This special issue deals with a new diagnostic system, the Operationalized Psychodynamic Diagnostic for Children and Adolescents (OPD-CA-2). It has been an established instrument in the clinical context in German-speaking countries for several years. With the English version of the manual published in 2017, the Spanish- and Turkish language version published in 2020 and 2021, the concept of operationalized psychodynamic diagnostics will spread even more widely internationally. We present in this special issue the initiatives and findings from contributors from Switzerland, Austria, Germany, Sweden and South America.
The question of symptom diagnosis versus structure and conflict diagnosis currently occupies many therapists. The OPD-CA can be seen as a supplement to conventional diagnostics with the ICD-11 or the DSM-5. A symptom diagnosis can in no way be dispensed; it is the symptoms from which the patients and their families suffer and which ultimately lead to a diagnostic examination and, if necessary, to counseling, psychotherapeutic treatment or another indication. However, the mere determination of the symptoms is not sufficient for an efficient treatment, because symptoms can often change spontaneously or different symptoms occur simultaneously, so that a purely symptom-specific treatment may not be very effective. The Operationalized Psychodynamic Diagnostics in Childhood and Adolescence (OPD-CA) therefore strives for a complex recording of psychodynamic processes that caused the symptoms and embeds them in the developmental context. The development concept is central and affects all aspects of the process, from the type of findings to the selection of relevant diagnostic categories to the process of diagnostic assessment on various content-related axes and finally, a treatment recommendation.
History of origin
The OPD-CA-2 (2017) is a psychodynamically oriented diagnostic system for children and adolescents, which is available in an extensive manual, published in a revised version 2017. It is based on the long-term work of a working group, starting in 1997, in which representatives of psychiatry and psychotherapy for children and adolescents regularly took part. Although the work was based on the OPD for adults, which had already presented operationalized psychodynamic diagnostics with different axes for the field of adult patients in 1996, OPD-CA is conceptually different, as the main focus lays on a developmental conceptualization which runs through all axes. The OPD-CA thus combines psychodynamic, developmental and clinical-psychiatric perspectives.
The age levels roughly adhere to Piaget's concept of development, namely levels 0 (about 0 to 1.6 years), 1 (1.7 to 5 years), 2 (6 to 12 years) and 3 (from 13 years of age), they have a medium degree of differentiation and can be linked to important normative points such as preschool, middle school, beginning physical maturity, etc. Level 3, from the age of 13, corresponds to the formal operational level according to Piaget. At this level, the young person has acquired self-reflective skills and higher-order metacognitive skills. Further, psychological perspectives become important at this stage of development. This applies to relationships, but also to processes of disease development. Coping skills are increasingly characterized by a multitude of differentiated strategies and their flexible use.
The axes at a glance
Psychodynamically relevant information are collected on four psychodynamic axes: the relationship patterns, the intrapsychic conflicts, the psychological structure and the treatment requirements of children and adolescents. These four axes may not only help for a decision for the indication, they can also be used for the therapy planning and - after the end of the therapy – be applied in order to evaluate the success of the therapy. A detailed interview is also available that helps to ask questions about the individual axes.
Axis “Relationship”
Adequate relationship diagnostics for children and adolescents requires that the different levels of relationships of the child or adolescent are taken into account. For this reason, the axis relationship is made up of different modules. The examiner can code different relationships, e.g., between child-examiner, child-father, child-mother, etc. up to triads. It is also possible to note the therapsist’s own countertransference in a separate coding. Central is the assessment of the behavior of the child or adolescent in the examination situation, on the one hand object-oriented (how does he or she influence the therapist?) and on the other hand subject-oriented (how does the child or the adolescent react to the therapist?). Complex feelings are described using a circular model, whereby two basic relationship constellations, the emotional quality of the relationship (affiliation) and the control in the relationship, can be assessed.
Axis “Structure”
The psychic structure axis is based on the psychoanalytic concept of structure, whereby it is assumed that structure is characterized by a relatively optimal adaptability in every age group. The axis is divided into four areas: Control (e.g., impulse control, dealing with negative affects, conflict resolution), Identity (e.g., self and object differentiation, self-experience), Interpersonality (e.g., contact, communication of one's own affects and deciphering other’s affects), and Attachment (e.g., secure basis, ability to be alone). Again, the developmental specific forms of expression on these four structural dimensions are described here, based on the age levels. The assessment of the structure relates to the last six months, discriminating between good integration (the described structural dimensions succeed in all described social areas under everyday conditions at almost any time and without significant outside help), moderate or low integration (the child or adolescent only succeed with additional or considerable external help in most or a few described social situations), and disintegration. In the case of the latter, despite intensive help, the structural performance is not satisfactory, in almost no situation relevant to the child or adolescent and at no time.
Axis “Conflict”
For the diagnosis in the OPD-CA, intrapsychic, long-term conflicts play a prominent role. It is crucial that they inhibit development and represent an important topic for the child or adolescent. Of the total of seven intrapsychic conflicts, the central or the second most important conflict is diagnosed on the basis of the available material. This assessment is based on how dysfunctional this conflict is and in how many areas of development (e.g., school, parents, friends) it becomes apparent. In each conflict area, a passive and an active mode of conflict management are distinguished from one another: The active mode occurs when counter-phobic defenses and reactions predominate. In the passive mode regressive defensive attitudes predominate. For each age group there is an operationalization of the respective conflict in the active and passive mode, each related to the family, peers, school/kindergarten and the body.
The seven different conflicts are as follows: (1) A closeness-distance conflict as a life-determining issue should only be diagnosed if it surpasses all other conflicts and its assignment is clear. It does not exist when children or young people are capable of flexible and reciprocal relationships. (2) In the case of submission versus control, the basic conflict revolves around the discussion of obedience/submission versus control/exercise of power, rebellion. (3) In the case of self-care versus being cared for, the child or adolescent experiences a secure relationship, but it is very much determined by claims to material or affective care or by their defense. (4) Self-esteem conflicts are about self-versus object-worth or the fact that self-experience is determined by the feeling of being worthless (passive mode) or by overestimating oneself (active mode). (5) Conflicts of guilt indicate an excessive loyalty to the parents or one of the parents, which is so massive that it hinders further development. (6) Oedipal conflicts are about dealing with sexuality in the passive and active mode, while (7) identity conflicts are about the search for identity in the active and passive mode. The clinical work with the conflict axis is described in Seiffge-Krenke et al. (Citation2014) based on long-term treatments.
Since the symptoms observed in children and adolescents can also be the result of acute severe stress, it must finally be assessed whether serious stress and trauma have been experienced by them in the last six months. These stressors can generally restrict the processing capacities and, among other things, leading to the intrapsychic conflict being changed in the sense of strong regression. Other clinical approaches should also be taken into consideration for traumatized patients. It is particularly problematic if the traumatic or highly stressful event that occurred some time ago takes up a topic that is also of great importance in the patient's intrapsychic conflict.
Axis “Prerequesites of treatment”
This axis includes subjective dimensions of children and adolescents, but also resources. The focus on resources in particular should not be lost, because all too quickly the focus is on the pathological and intrapsychic deficit. Here, for example, the subjective impairment of children and young people, their theories and hypotheses about their illness, the level of suffering and the motivation for change are recorded. Is he or she dissatisfied and does he or she express a need for change? What about his/her level of suffering?
The current living situation of the child or the young person, the family relationships and circumstances are taken into account as possible resources. The relationship with peers, which is of great importance for children and adolescents, is included as a further resource. Here, detailed questions are asked about the extent and quality of friendship relationships in order to determine to what extent they represent a resource in the event of possibly deficient family relationships. Support outside the family, e.g., through offers of help from institutions, is investigated, too. In the case of family resources, the openness of the family in the interview, the flexibility of the members, the relationship to one another and the exchange within the family are primarily used. It is important to what extent parents or other caregivers can perceive and verbalize ambivalent feelings towards the child, to what extent are transgenerational boundaries aware and the like. The family's motivation for change also belongs to this area of resources. Finally, intrapsychic resources include a conviction of control and self-efficacy, as well as their own competences that the child or adolescent has to deal with the current situation and problems. Insight also plays an important role, which is operationalized, among other things, by the ability to introspect and understand what the causes of the symptom(s) are. Furthermore, the category of special psychotherapy motivation covers the specific interest in reducing the existing problems or symptoms by continuing or deepening the resulting dialogue with the therapist. The gain from illness is also recorded; in some cases, it is considerable and can prevent patients from going into treatment or from working appropriately in the treatment. Therefore, the determination of the working alliance is also of great therapeutic importance. It relates to how well the patient can comply with agreements that affect the external framework (punctuality, frequency of hours, vacation regulations). As a rule, this ability to form an alliance only becomes clear after several preliminary discussions.
Empirical studies with the OPD-CA-2
As a rule, three training courses are offered to learn how to classify the axes on the basis of the manualization chapter of the OPD-CA-2. Reliability and validity of the different axes have been documented as satisfactory to good in different studies (OPD-CA-2 Task Force, Citation2017; Stefini et al., Citation2013). Training to learn the classification was found to be effective (Seiffge-Krenke et al., Citation2011). Further empirical studies have shown that the same conflict issues occur in clinically inconspicuous children and adolescents, albeit to a significantly lower extent, while the conflict values in clinical groups were three times higher, which speaks for the massive occupation and impairment caused by the conflicts (Seiffge-Krenke et al., Citation2014). All conflict topics appeared in all diagnoses. In patients with externalizing disorders, the conflict of submission vs. control is prominent, whereas in patients with internal disorders, the conflict of care is more common (Winter et al., Citation2011). The collection of data on the conflict and structural axis has proven to be an important aid for indication and treatment planning for inpatients and outpatients (Seiffge-Krenke et al., Citation2013a), especially in the context of structural deficits (Seiffge-Krenke et al., Citation2013b), but overall the assessment of all axes was recommended and useful (Seiffge-Krenke et al., Citation2013c). In addition, work with questionnaire versions of the axis has been published (Schrobildgen et al., Citation2019); two recent volumes present the work with clinical cases, based on the OPD-CA-2 (Seiffge-Krenke et al., Citation2014; Seiffge-Krenke & Schmeck, Citation2020).
Aim and scope of this special issue
In this special issue, contributors for different European countries (Sweden, Germany, Austria, Switzerland) and South America (Uruguay) who work with the OPD-CA-2 after extensive training describe their experiences in using this instrument. Both diagnostic and therapeutic questions are addressed. We strive to include different age groups as well as to offer the broadest possible spectrum of diagnoses and to ensure a good balance between inpatient and outpatient cases. We include empirical work as well as case studies in this volume. We very much hope that this work will stimulate the readers to work with the OPD-CA-2 and also to start research in the various fields of work.
This issue on OPD-CA-2 is divided into 4 sections. To begin with, Thomas Rosén and Stephan Hau give an overview about the history of developing an operationalized system for psychodynamic diagnostics. A focus is also laid on educational aspects and how to learn the OPD-CA-2-system.
The next section consists of studies dealing with diagnostic issues when applying the OPD-CA-2 system. Inge Seiffge-Krenke demonstrates how the same descriptive diagnosis may be based on very different conflicts implying different treatment strategies. How a thorough consideration of variables from the prerequisites of treatment axis can help with indication and development of treatment plan, is described in the article by Ilonka Schwarzenfeld and her colleagues. Furthermore, Katharina Weitkamp and her research group apply the OPD-CA-2 as a tool for investigating process-changes under the course of a treatment. Their focus is put on how mental structure, interpersonal relationships as well as intrapsychic conflicts change under treatment.
The third part of this issue summarizes studies which used the OPD-CA-2 system on different groups of subjects and discuss the clinical impacts of their OPD-CA-2 findings. Carola Cropp and Bastian Claaßen identified different groups of patients with respect to their relationship patterns and discuss the relevance of their findings for clinical practice. Nicolás Bagattini describes an adolescent psychotherapy and addresses the importance of a psychodynamic perspective when diagnosing adolescents.
Finally, research is presented in which non-patient groups are investigated. Fabian Escher, Lea Sarrar and Inge Seiffge-Krenke compare healthy adolescents and a group of patients with respect tot he conflicts revealed on the conflict axis oft he OPD-CA-2 System. Another healthy sample of adolescents was investigated by Asli Akin and colleagues. In their article they investigate how parenting behavior is related to unconscious conflicts in adolescents.
We would be delighted if this special issue encourages many readers to integrate the OPD-CA-2 into their clinical work and to report back to us, the OPD-CA task force, about their experiences with its use. it would also help the patients and their therapists.
Email: [email protected]; [email protected]
References
- OPD-CA-2 Task Force (2017). OPD-CA-2 Operationalized Psychodynamic Diagnosis in Childhood and Adolescence: Theoretical Basis and User Manual. Hogrefe.
- Schrobildgen, C., Goth, K., Weissensteiner, R., Lazari, O., & Schmeck, K. (2019). Der OPD-KJ2-SF – Ein Instrument zur Erfassung der Achse Struktur der OPD-KJ-2 bei Jugendlichen im Selbsturteil. Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie, 47(5), 428–440. https://doi.org/https://doi.org/10.1024/1422-4917/a000667
- Seiffge-Krenke, I., Dietrich, H., Adler-Corman, P., Timmermann, H., Rathegber, M., Winter, S., & Röpke, C. (2014). Die Konfliktachse der OPD-KJ-2: Ein Fallbuch für die klinische Arbeit. Vandenhoeck & Ruprecht.
- Seiffge-Krenke, I., Mayer, S., Rathgeber, M., & Sommer, T. (2013a). Konflikt- und Strukturachse der Operationalisierten Psychodynamischen Diagnostik des Kindes- und Jugendalters. Hilfe bei Indikation und Therapieplanung. Psychotherapeut, 58(1), 6–14. https://doi.org/https://doi.org/10.1007/s00278-012-0956-2
- Seiffge-Krenke, I., Fliedl, R., & Katzenschläger, P. (2013b). Diagnosespezifische Strukturdefizite. Psychotherapeut, 58(1), 15–23. https://doi.org/https://doi.org/10.1007/s00278-012-0955-3
- Seiffge-Krenke, I., Fliedl, R., & Katzenschläger, P. (2013c). Welche Vorteile bringt eine umfassende Diagnostik mit OPD-KJ bei kinder- und jugendpsychiatrischen Patienten? Zeitschrift fur Kinder- und Jugendpsychiatrie und Psychotherapie, 41(2), 121–132. https://doi.org/https://doi.org/10.1024/1422-4917/a000219
- Seiffge-Krenke, I., Mayer, S., & Winter, S. (2011). Beurteilerübereinstimmung bei der OPD-KJ: Wovon hängt sie ab und welchen Erfolg bringt das Training? Klinische Diagnostik und Evaluation, 4, 176–193.
- Seiffge-Krenke, I., & Schmeck, K. (2020). Diagnostische und therapeutische Arbeit mit der OPD-KJ-2. Vandenhoeck & Ruprecht.
- Stefini, A., Reich, G., Horn, H., Winkelmann, K., Ohmes, U., Frost, U., & Kronmüller, K.-T. (2013). Interrater-Reliabilität der OPD-KJ-Achsen Konflikt und Struktur. Praxis der Kinderpsychologie und Kinderpsychiatrie, 62(4), 255–269. https://doi.org/https://doi.org/10.13109/prkk.2013.62.4.255
- Winter, S., Jelen, A., Pressel, C., Lenz, K., & Lehmkuhl, U. (2011). Klinische und empirische Befunde zur OPD-KJ. Praxis der Kinderpsychologie und Kinderpsychiatrie, 60, 41–59.