Operationalisation of psychoanalytic constructs
A working group: ‘Operationalised Psychodynamic Diagnosis’, consisting of psychoanalysts, specialists in psychosomatic medicine, and psychiatrists, was founded in 1990 in Germany. The goal was to broaden the ICD-10 classification, which is oriented to symptoms and descriptions, to include fundamental psychodynamic dimensions. This working party developed a diagnostic inventory as well as a handbook (OPD Task-Force, 2001) for experienced therapists for training and clinical purposes. The OPD system is based on 4 psychodynamically relevant diagnostic axes with appropriate categories to complement ICD classification:
Axis I: Experience of illness and prerequisities for treatment
Axis II: Interpersonal Relations
Axis III: Conflicts
Axis IV: Structure
Axis V: Syndromal (according to Chapter V (F) of ICD 10)
During an initial 1-2 hour patient examination the clinician (or external observer) evaluates the patient’s psychodynamics and fills this in on the OPD evaluation sheet. There are interview guidelines to ensure the relevant information is obtained. These are flexible enough, however, that the interview can still be conducted as an open psychodynamic interview.
Classification schemes have been employed internationally to diagnose mental illness since 1980. The ‘Diagnostic and Statistical Manuals’ (DSM) of the American Psychiatric Association and the ‘International Classification of Mental and Behavioural Disorders’ (ICD) of the World Health Organisation have attained wide usage. Thus communication among diagnosticians worldwide has been simplified because areas of agreement and difference have been transparent. Psychodynamic psychotherapists who see conflict and relationship problems as causative for patients’ symptoms regret, however, the lack of relevance of the phenomenological and symptom-centred diagnoses of ICD and DSM. These therapists, such as the ‘Group for the Advancement of Psychiatry’ in its statement in the American Journal of Psychiatry call for a multidimensional perspective of human problems in the classification of mental disorders.
A further motive for the development of the OPD system emerged from the dissatisfaction of psychiatrists with the divergence of psychoanalytic theory. Freud began to understand personality with the help of drive theory, ego, id, and superego and thus created the basis of psychoanalytic classification. In case conceptualisation, drive theory, ego psychology and object relations theory are still used to differentiate personality. In the initial interview and in history taking psychotherapists use a multitude of (meta)-psychological categories to describe mental functions and their disorders. Many of these metapsychological theories were formulated in such an abstract way that they are more or less detached from clinical phenomena and cannot be applied. This development doubtless lead to theory heterogeneity and to confusion of concepts in psychoanalysis. The OPD system is intended as an empirical and theory independent instrument which promotes communication within psychoanalysis and with related disciplines. An important aspect, therefore, was the agreement in the OPD group regarding the extent to which indirect conclusion, for example unconscious components, are permitted in the clinical evaluation of behaviour patterns.
The OPD research group was able to access the experience of psychotherapy researchers in the operationalisation of relevant psychoanalytic constructs. Bellack & Hurvich (1969) already attempted to operationalise ego function and developed rating scales to enable judgement of the ego function as observed in clinical interviews. A series of research instruments assume that behaviour patterns are not only represented with others but above all in the therapeutic relationship and thus the empirical assessment of transference relationships is possible (Gill & Hoffmann, 1982; Luborsky & Crits-Christoph, 1998; Strupp & Binder, 1993). In psychotherapy research operationalisation of conflict (Perry, 1989; 1990) and of defense mechanisms (Perry & Cooper, 1989)] has also been attempted.
Weinryb and Rossel developed a more comprehensive approach to achieve a psychodynamic profile based on operationalised psychoanalytic constructs (Weinryb & Rössel, 1991). The 18 subscales of the Karolinska Psychodynamic profile were formulated with the goal of comprehensively assessing mental function and personality traits as they are reflected in a patient`s perception of himself and his relationships with others. The subscales are formulated on different levels of abstraction and the interpretation required for each subscale also varies. It is clear that psychodynamic operationalisation cannot remain at the behavioural level, but interpretation contributes to the judgement, since mental\intrapsychic conflict cannot be directly observed.
Brief discussion of the axes
Axis I: Experience of illness and prerequisities for treatment
Items relating to this axis concern the patients motivation and the indications for psychodynamic psychotherapy. Items are judged on a scale from absent (0), low (1), medium (2), high (3). There is also a category `unassessable`. The individual diagnostic dimensions are filled into a glossary. Anchor examples improve diagnostic reliability.
1. Severity of somatic illness
2. Severity of mental illness
3. Patient’s subjective suffering
4. Impairment of self-experience
5. Secondary benefit illness
6. Extent of physical impairment/disability
7. Comprehending and accepting psychodynamic and psychosomatic associations
8. Comprehending and accepting psychodynamic somatopsychic associations
9. Evaluation of appropriate treatment (psychotherapy)
10. Evaluation of appropriate treatment (medical treatment)
11. Motivation for psychotherapy
12. Motivation for physical treatment
14. Presentation of symptoms
-somatic symptoms to the fore
15. -mental symptoms to the fore
16. Psychosocial integration
17. Personal resources
18. Social support
19. Appropriateness of subjective impairment related to the severity of the illness
This axis illustrates the experience that illness course is not only determined by syndrome and symptoms but by the subjective and social context of the affected person. Social support and personal understanding of the illness have a great influence on the course, especially with regard to the psychotherapeutic treatment options.
Axis II: Interpersonal Relations
Mental disorders are ‘relationship disorders’, thus traditional interpersonal behaviour is central for the genesis and maintenance of mental disorders. Representation of dysfunctional or maladaptive behaviour has therefore become the focus of psychodynamic and psychotherapeutic research in recent years (Benjamin, 1974; Luborsky & Crits-Christoph, 1998; Strupp & Binder, 1993). Lifelong ‘accumulation’ of relationship experience in the form of cognitive affective schemata (Horowitz, 1991; Piaget, 1978) are therefore the foundation for what in psychoanalysis is conceptualised as transference and countertransference.
The basic structure of the OPD relationship axis depicts the circular or transactional character of human interaction (interchange of subjective experience and response to the environment). A framework was developed which encapsulates subjective experience concerning self and others on the initial level. On a second level it is possible to represent the experience of this other person (significant other, interviewer): how is the patient experienced by his objects or the interviewer and which impulses does he generate in them? The construction of the OPD instrument is achieved from the following two perspectives: how does the patient experience himself in relationships? The interviewer judges behaviour patterns as experienced by the patient vis-à-vis others. How does the patient experience the behaviour of others?
The therapist also evaluates transference and countertransference from these two perspectives: how does the therapist experience the initiation of the relationship through the patient? How does the therapist experience himself in the relationship to the patient?
Items of the OPD relationship axis help to define the variety of behaviours seen in relationships.
The categories come from the tradition of the interpersonal circle model, which depict relationships regarding affection and control (Benjamin, 1974; Kiesler, 1983, 1996; Leary, 1957).
Diagnostic integration of various experience perspectives enables the description of habitual behaviour patterns, although emphasis is on dysfunctional patterns, as is commonly the focus in psychotherapies.
Axis III: Conflicts
OPD distinguishes seven mental conflicts and has a category for limited conflict perception:
1. Dependence versus autonomy
2. Submission versus control
3. Desire for care vs. autarchy
4. Conflicts of self-value
5. Guilt conflicts
6. Oedipal sexual conflicts
7. Identity conflicts
8. Limited perception of conflicts and feelings
These seven basic conflicts and the last category (e.g. with somatising patients) are judged on the basis of ideal-type descriptions according to presence (dimensional evaluation from ‘not present’ to ‘present and not significant’ to ‘present and significant’ to ‘present and very significant’). Furthermore, for each patient the two main areas of conflict (category value) is given. Description of the basic conflicts and their method of processing occurs in the OPD system in connection with central life areas such as relationship to partner, family of origin, profession, ownership, behaviour in groups and illness experience. As well as lasting conflicts other major conflict can arise in response to acute life-changing stressors. To judge presence of such stressors, there is an appropriate category.
Conflict can be judged in history-taking on the basis of perceived behaviour and experience ways (scene, transference, countertransference) and manifest themselves on subject and object level (inner mental) and in interaction with others. Conflicts are often connected to prominent affect (e.g. anger in narcissistic disorders). There is a glossary for the conflicts in various forms (active or passive) in different life areas as well as a checklist.
The OPD conflict definitions are illustrated on the basis of the passive modality of ‘desire for care vs. autarchy’:
In the passive mode the patient is strongly bound to other people and expresses wishes concerning security and care. Separation and rejection are responded to with depressive mood and /or fear. The patient is very dependent and needy. In the countertransference, the therapist experiences worry, blackmail and helplessness. Intimate relationships are organised that separation appears impossible (e.g. financial linkage) and can be characterised by claustrophobic closeness. Grasping tendencies are reactively defended by frequently changing relationships. Need to be looked after means that the patient remains long and excessively loyally in the family of origin. In professional life the patient seeks accomplices and helpers, professional demands are understood as withdrawal of support and responded to with depression. In social situations the patient seeks caring relationships, and is regarded as demanding and tiring by others due to his wishes and demands. In times of illness the patient shows a passive, grasping expectant approach to the doctor and is difficult to rehabilitate.
Axis IV: Structure
OPD differentiates four levels of structure (good integrated, moderately integrated, low, disintegrated). Good integration means that an autonomous self possesses a mental internal space in which mental conflicts can be carried out. Moderate integration implies lower availability of regulating function and a weaker differentiation of mental substructures. With low integration the mental inner space and substructures are less developed thus conflicts are barely mentally worked out, but are mainly worked out in the interpersonal sphere. Disintegration is characterised by fragmentation and psychotic restitution of structure.
Operationalisation of structure is based on 6 structural categories:
For each structural category the manual allows determination of level of integration. Finally the structural profile as well as the total structural level can be determined. Additionally there is a checklist for each item and every subcategory for the rating (Rudolf, Oberbracht, & Grande, 1998).
Status- or Process- diagnosis: focus possibilities
OPD diagnostics can be used as status diagnostics in personality or psychotherapy research. The individual OPD axes are judged concerning the dysfunctional pattern of the relationship (axis I), the life determining conflicts (axis II), and the integration of the personality structure (axis IV). These psychodynamic dimensions complete the ICD-10 syndromal description (axis V). Axis I (Experience of illness and prerequisities for treatment) is especially suitable for patient populations concerning their subjective experience and their suitability for psychotherapy. Status diagnostics on the individual OPD axes or with the full OPD-system are especially useful where standardised psychodynamic point of view from individual patients or samples and for example with personality diagnostics should be coupled with other approaches.
Apart from research-oriented status diagnostics the most important goal of the OPD system is in the clinical therapeutic area. The OPD findings can supply the clinician with information to aid in deciding therapy indication and planning. Axis I can clarify the patient’s basic assumptions regarding eventual psychotherapy. Judgements of structure level (axis IV) are decisive for the choice of suitable psychotherapy methods above all regarding the alternative between more supportive structural or meaning-uncovering processes, as well as in certain circumstances for the deciding between in- or out-patient psychotherapy. The OPD findings can also indicate the topics to be worked on in psychotherapy: dysfunctional relationship patterns (axis II) in the sense of pathogenic convictions require special therapeutic attention and interventions so that therapy does not fail due to interaction complications; stressing the most prominent conflicts (axis III) or connections between different conflicts explains special therapeutic approaches on the other hand; content of structural problems illuminate vulnerability and available resources to be taken into account in therapeutic planning.
The psychotherapeutic consequences of OPD diagnostic are especially concrete in the logic of focus formulation and the determination of therapy goals related to this. In clinical research projects such as in the ‘Practice Study of Analytic Longtime Therapy’ (Grande, Rudolf, & Oberbracht, 1997; Grande et al., 2004; Rudolf et al., 2002; Rudolf et al., 2004), this process was used and evaluated in an outpatient setting. Determination of a dynamic relationship focus in the therapist group also allows team centred behaviour vis-à-vis the patient on the ward (Stasch, 2003, 2004).
On the basis of individual OPD diagnostics therapeutic foci can be named. The causative characteristics which maintain the disorder and therefore play a decisive role in the psychodynamics of the clinical picture are the foci of therapy. It seems that 5 foci are enough (Grande et al., 1997; Grande et al., 2004; Grande et al., 2003; Rudolf et al., 2002)] to capture the different aspects of a disorder; it appears advantageous to choose one relationship focus and at least one conflict and one structure focus. In the research projects independent observers interviewed the patients at regular intervals to ascertain the patient’s development concerning the foci; in the practice projects the therapists choose both foci and arrange treatment. In contrast to traditional psychoanalysis, which retrospectively describes often undesired developments of the patient (and emphasises that these should be allowed to happen without therapeutic intervention), the OPD group employs the logic, which also obtains in brief and focal therapy, and behavioural therapy, that therapist and patient determines together at the beginning of treatment the important psychodynamic foci for the particular problem and choose the suitable therapeutic approaches to restructure these foci.
The “Heidelberg Structural Change Scale” HSCS (Rudolf, Grande, & Oberbracht, 2000) was developed to differentiate therapeutic change in OPD findings above and beyond the simple dichotomy of present/not present. This scale is related to the „Assimilation of Problematic Experiences Scales“ APES (Stiles et al., 1992) and allows through its fine gradations a quantitative weighting of therapeutic change in each individual focus (Grande, Rudolf, & Oberbracht, 2000; Grande et al., 2001). Furthermore a structure (Rudolf et al., 1998) and a conflict checklist (Grande & Oberbracht, 2000) were developed which simplify the judgement of these two dimensions for the clinician. Use of these instruments especially allows differentiated description of therapeutic process and success from a specific psychoanalytic point of view.
This logic is especially developed for focus and therapy determination in axis IV (structure). but there are also concrete recommendations for therapeutic work (Rudolf, 2004), thus in a broader sense it is a therapy manual.
Since the OPD manual was published in 1996 many psychotherapists have become acquainted with it and have used it. Various translations are available. In 2003 the German child and adolescent version was published (Arbeitskreis OPD, 2003). More than 3000 therapists have been trained in the different training centres in German-speaking countries. In various psychosomatic clinics, abuse clinics, university departments for psychotherapy and psychosomatics the OPD is used in research projects, but also in the clinical day-to-day practice (Schneider, Lange, & Heuft, 2002). Current work on the further development of the OPD-System are geared/directed towards improving focus formulation and the therapy goal definition and thus the clinical applicability, so the system can be more used in day-to-day practice. It is planned to publish the OPD-II-version in spring 2006.
An operationalisation of psychodynamic diagnostics can overstep the boundaries of a purely descriptive psychiatric classification and use the advantages of an operationalisation of empirical psychodynamic constructs in association with the phenomenological diagnostic. The OPD can
1. give clinical-diagnostic guidelines for clinical use, which because of relative openly formulated diagnostic criteria (‘guidelines’) allow the user certain diagnostic freedom. The OPD contributes thus to greater transparence in the sense of quality assurance.
2. be very useful for psychodynamic psychotherapy training, since the operationalised mental phenomena are empirically formulated so the psychodynamic and phenomenological classification can be practiced.
3. be used as a research instrument, to contribute to more homogenisation of trial samples through stricter diagnostic criteria.
4. contribute to better communication within the scientific community (in a broader and narrower sense) concerning psychodynamic constructs. Through clearly improved reliability the OPD contributes to better communicability of psychodynamic formulations.
The richness but also the limitations of the OPD diagnostics are illustrated in the judgement of a video-taped case and discussion thereof. OPD is aimed to be no more than a basic compendium of the relevant psychodynamic constructs, which are allocated to 4 axes. The OPD manual provides only the basis for the clinical discussion, which is highly valued, however, by many clinics. Psychotherapists with little experience have a basis for further training. More complex psychoanalytic theories and detailed psychoanalytic case conception can be built on the basis of OPD.
Experience with the OPD system to date shows that the constructed axes are practicable and reliable for clinical use in very different treatment fields. The working group understands the operationalisation of psychodynamic diagnostics as a process which should contribute to further clarification and differentiation of the underlying constructs both in practice and in research.
Arbeitskreis, OPD-KJ (Ed.). (2003). Operationalisierte Psychodynamische Diagnostik im Kindes- und Jugendalter. Grundlagen und Manual. Bern: Huber.
Bellack, L., & Hurvich, M. (1969). Systematic study of ego functions. Journal of Nervous and Mental Diseases(148), 569-585.
Benjamin, L. S. (1974). Structural analysis of social behavior. Psychological Review, 81, 392-425.
Gill, M. M., & Hoffmann, I. Z. (1982). A method for studying the analysis of aspects of the patient's experience in psychoanalysis and psychotherapy. Journal of the American Psychoanalytic Association, 30, 137-167.
Grande, T., & Oberbracht, C. (2000). Die Konflikt-Checkliste. Ein anwenderfreundliches Hilfsmittel für die Konfliktdiagnostik nach OPD. In W. Schneider & H. Freyberger (Eds.), Was leistet die OPD? Empirische Befunde und klinische Erfahrungen mit der Operationalisierten Psychodynamischen Diagnostik (pp. 74-102). Bern: Huber.
Grande, T., Rudolf, G., & Oberbracht, C. (1997). Die Praxisstudie Analytische Langzeittherapie. Ein Projekt zur prospektiven Untersuchung struktureller Veränderungen in Psychoanalysen. In M. Leuzinger-Bohleber & U. Stuhr (Eds.), Psychoanalysen im Rückblick (pp. 415-431). Frankfurt a. M.: Psychosozial-Verlag.
Grande, T., Rudolf, G., & Oberbracht, C. (2000). Veränderungsmessung auf OPD-Basis: Schwierigkeiten und ein neues Konzept. In W. Schneider & H. Freyberger (Eds.), Was leistet die OPD? Empirische Befunde und klinische Erfahrungen mit der Operationalisierten Psychodynamischen Diagnostik (pp. 148-161). Bern: Huber.
Grande, T., Rudolf, G., Oberbracht, C., & Jakobsen, T. (2001). Therapeutische Veränderungen jenseits der Symptomatik. Wirkungen stationärer Psychotherapie im Licht der Heidelberger Umstrukturierungsskala. Zeitschrift für Psychosomatische Medizin und Psychotherapie, 47(3), 213-233.
Grande, T., Rudolf, G., Oberbracht, C., Jakobsen, T., & Keller, W. (2004). Investigating structural change in the process and outcome of psychoanalytic treatment: The Heidelberg-Berlin Study. In P. Richardson, H. Kächele & C. Renlund (Eds.), Research on psychoanalytic psychotherapy with adults (pp. 35-61). London: Karnac.
Grande, T., Rudolf, G., Oberbracht, C., & Pauli-Magnus, C. (2003). Progressive changes in patients' lives after psychotherapy: which treatment effects support them? Psychotherapy Research, 13(1), 43-58.
Horowitz, M. J. (1991). Person schemas and maladaptive interpersonal patterns. Chicago: University of Chicago Press.
Kiesler, D. J. (1983). The 1982 interpersonal circle: A taxonomy for complementarity in human transactions. Psychological Review, 90, 185-214.
Kiesler, D. J. (1996). Contemporary interpersonal theory and research. Personality, psychopathology, and psychotherapy. New York: Wiley.
Leary, T. (1957). Interpersonal diagnosis of personality. New York: Ronald Press.
Luborsky, L., & Crits-Christoph, P. (1998). Understanding transference. The Core Conflictual Relationship Theme method (2. ed.). New York: Basic Books.
OPD Task-Force (Ed.). (2001). Operationalized Psychodynamic Diagnostics (OPD). Foundations and manual. Kirkland: Hogrefe & Huber.
Perry, J. C. (1989). Scientific progress in psychodynamic formulation. Psychiatry, 52, 245-249.
Perry, J. C. (1990). The psychodynamic conflict rating scales. Cambridge, MA: The Cambridge Hospital.
Perry, J. C., & Cooper, S. H. (1989). An empirical study of defense mechanism. Archives of General Psychiatry, 46, 444-452.
Piaget, J. (1978). Die Äquilibration der kognitiven Strukturen. Stuttgart: Klett.
Rudolf, G. (2004). Strukturbezogene Psychotherapie. Leitfaden zur psychodynamischen Therapie struktureller Störungen. Stuttgart: Schattauer.
Rudolf, G., Grande, T., Dilg, R., Jakobsen, T., Keller, W., Oberbracht, C., et al. (2002). Structural changes in psychoanalytic therapys - the Heidelberg-Berlin Study on long-term psychoanalytic therapies (PAL). In M. Leuzinger-Bohleber & M. Target (Eds.), Outcomes of psychoanalytic treatment. Perspectives for therapists and researchers (pp. 201-222). London: Whurr Publishers.
Rudolf, G., Grande, T., Jakobsen, T., Krawietz, B., Langer, M., & Oberbracht, C. (2004). Effektivität und Effizienz psychoanalytischer Langzeittherapie: Die Praxisstudie analytische Langzeitpsychotherapie. In A. Gerlach, A.-M. Schlösser & A. Springer (Eds.), Psychoanalyse des Glaubens (pp. 515-528). Gießen: Psychosozial-Verlag.
Rudolf, G., Grande, T., & Oberbracht, C. (2000). Die Heidelberger Umstrukturierungsskala. Ein Modell der Veränderung in psychoanalytischen Therapien und seine Operationalisierung in einer Schätzskala. Psychotherapeut, 45, 237-246.
Rudolf, G., Oberbracht, C., & Grande, T. (1998). Die Struktur-Checkliste. Ein anwenderfreundliches Hilfsmittel für die Strukturdiagnostik nach OPD. In H. Schauenburg, H. Freyberger, M. Cierpka & P. Buchheim (Eds.), OPD in der Praxis. Konzepte, Anwendungen, Ergebnisse der Operationalisierten Psychodynamischen Diagnostik (pp. 167-181). Bern: Huber.
Schneider, G., Lange, C., & Heuft, G. (2002). Operationalized Psychodynamic Diagnostics and differential therapy indication in routine diagnostics at a psychosomatic outpatient department. Psychotherapy Research, 12(2), 159-178.
Stasch, M. (2003, 25.06.2003). Interpersonal tuning in inpatient psychotherapy. A clinical approach based on the Operationalized Psychodynamic Diagnostics (OPD). Paper presented at the 34. annual meeting of the Society for Psychotherapy Research (25.-29.06.2003), Weimar, Germany.
Stasch, M. (2004, 16.06.2004). Interpersonal diagnosis, treatment-focus and clinical implementation based on OPD-Axis II. Paper presented at the 35. annual meeting of the Society for Psychotherapy Research (16.-19.06.2004), Rome, Italy.
Stiles, W. B., Meshot, C. M., Anderson, T. M., & Sloan, W. W. (1992). Assimilation of problematic experiences: the case of John Jones. Psychotherapy Research, 2, 81-101.
Strupp, H. H., & Binder, J., L. (1993). Kurzpsychotherapie. Stuttgart: Klett-Cotta.
Weinryb, R. M., & Rössel, R. J. (1991). Karolinska Psychodynamic Profile KAPP. Acta Psychiatrica Scandinavia, 83, 1-23.