a psychotherapeutic perspective. From a scientific perspective, there is no evidence for efficacy of a "general" or "integrative" model of psychotherapy - which is in contrast to the Richtlinienverfahren for which evidence for efficacy exists. From a psychotherapeutic perspective psychotherapy cannot be taught, learnt and applied by use of tools or modules without a theoretical orientation. Conclusions: The concept of distinct psychotherapeutic approaches proves to be an in dispensable principal for orientation in psychotherapy, for both therapists and patients.

[Psychoanalytic single case studies of children and adolescents: characterisation with the "Inventory of Basic Information in Single Cases"]. / Psychoanalytische Einzelfallstudien von Kindern und Jugendlichen: Charakterisierung mit dem "Inventory of Basic Information in Single Cases".

Right from its beginning single case studies on children and adolescents have been an highly esteemed means of communication in psychoanalysis; from the view of treatment research time and again critical arguments are brought forward. As single case studies may provide relevant answers for detailed process aspects, in this study we present a methodology for systematizing the reporting culture.

How does neurobiological research influence psychoanalytic treatments?--Clinical observations and reflections from a study on the interface of clinical psychoanalysis and neuroscience.

One of the counterarguments against empirical research in psychoanalysis is that research negatively influences the treatment situation. In this paper, the impact of a neurobiological study on psychoanalytically oriented treatments is presented from three different perspectives: patients' views, a study group of participating psychoanalysts and a clinical case example. Twenty chronically depressed patients, 20 healthy controls and 16 psychoanalysts participated in the project on research. Results show a clear influence of the neurobiological study on the course of treatments. Patients consistently reported that study participation had a positive impact on their treatment experiences. However, study participation was conflictual for the psychoanalysts and forced them to carefully reflect on their unconscious and conscious involvement to establish a psychoanalytic stance independent from empirical research.

Pre-transplant depression as risk factor for survival of patients undergoing allogeneic haematopoietic stem cell transplantation.

INTRODUCTION: Depression is discussed as a possible risk factor for survival in cancer patients. We explored this relationship for patients undergoing allogeneic haematopoietic stem cell transplantation (HSCT). PATIENTS AND METHODS: The depression subscale of the Hospital Anxiety and Depression Scale (HADS) served as a measure for depression. One hundred and thirty-eight patients (mean age 41 years; different diagnoses) participating in a psycho-oncology study filled in the HADS after admission for allogeneic HSCT. They were followed-up for at least two years; 72 patients died during follow-up. RESULTS: Depression scores were not correlated with medical and psychosocial objective factors with the exception of having under-aged children. Controlling for medical factors that showed up as predictors for survival in our sample (patient's age at HSCT, having had a transplant before, risk for treatment failure) the HADS depression score (range 0-21) emerged as an independent predictor (Cox regression): hazard ratio = 1.087, 95% CI = 1.018-1.161. CONCLUSION: Depression is probably not a simple indicator of a worse health status. Further research is needed to decide if depression must be considered as an independent risk factor for survival when diagnosed in the pre-transplant period.

Physicians' prognostic estimates of survival for patients undergoing allogeneic hematopoietic stem cell transplantation.

OBJECTIVE: Patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) often demand a single estimate of their prognosis from their treating physician. Little is known about the validity of and the factors influencing these estimates. PATIENTS AND METHODS: We explored physicians' prognostic estimates (six-point scale from very good to very poor) in a sample of 136 patients participating in a psycho-oncology study. Patients (mean age, 41 years) were followed-up for at least 2 years, and 72 patients died during the follow-up period. RESULTS: Physicians' estimates were clearly associated with overall survival (univariate Cox regression: hazard ratio=1.51, 95% confidence interval=1.24-1.82). In a multivariate Cox regression model, these estimates were independent predictors for survival in addition to previous treatment (former HSCT) and donor type (related vs. unrelated). DISCUSSION: Physicians on transplant units are able to give a concise prognostic estimate that corresponds to real outcomes. Patients often do not have a sufficient understanding of the risks of their treatment. Obtaining such condensed information instead of a complex prognostic estimate might be easier to understand. For the physician, it might be helpful to reflect his/her individual method of condensing information to be able to give a concise prognosis and to achieve informed consent with the patient. A systematic description of the extensive implicit and explicit experiences regarding objective and subjective data and its respective weight could help to improve the training of future hematologists and should be explored in further studies.

Neural correlates of attachment trauma in borderline personality disorder: a functional magnetic resonance imaging study.

Functional imaging studies have shown that individuals with borderline personality disorder (BPD) display prefrontal and amygdala dysfunction while viewing or listening to emotional or traumatic stimuli. The study examined for the first time the functional neuroanatomy of attachment trauma in BPD patients using functional magnetic resonance imaging (fMRI) during the telling of individual stories. A group of 11 female BPD patients and 17 healthy female controls, matched for age and education, told stories in response to a validated set of seven attachment pictures while being scanned. Group differences in narrative and neural responses to "monadic" pictures (characters facing attachment threats alone) and "dyadic" pictures (interaction between characters in an attachment context) were analyzed. Behavioral narrative data showed that monadic pictures were significantly more traumatic for BPD patients than for controls. As hypothesized BPD patients showed significantly more anterior midcingulate cortex activation in response to monadic pictures than controls. In response to dyadic pictures patients showed more activation of the right superior temporal sulcus and less activation of the right parahippocampal gyrus compared to controls. Our results suggest evidence for potential neural mechanisms of attachment trauma underlying interpersonal symptoms of BPD, i.e. fearful and painful intolerance of aloneness, hypersensitivity to social environment, and reduced positive memories of dyadic interactions.

Measuring emotion in the voice during psychotherapy interventions: a pilot study.

The voice as a representation of the psychic world of patients in psychotherapeutic interventions has not been studied thoroughly. To explore speech prosody in relation to the emotional content of words, voices recorded during a semi-structured interview were analyzed. The subjects had been classified according to their childhood emotional experiences with caregivers and their different attachment representations. In this pilot study, voice quality as spectral parameters extracted from vowels of the key word "mother" (German: "Mutter") were analyzed. The amplitude of the second harmonic was large relative to the amplitude of the third harmonic for the vowel "u" in the secure group as compared to the preoccupied group. Such differences might be related to the subjects' emotional involvement during an interview eliciting reconstructed childhood memories.

Course of improvement over 2 years in psychoanalytic and psychodynamic outpatient psychotherapy.

OBJECTIVE: To assess and predict the level and course of symptomatic improvement in psychoanalytic (PAP) and psychodynamic psychotherapy (PD). METHODS: In a comprehensive longitudinal study, the course of improvement of 116 patients in PAP and of 357 patients in PD was tracked over a period of 2 years and analysed via hierarchical linear models. RESULTS: At baseline, over 90% of the patients reported substantial psychological, physical or interpersonal distress. In both forms of treatment, the course of improvement could be adequately fitted by a linear model. Symptom distress decreased notably within 2 years, with an especially sharp decline before the first formally scheduled therapy session. No significant differences between forms of treatment as to level or pace of symptom improvement could be observed. Prediction of speed of improvement was poor, with initial symptom distress showing the strongest influence while initial helping alliance had no predictive value. When comparing patients who finished their treatment within the 2-year observation period with those with still ongoing treatments, the former showed quicker symptom improvement. DISCUSSION: Strategies for the optimal allocation of valuable therapeutic resources should be reconsidered. An adaptive, outcome-oriented allocation strategy of therapeutic resources is proposed.

From turn-by-turn to larger chunks of talk: An exploratory study in psychotherapeutic micro-processes using conversation analysis.

Independent of theoretical orientation therapies of all kind are talk-in-interaction. Influential overall conceptualizations (as e.g. intervention) belong to a certain model of medicalizing the psychotherapeutic endeavor. Talk-in-interaction is the base for applying Conversation Analysis (CA) in psychotherapeutic process research. CA is a powerful tool originating from social science taking data, hypotheses and theories from careful observing in a similar way as infant observers did. The common discovery is that conversation precedes language. Some features of infantile proto-conversation survive in adult life. CA has directed careful attention to processes like turn-taking, repair, conditional relevances, etc. in observing the rules of interaction. However, in studying psychotherapy process turn-by-turn analysis alone does not suffice. It can be completed by a new model of common ground activities and package-by-package analysis turning attention to new objects of observation in therapeutic conversation (allusions, metaphorical framing activities). We propose a methodology for both kinds of analyses based on transcribed examples from the CEMPP-Project. This exploratory designed project (Conversation analysis of empathy in Psychotherapy Process; supported by the Köhler Foundation, Germany) compared psychoanalytic, psychodynamic and cognitive-behavioral treatments in five dyads each taking transcribed sessions from the beginning, the middle phase and the end; our database includes 45 transcribed sessions.

Electrophysiological correlates of error processing in borderline personality disorder.

The electrophysiological correlates of error processing were investigated in patients with borderline personality disorder (BPD) using event-related potentials (ERP). Twelve patients with BPD and 12 healthy controls were additionally rated with the Barratt impulsiveness scale (BIS-10). Participants performed a Go/Nogo task while a 64 channel EEG was recorded. Three ERP components were of special interest: error-related negativity (ERN)/error negativity (Ne), early error positivity (early Pe) reflecting automatic error processing, and the late Pe component which is thought to mirror the awareness of erroneous responses. We found smaller amplitudes of the ERN/Ne in patients with BPD compared to controls. Moreover, significant correlations with the BIS-10 non-planning sub-score could be demonstrated for both the entire group and the patient group. No between-group differences were observed for the early and late Pe components. ERP measures appear to be a suitable tool to study clinical time courses in BPD.

The German specimen case, Amalia X: empirical studies.

The authors provide a perspective on how psychoanalytic process research can be implemented. This is based on a process research model described elsewhere and summarizes the kinds of studies that can be situated on the four levels of the model. The authors summarize multiple empirical studies that were performed in a completely tape-recorded psychoanalytic therapy and have been published. These studies demonstrate the many modalities empirical process research has available to objectively study psychoanalytic process phenomena and their implication for outcome.

Neural Response during the Activation of the Attachment System in Patients with Borderline Personality Disorder: An fMRI Study.

Individuals with borderline personality disorder (BPD) are characterized by emotional instability, impaired emotion regulation and unresolved attachment patterns associated with abusive childhood experiences. We investigated the neural response during the activation of the attachment system in BPD patients compared to healthy controls using functional magnetic resonance imaging (fMRI). Eleven female patients with BPD without posttraumatic stress disorder (PTSD) and 17 healthy female controls matched for age and education were telling stories in the scanner in response to the Adult Attachment Projective Picture System (AAP), an eight-picture set assessment of adult attachment. The picture set includes theoretically-derived attachment scenes, such as separation, death, threat and potential abuse. The picture presentation order is designed to gradually increase the activation of the attachment system. Each picture stimulus was presented for 2 min. Analyses examine group differences in attachment classifications and neural activation patterns over the course of the task. Unresolved attachment was associated with increasing amygdala activation over the course of the attachment task in patients as well as controls. Unresolved controls, but not patients, showed activation in the right dorsolateral prefrontal cortex (DLPFC) and the rostral cingulate zone (RCZ). We interpret this as a neural signature of BPD patients' inability to exert top-down control under conditions of attachment distress. These findings point to possible neural mechanisms for underlying affective dysregulation in BPD in the context of attachment trauma and fear.

Coping and survival in patients with leukemia undergoing allogeneic bone marrow transplantation--long-term follow-up of a prospective study.

OBJECTIVE: The exploratory study examined the relationship between coping and survival in patients undergoing bone marrow transplantation (BMT). METHODS: Patients scheduled for BMT were recruited from 1990 until 1995 at the University Hospital of Ulm, Germany. They were interviewed before transplantation, and the corresponding records were checked in December 2002. Seventy-two audiotaped interviews could be analyzed for 34 coping strategies as defined in the Ulm Coping Manual (UCM). Main outcome measure was survival time post-BMT. RESULTS: On average, the patients were 35 years old, 65% were male, and 56% diagnosed acute leukemia (AL). Four coping strategies were found to show a clear trend towards an association with survival time: emotional support, acceptance, taking control, and compensation. The last strategy was associated with shorter, the others with longer survival. CONCLUSION: We found further evidence for an association between coping and survival. Because of the possible wide-reaching consequences for clinical management, replication of the data is essential.

The influence of prematurity, maternal anxiety, and infants' neurobiological risk on mother-infant interactions.

In this study, we investigated how the birth of a very low birth weight preterm (VLBW) infant influences the mother-infant interaction at 3 months. We also focused on the impact of the infant's neurobiological risk and maternal anxiety, and their interaction. The comparison of the VLBW preterm sample (n = 79) with an external full-term sample (n = 35) showed mother-infant interactions of the families with the preterm infant to be more vocally responsive during the interaction, but less facially responsive during the interaction. Additionally, higher levels of maternal anxiety were associated with preterm infants being less facially responsive in interaction with their mother. While neurobiological risk of the infant played a part in this association, with higher risk infants also being less facially responsive, the relationship with maternal anxiety and the mother-child interaction was stronger. How these findings may influence therapeutic interventions is discussed.

Rhythm and Blues - Amalie's 152nd session: From psychoanalysis to conversation and metaphor analysis - and back again.

Conversation analysis and psychotherapy process research is an evolving field promising new insights for therapeutic practice. As the specimen case of Amalie, especially her 152nd session, has been investigated using various methods - of which we give a short overview - we offer a new analysis of session 152 based on a new transcription which allows for more detailed listening to the prosodic properties of this analytic dyad. Our findings show a) how analyst and patient co-create their common conversational object called psychoanalysis; b) how a lot of up-to-now not described analytical tools are applied, that can be described as "practices"; c) how a "dance of insight" is enacted by both participants in a common creation making patterns of interaction visible from "both sides"; d) how participants create metaphors as conversational and cognitive tools to reduce the enormous complexity of the analytic exchange and for other purposes; e) that prosodic rhythmicity and other prosodic features are best integrated in a threefold model for analytic conversation consisting of "interaction engine", "talking to" and "talking about" the patient. The study is presented as hypothesis-generating research based on verbal, not statistical data.

[Central Relationship Patterns in Comparison with Different Objects]

In the present study the Relationship Episode Paradigm Interviews of 70 female patients with different psychoneurotic diseases were analysed with respect to object-specific patterns with the CCRT method. The most frequent categories are the same in all relationship episodes and in subsamples of relationship episodes with mother and father. These categories are also predominant in episodes with women and men. Relationship episodes with mother do not differ from episodes with father, and relationship episodes with women do not differ from episodes with men. But there are substantial differences in relationship episodes with the mother and women and between episodes with the father and men. Patients recount much more positive relationship patterns with women and men than with their parents. This could be understood as a hint of interpersonal resources.