Operationalized psychodynamic diagnosis in childhood and adolescence (OPD-CA-2)—A useful tool for improving diagnoses of psychological illnesses

Abstract

There has been a discontent with the diagnostic systems in use because for identifying a psychological disorder, the focus is laid on symptomatology only. “Operationalized Psychodynamic Diagnosis” (OPD) is as a tool for describing personality structure, to identify psychodynamically relevant characteristics, to judge suitability for psychotherapy and for treatment planning. The version OPD-CA has been developed for children and adolescents. The article gives an overview over the different axes and categories of the system and describes advantages from a clinical perspective. An overview is given about the specific training program required to learn to apply OPD-CA-diagnoses in clinical practice and about OPD-CA-education in Sweden. In addition, results from OPD-CA research are presented.

Keywords:

• psychodynamic diagnostics
• children
• conflicts
• psychological structure
• adolescents
• psychodynamic assessment

During the last decades there has been a continuous increase of psychological illnesses in Sweden (Bremberg, 2015) especially among adolescents, leading to a great demand of psychotherapists delivering evidence-based psychological treatments. A basic problem for delivering adequate psychological treatments is to identify the patients by diagnosing them correctly. There has been a discontent with the diagnostic systems in use (ICD and DSM) because in the diagnostic process for identifying a psychological disorder, the focus is laid on symptomatology only. Other important aspects are not considered, e.g., severity or chronicity of a disease, and, more important, psycho-social factors, motivation of the patient, personality structure, psychological capacities of dealing with affects or conflicts, relational capacities, and the ability to mentalize. There is a demand for a more multidimensional perspective on the patient and her problems which allows to understand intrapsychic and interpersonal mechanisms related to symptomatology the patient has developed.

Attempts to operationalize psychodynamic diagnostics

Within the psychodynamic field there have been several approaches over the years, to organize clinical data and observations into systems, in order to operationalize diagnostics, describe personality structure, aid assessment and devise treatment planning. The Hampstead Index (Freud, 1962) in Great Britain was such an early attempt as well as the descriptive developmental diagnostics by Blanck and Blanck (1974, 1979) in Germany. Bibring et al. (1961) had developed a catalogue of defense mechanisms and Perry (1990) described a list of ideographic basic conflicts. A more advanced approach was developed in Sweden: The Karolinska Psychodynamic Profile, KAPP (Weinryb & Rössel, 1991), which is based on a clinical interview and assesses eighteen different subscales, such as quality of interpersonal relationships, level of mental functioning, differentiation of affects, experience of one's own body, sexuality, and personality organization. In the US similar efforts were made, e.g., the Psychodynamic Diagnostic Manual-2 (PDM-2, Lingiardi & McWilliams, 2017) consists of three dimensions (personality patterns and disorders, mental functioning, manifest symptoms and concerns). In the PDM–2, the source of information is not limited to clinical interviews. It also integrates information from various forms of psychological testing and self-reports. Otto Kernberg (1984) developed the Structured Interview of Personality Organization—Revised (STIPO–R, Clarkin et al., 2016), a semi-structured interview that assesses several psychological dimensions such as identity, object relations, lower-level defenses, higher-level defenses, aggression and moral values.

The OPD-system

In 1992, a group of psychoanalysts, experts in psychosomatic medicine as well as psychiatrists in Germany set up a task force that called itself “Operationalized Psychodynamic Diagnosis” (OPD). The main objective for this task force was to develop a system that went beyond purely symptom-based diagnostic descriptions, when using the most common DSM or ICD diagnostic systems, which do not include the possibility for treatment planning. The task force took on the challenge to operationalize psychodynamic constructs stemming from different psychoanalytic theories and schools. The members of the task force formed a multi-center project which addressed another weakness in psychodynamic diagnostic processes: the low interrater agreement between clinicians when it came to more readily observable data with a low level of abstraction. Finally, the working group presented a diagnostic inventory containing five axes and a manual for training purposes for experienced clinicians which was revised in 2008. OPD-2 can be seen as a tool for describing personality structure in adults and to identify psychodynamically relevant characteristics, pertinent to judge suitability for psychotherapy and treatment planning. It has since then become a standard tool for psychotherapy assessment in Germany. The OPD-2 consists of five axes, the first four axes are designed to operationalize clinically relevant, psychodynamic constructs. The fifth axis consists of a formal ICD-10/DSM-5 diagnosis.

OPD for children and adolescents—OPD-CA

Psychodynamic psychotherapy for children and adolescents is scarcely offered in public Swedish healthcare settings, with a few notable exceptions. Over the last twenty years there has been a sharp decline in supply for this kind of therapy, due to national guidelines and demands for shorter treatments. The relative lack of empirical support for the effectiveness of psychodynamic child psychotherapy, has added to the decline. However, during the last decades an increasing number of empirical studies have shown the effectiveness and important value of psychodynamic psychotherapy approaches for children and adolescents. Midgley et al. (2017) and Midgley et al. (2021) give comprehensive overviews over the most relevant research findings on child therapy. During the last years more and more manualized psychodynamic treatments for children have been published (Goodman & Midgley, 2019).

In 1996 in Germany another task force was founded with the aim to develop an OPD instrument for adolescents and children. German versions of the system were published in 2003 and 2007 and were followed by an English version in 2017: OPD-CA-2. The main aims were to enable indication for therapy and treatment planning as well as giving support for parental work. The structure of the OPD-CA-2 is similar to the OPD-system for adult patients. The axes focus on interpersonal relations, prominent intrapsychic conflicts, the level of structure as well as prerequisites for treatment.

Of importance is the developmental concept applied in the OPD-CA-2. It combines different developmental approaches like the cognitive development described by Piaget (1952), findings from empirical psychology as well as developmental lines introduced within the psychoanalytical frame. These developmental aspects are connected with a psychopathological perspective and four age groups are differentiated (age group 0: 0–2 years, age group 1: 3–5 years, age group 2: 6–12 years, and age group 3: 13–18 years). However, only age groups one to three are relevant for OPD-CA-2, intending an age adequate diagnostic evaluation of the individual child/adolescent. The OPD-CA-2 consists of four axes (Axis I: Interpersonal Relations; Axis II: Conflicts; Axis III: Structure, and Axis IV: Experience of illness and prerequisites for treatment). Psychological assessment of children and adolescents, includes not only the individual child but also the family system as a whole. Parents take an active part in the assessment process, which makes it possible to observe the actual relation between parents and the child.

The 4 axes

Axis I assesses the client’s functional or dysfunctional relationship patterns, in part based on how the client describes relationship episodes with other people but to a larger extent based on how the relationship with the interviewer is formed by the interactions and play of the client during the assessment. There is quite limited information to be gained from doing a formal interview with a pre-school child, the assessor therefore relies mostly on information how the child behaves and relates in play activities and in interaction with the parents.

The client’s habitual relationship patterns reveal the interplay between wishes and related anxieties in relationships but also possible resources, e.g., when positive relationship behavior can be observed. In addition, aspects of transference and countertransference are systematically described in terms of relational items describing positive and negative affectivity and aspects of controlling and independency.

In Axis II, the client’s inner conflicts are under scrutiny. The idea of unconscious conflicts is a psychoanalytic mainstay, the definition put forth in the OPD-CA-2 is “…unconscious intrapsychic collisions of opposing affects, bundles of motivation, ambitions or behavioral tendencies (…).” (OPD-CA-2 Task Force, 2017, p. 52) In using this axis, the assessor gets an insight to central inner conflictual themes and also external current conflictual situations. Seven basic conflicts are defined: 1. Closeness versus Distance; 2. Submission versus Control; 3. Taking Care of Oneself vs. Being Cared For; 4. Self-Worth Conflict; 5. Guilt Conflict, 6. Oedipal Conflict, and 7. Identity Conflict. The conflicts are rated according to their presence in the material, resulting usually in one main conflict which is clearly present and dominating in the material and one or several other conflicts that are not so pronounced.

Axis III: depicts the qualities and/or inadequacies of inner mental structures of the client. Four different levels of structure are distinguished (good integrated level, limited integrated level, poor, and disintegrated level). The judgement of level of structure on this axis is done for four overarching dimensions: 1. Control, 2. Identity, 3. Interpersonality, and finally, 4. Attachment. The assessment should be made by taking into account the developmental age of the client, i.e., the different age-levels defined in the manual. The evaluation of the structure of a client should be made resource-oriented and with respect to the biographical context.

Axis IV: The Prerequisites for Treatment Axis is composed of three categories comprising subjective dimensions, resources as well as specific prerequisites for treatment. All items are to a large extent independent from theoretical conceptions. What is most important for treatment planning are the resources that can be identified for an individual client.

Clinical aspects

From what has been written so far it becomes quite clear how much additional information about the inner constitution of a client is collected by OPD-CA-2 diagnosis. The solely descriptive and symptom-oriented diagnosis via DSM or ICD supply us neither with genetic information nor with information about inner psychological conflicts, level of integration of psychological structure and of (maladaptive) relational patterns. It is quite clear that a similar F-diagnosis by DSM-5 or ICD-10 may obstruct the view to very different individual developmental processes of the disease, leading to different starting points and different recommendations for psychotherapy.

The OPD-CA-2 is a diagnostic system that allows status- as well as process-diagnosis. The diagnosis focusses on the status quo of personality at the beginning of a psychotherapy. However, OPD-CA-2 is also applicable for repeated measurements during the course of treatment and at the time of follow-up. Thus, it is possible to control for whether specific treatment goals have been achieved, e.g., a change in maladaptive relational patterns, an improvement of psychological structure or a change in main conflicts. OPD-CA-2 enables formalized diagnostic steps, transparent for all and replicable as well as understandable even for non-clinicians.

In order to make an OPD-CA-2 based assessment, the clinician first conducts a clinical interview. Length and format of the diagnostic assessment are adjusted to the different age-groups. The usual time frame is about 60 minutes for adolescents (age group 3, 13–18 years) and about 30 minutes for children from age group 2 (6–12 years). For smaller children (age group 1, 3–5 years) the interview consists mostly of play interactions. Here the clinician relies mostly on observation of behavior and play interactions. When assessing children from age group 2 more verbal interaction becomes possible. Play interactions may be commented and story completion tests can be applied. In age group 3 verbal information becomes most important. However, play interactions may still take place and behavior observations might be relevant as well.

The diagnostic assessment has to collect enough information, in order to reliably rate the four axes. The clinician strives not to make the assessment too structured, since a highly structured situation might help the interviewee to compensate for structural vulnerabilities or conflictual themes and will not reveal them. The OPD-CA-2 manual offers specific interview tools which support the clinician with descriptions of possible events during the assessment, suggestions of questions, interventions and formulations for how to collect relevant information for the diagnostic assessment of the different axes.

By applying the four axes of the system, it assures that the assessment is carried out in a systematic and structured fashion. The guidelines offered by the OPD-CA-2, give the clinicians enough scope to exercise their own judgements within the parameters set by the system. Having a common language and operationalizations for what constitutes relevant psychodynamic constructs, makes it possible to communicate clinical observations both within and outside the clinical and scientific field.

OPD-training and education

OPD-CA-2 is not applicable without training. It takes some time to get acquainted with the different items on the four axes, with their clinical expressions and the corresponding definitions to the different age groups in the manual. OPD-CA-2 as a complex system needs to be understood and applied in daily practice and is best learned in a group setting over a certain period of time.

OPD-CA-2 education is built very much on working with clinical case material. This is done in two steps, i.e., two series of three consecutive two-day workshops. The first series addresses the OPD-CA-2 on a basic level, in the second series workshops are performed on a more advanced level. The formal training of OPD-CA-2 begins with three separate, two-day workshops spread out approximately six to eight weeks apart. In order to become a reliable OPD-CA-2 assessor, continuous training is necessary. The workshops consist of lectures mixed with practical applications, where the participants rate interviews using the different axes of the system. The clinical material can vary from video- or audiotaped interviews or transcripts of interviews to oral or written case presentations or summaries of diagnostic interviews. To begin with, videotaped interviews are best suited for training of beginners. The group setting of between 10-20 participants has been shown to work best. Clinical discussions in the whole group may change with extensive work in small groups. The axes are discussed one by one and their evaluation is trained by using video-taped interviews and by applying the manual in small group discussions. The members can discuss the ratings in a small group setting before the results are compared with those of the other groups and commented by the OPD-instructor. A few cases are presented by the instructor, in order to show examples how different levels of structure, dominant conflictual themes and maladaptive interpersonal relationship patterns show up in the course of the interview.

The first workshop starts with a theoretical lecture of the OPD-CA-2 system, its basic principles and how it was developed. After presentation of the four axes of OPD-CA-2 relevant for the psychodynamic approach for diagnosing a patient, a case is presented either in form of a video or of an oral report of an OPD-interview. After the case-presentation, the whole group discusses the interview and develops a clinical understanding. In smaller groups a first OPD-evaluation is performed. One group focuses on the relational axes (I), the second group on axes II (conflicts) and a third group is dealing with axis III (structure). Afterwards the groups one by one report their results to the others and the entire group discusses, together with the OPD-expert teacher, all problems that may have evolved, ambiguities, uncertain ratings, etc. Day 1 of the first workshop closes with a first coherent OPD-CA-2 diagnosis, based on the results the different groups came up with. The second day of the first workshop contains more cases (video-taped interviews or oral presentations) which are also evaluated in small groups. Each group works with a different axis and at the end of the workshop all participants have worked with each of the three axes (I–III).

The second workshop deepens the understanding of the manuals and the operationalizations of the different dimensions of the OPD-CA-2 by diagnosing additional cases. Now the small groups work with all axes (axis I-III) together and at the end three different results of OPD-CA-2 diagnostics can be compared and discussed in the entire group. This work is performed during both days of workshop 2. The third and last workshop of the basic module is structured in the same way as workshop 2 but the participants bring material from their own interviews, such as video recordings or transcripts of interviews and discuss them. The first part of the task is doing an OPD-CA-2 based interview, the second part is to rate the interview on respective axes.

It goes without saying that confidentiality applies during all workshops. After having completed all three workshops the participants are able to use the OPD-CA-2 independently and get a diploma confirming their successful participation. Some participants have formed supervision groups that meet a handful times per year, for case seminars to solidify their skills.

It is clear that it takes some time and training to become acquainted with the different categories and with all the definitions and criteria described in the manual for diagnosing the most prominent conflicts, the psychic structure and the relational patterns that the patient offers. However, the most difficult part of the OPD-CA-2 training turned out to bed the “level of inference”, i.e., to which extent is it possible to interpret from the manifest information to latent constructs and theories. Psychodynamic psychotherapists are trained to make inferences based on assumptions about non-manifest and underlying processes. The OPD-CA-2 system however, is geared towards observation of solely manifest, phenomenological data. Clinicians well versed in psychoanalytical theory and thinking, have to restrain their urges to make inferences that are too far removed from the data descriptively present in the interviews. An often-recurring comment from the OPD-expert might be: “where do you find that in the data”. In order to make the operationalizations in the OPD-CA-2 manual clear for the users, it takes quite a few examples and discussions before they are fully understood and mastered. Especially Axis-I seems to be the most challenging one to learn, partly because a number of the items used to describe aspects of maladaptive interpersonal relations are not self-explanatory. Furthermore, the understanding of the different perspectives of this kind of relationship matrix, is new to most clinicians.

The OPD-CA-2 requires a substantiation of the assessments closely based or oriented on the manifest material, without interpretative steps. This seems to be easier to carry out for psychotherapists in training than for experienced clinicians who are used to structure and interpret the material with respect to their theoretical orientation. To put aside all theoretical pre-assumptions and to study the manifest text unbiased, can be a real challenge for clinicians used to apply their theoretical models for years.

The OPD-2 has spread outside the German language sphere and the manual was translated into English, Spanish and Chinese. There are extensive trainings given in both China and South America. The OPD-2 found its way into Scandinavia first via Denmark and Finland. The authors arranged an OPD-2 course in Sweden for the first time in 2015. The training was led by the founder and developer of the OPD-system and by the former OPD-2 spokesperson, professor Manfred Cierpka. Since then, OPD training workshops have been implemented on a regular basis. Currently, covid-19 pandemic has set a stop for workshops in real life. However, an online-version of the training program is under construction. In 2018, the first series of training workshops in OPD for children and adolescents (OPD-CA-2) was given, held by professor Inge Seiffge-Krenke who is head and speaker of the OPD-CA-2 taskforce in Germany.

The training opportunities in Sweden have attracted interest almost exclusively from psychologists and psychotherapists with a background in psychodynamic psychotherapy. When the first author did his OPD-2 training in Copenhagen in 2012, there was a somewhat wider variety in the participant’s psychotherapy training background, e.g., CBT-therapists were taking part. It seems possible that the Danish colleagues were more successful in introducing the OPD-training workshops to a wider range of clinicians with different educational backgrounds. Even though similar efforts were made in Sweden, Swedish psychologists and psychotherapists who participated mostly had a PDT-background. The participants in the Swedish workshops worked mainly within psychiatry, psychotherapy training institutes, primary care psychological services or in private practice. The same is true for the workshops in OPD-CA-2. Psychologists working in psychiatric settings who are faced daily with making diagnostic decisions based on the DSM-5, have found the OPD-CA-2 as a useful complement for organizing important and useful clinical observations that are left out in formal diagnoses.

At Stockholm university, training of adult version of the OPD has been integrated into the psychology education program and the postgraduate psychotherapy training program. A basic module of OPD-diagnosis is introduced in the theoretical course on diagnostics under term 7. A more extended version of this basic module is applied at the beginning of the psychotherapy education program in which students train OPD by rating video-taped interviews and by using own case material. They also use OPD as a process tool.

When it comes to OPD-CA-2, introductory lectures are included in the education program for child- and adolescents psychotherapist at Erica-Stiftelsen in Stockholm. However, compared to the psychotherapy education programs offered at several Swedish universities the number of psychotherapists in education programs specialized in child and adolescent psychotherapy is quite small. Therefore, it would be of interest that the OPD-CA-2 education continues to grow in the future. At the moment new formats for the workshops are developed and from 2022 there will be a possibility of a web-based digital OPD-CA-2 workshop series.

Research on OPD-2/OPD-CA-2

Since the publication of the first version of OPD vivid and ongoing research activities focusing on different dimensions and axes of the OPD could be observed. Both et al. (2019) identifies 189 publications on OPD within a five-year period until 2017 covering studies on validity and reliability of the instrument, process and outcome studies as well as studies on different mental disorders. Cierpka et al. (2007) list 32 empirical studies published between 1996 and 2005 and investigating reliability, construct validity, predictive validity, criterion validity and clinical validity of the different axes of the OPD. The reliability for axis II and III is judged as satisfactory and for axis IV as good. Predictive value of OPD-dimensions for psychotherapy outcome have been investigated (Schneider et al. 2015) and applications of OPD in extra-clinical settings (e.g., Both et al. 2017, 2020) as well as cross-cultural adaptations have been performed (Vicente et al., 2012).

The English version of the second edition of the OPD-System was published in 2008 and since then a lot of clinical experiences have been collected, extensive research has been performed and OPD has been continuously spreading over the world. Currently, efforts of improvement and further development of the system are on its way and a third version of the OPD will be published soon.

As the English manual of OPD-CA-2 has only been published four years ago in 2017, publications of studies using OPD-CA-2 are quite sparse and above all have been performed in German speaking countries. The relation between personality structure, defensive styles and unconscious conflicts was studied (Weber et al., 2020). Pokieser et al. (2019) investigated how self-injuries in adolescence are related to structure and relationship assessment with OPD-CA-2. The structure axis was even used to investigate how structural integration in adolescents was related to mental disorders later on in life (Bock et al., 2019). Schrobildgen et al. (2019) developed and used a self-judgement instrument for the structure axis which makes it easier to evaluate the psychological structure of adolescents even in non-clinical contexts and compare the results to clinical groups. Finally, this volume introduces a collection of recent research efforts and studies using the OPD-CA-2 system.

Disclosure statement

The authors declare that they have no competing interests.