When one tool is not enough: An integrative psychotherapeutic approach to treating complex PTSD.

Complex posttraumatic stress disorder (CPTSD) is a term representing the psychopathological implications of exposure to chronic, inter-personal trauma. These include the main symptoms of PTSD, as well as changes in identity, emotion regulation, and inter-personal relationships. Self-harm and dissociation (i.e., disintegration of mental processes) are also quite common in CPTSD. Considering this complex and often severe clinical picture, mental health professionals often find it difficult to effectively treat CPTSD. In this paper, we present an integrative approach to the treatment of CPTSD based on a combination of techniques from several psychotherapy approaches. The case described here illustrates the need for therapeutic flexibility and eclecticism when treating individuals exposed to chronic trauma. We show the advantages of flexible therapeutic attunement, which enables the therapist to respond to the changing need of the patient, as well as her fluid clinical picture and symptom manifestation. The case also illustrates how interventions taken from psychodynamic therapy, Dialectical behavior therapy, and Eye Movement Desensitization and Reprocessing may be applicable in various stages of treatment, alleviating the patient's distress in several psychological and physical domains.

Dynamic relations between mentalization techniques and therapeutic alliance in psychodynamic child therapy: An evidence-based case study.

Therapeutic alliance and mentalization are common factors inherent to all effective treatments. Mentalization-based interventions have the potential to create a safe relationship, which makes further mentalizing interventions possible. However, to date, no study has examined the bidirectional relationship between these variables in child psychotherapy. In an evidence-based case study design, psychodynamic therapy processes of two Turkish children (age: 9 and 10 years) who presented with social withdrawal problems were compared. All their sessions (34 sessions from Case No. 1 and 31 from Case No. 2) were coded using the Therapy Process Observational Coding System-Alliance Scale and Mentalization-Based Treatment for Children Adherence Scale. Outcome scales pertaining to symptoms, attachment, and mentalization were administered at baseline and at termination. Time-series Granger Causality tests revealed that in the case with clinically significant outcome, mentalization techniques predicted therapeutic alliance in the subsequent sessions, which predicted the use of further mentalization interventions. However, this relationship was not supported in the case with no significant improvement. Selected sessions were clinically analyzed with verbatim session vignettes. Our findings indicate that mentalization techniques in child therapy are closely related to the therapeutic relationship. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Habit-reversal training: a psychotherapeutic approach in treating body-focused repetitive behaviour disorders.

Body-focused repetitive behaviours (BFRBs) are recurrent, compulsive, destructive behaviours directed towards the body. Although studies have demonstrated a 12-14% prevalence rate, researchers found that dermatologists and psychiatrists show a lack of knowledge regarding psychodermatology resources and information about BFRB disorders (BFRBDs) such as trichotillomania (TTM). There is limited research about treatments including ones investigating the clinical applications of various self-help training such as decoupling (DC) and DC in sensu (DC-is) as well as about habit-reversal training (HRT). HRT is a five-component behavioural intervention that aims to develop a competing response to a specific unwanted behaviour. Studies have found substantial support for HRT's efficacy in treating a variety of maladaptive repetitive behaviours including onychotillomania, TTM, skin-picking disorder and chronic cheek biting. Additionally, many psychotherapies can augmented HRT. Psychotherapies include acceptance and commitment therapy, dialectical behaviour therapy, psychodynamic psychotherapy, mindfulness mediation and the cognitive psychophysiological model. A recently investigated variant of HRT, DC-is, resulted in consistently satisfactory objective and subjective improvement for treating BFRBDs, and HRT showed good subjective but poor objective improvement compared with standard DC. HRT and HRT variants are effective therapeutic treatments for BFRBDs; however, further randomized double-blinded and placebo-controlled trials are required to examine HRT's therapeutic profile.

Mentalization-oriented psychodynamic group therapy for patients with personality disorders: a naturalistic prospective cohort study.

OBJECTIVES: Patients with personality disorders (PDs) are often treated with non-manualized psychodynamic group therapy (PDT) lasting for several years. Non-manualized PDT often combines a variety of therapeutic approaches from different PDT traditions, including mentalization-based therapy. Currently, little is known about the effect of this long-term, costly treatment. This study investigated the extent to which patients with different PDs benefit from mentalization-oriented PDT as it is implemented in clinical practice in terms of symptom severity, interpersonal problems, and general functioning. METHODS: The design was a naturalistic, prospective cohort study. Seventy-five consecutive PD patients were assessed before treatment with the Symptom Checklist-90 Revised (SCL-90-R) as the primary outcome measure and the Inventory of Interpersonal Problems (IIP) and Global Assessment of Functioning (GAF) as secondary outcome measures. The sample was repeatedly assessed every 12 months for up to 36 months. Paired t-tests were applied to examine the effectiveness of the intervention. RESULTS: Among completers (n = 42; 56%), improvement was observed on the SCL-90-R: Global Severity Index (mean change = -0.45 [95% CI = -0.72, -0.19]; Cohen's d = -0.55), Positive Symptom Distress Index (-0.40 [-0.63, -0.17]; -0.56); Positive Symptoms Total (-10.70 [-17.31, -4.09]; -0.52). Secondary outcomes also improved: IIP-total (mean change = -0.50 [95%CI = -0.74, -0.25]; Cohen's d = -0.66); GAF-Functioning (8.79 [6.32, 11.27]; 1.15); and GAF-Symptoms (10.67 [8.09, 13.25]; 1.34). CONCLUSIONS: Completers improved on symptom severity, interpersonal problems, and general functioning, with within-group effect sizes ranging from medium to large. Approximately half the sample dropped out, suggesting that mentalization-oriented PDT spanning several years may be unrealistic for many patients with PD. Significant outcomesThere are no clear guidelines for psychological interventions targeting personality disorders (PDs), and currently eclectic and non-manualized psychodynamic approaches lasting for up to 3 years are prevailing in some clinical practices.Although this treatment approach may have an effect on compliant patients, the high drop-out rate indicates that it may not be suitable for a large proportion of PD patients since it requires long-term commitment. Furthermore, it is difficult to identify the content of the non-manualized psychodynamic therapy and what helps the patients.More specific clinical guidelines emphasizing the application of evidence-based treatments or at least manualized treatments are warranted for the treatment of emotionally unstable PDs and other PDs. LimitationsThe naturalistic study design, without any control group, limits conclusions about mechanisms of action of the intervention.Since the intervention was not manualized, it is unknown exactly which treatment was actually administered, which reduces external validity.The outcomes are based on completer data of a relatively small sample size with high drop-out rate.

[Office-based psychosomatic medicine with a focus on acute care]. / Das Praxismodell der Psychosomatischen Medizin und Psychotherapie mit Akut- beziehungsweise Versorgungsschwerpunkt neben der Richtlinienpsychotherapie.

Objectives: In Germany, the office-based psychosomatic medicine with focus on acute care offers psychosomatic treatment besides primary care by general practitioners and regular psychotherapy. The aim of this study is to determine specific characteristics of these innovative office-based practices. Methods: In a qualitative cross-sectional study, twelve board-certified specialists in psychosomatic medicine, practicing office-based psychosomatic medicine were surveyed by means of semi-structured telephone-interviews. After transcription and coding in MAXQDA 2020, a content analysis was conducted. Results: The innovative practice model was characterized by high numbers of initial contacts in walk-in or pre-planned consultation hours. Besides regular psychotherapy long-term and low-threshold treatment was offered. Physician assistants organised the workflow and administrative tasks. For settlement the EBM-number psychosomatic interview or short-term treatment was used. Focusses were set on somatopsychic and socio-medical treatment and consultant support. Psychotherapy often was realised in form of group sessions by integrating behavioural and psychodynamic psychotherapy. Discussion: The innovative psychosomatic practice model with focus on acute care shows an independent profile. A treatment based on medical understanding of complex somatic disease processes can be provided to somatopsychic patients. Future studies should compare this practice model to psychosomatic practices receiving a treatment by guideline psychotherapy. Conclusions: In Germany, the practices of psychosomatic medicine with a focus on acute care closes an increasing gap in psychosomatic care and augments treatment possibilities, especially for elderly and multimorbid patients.

The Relevance of Internal Working Models of Self and Others for Equine-Assisted Psychodynamic Psychotherapy.

Attachment characteristics play a key role in mental health and in understanding mental disorders. The aim of this study was to gain insight into the role the attachment characteristics can play in treatment effects in adult patients with intrapsychic and interpersonal problems who underwent Equine-assisted Short-term Psychodynamic Psychotherapy (ESTPP). In the first part of the study, we compared the effects of ESTPP to treatment-as-usual from a previous dataset regarding psychological dysfunction. For this, an explorative experimental non-randomized pre-treatment and 1-year post-treatment design was used. A mixed model revealed a significant decline in psychological dysfunction for both conditions, with no significant difference between the two. In the second part of the study, we examined the course of ESTPP effects over the period of 1 year when controlled for attachment styles and, subsequently, for internal working models of self and others. To this end, measurements were taken at baseline, 2 months waiting time, one-week intensive module, 6 months, and one year after the start of the treatment. Mixed models accounted for repeated measures showed significant improvements in psychological dysfunction, remoralization, and depression for ESTPP patients over time. The study implies that models of self and others may be used to predict the course of effects, which is relevant in determining what works for whom. In particularly, duration and intensity of therapy and a focus on the Model of Self seem relevant for shaping a more personalized treatment. ESTPP seems beneficial for patients with low pre-treatment attachment security.

Psychodynamic Child and Adolescent Psychiatry and the Future of Our Field.

The Accreditation Council for Graduate Medical Education (ACGME) requirements for child and adolescent psychiatry training require that child and adolescent psychiatry fellows demonstrate competence in psychodynamic psychotherapy.1 Child and adolescent psychiatry educators may turn to JAACAP to find up-to-date advances in psychodynamic psychotherapy to teach. However, the term psychodynamic appears to be hard to find, literally. A search on https://www.jaacap.org/ of past issues for psychodynamic2 resulted in 4 articles published in the past year, but none have the word psychodynamic in the title. Three articles describe newer evidence-based forms of psychotherapy: brief focused parent-infant psychotherapy, adolescent-focused therapy, and mentalization-based treatment. These are are described in their respective articles as "psychodynamic-based," as "psychodynamically informed," and having "historical roots in psychodynamic psychotherapy." As none are specifically titled psychodynamic therapy, it is unclear whether teaching these modalities would satisfy the ACGME requirement of competence in psychodynamic psychotherapy. Comparatively, this linguistic dilution does not seem to affect cognitive-behavioral therapy (CBT), another psychotherapy required by the ACGME1: specialized branches such as trauma-focused CBT, CBT for psychosis, and CBT for insomnia all retain the parent name of CBT. Therefore, it is important to define psychodynamic.

Multimodal affect analysis of psychodynamic play therapy.

Objective: We explore state of the art machine learning based tools for automatic facial and linguistic affect analysis to allow easier, faster, and more precise quantification and annotation of children's verbal and non-verbal affective expressions in psychodynamic child psychotherapy. Method: The sample included 53 Turkish children: 41 with internalizing, externalizing and comorbid problems; 12 in the non-clinical range. We collected audio and video recordings of 148 sessions, which were manually transcribed. Independent raters coded children's expressions of pleasure, anger, sadness and anxiety using the Children's Play Therapy Instrument (CPTI). Automatic facial and linguistic affect analysis modalities were adapted, developed, and combined in a system that predicts affect. Statistical regression methods (linear and polynomial regression) and machine learning techniques (deep learning, support vector regression and extreme learning machine) were used for predicting CPTI affect dimensions. Results: Experimental results show significant associations between automated affect predictions and CPTI affect dimensions with small to medium effect sizes. Fusion of facial and linguistic features work best for pleasure predictions; however, for other affect predictions linguistic analyses outperform facial analyses. External validity analyses partially support anger and pleasure predictions. Discussion: The system enables retrieving affective expressions of children, but needs improvement for precision.

The Effect of Psychotherapy on Quality of Life in IBD Patients: A Systematic Review.

BACKGROUND: Patients with inflammatory bowel disease (IBD) express a need for additional psychotherapy; however, psychological support is not incorporated in the routine care of persons with IBD. This systematic review aims to assess the effect of psychotherapy on quality of life (QoL). METHODS: A systematic search was conducted on October 7, 2019, using Embase, Medline (Ovid), PubMed, Cochrane, Web of Science, PsycInfo, and Google Scholar to collect all types of clinical trials with psychotherapeutic interventions that measured QoL in patients with IBD aged ≥18 years. Quality of evidence was systematically assessed using the Grading of Recommendations Assessment, Development, and Evaluation criteria. RESULTS: Out of 2560 articles, 31 studies (32 articles) were included with a total number of 2397 patients with active and inactive IBD. Of the 31 eligible studies, 11 reported a significant positive effect and 6 had ambiguous results regarding the impact of psychotherapeutic interventions on QoL. Treatment modalities differed in the reported studies and consisted of cognitive-behavioral therapy, psychodynamic therapy, acceptance and commitment therapy, stress management programs, mindfulness, hypnosis, or solution-focused therapy. All 4 studies focusing on patients with active disease reported a positive effect of psychotherapy. Trials applying cognitive-behavioral therapy reported the most consistent positive results. CONCLUSIONS: Psychotherapeutic interventions can improve QoL in patients with IBD. More high-quality research is needed before psychological therapy may be implemented in daily IBD practice and to evaluate whether early psychological intervention after diagnosis will result in better coping strategies and QoL throughout life.

Psychodynamic Based Equine-Assisted Psychotherapy in Adults with Intertwined Personality Problems and Traumatization: A Systematic Review.

The growing field of equine-assisted psychotherapy (EAP), a subfield of animal-assisted psychotherapy (AAP), needs theoretically-based clinical studies. This systematic review examines the existing clinical studies in adult populations on psychodynamic psychotherapy combined with equine-assisted psychotherapy. An electronic database search was divided in two studies to identify publications on 1) EAP combined with psychodynamic psychotherapy and 2) EAP combined to personality problems and traumatization in order to compile studies by population, intervention, outcome and therapeutic assets. Study 1 revealed no relevant clinical studies on EAP with a psychodynamic background with an adult population. Study 2 revealed 12 publications to review predominantly addressing veterans with PTSD. The methodological limitations of most of the studies restrain the overall findings on outcome. However, overall positive effects for EAP, specifically on its experiential features and on finding interpersonal trust for patients, can be discerned. There is an apparent need for clinical studies meeting methodological standards on psychodynamic underpinned EAP methodologies in adults with intertwined personality problems and traumatization.

Behavioural activation therapy for depression in adults.

BACKGROUND: Behavioural activation is a brief psychotherapeutic approach that seeks to change the way a person interacts with their environment. Behavioural activation is increasingly receiving attention as a potentially cost-effective intervention for depression, which may require less resources and may be easier to deliver and implement than other types of psychotherapy. OBJECTIVES: To examine the effects of behavioural activation compared with other psychological therapies for depression in adults. To examine the effects of behavioural activation compared with medication for depression in adults. To examine the effects of behavioural activation compared with treatment as usual/waiting list/placebo no treatment for depression in adults. SEARCH METHODS: We searched CCMD-CTR (all available years), CENTRAL (current issue), Ovid MEDLINE (1946 onwards), Ovid EMBASE (1980 onwards), and Ovid PsycINFO (1806 onwards) on the 17 January 2020 to identify randomised controlled trials (RCTs) of 'behavioural activation', or the main elements of behavioural activation for depression in participants with clinically diagnosed depression or subthreshold depression. We did not apply any restrictions on date, language or publication status to the searches. We searched international trials registries via the World Health Organization's trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished or ongoing trials. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of behavioural activation for the treatment of depression or symptoms of depression in adults aged 18 or over. We excluded RCTs conducted in inpatient settings and with trial participants selected because of a physical comorbidity. Studies were included regardless of reported outcomes. DATA COLLECTION AND ANALYSIS: Two review authors independently screened all titles/abstracts and full-text manuscripts for inclusion. Data extraction and 'Risk of bias' assessments were also performed by two review authors in duplicate. Where necessary, we contacted study authors for more information. MAIN RESULTS: Fifty-three studies with 5495 participants were included; 51 parallel group RCTs and two cluster-RCTs. We found moderate-certainty evidence that behavioural activation had greater short-term efficacy than treatment as usual (risk ratio (RR) 1.40, 95% confidence interval (CI) 1.10 to 1.78; 7 RCTs, 1533 participants), although this difference was no longer evident in sensitivity analyses using a worst-case or intention-to-treat scenario. Compared with waiting list, behavioural activation may be more effective, but there were fewer data in this comparison and evidence was of low certainty (RR 2.14, 95% CI 0.90 to 5.09; 1 RCT, 26 participants). No evidence on treatment efficacy was available for behavioural activation versus placebo and behavioural activation versus no treatment. We found moderate-certainty evidence suggesting no evidence of a difference in short-term treatment efficacy between behavioural activation and CBT (RR 0.99, 95% CI 0.92 to 1.07; 5 RCTs, 601 participants). Fewer data were available for other comparators. No evidence of a difference in short term-efficacy was found between behavioural activation and third-wave CBT (RR 1.10, 95% CI 0.91 to 1.33; 2 RCTs, 98 participants; low certainty), and psychodynamic therapy (RR 1.21, 95% CI 0.74 to 1.99; 1 RCT,60 participants; very low certainty). Behavioural activation was more effective than humanistic therapy (RR 1.84, 95% CI 1.15 to 2.95; 2 RCTs, 46 participants; low certainty) and medication (RR 1.77, 95% CI 1.14 to 2.76; 1 RCT; 141 participants; moderate certainty), but both of these results were based on a small number of trials and participants. No evidence on treatment efficacy was available for comparisons between behavioural activation versus interpersonal, cognitive analytic, and integrative therapies. There was moderate-certainty evidence that behavioural activation might have lower treatment acceptability (based on dropout rate) than treatment as usual in the short term, although the data did not confirm a difference and results lacked precision (RR 1.64, 95% CI 0.81 to 3.31; 14 RCTs, 2518 participants). Moderate-certainty evidence did not suggest any difference in short-term acceptability between behavioural activation and waiting list (RR 1.17, 95% CI 0.70 to 1.93; 8 RCTs. 359 participants), no treatment (RR 0.97, 95% CI 0.45 to 2.09; 3 RCTs, 187 participants), medication (RR 0.52, 95% CI 0.23 to 1.16; 2 RCTs, 243 participants), or placebo (RR 0.72, 95% CI 0.31 to 1.67; 1 RCT; 96 participants; low-certainty evidence). No evidence on treatment acceptability was available comparing behavioural activation versus psychodynamic therapy. Low-certainty evidence did not show a difference in short-term treatment acceptability (dropout rate) between behavioural activation and CBT (RR 1.03, 95% CI 0.85 to 1.25; 12 RCTs, 1195 participants), third-wave CBT (RR 0.84, 95% CI 0.33 to 2.10; 3 RCTs, 147 participants); humanistic therapy (RR 1.06, 95% CI 0.20 to 5.55; 2 RCTs, 96 participants) (very low certainty), and interpersonal, cognitive analytic, and integrative therapy (RR 0.84, 95% CI 0.32 to 2.20; 4 RCTs, 123 participants). Results from medium- and long-term primary outcomes, secondary outcomes, subgroup analyses, and sensitivity analyses are summarised in the text. AUTHORS' CONCLUSIONS: This systematic review suggests that behavioural activation may be more effective than humanistic therapy, medication, and treatment as usual, and that it may be no less effective than CBT, psychodynamic therapy, or being placed on a waiting list. However, our confidence in these findings is limited due to concerns about the certainty of the evidence. We found no evidence of a difference in short-term treatment acceptability (based on dropouts) between behavioural activation and most comparison groups (CBT, humanistic therapy, waiting list, placebo, medication, no treatment or treatment as usual). Again, our confidence in all these findings is limited due to concerns about the certainty of the evidence. No data were available about the efficacy of behaioural activation compared with placebo, or about treatment acceptability comparing behavioural activation and psychodynamic therapy, interpersonal, cognitive analytic and integrative therapies. The evidence could be strengthened by better reporting and better quality RCTs of behavioural activation and by assessing working mechanisms of behavioural activation.

Integrative therapy (short-term psychodynamic psychotherapy & cognitive-behavioral therapy) and cognitive-behavioral therapy in the treatment of generalized anxiety disorder: A randomized controlled trial.

BACKGROUND: and purpose: Cognitive-behavioral therapy and psychodynamic psychotherapy are common psychotherapies used for mental disorders. The purpose of the present article was to achieve an integration of cognitive-behavioral therapy and short-term psychodynamic psychotherapy that enjoys simultaneously the effects of cognitive-behavioral therapies and the stability of short-term psychodynamic psychotherapies. MATERIALS AND METHODS: It was a pre-test/post-test experimental study. Selected based on a purposive non-probabilistic sampling method, the sample studied here consisted of 36 people diagnosed with generalized anxiety according to Clinical Diagnostic Interview, psychiatrist diagnosis and Hamilton Rating Scale for Anxiety (HRSA). They were divided randomly into three 12 person groups: two treated groups by integrative therapy and cognitive-behavioral therapy, and one control group. Only pre-test and post-test were employed for the control group without any kind of treatment. To select patients and evaluate the effects of each type of treatments, the "Hamilton Rating Scale for Anxiety" and "Beck Depression Inventory" were applied for the pre-test/post-test and the differential diagnosis, respectively. The results obtained were analyzed by covariance and ANOVA analyses using SPSS software. RESULTS: The results of the study indicate the efficacy of both cognitive-behavioral therapy and integrative therapy in the treatment of generalized anxiety and integrative therapy was more effective in the treatment of generalized anxiety compared to cognitive-behavioral therapy. CONCLUSION: Integrative treatment not only to be effective in the treatment of generalized anxiety disorder and the reduction of its symptoms, but also to be more effective than cognitive-behavioral therapy.

Dynamic interpersonal therapy for moderate to severe depression: a pilot randomized controlled and feasibility trial.

BACKGROUND: Improving Access to Psychological Therapies (IAPT) services treat most patients in England who present to primary care with major depression. Psychodynamic psychotherapy is one of the psychotherapies offered. Dynamic Interpersonal Therapy (DIT) is a psychodynamic and mentalization-based treatment for depression. 16 sessions are delivered over approximately 5 months. Neither DIT's effectiveness relative to low-intensity treatment (LIT), nor the feasibility of randomizing patients to psychodynamic or cognitive-behavioural treatments (CBT) in an IAPT setting has been demonstrated. METHODS: 147 patients were randomized in a 3:2:1 ratio to DIT (n = 73), LIT (control intervention; n = 54) or CBT (n = 20) in four IAPT treatment services in a combined superiority and feasibility design. Patients meeting criteria for major depressive disorder were assessed at baseline, mid-treatment (3 months) and post-treatment (6 months) using the Hamilton Rating Scale for Depression (HRSD-17), Beck Depression Inventory-II (BDI-II) and other self-rated questionnaire measures. Patients receiving DIT were also followed up 6 months post-completion. RESULTS: The DIT arm showed significantly lower HRSD-17 scores at the 6-month primary end-point compared with LIT (d = 0.70). Significantly more DIT patients (51%) showed clinically significant change on the HRSD-17 compared with LIT (9%). The DIT and CBT arms showed equivalence on most outcomes. Results were similar with the BDI-II. DIT showed benefit across a range of secondary outcomes. CONCLUSIONS: DIT delivered in a primary care setting is superior to LIT and can be appropriately compared with CBT in future RCTs.

Anterior hippocampal volume predicts affect-focused psychotherapy outcome.

BACKGROUND: The hippocampus plays an important role in psychopathology and treatment outcome. While posterior hippocampus (PH) may be crucial for the learning process that exposure-based treatments require, affect-focused treatments might preferentially engage anterior hippocampus (AH). Previous studies have distinguished the different functions of these hippocampal sub-regions in memory, learning, and emotional processes, but not in treatment outcome. Examining two independent clinical trials, we hypothesized that anterior hippocampal volume would predict outcome of affect-focused treatment outcome [Interpersonal Psychotherapy (IPT); Panic-Focused Psychodynamic Psychotherapy (PFPP)], whereas posterior hippocampal volume would predict exposure-based treatment outcome [Prolonged Exposure (PE); Cognitive Behavioral Therapy (CBT); Applied Relaxation Training (ART)]. METHODS: Thirty-five patients with posttraumatic stress disorder (PTSD) and 24 with panic disorder (PD) underwent structural magnetic resonance imaging (MRI) before randomization to affect-focused (IPT for PTSD; PFPP for PD) or exposure-based treatments (PE for PTSD; CBT or ART for PD). AH and PH volume were regressed with clinical outcome changes. RESULTS: Baseline whole hippocampal volume did not predict post-treatment clinical severity scores in any treatment. For affect-focused treatments, but not exposure-based treatments, anterior hippocampal volume predicted clinical improvement. Smaller AH correlated with greater affect-focused treatment improvement. Posterior hippocampal volume did not predict treatment outcome. CONCLUSIONS: This is the first study to explore associations between hippocampal volume sub-regions and treatment outcome in PTSD and PD. Convergent results suggest that affect-focused treatment may influence the clinical outcome through the 'limbic' AH, whereas exposure-based treatments do not. These preliminary, theory-congruent, therapeutic findings require replication in a larger clinical trial.

State of the Art Treatment Options for Actual and Potential Sexual Offenders and New Prevention Strategies.

Sexual violence is a significant and devastating issue for men and women throughout the world. Its consequences are not only disastrous for victims of sexual violence but are also extremely costly (estimated cost of $41,000 per rape) for society. Successful treatment of sexual offenders is therefore an important goal for society as well as for victims and offenders themselves. Over the years, multiple treatment approaches for sex offenders have been developed. Treatment programs range from the risk-need-responsivity (RNR) model, which focuses on providing tailored treatment for high-risk and low-risk offenders, to psychodynamic models. This article presents an overview for clinicians of state-of-the-art offender treatment, describing the most common treatment approaches, in particular the RNR model, cognitive-behavioral programs (relapse prevention programs, sexual offender treatment programs), psychodynamic approaches (transference-focused psychotherapy, mentalization-based therapy), the Good Lives Model, as well as pharmacological options. In addition, it provides an evaluation of the various treatment programs. However, given the fact that most acts of sexual violence will never be reported to the police, the question arises if treating convicted perpetrators is enough. Do we need rather-in terms of preventive work-a program for potential sexual offenders and men with delinquent sexual fantasies? Given the prevalence of sexual violence and its impact on victims, society, and the medical community, it would be remiss not to try to reach potential/unconvicted perpetrators. This article offers novel ideas and a project the goal of which is to prevent sexual offenses against women by introducing the "I CAN CHANGE" program from Hannover Medical School.

Psychotherapy with Suicidal Patients: The Integrative Psychodynamic Approach of the Boston Suicide Study Group.

Psychotherapy with suicidal patients is inherently challenging. Psychodynamic psychotherapy focuses attention on the patient's internal experience through the creation of a therapeutic space for an open-ended exploration of thoughts, fears, and fantasies as they emerge through interactive dialogue with an empathic therapist. The Boston Suicide Study Group (M.S., M.J.G., E.R., B.H.), has developed an integrative psychodynamic approach to psychotherapy with suicidal patients based on the authors' extensive clinical work with suicidal patients (over 100 years combined). It is fundamentally psychodynamic in nature, with an emphasis on the therapeutic alliance, unconscious and implicit relational processes, and the power of the therapeutic relationship to facilitate change in a long-term exploratory treatment. It is also integrative, however, drawing extensively on ideas and techniques described in Dialectical Behavioral Therapy (DBT), Mentalization Based Treatment (MBT), Cognitive-Behavioral Therapy (CBT), as well on developmental and social psychology research. This is not meant to be a comprehensive review of psychodynamic treatment of suicidal patients, but rather a description of an integrative approach that synthesizes clinical experience and relevant theoretical contributions from the literature that support the authors' reasoning. There are ten key aspects of this integrative psychodynamic treatment: 1. Approach to the patient in crisis; 2, instilling hope; 3. a focus on the patient's internal affective experience; 4. attention to conscious and unconscious beliefs and fantasies; 5. improving affect tolerance; 6. development of narrative identity and modification of "relational scripts"; 7. facilitation of the emergence of the patient's genuine capacities; 8. improving a sense of continuity and coherence; 9 attention to the therapeutic alliance; 10. attention to countertransference. The elements of treatment are overlapping and not meant to be sequential, but each is discussed separately as an essential aspect of the psychotherapeutic work. This integrative psychodynamic approach is a useful method for suicide prevention as it helps to instill hope, provides relational contact and engages the suicidal patient in a process that leads to positive internal change. The benefits of the psychotherapy go beyond crisis intervention, and include the potential for improved affect tolerance, more fulfilling relational experiences, emergence of previously warded off experience of genuine capacities, and a positive change in narrative identity.

Psychodynamic art psychotherapy for the treatment of aggression in an individual with antisocial personality disorder in a secure forensic hospital: A single-case design study.

The aim of this single-case study was to investigate the responses to psychodynamic art psychotherapy from a man who had a diagnosis of antisocial personality disorder and ongoing aggressive behavior in a secure care setting. The intervention was 19 sessions of psychodynamic art psychotherapy lasting up to 1 hr per week. This study uses a single-case design with pretreatment, treatment, and posttreatment follow-up assessment of symptoms using multiple methods reported by the therapist, other staff members, and the patient. Treatment progress was assessed by (a) repeated self-report symptom measurements, (b) continuous assessment of observed aggressive behavior and risk incident reports in the hospital, (c) pre-post treatment assessment of relationship patterns and interpersonal schemas, and (d) interviews with the patient and his nurse at 9-month follow-up, retrospectively assessing the change. The patient showed a clinically significant reduction pre-post and pre-follow-up in symptoms. Behavioral observations indicated a reduction of overt aggression and risk-related incidents. Comparison of the Core Conflictual Relationship Theme pre-post treatment indicated positive changes in interpersonal schemas. This illustrative systematic single-case study highlights the potential for investigation of a novel psychotherapeutic approach that has in turn led to further developments in clinical research. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Juggling thoughts and feelings: How do female patients with borderline symptomology and substance use disorder experience change in mentalization-based treatment?

OBJECTIVE: The aim of this study was to explore the experience of central psychological change processes for female patients with borderline symptomology and substance use disorder in mentalization-based treatment. METHOD: Semi-structured qualitative interviews on experiences from mentalization-based treatment with 13 participants were conducted. The interview material was analysed within a hermeneutical-phenomenological epistemology, with emphasis on researcher reflexivity. RESULTS: The following themes regarding central psychological change processes were found: "by feeling the feeling," "by thinking things through," "by walking in your shoes to see myself" and "by stepping outside of own bad feelings in seeing you." Two of these themes dealt with intra-psychic modes of how to relate to own mind-states. First, they had a shift from avoiding emotions into tolerating emotions. Second, they discovered the ability to think mental states through. Two themes dealt with mental stances for dealing with interpersonal situations, where one mode included a self-reflective stance in difficult encounters, and the other mode entailed an empathic reflective stance by exploring others' intentionality. CONCLUSIONS: The findings are in line with theoretical assumptions that increasing mentalizing capacity is a central change process for these patients. Furthermore, the findings demonstrate the complex interaction between different modes of mentalizing. Clinical or methodological significance of this article: The article explores change processes in manualized psychotherapy for patients with comorbid borderline personality disorder and substance use disorder, a focus which is not researched in the clinical literature. We claim that putting attention to this patient group and investigating their potential in psychotherapy is of clinical significance. Methodologically, this article utilizes thematic analyses within an epistemology following a specific procedure that is step based and transparent, thus it is of interest for qualitative researchers who also utilize thematic analyses.

Implementing brief Dynamic Interpersonal Therapy (DIT) in a VA Medical Center.

Background: Given increasing mental health needs in the VA, identifying strategies to deliver new services is critical.Aims: This paper describes the process of navigating provider, patient and systems barriers of an initiative to increase choice, access and quality of psychotherapy at the VA by incorporating an evidence-based short-term, psychodynamic psychotherapy.Methods: Brief Dynamic Interpersonal Therapy (DIT) was selected as a viable model for implementation. Data were gathered on the process of implementation, barriers, Veterans seen, and access to psychodynamic psychotherapy.Results: Nine psychologists and 22 masters level pre-doctoral psychology externs have delivered DIT to 73 Veterans. Veterans referred for psychodynamic psychotherapy annually increased 360%. Furthermore, DIT has become the dominant form of psychodynamic psychotherapy requested of the psychology service representing 70.1% of psychodynamic psychotherapy referrals. Strategies are presented for addressing: (1) provider ability, flexibility and motivation, (2) Veteran perception of relevance, distinctiveness and adaptability to complex presenting issues and (3) administrative support.Conclusions: Implementing an evidence-based short-term psychodynamic treatment option in the VA is feasible. VA mental health providers can be trained in brief psychodynamic psychotherapy and can successfully implement those approaches in VA settings. Finally, psychodynamic treatment approaches may serve as a promising alternative to currently available treatments.

Twelve-Month Outcomes Following Successful Panic-Focused Psychodynamic Psychotherapy, Cognitive-Behavioral Therapy, or Applied Relaxation Training for Panic Disorder.

OBJECTIVE: Given the chronic, episodic nature of panic disorder, it is important to examine long-term outcomes of patients who respond well to various psychotherapies. METHOD: Out of 116 patients with DSM-IV panic disorder who evidenced a ≥ 40% reduction in panic and avoidance symptoms on the Panic Disorder Severity Scale (PDSS) after 12-14 weeks of panic-focused psychodynamic psychotherapy, cognitive-behavioral therapy, or applied relaxation training as part of a 2-site randomized controlled trial conducted between January 2007 and July 2012, 91 patients provided at least 1 PDSS datapoint during follow-up. Patients were assessed at each of the 12 following months using the PDSS, the Sheehan Disability Scale (SDS), and the Hamilton Depression Rating Scale (HDRS) and twice during the follow-up period with the Anxiety Disorders Interview Schedule. RESULTS: Patients with panic disorder who responded to 1 of 3 treatments maintained their gains on the PDSS, SDS, and HDRS with no differences by condition in rates of change over the follow-up period (all P values ≥ .20). Similarly, 57% of improved patients did not have a panic disorder diagnosis by the end of 1 year, regardless of the treatment received. No differences in rates of panic disorder diagnosis were found across treatment conditions at either 6 months or 12 months (all P values ≥ .78). Results should be interpreted in light of the fact that patients giving data at follow-up experienced lower symptom levels at treatment termination than those not providing data. CONCLUSIONS: Improvement in any of the 3 treatments examined in this trial was largely maintained for a year following the end of therapy. Future treatment development could focus on factors to increase the level of response in the active phase of therapy. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00353470.