[Healthier after Psychotherapy? Analysis of Claims Data (Lower Saxony, Germany) on Sickness Absence Duration before and after Outpatient Psychotherapy]. / Gesünder nach der Psychotherapie? Sekundärdatenanalyse der Arbeitsunfähigkeitszeiten vor und nach ambulanter Verhaltenstherapie, tiefenpsychologisch fundierter und analytischer Psychotherapie.

INTRODUCTION: In employed populations sickness absence can be used as a good indicator of health status. In the present study, it was examined how periods of sickness absence are developing within one year before and after psychotherapy under comparison of three types of psychotherapy (behavior therapy, psychodynamic psychotherapy, and psychoanalysis), all fully covered by statutory health insurance. METHODS AND DATA: The analyses were performed with pseudonymized claims data from the AOK Niedersachsen, a statutory health insurance (N=2,900,065 insured). Certified sickness absences before and after psychotherapy were examined for 9,916 patients. Parallelized controls were used to build a comparison of the length of sickness absences. Analyses were performed separately for women and for men. RESULTS: Within one year before starting psychotherapy, patients had longer sickness absences than controls on average. There was a reduction in the length of sickness absence of 20 days (median) within one year before to 12 days (median) within one year after the psychotherapy. The obtained differences between types of psychotherapy were considerable. DISCUSSION: Differences in terms of sickness absences may in part be explained by socio-demographic differences. Patients who underwent psychoanalysis were younger and had higher educational levels. However, it remains unclear why the differences of sickness absence periods were that high. It has to be discussed whether self-selection of patients with better health into psychoanalysis had occurred. CONCLUSIONS: Patients undergoing psychoanalysis differ from patients who underwent other types of psychotherapy in terms of their duration of sickness absence as well as socio-demographic profile. Thus, due to differences in the composition of patients future research in psychotherapy will have to differentiate by type of psychotherapy.

Doctoral training in clinical psychology across 23 years: Continuity and change.

OBJECTIVE: Doctoral training in clinical psychology has undergone substantial changes in recent decades, especially with the increasing heterogeneity of training models and graduate students. To document these changes, we analyzed program, student, and faculty characteristics of American Psychological Association (APA)-accredited clinical psychology programs over a 23-year span. METHOD: We surveyed directors of clinical training about their doctoral programs every 2 years from 1991 to 2013, securing 90%-98% response rates. With minimal exceptions, the survey questions remained constant. RESULTS: Percentages of female and racial/ethnic minority students continued to grow, such that women now comprise about three quarters of trainees and ethnic minorities about one quarter. There has been a decisive shift in faculty theoretical orientation toward cognitive/cognitive-behavioral and away from psychodynamic/psychoanalytic. Internship match rates were relatively high and stable until the early 2010s but have recently rebounded. CONCLUSION: We discuss the limitations of these survey results and their implications for the future of doctoral training in clinical psychology.

Psychoanalytic training experience and postgraduate professional development - Part II.

This exploratory study looks at the training and postgraduate experience of the 2008-2014 graduates of the Chicago Institute for Psychoanalysis. It follows our former study of all living graduates through the year 2007 (Schneider et al., 2014). The survey developed and used in the first study, with a few additional questions added to increase our understanding of the training experience, was sent to 38 graduates with a return rate of 58%. As with the first survey, graduates were invited to assess, among other training experiences, their training analysis, classroom work, and supervision, and to tell of their post-graduation involvement in teaching, supervising, study groups and other professional endeavors. They were also asked to rate their satisfaction with themselves as psychoanalysts and with their analytic career. The questions added to the previous survey related to the graduates' theoretical orientation, the influence on their training experiences of the change in gender distribution, and of the diversity of professions now represented in the analytic training program. They were also encouraged to provide spontaneous narrative data. The data from our second survey showed important differences when compared with our first. In the first survey male respondents were in the majority; in the second, women held the majority. Of the professions represented in the training program, psychiatry was the majority in the first survey, psychology and social work held the majority in the second. Most respondents claimed an object-relation theoretical orientation. Analytic immersion continues to decrease, with most respondents having two patients at the time of graduation and one at the time of the survey.

Lo arcaico: reflexiones sobre los comienzos de la vida psíquica / The archaic: reflections on the beginning of psychic life and its impact upon the organization of personal life

Este trabajo revisa las alusiones de Freud a procesos psíquicos tempranos y su uso del término «arcaico» como sinónimo de filogenético. Examina la aparición del neologismo «lo arcaico» como nombre y presenta la etiología y manifestaciones de lo arcaico en la clínica psicoanalítica. Reconsidera la noción de representación proponiendo que debemos ón proponiendo que debemos postular una representación vivencial: una form afectiva de representarse a sí mismo con el otro en un escenario de encuentro relacional corporal ya sea integrado o fallido. Sugiere que la comunicación entre personas requiere la correspondencia intencional de sentimientos juntamente con mensajes complementarios, ya sean verbales o gestuales. Retomando las «pequeñas pulsiones» de Freud, propone restaurarles su valor psíquico como fundantes de la mente, del cuerpo erógeno y del deseo psíquico de vivir. Ofrece observaciones de investigadores de la primera infancia para fundamentar sus propuestas. Presenta ilustraciones clínicas de otros autores y la de su paciente D. J. Propone que conceptualicemos la «pulsión de muerte» como las consecuencias dinámicas y sintomáticas de haber perdido toda esperanza de comunicarse con otros como un sí mismo reconocido. Concluye con reflexiones técnicas para elaborar los procesos arcaicos durante el psicoanálisis (AU)

This paper examines Freud’s allusions to early psychic processes and his use of the term «archaic» as a synonym for phylogenetic. The author examines the appearance of the neologism «the archaic» and presents the aetiology and manifestations of the archaic in psychoanalytic clinical practice. The notion of representation is reconsidered, suggesting the advancement of an experiential representation: an effective way to represent oneself with the other in a scene of bodily relational encounter, whether integrated or failed. The author suggests that the communication between persons requires the intentional reciprocity of feelings together with complementary messages, be they verbal or gestural. Returning to Freud’s «little [ad hoc] instincts», the author proposes reinstating their psychic value as foundational to the mind, the erogenous body and the psychic desire to live. Observations by early Childhood researchers are provided to lay the foundations for the author’s proposals. Clinical illustrations of the author’s patient DJ. and those of other authors are presented. The author proposes that we conceptualize the «death drive» as the dynamic and symptomatic consequences of having lost all hope of communicating with others as a recognized self. The Work concludes With reflections on technique to work through the archaic processes during analysis (AU)

Current Trends in Theoretical Orientation of Psychologists: The Case of Quebec Clinicians.

OBJECTIVE: Trends indicate that clinical psychologists' theoretical orientations have changed over the last decades in North America, but research on this topic in Canada is scarce. We analyzed the orientation of psychologists over the last 20 years in the province of Quebec, where 46% of Canadian psychologists are located. METHOD: Data were collected annually through the board registration form of Quebec psychologists' professional order from 1993 to 2013. Univariate statistical analyses were realized on aggregated data. RESULTS: In 20 years, the proportion of clinicians choosing cognitive-behavioral therapy (CBT) as their main orientation grew from 18.4% to 38%, while preference for other orientations slightly declined. Existential-humanistic and psychodynamic-psychoanalytic approaches remained the primary orientation for around 21.7% and 21.5%, respectively. In 2013 (N = 8608), when taking into account 2 choices of theoretical orientation, 55.8% of clinicians chose CBT, 34.3% existential-humanistic orientation, 27.9% psychodynamic-analytic theories, and 21.8% systemic-interactional orientation. CONCLUSIONS: Findings underline trends in Quebec clinical practice characterized by an increase in the number of psychologists identifying cognitive-behavioral approach as their primary self-reported theoretical orientation.

Avaliação psicológica como fator protetor à interrupção de tratamento na psicoterapia psicanalítica de crianças: dados empíricos / Psychological assessment as a protective factor against treatment dropout in psychoanalytic child psychotherapy of children: empirical data

A avaliação psicológica pode fornecer informações importantes sobre sintomas, personalidade, diagnóstico e prognóstico do paciente, auxiliando no desenvolvimento de estratégias terapêuticas. Esta coorte retrospectiva objetivou determinar se há associação entre a realização de avaliação psicológica antes da psicoterapia e a permanência dos pacientes em tratamento. Foram analisados prontuários de 2.106 crianças atendidas em dois ambulatórios de saúde mental em Porto Alegre. Crianças que haviam realizado avaliação psicológica antes de iniciar a psicoterapia apresentavam 65% mais chance de aderir ao tratamento e 44% menos chance de abandoná-lo do que crianças que não haviam realizado avaliação psicológica. A avaliação psicológica auxilia os pais a se engajarem no tratamento de suas crianças, tornando-o menos coercitivo, além de fornecer uma fundamentação mais concreta para o subjetivo processo psicoterapêutico. (AU)

Psychological assessment can provide important information on patient's symptoms, personality, diagnosis and prognosis assisting in the development of therapeutic strategies. This retrospective cohort study aimed to determine whether there is association between performing a psychological assessment prior to psychotherapy and keeping the treatment. Medical records of 2,106 children seen in two outpatient mental health clinics in Porto Alegre were analyzed. Children who had undergone psychological assessment before starting psychotherapy were 65% more likely to adhere to the treatment and 44% less likely to drop it out than were children who had not been assessed. Psychological assessment helps parents understand their children's treatment, making it a less coercive process and provides a more concrete foundation for the otherwise subjective psychotherapeutic process. (AU)

Patient suicides in psychiatric residencies and post-vention responses: a national survey of psychiatry chief residents and program directors.

OBJECTIVES: This report focuses on post-vention measures taken by U.S. psychiatry residencies when a resident-in-training experiences a patient suicide. METHODS: A survey distributed to program directors and chief residents obtained an estimate of the frequency of psychiatric residents' experiencing a patient suicide and the frequency of numerous post-vention activities utilized by psychiatric residencies in 2008. The survey looked at the presence or absence of a post-vention protocol within a program and determined whether there was an effect on the number of patient suicides and the frequency of post-vention activities within a program. The data were compared with the results of a similar survey from 1994 to determine whether there had been significant progress in the practice of supportive post-vention activities within training institutions. RESULTS: There was a 21% response rate from chief residents (N=54) and a 31.1% response rate from program directors (N=94). Chief residents reported 1.44 suicides per residency, and program directors reported 0.88 suicides per residency for the 2008 calendar year. This corresponded to approximately 1 in 20 residents' experiencing a patient suicide in the 12-month period. Both groups reported approximately 1 in 5 psychiatry residency programs with written post-vention protocols, which was unchanged from the 1994 survey. When a protocol was in place, chief residents reported a statistically significant increase in timely notification of the program director, process groups, therapy or counseling, and emergency leave, whereas program directors reported a statistically significant decrease in post-vention therapy or counseling. Further statistical analysis revealed a tendency for programs with post-vention protocols to have more reported suicides. CONCLUSIONS: Post-vention protocols may be developed by residencies as a need to address residents experiencing a patient suicide. Discrepancies in the reports of chief residents and program directors in post-vention activities may reflect a lack of consensus on post-vention training and education within psychiatric residencies.

[Balint group work in Germany - results from a survey of Balint group leaders]. / Praxis der Balintgruppenarbeit in Deutschland- Ergebnis einer Umfrage unter Leitern von Balintgruppen.

OBJECTIVES: Based on a postal survey of Balint group leaders from the year 2004, this study analyses the characteristics of Balint group work as described by Michael Balint (1896-1970)in modern Germany. METHOD: A questionnaire was sent to 503 German Balint group leaders, 333 (66.2 %) of whom returned the questionnaire (40.5 % women, mean age 57.2 years). RESULTS: Most Balint group leaders are specialists in psychosomatic medicine and psychotherapy (30.6 %), psychiatry and psychotherapy (17.1 %) or are general practitioners (12.3 %). Psychoanalysts rarely serve as Balint group leaders. Sessions are normally held every 2 weeks (26.7 %) or once a month (26.4 %). Despite the original intention of Michael Balint, the idea of holding weekly Balint groups is now seldom(3.9 %). 85 %of the Balint group leaders prefer sessions lasting 90 minutes. An average of 8.6 participants attend, with 2.1 persons missing. There is a great heterogeneity in the professions of Balint group leaders. 17.4 % of them are older 65 years. CONCLUSIONS: This study shows that Balint group work in Germany is well integrated in both general practice and psychotherapy, and it is still of great interest to many specialists of other disciplines as well as a good way to realize further education. The ideas of Michael Balint are very much alive, but - because of the changed realities in the medical field - no longer as he originally foresaw, but in settings adapted to the new situations in medicine.

Is psychoanalytic education effective?: comment on Damsa et al. (2010).

While a growing body of empirical data attests increasingly to the efficacy of psychoanalytic treatment, what data do we have that attests to the effectiveness of psychoanalytic education? In this comment on Damsa et al. (2010), I briefly address that question and suggest that-if we are to truly generate passionate interest in psychoanalysis among psychiatric residents and other mental health professionals in training-perhaps we need to begin by researching the largely unresearched process of psychoanalytic education and supervision.

Do psychotherapists speak to psychopharmacologists? A survey of practicing clinicians.

While more Americans are taking psychotropic medication than ever before, psychiatrists are providing less psychotherapy, leading to the prevalence of "split-treatment" whereby two professionals provide care. Communication between clinicians treating the same patient has traditionally been an accepted principle of optimal care, however there has been no published data documenting whether or not private practice therapists actually do communicate with the psychiatrists who prescribe for their patients. A pilot study was conducted in which a nine-item anonymous survey was distributed to non-medical psychotherapists in Manhattan. Information was gathered about professional degree and discipline, duration and size of practice, and frequency of communication with professionals who prescribe for their patients. Fifty-three psychotherapists averaging over 21 years in practice returned completed surveys. Respondents reported on 1,197 psychotherapy patients, with 434 (36%) concurrently taking medication. No communication had taken place between psychotherapist and psychopharmacologist on behalf of 22% of the psychotherapy patients taking medication. Only 7 of the 53 respondents reported having quarterly communication with the prescribing physician for all split-care patients. Despite methodological limitations, study findings document that communication between professionals is not taking place on behalf of many patients in split-treatment. These findings raise questions about the quality and safety of treatment delivered in this fashion, about the need for guidelines for the conduct of split treatment, and perhaps about the traditionally assumed need for communication itself.

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.

A cross-sectional survey of child and adolescent analysts in New York City.

The field of child and adolescent psychoanalysis has been considered an endangered specialty for many decades. This study surveyed the nature of the practice of child and adolescent analysts (graduates and candidates) affiliated with three institutes accredited by the American Psychoanalytic Association in the New York City area. Sixty-one percent of those surveyed (63 of 103) responded. The child and adolescent analysts in this cohort treat a total of 201 adult, child, and adolescent analytic cases (M = 3.2, SD = 2.6). Of these cases, 17% are at a three-times-weekly frequency. Child and adolescent analytic practice is small, with a total of 56 analytic cases (M = .9, SD = 1.2). While 64% of these analysts have no child or adolescent analytic cases currently in treatment, 24% have very active child and adolescent analytic practices, conducting 73% of all the child and adolescent analyses reported. Implications of these findings and recommendations for future work are discussed.

[Saving psychoanalysis. At any cost?]. / Die Psychoanalyse soll gerettet werden. Mit allen Mitteln?

Although long-term psychoanalysis has been criticized due to lacking scientific efficacy, a meta-analysis by Leichsenring and Rabung concludes it is even more effective than other psychological interventions and follows a dose:response relationship (i.e. the longer the better). We reassessed this meta-analysis and find that its conclusions are not warranted. First, major parts of them are not based on the included randomised clinical trials (11) but on observational studies (12), which are known to be subject to investigator bias. The definition of long-term psychoanalysis included mainly randomised clinical trials with fewer than 50 treatment sessions, which is untypically short for this kind of intervention. Comparison groups were misclassified (especially the classification "cognitive interventions"). Important disorders were not clearly defined, hindering any interpretation of which treatment is to be indicated. Moreover the authors did not consider the lack of acceptance and attrition rates, nor did they include intention-to-treat data sets. For some of the studies only 45% of samples were included in the meta-analysis. We conclude that a few of the included randomised clinical trials using psychodynamic short-term interventions truly are promising and of high quality; however these do not justify generalizations on long-term psychoanalysis, and the presented meta-analysis is clearly biased.

A pathway to therapeutic change: changes in self-representation in the treatment of adolescents and young adults.

Processes that lead to normal development of the representations of self and others are also central to understanding processes of therapeutic change. In long-term, intensive, psychodynamically oriented, inpatient treatment of seriously disturbed, treatment-resistant adolescents and young adults, we found that changes in the level of differentiation-relatedness in patients' self-representation were primarily associated with changes in the level of differentiation-relatedness of their description of their therapist. A best-fit model indicated that change in the patient's description of the therapist and of a self-designated significant other outside the family added significantly to the explained variance predicting change in self-representation. Exploratory structural equation modeling also suggested that patients' growing recognition of the therapeutic relationship (measured by a more mature representation of the therapist) is associated with changes in the patients' overall level of clinical functioning. These results add further support to the importance of the therapeutic relationship in building more differentiated and integrated representations of self and of significant others.

Practice patterns and treatment choices among psychiatrists in New Delhi, India: a qualitative and quantitative study.

OBJECTIVE: Several issues relevant to the care of Asian Indian patients remain poorly explored. Little is known about the practice patterns of psychiatrists in India, such as daily practice routines or treatment approaches, which we describe in New Delhi, India. METHODS: We focused on psychiatric practice, as perceived by Indian psychiatrists, using a sample from the USA as a comparison group. We used triangulated, qualitative methods from data gathered in India (ethnographic interviews with 16 Delhi psychiatrists, observation of treatment in India, and treatment of Indian patients) to design and validate a survey distributed to a sample of 34 psychiatrists in New Delhi and 34 in Baltimore, Maryland who treat Indian patients. RESULTS: Delhi psychiatrists saw more patients daily (24.3 vs. 11, P<0.001), and spent less time on new evaluations (33.3 vs. 69 min, P<0.001). Both groups had similar approaches to major disorders. But, Delhi psychiatrists were less likely to combine medication treatment with psychotherapy (P<0.05), and more likely to advise families to secretly administer medications in treatment refusal, such as in acute schizophrenia (P<0.001) or major depression (P<0.01). CONCLUSIONS: These differences highlight the salience of local cultural context in the practice of psychiatry and in the treatment of Indian patients. Delhi psychiatrists are overwhelmed by the epidemic levels of untreated illness, spend less time with patients, and rely more heavily on medication treatment. Delhi psychiatrists employ unique approaches to handling difficult treatment issues, such as treatment refusal, intensive involvement of the family, and recommendations to the family about suitability for marriage for a patient.

[Depression treatment by psychiatrists - treatment strategies and experienced barriers from psychiatrists' point of view]. / Fachärztliche Depressionsbehandlung - subjektive Wahrnehmung der Versorgungssituation und erlebte Barrieren.

OBJECTIVE: To analyse the status quo of depression treatment (procedure, responsibilities, and treatment barriers) from psychiatrists' point of view. METHODS: Cross-sectional survey (n = 71 psychiatrists; return rate: 45.5 %). RESULTS: Diagnostic and therapeutic knowledge were validated as good. Psychiatrists view their responsibility mainly in identifying depressed patients, in differential diagnosis and medical treatment. The clinical diagnosis corresponded only in 52.7 % to ICD-10 criteria. Pharmacotherapy and referral were according to guidelines. Psychiatrists were less satisfied with cooperation with the psychosocial sector (social service, counselling centres) than with family physicians, psychotherapists and hospitals. The need for continuous medical education was seen specifically regarding therapeutic procedures (prophylaxis of relapse and combined therapy) and less concerning the diagnoses. CONCLUSIONS: The results affirm the quality outpatient psychiatric care of depressive patients. Improvement potentials regard evidence-based diagnostic and networking with the psychosocial sector.

[Prevalence of psychotherapeutic treatments in citizens of Buenos Aires city]. / Prevalencia de tratamiento psicopaterapéutico en los habitantes de la ciudad de Buenos Aires.

INTRODUCTION: Little data exist about the prevalence of psycotherapy used by the general population of the city of Buenos Aires. The aim of our study was to determine this prevalence, the demographic characteristics of the population that receives psychotherapy, as well as types and characteristics of these psycotherapies. METHOD: A survey was conducted among 1510 inhabitants in different neighbourhoods of the city of Buenos Aires. RESULTS: During the month previous to the survey, 15.6% of the population received psychotherapy treatment, 21% during the last year and 41.6% had received before. Psychoterapy treatment is more prevalent among women and people with higher educational and social-economic level, and it is less frequent in the elderly group. No differences in the use of psychotherapy exist according to marital status. Forty four percent of the patients under treatment at the moment of the survey were unaware of the type of psychotherapy received, 41.3% knew that they were receiving psychoanalytic therapy and 8% cognitive-behavioral psychotherapy. Eighty-two percent of the treatments were conducted by psychologists and 11% by physicians. CONCLUSIONS: The use of the psychotherapy is very extended among the general population of the city of Buenos Aires.