Wolfgang Aichhorn

Real-Time Monitoring of Psychotherapeutic Processes: Concept and Compliance

Objective: The feasibility of a high-frequency real-time monitoring approach to psychotherapy is outlined and tested for patients compliance to evaluate its integration to everyday practice. Criteria concern the ecological momentary assessment, the assessment of therapy-related cognitions and emotions, equidistant time sampling, real-time nonlinear time series analysis, continuous participative process control by client and therapist, and the application of idiographic (person-specific) surveys. Methods: The process-outcome monitoring is technically realized by an internet-based device for data collection and data analysis, the Synergetic Navigation System. Its feasibility is documented by a compliance study on 151 clients treated in an inpatient and a day-treatment clinic. Results: We found high compliance rates (mean: 78.3%, median: 89.4%) amongst the respondents, independent of the severity of symptoms or the degree of impairment. Compared to other diagnoses, the compliance rate was lower in the group diagnosed with personality disorders. Conclusion: The results support the feasibility of high-frequency monitoring in routine psychotherapy settings. Daily collection of psychological surveys allows for the assessment of highly resolved, equidistant time series data which gives insight into the nonlinear qualities of therapeutic change processes (e.g., pattern transitions, critical instabilities).

Real-Time Monitoring in der Psychotherapie

Since several years, internet-based technologies for the monitoring of psychotherapy processes were partially established in in-patient and day treatment centres. We discuss the usefulness and some methodological requirements of process monitoring devices, with a more detailed description of the Synergetic Navigation System (SNS). Continuous self-ratings and the use of feedback-tools like the SNS will have therapeutic implications on patients as well as therapists and their professional cooperation with the patient. Studies on the effects of feedback-systems on patients and therapists should be realized, and the quality of feedback-sessions as well as the competencies in the management of nonlinear processes and feedback-systems should be enhanced. Real-time monitoring is ready to get an integrated part of clinical practice and of clinical training programs.

Psychotherapy Is Chaotic-(Not Only) in a Computational World

Objective: The aim of this article is to outline the role of chaotic dynamics in psychotherapy. Besides some empirical findings of chaos at different time scales, the focus is on theoretical modeling of change processes explaining and simulating chaotic dynamics. It will be illustrated how some common factors of psychotherapeutic change and psychological hypotheses on motivation, emotion regulation, and information processing of the clients functioning can be integrated into a comprehensive nonlinear model of human change processes. Methods: The model combines 5 variables (intensity of emotions, problem intensity, motivation to change, insight and new perspectives, therapeutic success) and 4 parameters into a set of 5 coupled nonlinear difference equations. The results of these simulations are presented as time series, as phase space embedding of these time series (i.e., attractors), and as bifurcation diagrams. Results: The model creates chaotic dynamics, phase transition-like phenomena, bi- or multi-stability, and sensibility of the dynamic patterns on parameter drift. These features are predicted by chaos theory and by Synergetics and correspond to empirical findings. The spectrum of these behaviors illustrates the complexity of psychotherapeutic processes. Conclusion: The model contributes to the development of an integrative conceptualization of psychotherapy. It is consistent with the state of scientific knowledge of common factors, as well as other psychological topics, such as: motivation, emotion regulation, and cognitive processing. The role of chaos theory is underpinned, not only in the world of computer simulations, but also in practice. In practice, chaos demands technologies capable of real-time monitoring and reporting on the nonlinear features of the ongoing process (e.g., its stability or instability). Based on this monitoring, a client-centered, continuous, and cooperative process of feedback and control becomes possible. By contrast, restricted predictability and spontaneous changes challenge the usefulness of prescriptive treatment manuals or other predefined programs of psychotherapy.

Systemic Case Formulation, Individualized Process Monitoring, and State Dynamics in a Case of Dissociative Identity Disorder

Objective: The aim of this case report is to demonstrate the feasibility of a systemic procedure (synergetic process management) including modeling of the idiographic psychological system and continuous high-frequency monitoring of change dynamics in a case of dissociative identity disorder. The psychotherapy was realized in a day treatment center with a female client diagnosed with borderline personality disorder (BPD) and dissociative identity disorder. Methods: A three hour long co-creative session at the beginning of the treatment period allowed for modeling the systemic network of the clients dynamics of cognitions, emotions, and behavior. The components (variables) of this idiographic system model (ISM) were used to create items for an individualized process questionnaire for the client. The questionnaire was administered daily through an internet-based monitoring tool (Synergetic Navigation System, SNS), to capture the clients individual change process continuously throughout the therapy and after-care period. The resulting time series were reflected by therapist and client in therapeutic feedback sessions. Results: For the client it was important to see how the personality states dominating her daily life were represented by her idiographic system model and how the transitions between each state could be explained and understood by the activating and inhibiting relations between the cognitive-emotional components of that system. Continuous monitoring of her cognitions, emotions, and behavior via SNS allowed for identification of important triggers, dynamic patterns, and psychological mechanisms behind seemingly erratic state fluctuations. These insights enabled a change in management of the dynamics and an intensified trauma-focused therapy. Conclusion: By making use of the systemic case formulation technique and subsequent daily online monitoring, client and therapist continuously refer to detailed visualizations of the mental and behavioral network and its dynamics (e.g., order transitions). Effects on self-related information processing, on identity development, and toward a more pronounced autonomy in life (instead of feeling helpless against the chaoticity of state dynamics) were evident in the presented case and documented by the monitoring system.

Prozessfeedback in der Psychotherapie

ZusammenfassungTherapiefeedback auf Grundlage eines hochfrequenten Prozess-Monitorings findet in der Psychotherapie zunehmend Anwendung und Interesse. Damit eröffnen sich Möglichkeiten, nichtlineare Prozesse und diskontinuierliche Musterwechsel zu erfassen. Methodisch stellt sich die Frage, wie solche Musterwechsel (Ordnungsübergänge) auf der Grundlage von Prozessdaten dargestellt werden können, und ob es hierfür geeignete Frühindikatoren gibt. Praktische Fragen beziehen sich auf die Eignung von Therapiefeedback bei antriebsgeminderten depressiven Patienten und auf die Erkennbarkeit von Ordnungsübergängen im Einzelfall. Die Prozesserfassung erfolgt in der vorgestellten Kasuistik eines depressiven Patienten mit dem Synergetischen Navigationssystem (SNS), ein internetbasiertes System zur kontinuierlichen Datenerfassung mit implementierten Methoden der nichtlinearen Zeitreihenanalyse und Möglichkeiten der Visualisierung der Ergebnisse. Die Falldarstellung illustriert mehrere Möglichkeiten, Ordnungsübergänge und deren Frühindikatoren in der Psychotherapie zu visualisieren und verdeutlicht, dass ein hochfrequentes Therapie-Monitoring auch bei Zuständen von Antriebsminderung und Grübelneigung sinnvoll einsetzbar ist. Deutlich wird auch, dass regelmäßige Selbsteinschätzungen und feedbackbasierte Reflexionsgespräche zusammen mit anderen therapeutischen Angeboten zu Synergieeffekten führen können.AbstractTherapy feedback based on high-frequency process monitoring is applied by an increasing number of practitioners. The technology allows the assessment of nonlinear dynamics and discontinuous pattern transitions. The methodological question is on the data-based representation of such transitions and its precursors in the change dynamics of each single case. Practical questions concern the feasibility and usefulness of high-frequency monitoring in depressed and ruminating patients. In this case study we used the synergetic navigation system (SNS) which is an internet-based device for data collection (e.u202fg. daily self-ratings by axa0process questionnaire) with implemented methods of nonlinear time series analysis and the visualization of the results. This case study illustrates different methods for the visualization of pattern transitions and its precursors in axa0psychotherapeutic process. It demonstrates the usefulness of therapy feedback in axa0case of depression with reduced activity level and rumination. Therapy feedback based on daily self-assessment combined with other therapeutic activities co-creates the emergence of an order transition and effective outcome.

Systemische Fallkonzeption und State-Dynamik bei einer Patientin mit struktureller Dissoziation der Persönlichkeit

Das Fallbeispiel beschreibt die Vorgehensweise des synergetischen Prozessmanagements in einem tagesklinischen Setting. Dargestellt wird der therapeutische Prozess einer Patientin mit Borderline-Personlichkeitsstorung und komplexer dissoziativer Storung. Die Entwicklung der Patientin wurde begleitet und reflektiert mit einem Prozessmonitoring, welches auf einem taglich ausgefullten personlichen Fragebogen beruht. Am Beginn des Monitorings und des regelmasigen Prozessfeedbacks, das im Rahmen der therapeutischen Einzelgesprache stattfand, stand die Entwicklung eines idiographischen Systemmodells, welches in einer etwa dreistundigen Arbeit zusammen mit der Patientin entwickelt wurde. Fur die Patientin war es entscheidend zu erkennen, wie ihre verschiedenen Personlichkeits-States in den Komponenten des Modells reprasentiert waren und wie sich die Ubergange zwischen den States und deren jeweilige Trigger psychologisch nachvollziehen und erklaren liesen. Der mit dem »Synergetischen Navigationssystem« (SNS) mogliche Einblick in die Dynamik und die Verlaufsmuster ihrer Personlichkeitszustande (erfasst mithilfe taglicher Selbsteinschatzungen) lieferte die Grundlage fur einen veranderten Umgang mit diesen. Die Effekte im Bereich der selbstbezogenen Informationsverarbeitung und Identitatsentwicklung waren bemerkenswert. Die idiographische Systemmodellierung und das SNS in Kombination ermoglichten sowohl der Therapeutin als auch der Patientin ein umfassendes Verstandnis der personlichen Psychodynamik und der Prozessmuster der Therapie.

Real-Time-Monitoring in der Behandlung komplexer posttraumatischer Belastungsstörung: Ein Fallbericht

Hintergrund: Anhand eines Fallbeispiels soll gezeigt werden, wie Real-Time-Monitoring die Therapie von PatientInnen mit komplexer posttraumatischer Belastungsstörung (PTBS) wirksamer gestalten hilft. Patient und Methoden: Die Fallkonzeption und Behandlung fußten auf einem störungsspezifischen stationären Behandlungsprogramm für komplex traumatisierte Erwachsene und orientierten sich an Empfehlungen bezüglich der traumafokussierten Behandlung von Patienten mit pathologischem Narzissmus. Der Veränderungsprozess des Patienten wurde mit einem webgestützten Tool für Real-Time-Monitoring (Synergetic Navigation System) erfasst und im Therapieverlauf wiederholt gemeinsam mit dem Patienten reflektiert. Ergebnisse: Der Patient remittierte hinsichtlich PTBS, Depression, somatoformer Beschwerden, interaktioneller Schwierigkeiten, Selbstwirksamkeit und Beeinträchtigungen des psychischen Wohlbefindens. Insbesondere konnten im Rahmen von Feedback-Gesprächen die persönlichkeitsspezifischen affektiven Dynamiken von Scham, Schuld und Wut des Patienten sowie deren kritische Instabilitäten und Phasenübergänge im Rahmen der Traumakonfrontation reflektiert werden. Der Patient entwickelte neue Selbstfürsorgemuster und lernte, eigene Gefühle wahrzunehmen, zu verantworten und zu regulieren. Schlussfolgerungen: Die auf Traumakonfrontation ausgerichtete multimodale Therapie erwies sich im vorliegenden Fall als geeignet, neben den Kernsymptomen der PTBS auch bedeutsame komorbide Symptome wirksam zu reduzieren. Das Real-Time-Monitoring unterstützt die Identifizierung und Bearbeitung zentraler affektiver Dynamiken eines Patienten und erlaubt so, die Therapie von Patienten mit komplexen Traumafolgestörungen und persönlichkeitsprägender Symptomatik effektiver zu gestalten.

Personality development in psychotherapy: a synergetic model of state-trait dynamics

AbstractnTheoretical models of psychotherapy not only try to predict outcome but also intend to explain patterns of change. Studies showed that psychotherapeutic change processes are characterized by nonlinearity, complexity, and discontinuous transitions. By this, theoretical models of psychotherapy should be able to reproduce these dynamic features. Using time series derived from daily measures through internet-based real-time monitoring as empirical reference, we earlier presented a model of psychotherapy which includes five state variables and four trait variables. In mathematical terms, the traits modulate the shape of the functions which define the nonlinear interactions between the variables (states) of the model. The functions are integrated into five coupled nonlinear difference equations. In the present paper, we model how traits (dispositions or competencies of a person) can continuously be altered by new experiences and states (cognition, emotion, behavior). Adding equations that link states to traits, this model not only describes how therapeutic interventions modulate short-term change and fluctuations of psychological states, but also how these can influence traits. Speaking in terms of Synergetics (theory of self-organization in complex systems), the states correspond to the order parameters and the traits to the control parameters of the system. In terms of psychology, trait dynamics is driven by the states—i.e., by the concrete experiences of a client—and creates a process of personality development at a slower time scale than that of the state dynamics (separation of time scales between control and order parameter dynamics).

The Nature of Emotions

Nothing renders more quality and meaning to life than emotions. They determine how we experience ourselves and the world around us. Emotions provide experiences with individual meaning and determine how we remember things and what we remember. Emotions are the most important motivational factor in all forms of development and they determine our decisions and actions. Every human interaction, drawing near as well as drawing apart, is emotionally determined. Emotions create personal relationships and they are the “glue” for social relationships. In this context, emotions and the physical body are one inseparable unit. It is quite difficult to find a unified definition because terms such as “affect,” “emotion,” and “feelings” are often used interchangeably. Moods tend to be experienced as prolonged feelings and, in contrast to emotions, moods are not focused on particular objects. Emotions have varied functions. They are part of the human primary motivational system and ensure survival. Emotions regulate interactions between individuals and play an essential role in the development of a child’s personality within a mother-child dyad because they form identity. Emotions provide quick motor action-readiness, for example in dangerous situations. They channel sensory stimuli and support memory formation (Blumenstock, Volkart/ Heri)1.