SS-04-01

Why do we need disorder-specific psychotherapy?

F. Hohagen. Clinic for Psychiatry Medical University of Lüibeck, Liibeck, Germany

During the last decades training in and the clinical practice of psychotherapy have been dominated by psychotherapy schools. At present, psychodynamic psychotherapy/psychoanalysis and cognitive behavioral psychotherapy are the most common methods. However, there is increasing critical discussion of whether a school-oriented approach to psychotherapy is justified or whether it should be replaced by a disorder-oriented approach. Although school-oriented psychotherapy is based on a plausible theoretical background, this does not necessarily mean that the therapy of respective mental disorders is clinically beneficial. For example, the “Critical Incident Stress Debriefing Therapy” according to Mitchell is based on a plausible theory, but evaluation studies have shown that this method of therapy did not prevent patients from developing posttraumatic stress disorder (PTSD) one year after the trauma but that PTSD symptoms actually increased. Furthermore, psychotherapists trained only in the methods of one school of psychotherapy tend to employ only those techniques learned during their training, not taking into consideration disorder-oriented therapy interventions. Additionally, although most schools of psychotherapy claim to be able to treat every mental disorder with one methodological approach, very often they do not meet the specific demands of the respective mental disorder and show a certain resistance to integrating other psychotherapy methods into the treatment plan. In recent years, an increasing number of disorder-oriented psychotherapies have been developed and evaluated. These focus on the special symptomatology of a mental disorder, taking into consideration both the patient's needs and the special demands of the respective mental disorder. Examples include dialectic behavioral therapy for borderline-personality disorders according to Linehan, cognitive-behavioral analysis system of psychotherapy (CBASP) according to McCullough for the treatment of chronic depression, and interpersonal psychotherapy according to Klerman and Weitzman for the treatment of acute depression. Changing from school- to disorder- oriented psychotherapy has consequences for psychotherapy training, which should include basic psychotherapy training. Furthermore, the costs for psychotherapy methods should be reimbursed only if a sufficient number of evaluation studies have shown their clinical efficiency in controlled trials for certain indications. In the future, the practice of psychotherapy will have to become much more specialized than it is today in most countries.

SS-04-02

Why do we need school-specific psychotherapies?

M. Linden, C. Müller. Charite Berlin Rehab. Centre Seehof Teltow/Berlin, Germany

Psychotherapy is what psychotherapists do with their patients. Evaluation of psychotherapist behaviour and competency has to differentiate between therapist-patient relationship, gen-eral techniques, illness specific techniques, session strategy, therapy strategy, and treatment heuristics. Skills on these different levels of psychotherapeutic behaviour can be described, monitored, learned and evaluated. In respect to therapist training, competency in general techniques is most important to guarantee that a therapist can cope with different patients and problems. For behaviour therapy, the authors have developed the therapist competency checklist, an instrument which allows to qualify therapist expertise in general behaviour therapy tech-niques. Items are e. g. home work assignment, eliciting of automatic thoughts, or role play. It is evident, that such techniques need a theoretical framework in order to understand how they work, when they should be used in the treatment of an individual patient, or how to evaluate their effects. Techniques and background theory are what is traditionally called a “psychotherapy school”. Psychotherapist do what they have learned and what they know how to do. They need prac-tice in administering techniques and they need theoretical knowledge in order to guide their interventions. The question is, how many sets of techniques are needed and must be learned in order to be able to treat different illnesses and patient problems. This question must be answered under consideration of the fact, that no psychotherapist has ever been long enough in training in order to see only one patient of all types, which he may see when being in clinical practice. Our view is that it is preferable to give a therapist a profound expertise in one set of general techniques and theories than to provide him or her with a superficial glimpse of diverse approaches. This means to give psychotherapists a basic training in one school. Apart from training issues, this also allows to ask for differential indications of altema-tive treatment approaches. Therapists and patients should be appreciate that also in psychotherapy there is more than one treatment approach and option.

SS-04-03

Individual treatment plan, disorder-oriented psychotherapy, or both?

F. Caspar. Universität Freiburg KlinikPsychologie, Freiburg, Germany

To provide essentially the same kind of psychotherapy for all patients is outdated: It needs to be adapted to the patients. The question is, how and according to what criteria. A differenciation according to diagnoses has become the main avenue of adapting treatment to patients. It is obvious that effect sizes can be increased when taking into account that different disorders require different treatments. Problems arise in the case of comorbidity, in the case of obvious suffering requiring treatment without fitting any ICD or DSM category, for the many diagnostic categories for which no disorder specific manual exists, and for the cases in which additional factors make the treatment of choice for a disorder less than ideal. While the experimental logic of creating and using evidence for the effectiveness of treatment seems to require a bleaching out of variation, practice with patients who do not correspond to the selection for randomized cinical trials, requires variation. A general model is presented which postulates the simultaneous, smooth integration of a variety of factors according to which it is a matter of course that treatment plans should at the same time take disorder specific techniques into account AND be individualized along a number of additional criteria.

SS-04-04

A comparison of dynamic and cognitive psychotherapy in the treatment of cluster personality disorders

M. Svartberg. Trondheim, Norway