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.

[Results of the pilot project of the Techniker-Krankenkasse "quality monitoring in outpatient psychotherapy" - a commentary by the project's scientific advisory board]. / Zu den Ergebnissen des Modellprojektes der Techniker-Krankenkasse zum Qualitätsmonitoring in der ambulanten Psychotherapie - eine Replik des wissenschaftlichen Beirats.

In order to objectify the discussion about a project of the TK, a German health insurance company, which aimed to analyse the effects of a specific quality monitoring system on psychotherapy outcomes, the scientific advisory board summarized the main results of the study. The main results were cited from the final report which confirms the confirmatory character of the study design that aimed to test the hypothesis of the superiority of the quality monitoring system compared to the system of peer review-based approval of therapies. The quality monitoring system represents a complex intervention which is composed of several single intervention elements. Thus, the study results allow only the conclusion that the overall complex interven-tion did not prove to be superior. Further studies are needed with regard to the effectiveness of single components. Finally, the issues of representativeness and selectivity of the study and the sample are discussed and their importance is -underlined by reference to the literature.

[The project of the Techniker-Krankenkasse: some comments on the results by the project's scientific advisory board]. / Das Modellprojekt der Techniker-Krankenkasse: Eine Kommentierung der Ergebnisse aus der Sicht des wissenschaftlichen Projektbeirates.

The Project of the Techniker Krankenkasse compared 2 systems of quality assurance in outpatient psychotherapy, the established peer review system based on qualitative individual case reports and a new model based on psychometric assessment and feed-back systems. In this publication the members of the project advisory board comment on the results and limitations of the study. 400 psychotherapists in private practice participated in a cluster-randomized comparison study, 200 were allocated to the intervention group, and 200 to the control group. In both groups assessments were performed at 3 points in time, one at the beginning of treatment, one at the end of treatment and one at follow-up 12 months post-treatment. No significant differences in psychotherapeutic outcome were observed in the 2 groups. The hypothesis of a better outcome associated with the psychometric assessment and benchmarking procedure was not confirmed.

[Structural change as an outcome paradigm in psychodynamic psychotherapy - results of the PAL-Study (long-term psychoanalytic psychotherapy study]. / Umstrukturierung als Ergebnisparadigma der psychodynamischen Psychotherapie - Ergebnisse aus der Praxisstudie Analytische Langzeittherapie.

OBJECTIVE: Psychodynamic psychotherapies have proved to lead to relevant symptomatic improvement. An unresolved question, however, is what amount of psychodynamic change can be expected beyond symptom relief. For theoretical and methodological reasons rooted in the psychodynamic approach, this question has been difficult to answer until now. METHOD: In the German study PAL (long-term psychoanalytic psychotherapy), 32 patients in psychoanalytic therapy and 27 patients in psychodynamic psychotherapy were studied from the perspective of therapists, patients and researchers through three years post-treatment. In this paper we study the aspect of psychodynamic change of dysfunctional relations, unconscious conflicts and structural aspects as diagnosed by the Operationalized Psychodynamic Diagnostic method. Structural change is rated by the Heidelberg Structural Change Scale. RESULTS: A comparison of the two forms of therapy shows more structural change in long-term psychoanalytic psychotherapy compared to the shorter psychodynamic psychotherapy. A comparison of patients with a high level and a low level of structural change revealed that the highly changed patients showed greater symptom relief and greater satisfaction with therapy, and that their therapists perceived a better overall result of treatment. DISCUSSION: For psychodynamic psychotherapies structural change seems to be a relevant paradigm of outcome in addition to symptom relief. In longer and more frequent psychoanalytic therapies more structural change occurs compared to shorter psychodynamic psychotherapies. Beside the amount and length of treatment, the different therapy targets - working through vs. supportive - seem to be important.

Structural change as a predictor of long-term follow-up outcome.

Based on data from psychoanalytic long-term psychotherapies, the predictive value of three measures of pre-post change for retrospective patient assessments of outcome at 1-year and 3-year follow-up was investigated. Pre-post changes were measured using the Global Severity Index (GSI), the Inventory of Interpersonal Problems (IIP) total score, and the Heidelberg Structural Change Scale (HSCS). In line with psychoanalytic theory, it was assumed that structural changes cause especially persistent changes and would, therefore, be most suitable to predict the follow-up criterion. This expectation was confirmed: Pre-post changes in GSI and IIP were only weakly associated with assessments at 1-year follow-up and not at all with assessments at 3-year follow-up. In contrast, correlations between changes in HSCS and outcome assessments were highly significant at both occasions.

[Attitudes of medical students towards psychotherapeutic treatment and training]. / Einstellungen von Medizinstudierenden zu psychotherapeutischen Behandlungsverfahren und Weiterbildungen.

OBJECTIVES: Against the background of insufficient medical care for patients with psychiatric and psychosomatic disorders it is important to ascertain the interests and attitudes of medical students towards mental disorders, psychotherapeutic treatment and training. METHODS: Medical students (N = 366) in their clinical training were given half-standardized questionnaires about their attitudes towards psychotherapeutic treatments, their career plans, psychosocial distress and sociodemographic characteristics. RESULTS: There was an overall high interest in psychological distress of patients and in psychotherapeutic treatment methods. Contrary to these findings, however, only few medical students were willing to specialize in psychosomatic medicine, psychiatry or psychotherapy. Psychosomatic and psychotherapeutic career choices were more frequent in women as well as in students who had experienced psychological distress themselves, and who had undergone psychotherapy, and who were less oriented toward economic success and careers. CONCLUSIONS: Medical students regarded psychological characteristics as generally interesting and important for medical care, but rarely considered specializing in these medical fields after graduation. Potential remedies (e.g., improved teaching of psychosocial competences and psychotherapeutic knowledge, career counselling) are discussed.

[Results of psychoanalytic long-term therapy in specific diagnostic groups: improvement in symptoms and interpersonal relationships]. / Ergebnisse analytischer Langzeitpsychotherapien bei spezifischen psychischen Störungen: Verbesserungen in der Symptomatik und in interpersonellen Beziehungen.

OBJECTIVES: In the present paper, data from four German studies on the efficacy of outpatient psychoanalytic long-term psychotherapy were examined for symptom reduction (SCL-90-R) and reduction of interpersonal problems (IIP-D). Specifically, the research question addressed the efficacy of long-term therapy in specific diagnostic groups and was was compared with that of a parallel group who underwent shorter-term psychodynamic therapy. METHODS: Data from four German studies addressing the efficacy of outpatient psychoanalytic long-term therapy were collected. Evaluation of these data was carried for specific diagnostic groups allowing for comorbid diagnoses. The effects of psychoanalytic therapy were assessed by pre-post and pre-follow-up comparisons using paired t-tests. Additionally, effect sizes were calculated. Psychoanalytic long-term psychotherapy and shorter-term psychodynamic therapy were compared by using a repeated measure ANOVA: Pretreatment vs. posttreatment/follow-up (two-levels) with the between subject factor "therapy conditions" (two levels). RESULTS: The results showed that in terms of improvement of symptoms and interpersonal problems, psychoanalytic long-term therapy was at least as effective as shorter term psychodynamic therapy with regard to the following ICD-10 diagnostic groups: affective disorders (F3), anxiety disorders (F40; F41; F42), personality disorders (F60; F61; F62), and a group of mixed neurotic disorders (F43; F50; F51; F1; F55). Effect sizes were large and remained stable at follow-up. CONCLUSIONS: The authors emphasize the clinical relevance of the examined diagnostic groups and relatively large effects achieved by the psychoanalytic treatment. Furthermore, the occurrence of comorbid diagnoses and their consequences are discussed. The authors stress that the specific effects of psychoanalytic therapy can only be very insufficiently tapped by the outcome measures referring to symptoms and interpersonal problems.

[Changes in emotional experience during the course of psychoanalytic therapy]. / Veränderungen des Emotionserlebens im Verlauf psychoanalytischer Langzeitbehandlungen.

OBJECTIVES: Does the subjective emotional experience of patients change in the course of psychoanalytic treatment? METHODS: Ten patients were interviewed four times during their first two years in psychoanalytic therapy. Interviews were coded with regard to the patients' subjective emotional experience. Changes in individual emotion profiles were then tested for associations with therapy outcome using a hierarchical linear model. RESULTS: Better therapy outcome was associated with an increase in emotional variability and a decrease in the proportion of negative emotions. In contrast, neither the number of emotions verbalized by the patients nor the frequencies of specific emotion categories were associated with therapy outcome. CONCLUSIONS: Remarkable changes of emotional experience during the course of psychoanalytic treatment could be demonstrated. Particularly, a more variable emotional experience proved to be closely associated with improvement in mental health.

[Operationalized psychodynamic diagnostic (OPD)--potential for quality assurance]. / Potenzial der Operationalisierten Psychodynamische Diagnostik (OPD) für die Qualitatssicherung.

OBJECTIVES: Psychotherapy is subjected to the legal conditions of quality assurance(QA). Does operationalized psychodynamic diagnostics (OPD) contribute substantially to this? METHODS: We investigated the application of OPD in outpatient psychodynamic psychotherapy, inpatient treatment, rehabilitation, and legal assessment. RESULTS: Psychodynamic diagnostics, treatment plan, and evaluation by means of the OPD and Heidelberg Structural Change Scale (HSCS) may be comprehensibly described for quality assurance (QA) of outpatient and inpatient psychotherapy. Virtually all psychodynamic conceptualized departments for psychosomatic medicine and psychotherapy as well as some rehabilitation centres applied OPD. Furthermore, data-collection periods were defined during and after inpatient short- and long-term psychotherapy. OPD serves QA in legal assessment and is of a pivotal significance in judicial proceedings. CONCLUSIONS: It must be deliberated whether more extensive use of QA, in cooperation with outpatient psychotherapists and in comparison to institutions, could be of benefit to patients.

[Gaining insight and structural capability as goals of psychodynamic psychotherapy]. / Konfliktaufdeckende und strukturfördernde Zielsetzungen in der tiefenpsychologisch fundierten Psychotherapie.

Psychodynamic psychotherapy in the sense of German psychotherapy guidelines is currently the most frequently used treatment in outpatient psychotherapy. This report summarizes the psychodynamic fundaments of this method and distinguishes the conflict exposure and the structure formation as significant therapeutic aims. The subject of personality structure is dealt with according to the OPD (operationalized psychodynamic diagnosis) system which allows an operationalization and empirical investigation of structural aspects. The treatment techniques used to achieve structure-related therapy aims (e.g. the ability to differentiate affects, impulse control, empathy, emotional expression, attachment, separation, etc.) are described in detail.

[Etiological models and therapeutic techniques in the psychodynamic treatment of depression]. / Störungsmodell und Interventionsstrategien in der psychodynamischen Depressionsbehandlung.

Psychodynamic treatment of depression is described as a problem-centered approach which is derived from the etiological model. This treatment is conceptually based on the internalisation of problematic relationship patterns, the development of structural vulnerability, and the formation of specific coping patterns. The therapeutic interventions specific to depression treatment deal with the present state of vulnerability and the tendency to overstrain oneself, which are the result of depressive personality development and which support new relationship experiences. Special emphasis is placed on the specific therapeutic attitude which allows treatment particularly of interpersonal problems by reflecting, supporting and confronting. Psychodynamic depression treatment is problem-centered in that it is tailored to the specifically problematic kinds of relationship expectations and relationship problems as well as the related problems of self esteem.

[Psychotherapy of somatoform disorders]. / Die psychotherapeutische Behandlung somatoformer Störungen.

OBJECTIVES: To present a review of the current state of the art of psychotherapy of somatoform disorders from a psychodynamic-interpersonal perspective. METHODS: The review is based on an analysis of the literature used for evidence-based guidelines on the treatment of somatoform disorders and on our own experiences and models of these disorders. An elaboration of practical aspects of psychotherapy with these patients makes up an essential part of the review. RESULTS AND DISCUSSION: Psychotherapy of somatoform disorders is efficient and effective if the typical interpersonal patterns of these patients are taken into account and if the therapist maintains a more active attitude, avoiding early psychosocial interpretations of the somatoform complaints.

[50 years of the Journal of psychosomatic medicine]. / 50 Jahre Zeitschrift für Psychosomatische Medizin.

This article is a review of the historical development of this journal from its establishment in 1954 to the present. The history of its founding will first be briefly outlined and illustrated with some facsimile prints from that time. The thematic focuses as they evolved over the last five decades will then be reviewed. In a further chapter individuals will be presented who have contributed significantly to the journal and made it what it is today.

[Results of psychodynamic inpatient psychotherapy in relation to diagnosis]. / Störungsbezogene Ergebnisse psychodynamisch-stationärer Psychotherapie.

Therapy outcome is analysed according to the main diagnoses in a 5 years' sample of psychodynamic inpatient psychotherapy (n=461) and controlled in a 6-9 months follow-up (n=312). Therapy effects, as measured in a pre-post comparison of the patients' self-rating, are generally good and especially noticeable for affective and anxiety disorders, whereas the effects for somatoform disorders are relatively low. The opposite tendencies are seen in follow-up, i.e. relapses in anxiety and affective disorders, and further improvement in somatoform disorders. A surprisingly positive outcome is shown for personality disorders and especially for severe personality disorders (e.g. Borderline). Regardless of the diagnoses, 80% of the patients show a high degree of satisfaction with their treatment and its outcome.

Patterns of interpersonal problems and their improvement in depressive and anxious patients treated with psychoanalytic therapy.

Interpersonal problems were studied in 121 patients treated with psychoanalytic therapy using the Inventory of Interpersonal Problems. Four characteristic subtypes were identified, which differed in the quality and flexibility of their interpersonal behavior. Independent of the predominant type of interpersonal problems, the psychotherapy treatment led to strong decreases in interpersonal distress and increases in interpersonal differentiation. Psychoanalytic therapy was highly effective for all identified interpersonal subtypes and seems to help patients achieve more satisfactory relationships.

[The clinical emotions list - a procedure for assessing patients' affective repertoires]. / Die Klinische Emotionsliste - ein Verfahren zur Erfassung des affektiven Erlebensrepertoires von Patienten.

Using 20 video-interviews with psychosomatic outpatients we developed a category system that should allow a differentiated and complete assessment of a person's affective repertoire. In doing so we considered the psychological literature on verbal expression of emotions. Semantic construction, distinguishing emotion categories from one another, was chosen as the main criterion for coding. The final version of the Clinical Emotions List contained 48 items. An exploratory analysis of another ten Interviews with patients showed satisfactory reliability of the system.

Do interpersonal behavior and emotional experience change in the course of successful long-term psychoanalytic therapies?

The way in which patients behave toward others is considered to be a correlate of mental health and thus of successful psychotherapy. Until now, research regarding the extent to which this assumption is justified has produced contradictory findings. On the basis of 2 definitions of normal interpersonal behavior (Benjamin, 1993; Crits-Christoph, Demorest, Muenz, & Baranackie, 1994), the authors studied 10 patients undergoing psychoanalytic therapy to determine whether changes in their descriptions of interpersonal relationships were associated with a decrease in self-reported symptoms and interpersonal problems during the first 2 years of treatment. Using a hierarchical linear model, the authors identified moderate to high correlations in the expected direction: The patients' affiliative behavior toward their objects as well as the average valence and variability of their affective experience increased when therapy was successful. In contrast, patients' descriptions of their objects' behavior did not change in a systematic manner.