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.

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.

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.

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.

Tracking functional brain changes in patients with depression under psychodynamic psychotherapy using individualized stimuli.

OBJECTIVE: Neurobiological models of depression posit limbic hyperactivity that should normalize after successful treatment. For psychotherapy, though, brain changes in patients with depression show substantial variability. Two critical issues in relevant studies concern the use of unspecific stimulation experiments and relatively short treatment protocols. Therefore changes in brain reactions to individualized stimuli were studied in patients with depression after eight months of psychodynamic psychotherapy. METHODS: 18 unmedicated patients with recurrent major depressive disorder were confronted with individualized and clinically derived content in a functional MRI experiment before (T1) and after eight months (T2) of psychodynamic therapy. A control group of 17 healthy subjects was also tested twice without intervention. The experimental stimuli were sentences describing each participant's dysfunctional interpersonal relationship patterns derived from clinical interviews based on Operationalized Psychodynamic Diagnostics (OPD). RESULTS: At T1 patients showed enhanced activation compared to controls in several limbic and subcortical regions, including amygdala and basal ganglia, when confronted with OPD sentences. At T2 the differences in brain activity between patients and controls were no longer apparent. Concurrently, patients had improved significantly in depression scores. CONCLUSIONS: Using ecologically valid stimuli, this study supports the model of limbic hyperactivity in depression that normalizes after treatment. Without a control group of untreated patients measured twice, though, changes in patients' brain activity could also be attributed to other factors than psychodynamic therapy.

[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.

Psychotherapeutic/psychoanalytic treatment of the elderly.

Elderly patients who may have been able to deal satisfactorily with earlier periods of stress may find that in later life they are impacted by an array of devastating losses and crises subverting their abilities to adapt satisfactorily. Psychotherapeutic/psychoanalytic treatment has been demonstrated to be helpful to many elderly patients, especially if the psychotherapist/psychoanalyst chooses to relax a traditional analytic stance and actively engage the patient with the exploration of new relationships and activities that may relieve any residual loneliness. We also propose that an alternative concept of termination be considered, one that includes the possibility of post-termination follow-up contacts between patient and analyst. We detail the advantages for both patient and analyst of this concept, which may be particularly useful for elderly patients.

An alternative conception of termination and follow-up.

Traditional psychoanalytic theory prescribes total patient-analyst separation after termination to facilitate mourning the loss of the analyst. This paper provides a rationale derived from contemporary (especially relational/interpersonal) theory for an alternative conception of termination and follow-up based on the central role of the analyst as a real person involved in a mutually caring patient-analyst relationship. Patient-analyst follow-up may provide numerous positive benefits: The patient may reexperience the analyst's caring, may reinvigorate helpful introjections of the analyst, and may have additional opportunity to deal with unresolved idealization of the analyst. The analyst may learn about the patient's unpredictable, inevitable post-termination changes, positive and negative, and improve his or her understanding of the course and outcome of treatment.

The relationship of introject affiliation and personal therapy to trainee self-efficacy: a longitudinal study among psychotherapy trainees.

This study explored how introject affiliation and trainee self-efficacy (TSE) are related and change during training in cognitive-behavioral, psychodynamic, and psychoanalytic therapy. The study was conducted in Germany, where psychotherapy training contains extensive personal therapy. Therefore, we could examine the impact of both personal therapy and introjects on changes in the trainees' self-perceived efficacy. In all, 171 participants filled out questionnaires concerning introjects (Structural Analysis of Social Behavior-Intrex) and TSE (Healing Involvement subscale of the Work Involvement Scales) as well as additional questions concerning length of and satisfaction with personal therapy. Seventy-one participants filled out the same questionnaires 3 years later. The degree of affiliation in the trainees' introjects was positively correlated with their self-efficacy. Furthermore, after 3 years of training, introjects demonstrated more affiliation and TSE increased. In addition, the trainees' satisfaction with, but not length of, their personal therapy had a moderating effect on the relation between the change in their affiliative introjects and self-efficacy. Introject affiliation of psychotherapy trainees is not invariant but changes during the course of training, at least in trainings that include personal therapy. Changes in affiliation were significantly related to positive changes in TSE-but only if the trainee's personal therapy was considered to be highly satisfactory.

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.

Changes in prefrontal-limbic function in major depression after 15 months of long-term psychotherapy.

Neuroimaging studies of depression have demonstrated treatment-specific changes involving the limbic system and regulatory regions in the prefrontal cortex. While these studies have examined the effect of short-term, interpersonal or cognitive-behavioural psychotherapy, the effect of long-term, psychodynamic intervention has never been assessed. Here, we investigated recurrently depressed (DSM-IV) unmedicated outpatients (N = 16) and control participants matched for sex, age, and education (N = 17) before and after 15 months of psychodynamic psychotherapy. Participants were scanned at two time points, during which presentations of attachment-related scenes with neutral descriptions alternated with descriptions containing personal core sentences previously extracted from an attachment interview. Outcome measure was the interaction of the signal difference between personal and neutral presentations with group and time, and its association with symptom improvement during therapy. Signal associated with processing personalized attachment material varied in patients from baseline to endpoint, but not in healthy controls. Patients showed a higher activation in the left anterior hippocampus/amygdala, subgenual cingulate, and medial prefrontal cortex before treatment and a reduction in these areas after 15 months. This reduction was associated with improvement in depressiveness specifically, and in the medial prefrontal cortex with symptom improvement more generally. This is the first study documenting neurobiological changes in circuits implicated in emotional reactivity and control after long-term psychodynamic psychotherapy.

The role of mentalization in the psychoanalytic treatment of chronic depression.

Mentalization has been proposed as a key concept in understanding therapeutic change in patients with Borderline Personality Disorder (BPD). However, little is known about mentalization in chronic depression. This study investigated the role of mentalization in the long-term psychoanalytic treatment of chronic depression. Mentalization measured with the Reflective Functioning Scale (RFS) was examined in patients with chronic depression (n = 20) in long-term psychoanalytic treatment and compared to healthy controls (n = 20). Results show that global RF scores did not differ significantly between patients and controls. However, depressed patients tended to have lower RF scores concerning issues of loss. Furthermore, RF was unrelated to symptoms and distress as assessed by the Beck Depression Inventory (BDI) and the SCL-90. RF did not predict therapeutic outcome as measured with the BDI but predicted changes in general distress after 8 months of psychoanalytic treatment as measured by the SCL-90. Moreover, correlations between RF and the Helping Alliance Questionnaire indicated that patients with higher RF were able to establish a therapeutic alliance more easily compared to patients with low RF.

Individualized and clinically derived stimuli activate limbic structures in depression: an fMRI study.

OBJECTIVES: In the search for neurobiological correlates of depression, a major finding is hyperactivity in limbic-paralimbic regions. However, results so far have been inconsistent, and the stimuli used are often unspecific to depression. This study explored hemodynamic responses of the brain in patients with depression while processing individualized and clinically derived stimuli. METHODS: Eighteen unmedicated patients with recurrent major depressive disorder and 17 never-depressed control subjects took part in standardized clinical interviews from which individualized formulations of core interpersonal dysfunction were derived. In the patient group such formulations reflected core themes relating to the onset and maintenance of depression. In controls, formulations reflected a major source of distress. This material was thereafter presented to subjects during functional magnetic resonance imaging (fMRI) assessment. RESULTS: Increased hemodynamic responses in the anterior cingulate cortex, medial frontal gyrus, fusiform gyrus and occipital lobe were observed in both patients and controls when viewing individualized stimuli. Relative to control subjects, patients with depression showed increased hemodynamic responses in limbic-paralimbic and subcortical regions (e.g. amygdala and basal ganglia) but no signal decrease in prefrontal regions. CONCLUSIONS: This study provides the first evidence that individualized stimuli derived from standardized clinical interviewing can lead to hemodynamic responses in regions associated with self-referential and emotional processing in both groups and limbic-paralimbic and subcortical structures in individuals with depression. Although the regions with increased responses in patients have been previously reported, this study enhances the ecological value of fMRI findings by applying stimuli that are of personal relevance to each individual's depression.