The norwegian guidelines

Extract from the Norwegian Guidelines for Psychosis

The Norwegian Guidelines are unusual in that they have a section that clearly supports psychodynamic approaches to psychosis and justifies them on a number of grounds including their unsuitability for random controlled trials the usual basis for contemporary mental health guidelines.

Translation may be approximate


Psychodynamic treatment modalities can be used by educated health personnel to understand the experiences of patients with psychotic disorders.

After individual assessment adapted supportive psychodynamic psychotherapy, following phase-specific principles, can be offered in the nonpsychotic illness phases.


The term "psychodynamic" emphasizes the active interaction between the individual and the physical and psychological environment. Psychodynamic psychotherapy attends to the relationship between the individual and the environment as the primary focus area in the treatment process. The psychodynamic understanding therefore includes both knowledge of personal vulnerability and protective factors. Psychodynamic psychotherapy focuses on the ability to regulate emotions, understand vulnerable relational experiences and to provide insight into challenging relational patterns.

Psychodynamic therapies

Psychosis disorders were initially considered unsuitable for psychoanalytic oriented treatment (242; 243). In the 1940s, 50s and 60s psychodynamic treatment approaches were tried out, especially in the United States (244; 245), and they are also extensively used in modified form in our time (246). From this experience gained and further understanding of the complexity of the psychosis, the perspective has shifted from a treatment aimed at comprehensive personality change to a treatment more aimed at better coping with stress factors.

Patients with psychotic disorders have difficulties dealing with environments characterized by lack of structure and those with high emotional pressure. This has implications for the organization and scope of psychotherapeutic treatment. Modern psychodynamic psychotherapy for psychosis is anchored in a clear model, where the therapist presents him or herself in clear, actively participating manner and is supportive and open. The earlier techniques focussing mainly on the idea that interpretations of unconscious phantasy lead to change have been abandoned in favour of working with the individual’s vulnerable areas.

Ordinary or classical psychoanalytic approach is generally not recommended for people with psychotic disorders, because the unstructured format and mobilization of strong emotions can be stressful. Psychodynamic psychotherapy in psychosis will be psychodynamic based therapeutic conversations. The therapist must take into account the phase of psychosis disorder the patient is in, and know if the patient is psychotic or not.

In the psychodynamic approach it is important to establish a good working relationship both with patients and their families. The therapists must, based on psychodynamic theory, be able to handle negative reactions, transference reactions and their own feelings.

Psychodynamic based therapeutic conversations can be important when one follows a patient with psychosis in the overall treatment regimen, over time (247). Therapeutic meetings emphasize relationship building and try to help the patient to cope with stress better and relate to delusions in a better way. The therapist and patient should agree on what are the goals of the talks, and what is expected of both parties.

When the phase with active psychosis symptoms is over, the objective of the therapy is to prevent secondary complications such as those with relations with family, friends, school and / or work, and to reduce vulnerability to stress and work through the trauma of having been psychotic. If the patient is still psychotic, the objective is to build and maintain a cooperative relationship and help the patient to distinguish better between fantasy and reality (247).

Unlike cognitive models psychodynamic therapy has traditionally not had any defined length to the course of treatment, but has been adapted to the patient's individualisation process, symptoms and functioning. Psychodynamic psychotherapy is a treatment that is suitable in the work with ?? affect regulation and by focusing on vulnerable areas of the patient, areas that may be challenging in the relation to other people. In patients who are stable and in recovery psychodynamic psychotherapy can be useful for further assisting in integrating experiences and contribute to an improved sense of self as part of the recovery process.

There are few controlled randomized studies on psychoanalytic or psychodynamic psychotherapy in psychosis, mostly because the very character of these forms of therapy with its flexibility to the individual is unsuitable for this type of evaluation. (248).

Further reading

Freud S. On narcissism: an introduction [Zur Einfuhrung des Narzissmus]. part I of Joseph Sandler,Peter Fonagy,Ethel Spector, see google books

Freud S. The Unconscious. I: The standard edition of the complete psychological works of Sigmund Freud. Volume XIV, 1914-1916, On the history of the psychoanalytic movement, Papers on metapsychology and other works. London: Hogarth Press; 1957.See book on Amazon

Sullivan HS. The onset of schizophrenia. 1927. Am J Psychiatry 1994; 151(6 Suppl):134-9.see first page in annuals American Journal of Psychiatry 

Fromm-Reichmann F. Principles of intensive psychotherapy. Chicago: University of Chicago Press; 1960. See boo

Alanen YO. Vulnerability to schizophrenia and psychotherapeutic treatment ofschizophrenic patients: towards an integrated view. Psychiatry 1997;60(2):142-57. .see abstract

Rosenbaum B, Harder S, Knudsen P, Koster A, Lindhardt A, Lajer M, et al. Supportive psychodynamic psychotherapy versus treatment as usual for first episode psychosis: two-year outcome. Psychiatry 2012; 75(4):331-41.see full text article

Leichsenring F, Rabung S. Long-term psychodynamic psychotherapy in complex mental disorders: Update of a meta-analysis. Br J Psychiatry 2011;199(1):15-22 see full text article


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