Hong Kong J Psychiatry 2009;19:165-6


Operationalized Psychodynamic Diagnosis OPD-2: Manual of Diagnosis and Treatment Planning

Editor: OPD Task Force
Hogrefe & Huber Publishers
USD75.00; pp332; ISBN: 978-0-88937-353-2

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As the name suggests, this book acts as a manual for standardising psychodynamic diagnoses for the different mental and psychosomatic disorders classified in ICD 10 and the DSM IV. The title drew my attention immediately because I think this has long been lacking and such a book can be a valuable aid to our current practice.

In the first chapter, the author explains that this book is based mainly on the work of the ‘Operationalized Psychodynamic Diagnosis’ taskforce, which was formed in 1992 by a group of psychoanalysts, psychosomatically oriented therapists and psychiatrists in Germany. They aimed to expand the symptom-based, description-oriented classification of mental disorders by adding some fundamental psychodynamic dimensions. A diagnostic inventory and manual called ‘Operationalized Psychodynamic Diagnosis’ (OPD) was then developed for use in clinical practice and as a training manual for experienced therapists. After many years of application in different settings including in- and out-patients, training, and research, and with the availability of research findings based on it, the task force has decided that now is the right time to offer a revised version, OPD-2. This revision takes it from a purely diagnostic instrument to one that also helps with treatment planning and change measurement. The rest of Chapter 1 discusses fundamental considerations made when designing the multi-axial diagnosis and the process of operationalisation of the psychodynamic and psychoanalytic constructs, which was not at all easy.

The second chapter summarises the OPD-1 experiences and empirical findings used to develop OPD-2. The OPD-2 has 5 axes, with the first 4 being the psychodynamic axes identifying characteristics of patients as follows: firstly, how they experience their illness and the prerequisites they bring to treatment; secondly, their dysfunctional relationship patterns; thirdly, their unconscious conflicts; and fourthly, their structural characteristics and structurally based vulnerabilities which are very much equivalent to the concept of personality. The last axis concerns mental and psychosomatic disorders in line with chapter V of the ICD 10. Chapters 3 and 4 discuss the operationalisation and manualisation of the Axes of OPD-2, which are very useful for understanding the whole system and how to apply it in a standardised way in clinical settings and research. I find that the concepts are clear, and well illustrated by good use of case vignettes. Axis I on the experience of illness and prerequisites for treatment coincides with our concept of psychological- mindedness, but is not limited to it. It also includes motivation for change, secondary gain issues, and the strengths and resources that patients bring to treatment, which appear to go beyond the conventional emphasis on psychodynamics.

Axis II on interpersonal relationships includes the interpersonal presentation of intra-psychic conflicts and structures, which are very much related to transference and counter-transference, the observation and assessment of which can now be documented in a more standardised way. Axis III on conflict and Axis IV on structure offer a very useful distinction between the 2 constructs, which helps very much with the selection of therapeutic stances, foci and techniques. With a low level of integration of structure, meaning, in our conventional terms, patients with more severe personality problems, the distinct occurrence of unconscious conflict, such as submission versus control, or need for care versus self-sufficiency becomes unclear, so the selection of these conflicts as treatment foci becomes unrewarding. As a whole, I found these 2 chapters very educational and especially useful for clarification of some psychodynamic concepts, constructs and word confusions that we sometimes encounter.

Chapter 5 is very practical as it describes the principles of an OPD interview and how you can do it in different phases. Chapter 6 gives longer case vignettes for further illustration of the process of case evaluation and documentation. It allows us to have a better view of the whole picture of the assessment of a clinical case.

Chapter 7 had the greatest impact on me. It is on focus selection and treatment planning, and clearly illustrates the principles behind and, most importantly, examines the relative importance of conflict-based or structure-based limitations on patients. This helps direct our adaptation of techniques in accordance with the structural possibilities of the patients, avoiding detours or false starts which can be very frustrating for both patients and their therapists.

Chapter 8 describes OPD-based change measurement and its clinical application. Chapter 9 tells how OPD-2 can be applied to different areas such as expert assessment, inpatient treatment, rehabilitation, training and the giving of expert opinion. It can also help provide quality assurance in psychotherapy. Subsequent chapters give detailed descriptions of ways to seek systematic training covering the application of OPD. One of the final chapters gives details of the tools needed to work effectively with OPD, including different checklists for assessment of conflict and structure and interview tools for the different axes.

I find this book very informative, educational, and practical because it offers us ways to enhance our clinical work and research as therapists. The inclusion of more psychodynamic or psychotherapeutic dimensions into our clinical practices is something we must do in order to face the diversity of mental disorders and individual differences we encounter in this era. I appreciate the great effort the task force has put into this project, which is a difficult one, and the results show their deep commitment.

Although valuable, this book is not easy to read or understand, especially for beginners in the field of psychodynamics or psychotherapy. The initial target audience was experienced therapists who already have a high level of knowledge and skills in the areas under discussion, so there is little detailed explanation of the concepts involved, or teaching of the skills needed for its application. Apart from this, the discussion of intervention is limited only to the planning, with no attempt to deal with the actual intervention process and likely obstacles.

Despite this, I highly recommend this book to all psychodynamically oriented therapists and psychiatrists, and also to trainees who are interested in learning more comprehensive psychodynamic formulation to enhance their capacity and enable them to develop into competent psychotherapists.

TSF Chan, FHKCPsych, FHKAM (Psychiatry) Department of Psychiatry
Tai Po Hospital
Tai Po
Hong Kong SAR, China

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