Operationalized Psychodynamic Diagnosis and OPD-guided focal treatment

1. Introduction

Version followed: OPD-2 (Arbeitskreis OPD 2006; English edition OPD Task Force 2008) is the operational base. OPD-3 (Arbeitskreis OPD 2023; revised 2nd edition 2024 edited with Cord Benecke; Hogrefe lists the English OPD-3 as forthcoming) is flagged as “OPD-3” wherever a documented change applies. [source: Hogrefe OPD-3 pages; Cierpka 2010; Thieme 2025]

What it is. OPD (Operationalized Psychodynamic Diagnosis) is a multiaxial psychodynamic system for diagnosis and treatment planning. It was developed from the early 1990s by the German-speaking OPD Task Force (Arbeitskreis OPD) of psychoanalysts, psychosomatic physicians and psychiatrists. It is mainly a diagnostic and case-formulation framework, not a manualised therapy. A semi-structured interview of about 1–2 hours is rated on these axes:

OPD-2 (five axes): I. illness experience and prerequisites for treatment; II. interpersonal relations; III. conflict; IV. structure; V. mental and psychosomatic disorders (ICD).
OPD-3 (four axes): mental disorders are folded into Axis I (“mental disorders, illness experience and prerequisites for treatment”). All axes are made more dimensional, and conflicts are rated at every level of structural integration.

From the ratings, the clinician chooses a small set of foci: a relationship focus, plus conflict and structure foci. Change in each focus is tracked with the Heidelberg Structural Change Scale (HSCS). [source: Cierpka et al. 2007; Cierpka 2010; ÖAGG OPD-3 curriculum; Thieme 2025]

How change happens. OPD assumes that a few psychodynamic problem areas cause and maintain the symptoms: a dysfunctional relationship pattern, repetitive unconscious conflicts, and structural vulnerabilities (limits in self- and object-related functions). Change means the patient progressively integrates these focal areas. Patients move from not perceiving the problem, through acknowledging and exploring it, to restructuring it; losing symptoms is not enough on its own. [source: Rudolf, Grande & Oberbracht 2000; Grande et al. 2004 as quoted in Dagnino 2012; Huemmeler]

Technique depends on the kind of problem. A conflict is a motivated compromise and is uncovered and interpreted. A structural limitation is a real incapacity and is acknowledged and built up. [source: Grande 2007]

Section 4 therefore covers two things. It covers (a) the OPD interview, rating and planning procedures, at training level without reproducing checklists. It also covers (b) the treatment principles that OPD authors attach to foci, chiefly Grande 2007 and Rudolf's structure-related psychotherapy. Anything beyond these is marked [synthesis]. Reliable rating requires certified training: a basic course plus advanced video-rating courses and an exam. [source: ÖAGG curriculum]

2. Framework

OPD prescribes no fixed session count or therapy length. It has been used in long-term outpatient analytic therapy (the Heidelberg “Praxisstudie Analytische Langzeittherapie”), in inpatient psychosomatic units, and in planning shorter focal therapies. The stages below form the OPD-guided sequence; the timings are typical, not mandated. [source: Cierpka et al. 2007; OPD-2 Leseprobe] [uncertain: no single primary text gives a stage-by-stage protocol; sequence assembled from the sources cited]

Stage 1 — OPD interview (1–2 sessions, about 60–120 min in total).

Goal: gather material for every axis and observe the relationship pattern as it happens in the room.
Format: semi-structured. The interviewer moves flexibly between open psychodynamic exploration and structured inquiry. Video recording is standard in training and research.
Move on when: you have (a) several concrete relationship episodes; (b) self- and object-experience across life areas (partner, family of origin, work, possessions, body and sexuality, illness); (c) the patient's illness concepts and motivation; (d) a symptom picture good enough for a syndromal diagnosis.
[source: Cierpka et al. 2007; Cierpka 2010; Portuguese OPD-2 review (redalyc)]

Stage 2 — Rating (outside the session).

Goal: operationalised profiles. These are: the Axis I ratings; Axis II items for each perspective plus a relationship-dynamic formulation; Axis III conflicts with their significance and mode (main conflicts ranked); Axis IV levels per structural dimension plus an overall level; and the ICD diagnosis (Axis V in OPD-2, inside Axis I in OPD-3).
Move on when: every axis is rated, or explicitly marked “not assessable”, and the main conflicts and overall structural level are fixed.
[source: Cierpka 2010; Cierpka et al. 2007]

Stage 3 — Case formulation, indication and focus selection.

Goal: choose up to about five foci: always one relationship focus, plus at least one conflict focus and at least one structure focus. Then classify the basic approach as conflict-oriented, structure-oriented or mixed.
Indication decisions: readiness and motivation (Axis I: stabilise or prepare first if needed); inpatient vs outpatient; supportive-structural vs interpretive-uncovering technique (Axis IV).
Move on when: each focus is formulated in plain language and plausibly linked to the onset or maintenance of the symptoms.
[source: Cierpka 2010; Cierpka et al. 2007; Dagnino 2012]
The number of foci varies between sources: about five (Cierpka; Grande, Rudolf & Oberbracht 2000, cited in Dagnino) vs three or four (Portuguese review). [uncertain]

Stage 4 — Feedback and agreeing foci with the patient (about 1 session).

Goal: set the foci jointly at the start of treatment, and rate the baseline HSCS level for each focus.
Move on when: the patient recognises at least part of each focus as their own, or the unrecognised part is itself noted as the focus problem.
[source: Cierpka et al. 2007; Dagnino 2012; de la Parra & Vanegas-Osorio]

Stage 5 — Focus-oriented treatment.

Goal: move each focus up the HSCS using technique matched to its type (Section 4B).
Length: set by setting and indication. In the long-term outpatient research, OPD interviews and HSCS ratings were repeated at 80, 160 and 240 sessions. [source: Huemmeler]
Revise foci when: new material shows a more central pattern, or a focus has been worked through. [source: Dagnino 2012]

Stage 6 — Re-assessment and ending.

Goal: document the HSCS level per focus, repeat the OPD interview or questionnaires, and plan termination.
End when: the central foci have reached restructuring levels. One German long-term study treats HSCS level 5 as a critical threshold (“magische Grenze 5”). [source: Lehmanns TOC] [uncertain: threshold as a termination criterion is inferred; the OPD manuals do not set an ending rule]

3. Guiding principles

Multiaxial complement, not replacement. Make the ICD diagnosis too; the psychodynamic axes add to it and do not replace it. [source: Cierpka 2010; buffl summary]
Operationalise; minimise inference. Rate from observable descriptions with defined anchors, and keep your theory out of the rating. [source: Cierpka et al. 2007]
Dimensional rating (strengthened in OPD-3). Rate the severity of each conflict and the level of each structural function, rather than present/absent. [source: Hogrefe OPD-3]
Conflict and structure are distinct and both present. For every problem area, ask whether the structure is basically intact (so conflict is the focus) or fragile (so the conflict is mainly the occasion where the deficit shows). [source: Grande 2007]
Rate conflicts at all structural levels (OPD-3). Do not skip conflict diagnosis for severely impaired patients. [source: Thieme 2025]
Do not attribute intent to incapacity. Treating structural deficits as defensive manoeuvres overburdens patients and can lead the therapist to see them as malicious. [source: Grande 2007]
A relationship focus is always included. The dysfunctional relationship pattern is where the problems will show in therapy, so plan for it from the start. [source: Cierpka 2010; Dagnino 2012]
Foci must be causally relevant. Choose an area only if it plausibly produces or maintains the symptoms. [source: Dagnino 2012]
Foci are joint and emerge from the patient's material. Formulate them in the patient's terms and agree them with the patient; the focus “is not something external”. [source: de la Parra & Vanegas-Osorio; Cierpka et al. 2007]
Few foci. Use about five at most, so that both you and the patient can keep them in mind. [source: Cierpka et al. 2007]
Countertransference is data, but only shared countertransference. Use the reactions that other people would probably also have towards this patient, not idiosyncratic ones. [source: Grande 2007]
Axis I comes first for indication. Match the offer to the patient's illness concepts and motivation; prepare or stabilise before uncovering work. [source: OPD-2 Leseprobe; Cierpka 2010]
Structural level selects the technique. Higher integration favours interpretive, conflict-focused work; lower integration favours supportive, structure-focused work. [source: Cierpka et al. 2007; OPD-2 Leseprobe]
Change is measured per focus. Track HSCS movement on each focus as well as symptom checklists. [source: Rudolf, Grande & Oberbracht 2000; Huemmeler]
In teams, one shared formulation. On wards, a shared relationship-dynamic focus aligns staff behaviour and prevents split enactments. [source: Cierpka et al. 2007; Cierpka 2010]
Train before you rate. Reliability depends on rater training, the quality of the material and clinical experience. [source: OPD-2 Leseprobe; ÖAGG curriculum]

4. Intervention inventory

Part A covers the OPD diagnostic and planning procedures (items 1–16). Part B covers the focus-oriented treatment interventions OPD authors describe (items 17–26). The official OPD-2/OPD-3 interview guide, item lists, checklists and the HSCS manual are paraphrased here, not reproduced; consult the manuals for the anchors. Example language is illustrative unless quoted.

A1. Conducting the OPD interview (overall technique)

Purpose: to gather, in about 1–2 hours, enough material to rate every axis. Both what the patient says and how they relate to you count as data. [source: Cierpka et al. 2007; Cierpka 2010]
Steps:
1. Start open: let the patient structure the opening so you can see how they organise themselves and the contact.
2. Move through the content areas (A2–A6) while following the patient's associations.
3. When an axis lacks data, switch to targeted, concrete questions. Then return to open listening.
4. Keep noting your own reactions, impulses and fantasies (A7).
5. Close by summarising and checking the patient's state.
Phases: secondary teaching summaries describe these phases: opening (current distress and illness experience), relationship episodes, self- and object-experience and life design, motivation and prerequisites for therapy, and symptom diagnosis. The OPD-2 handbook literature has a chapter on “the phases of the OPD interview”. [uncertain: phase names from a student summary (buffl) and a table of contents (Lehmanns), not from the manual text]
Example language (illustrative): “I'd like first to hear in your own words what brings you here.” … “We have about an hour; at times I'll ask quite specific questions so I get a full picture.”
Watch for: staying too structured (you lose the transference data) or too open (you can't rate structure or Axis I). It is working if at the end you can tell at least three concrete interpersonal scenes and describe the patient's self-experience.

A2. Opening phase: complaints and illness experience

Purpose: collect Axis I material (how the patient experiences, presents and explains the illness) and see how they introduce themselves. [source: Cierpka 2010]
Steps:
1. Invite a free account of the complaints.
2. Ask about onset, duration and the life situation at onset (triggers and conflict-like strain).
3. Explore the patient's own explanation of the illness (psychological, somatic or social) and what kind of help they expect.
4. Note how they present the problem: physical, psychological or social complaints.
Example language (illustrative): “What do you think the illness has to do with? … What would help, in your view?”
Watch for: a gap between what the patient expects (e.g. a purely somatic fix) and what you are offering. That gap is an Axis I finding, not something to correct immediately.

A3. Eliciting relationship episodes

Purpose: gather concrete interactions for Axis II and the conflict themes for Axis III. [source: Cierpka 2010; Grande 2007]
Steps:
1. Ask for specific, recent scenes with important others (partner, family, work, friends), not generalisations.
2. For each scene, get: what the other did, what the patient felt and did, how the other reacted, and how it ended.
3. Look for repetition across scenes and life areas.
4. Ask what the patient wished for in the scene.
Example language (illustrative): “Can you tell me about a recent time it went like that with your partner — what exactly happened? … And what did you do then? … How did they respond?”
Watch for: summaries with no scene (ask for one example). Note that patients describe others' actions and their own reactions, but rarely their own contribution: that is the blind spot the formulation will capture. [source: Grande 2007]

A4. Exploring self-experience, object-experience and life areas

Purpose: gather material for structure (Axis IV) and conflict (Axis III) across life areas. [source: Cierpka 2010; de la Parra & Vanegas-Osorio]
Steps:
1. Ask the patient to describe themselves and an important other person. Listen for differentiation, coherence and realism.
2. Explore how they handle strong feelings, impulses, self-esteem dips, closeness and separation.
3. Go through the life areas (family of origin, partnership, work, possessions and money, body and sexuality, illness) for recurring themes and active vs passive handling.
4. Note identity and values, and the use of fantasy and inner dialogue.
Example language (illustrative): “How would you describe yourself to someone who doesn't know you? … And your mother — what kind of person is she?” … “When you get very angry, what happens inside you, and what do you do with it?”
Watch for: thin, contradictory or merged descriptions of self and others (a structural sign) as against rich descriptions organised around one theme (a conflict sign). Do not push affect hard in patients who are flooding.

A5. Assessing treatment prerequisites (Axis I, psychotherapy module)

Purpose: judge readiness, wishes about treatment, openness to psychotherapy, resources, and internal and external obstacles, including secondary gain from the illness. [source: Cierpka 2010]
Steps:
1. Ask what the patient expects from treatment and from you.
2. Explore past treatment experience.
3. Ask about supports and practical barriers.
4. Gently explore what might be lost if the symptoms went.
Example language (illustrative): “What would be different if this were better? … Is there anything that would also get harder?”
Watch for: low motivation or a purely somatic illness concept. These call for a preparatory phase (B10), not exclusion.

A6. Symptom and syndrome assessment

Purpose: an ICD diagnosis (OPD-2 Axis V; part of Axis I in OPD-3), including the personality disorder category where it applies. [source: Cierpka 2010; ÖAGG curriculum]
Steps: systematically screen the main symptom areas, including risk. Use standard diagnostic criteria and your service's structured risk assessment for suicidality or self-harm.
Watch for: leaving this until the very end, when time is short. Schedule a second appointment if needed.

A7. Diagnostic use of countertransference

Purpose: to fill in the perspective the patient cannot report: their unconscious relational “offer” and the reaction it tends to draw from others. [source: Grande 2007; Cierpka 2010]
Steps:
1. During the interview, register how the patient treats you, how you experience yourself in response, and which impulses arise (e.g. to console, to withdraw, to argue).
2. Afterwards, sort the reactions that others would probably share from those that are your own.
3. Use only the shared ones in Axis II.
Example language: internal, not spoken.
Watch for: idiosyncratic reactions entering the rating. Check them in supervision or video review.

A8. Rating Axis I (illness experience and prerequisites)

Purpose: a profile of severity, suffering, illness presentation, illness concepts, change concepts, resources and obstacles. [source: Cierpka 2010]
Steps:
1. Rate each item of the basic module on the 0–4 scale, using 9 when it cannot be assessed (OPD-2 basic module: 19 items).
2. Add the psychotherapy module if psychotherapy is being considered.
3. Check each rating against the glossary anchors.
Watch for: confusing the patient's suffering with your judgement of severity. Rate them separately.
OPD-3: Axis I also holds the disorder diagnosis and is more dimensional. [source: Hogrefe OPD-3; ÖAGG] [uncertain: item-level changes in OPD-3]

A9. Rating Axis II and writing the relationship-dynamic formulation

Purpose: turn the episodes into a recurring dysfunctional pattern, which becomes the relationship focus. [source: Grande 2007; Cierpka 2010]
Steps:
1. Using the OPD item lists (based on the interpersonal circumplex of affiliation and control), choose up to three items per perspective. The perspectives are: how the patient experiences others; how the patient experiences themselves in reaction; how others (and you) experience the patient, i.e. the patient's “offer”; and how others (and you) react.
2. Write the formulation as a closed circle:
  - (I) the patient repeatedly experiences others as doing X and feels compelled to react with Y;
  - (II) others experience this reaction as an offer Z that draws them in, and the patient barely sees their own active part;
  - (III) the offer provokes reactions W in others and in the interviewer;
  - (IV) check whether the patient would experience W just as they experience others. If so, the circle closes and is self-perpetuating.
3. Phrase it so the patient could recognise it.
4. [source: Grande 2007; Cierpka 2010] [uncertain: the OPD-2 item list is reported as 30 indicators in OPD-1 sources; the OPD-2/OPD-3 count was not verified]
Example formulation (illustrative): “She experiences others as ignoring her needs and feels she must adapt and ask for nothing; others experience her as undemanding and easy to overlook, and do overlook her; she then feels confirmed in being disregarded and becomes bitter.” (modelled on Grande 2007's first case type)
Watch for: a formulation that only blames others (step II is missing) or that only accuses the patient (no empathy for their position). It is working when you can predict how the pattern will show up with you.

A10. Rating Axis III (conflict)

Purpose: identify the repetitive, life-shaping unconscious conflicts and how the patient handles them. [source: Cierpka et al. 2007; Cierpka 2010]
Steps:
1. Rate each of the seven conflicts dimensionally, from not present to very significant: individuation vs dependency; submission vs control; desire for care vs self-sufficiency; self-worth; guilt; oedipal; identity.
2. Rank the main conflict(s). OPD-1/OPD-2 sources say two; one review says three. [uncertain]
3. Rate the processing mode: predominantly active, predominantly passive, or mixed.
4. Separately rate “limited perception of conflicts and feelings” (defended perception). A student summary describes this as K0 and as new in OPD-3. [uncertain: it already appears in OPD-1/OPD-2 sources]
5. Separately record conflict-like stress caused by current events (conflictual strain), which is not a lifelong conflict.
6. Use the guiding affects as aids: e.g. anger for submission vs control, shame for self-worth, guilt for the guilt conflict. [source: de la Parra & Vanegas-Osorio]
7. OPD-3: rate conflicts at every structural level, including low integration. [source: Thieme 2025]
Watch for: reading a structural deficit as an active conflict mode, and scattering ratings across many conflicts. Look for one or two that organise several life areas.

A11. Rating Axis IV (structure)

Purpose: a profile of the capacities for self- and object-related regulation that determines technique and setting. [source: de la Parra & Vanegas-Osorio; Portuguese OPD-2 review]
Steps:
1. Rate the eight OPD-2 sub-dimensions: self-perception and object perception; self-regulation and regulation of relationships; internal communication and communication with the outside world; attachment to internal objects and to external objects. OPD-1 used six categories, including defence.
2. Rate each on the four levels (high 1, moderate 2, low 3, disintegrated 4), with half steps.
3. Derive an overall level.
4. Mark the most impaired sub-dimensions as candidate structure foci.
Watch for: rating structure from one crisis scene. Base it on the habitual level across situations.
OPD-3: structure is rated more dimensionally. [uncertain: other OPD-3 structure changes]

A12. Integrating conflict and structure

Purpose: decide which perspective leads for each problem area, because this sets the stance. [source: Grande 2007; Thieme 2025]
Steps:
1. Take each key phenomenon (e.g. emotional flooding, self-esteem collapse, breakdown in communication) and ask: is the structure basically intact, so that a conflict is driving this? Or is it fragile, so that the conflict is only the occasion on which a deficit shows?
2. Classify the relationship pattern by one of Grande's four relational principles (B1–B7 below).
3. Record the overall approach as conflict-, structure-oriented or mixed.
Watch for: defaulting to conflict interpretation with low-integrated patients, or to support alone with well-integrated ones.

A13. Focus selection and case formulation

Purpose: choose the few areas that therapy must change. [source: Cierpka 2010; Cierpka et al. 2007; Dagnino 2012]
Steps:
1. Write the relationship focus from A9.
2. Add the most prominent conflict(s) with their mode and the most impaired structural dimension(s).
3. Test each focus: does it plausibly maintain the symptoms?
4. Keep to about five foci.
5. Weight conflict vs structure foci by the overall structural level.
6. Write a short narrative formulation linking the foci to the history and symptoms.
Example (structure modelled on Cierpka 2010): relationship focus: repeated abandonment and self-devaluation leading to over-adaptation; conflict foci: desire for care vs self-sufficiency, plus self-worth; structure focus: affect flooding and self-regulation.
Watch for: foci phrased in jargon, or more foci than you can track.

A14. Feedback and agreeing the foci with the patient

Purpose: make the foci joint working hypotheses. [source: Cierpka et al. 2007; Dagnino 2012]
Steps:
1. Translate each focus into everyday language anchored in the patient's own episodes.
2. Present it tentatively and ask for correction.
3. Agree goals per focus.
4. Keep defended parts as hypotheses to return to.
Example language (illustrative): “From what you told me, there's a pattern: you sense people will leave, so you make yourself very easy to be with — and then you feel invisible. Does that fit?”
Watch for: compliance without recognition. Note how the patient handles the feedback, because that is often the relationship pattern itself.

A15. Rating and monitoring foci with the HSCS

Purpose: measure change per focus with finer steps than “changed / not changed”. The scale was modelled on Stiles' assimilation scale (APES) and grounded in a psychoanalytic process model. [source: Rudolf, Grande & Oberbracht 2000; Cierpka 2010]
Steps:
1. At baseline and at set intervals, rate each focus on the seven-level scale. Paraphrased, the levels are:
  1. the focus problem is not perceived;
  2. unwanted preoccupation, where the problem forces itself on the patient;
  3. vague perception of the focus;
  4. acknowledgement and exploration of the focus;
  5. old structures in the focus area dissolve;
  6. reorganisation in the focus area;
  7. the focus is resolved or integrated.
2. Use intermediate steps where the manual allows.
3. Base ratings on interview material or session process, ideally with a second rater.
4. [uncertain: level wording recalled from Grande and colleagues' publications; the HSCS manual (appendix in the OPD-2 literature) is not drawn on]
Example language: the rating is not spoken. A clinical check could be (illustrative): “When this happens now, how do you notice it?”
Watch for: symptoms improving while the focus is stuck at 1–3 (fragile change), and temporary crises around level 5, which can belong to restructuring. [source: Lehmanns TOC on crises in restructuring]

A16. Re-assessment: repeat interview and self-report adjuncts

Purpose: check foci and structural change over time. [source: Huemmeler; Thieme 2025]
Steps:
1. Repeat the OPD interview at planned points (research schedules used about every 80 sessions in long-term therapy).
2. Re-rate HSCS and axes.
3. Optionally add the OPD Structure Questionnaire and the OPD Conflict Questionnaire (self-report instruments developed from OPD) to screen or track.
4. Revise foci with the patient.
Watch for: treating questionnaire scores as replacements for interview-based ratings. [synthesis]

Part B — Focus-oriented treatment interventions. Grande (2007) links each type of relationship problem to a central patient intention and a main therapeutic strategy. There are four relational principles: conflict mode (B1–B2), structural incapacity (B3–B5), protection of vulnerability (B6) and secondary offensive coping (B7). Mixed presentations are the norm, so combine the items to fit. Rudolf's structure-related psychotherapy (Rudolf 2004/2006) is the authors' reference manual for structure foci. [uncertain: Rudolf's manual is not drawn on; B3–B5 rely on Grande 2007's account]

B1. From defence to motive: interpretive conflict work (conflict mode)

Purpose: for conflict foci where structure is basically intact (Grande's “conflict mode”). The pattern is a compromise between contradictory wishes aimed at the other person, who is both hoped for and disappointing. [source: Grande 2007]
Steps:
1. Start at the defence: point out the protective behaviour visible in the session.
2. Clarify its function: what it prevents the patient from feeling or risking.
3. Move towards the defended wish and fear.
4. Interpret the link to the relationship focus and the conflict (e.g. desire for care vs self-sufficiency, passive mode).
5. Let the affect build. Return to the theme across sessions.
Example language (illustrative): “You said you didn't mind at all that he forgot — very quickly. I wonder whether not minding protects you from how much you wanted him to remember.”
Watch for: intellectual agreement with no affect (go back to the defence) and flooding (consider whether structure is weaker than rated). It is working when the patient brings their own examples, feels the conflicting wishes, and starts to see their active part (the HSCS moves from 3 to 4 and above). The goal is that the patient becomes the “director” of a drama that until now has only happened to them. [source: Grande 2007]

B2. Working the conflict in the here-and-now relationship

Purpose: use moments when the conflict is enacted with you. These are the most valuable moments in conflict-mode work. [source: Grande 2007]
Steps:
1. Allow yourself to be cast in the role the patient's pattern assigns, without acting it out fully.
2. Notice the moment (often signalled by your countertransference matching step III of the formulation).
3. Name the interaction between you, then link it to the relationship focus.
4. Explore what the patient expected from you.
Example language (illustrative): “Just now I moved on to my question and you went quiet and agreed. I think something like what happens with your colleagues may have happened here — did you feel I wasn't interested?”
Watch for: shame or feeling accused. Frame it as a shared discovery. Do not use this with patients for whom mobilising affect leads to overwhelm (B3–B6).

B3. Mirroring and confronting structural incapacity

Purpose: for structural foci where object-related functions are impaired, such as object perception, regulating relationships and communication. There is no hidden intention: the difficulties “happen” to the patient. [source: Grande 2007]
Steps:
1. Treat the deficit itself as the problem; do not look for a hidden motive.
2. Mirror back concretely how the patient's behaviour or words land on others, including on you.
3. Confront tactfully when perception of others is distorted, contrasting it with other possible readings.
4. Avoid techniques that mobilise affect.
Example language (illustrative): “When you said that, I noticed I felt pushed away. I don't think you meant that. Could others be reacting to that tone rather than to you?”
Watch for: the patient hearing confrontation as an attack. Reduce the intensity and add support (B5). It is working when the patient starts to anticipate others' reactions.

B4. Stepping back after relational “accidents”

Purpose: turn breakdowns into practice in observing. Grande describes this as helping the patient move from the stage to the audience. [source: Grande 2007]
Steps:
1. When an incident happens (a blow-up at work or in the session), first settle arousal.
2. Reconstruct the sequence slowly and concretely: trigger, perception, feeling, impulse, action, consequence.
3. Identify the point where the regulation failed.
4. Consider together what else could have been done.
Example language (illustrative): “Let's slow it down and look at it like a film. What was the first moment you noticed something changing in you?”
Watch for: re-flooding while recounting (slow down further) and blaming loops. It is working when the patient starts the reconstruction themselves.

B5. Supportive, parental functions for self-observation, self-care and self-regulation

Purpose: for structural foci in self-related functions, such as self-perception, affect differentiation, self-regulation and self-esteem regulation. Temporarily take over a function and gradually hand it back. [source: Grande 2007; Cierpka et al. 2007 on Rudolf] [uncertain: specific Rudolf techniques]
Steps:
1. Help name and differentiate feelings and body states.
2. Model self-observation aloud.
3. Support self-care (sleep, limits, help-seeking).
4. Work out alternative ways to regulate.
5. Reduce your input as the patient's own capacity grows.
Example language (illustrative): “It sounds like there was something between anger and disappointment — which was stronger?” … “What could you do for yourself on an evening like that?”
Watch for: dependency on your regulation (plan the handover) and you sliding into advice-giving that bypasses the patient's own perception. [synthesis]

B6. Protecting vulnerability: an accompanying, co-regulating stance

Purpose: for patients whose distancing, controlling or devaluing protects a fragile self from being overwhelmed by closeness. [source: Grande 2007]
Steps:
1. Read the behaviour as protection, not attack.
2. Keep a steady, caring presence.
3. Calibrate closeness: warmth can increase the threat, while coolness confirms the fear.
4. Name the protective function gently.
5. Let the patient regulate distance and pacing.
Example language (illustrative): “It makes sense to keep some distance until you know what this is like. We can take it at your speed.”
Watch for: withdrawal after sessions that felt good. That is a sign the closeness was too much, not a failure. It is working when the patient tolerates more contact without increased defence.

B7. Secondary offensive coping: calibrated confrontation with the vulnerability in view

Purpose: for aggressive, devaluing or sexualised behaviour that mainly restores a threatened self but also gratifies. Grande calls this one of the most demanding constellations. [source: Grande 2007]
Steps:
1. Recognise your counter-impulse to defend or retaliate.
2. Recall the underlying powerlessness or fragility to regain empathy.
3. Set a clear limit on the behaviour.
4. Confront only at a strength the patient can bear.
5. Link the behaviour to the moment of threat that preceded it.
Example language (illustrative): “I'm not going to discuss my private life. I did notice this came right after we talked about your being let go — maybe that left you feeling small in here.”
Watch for: escalation if the confrontation shames the patient, and collusion if you avoid it. Boundary issues need supervision. It is working when the patient can name the threat that came before the offensive move.

B8. Not closing the circle: responding outside the expected pattern

Purpose: to prevent the therapy from confirming the dysfunctional relationship pattern. OPD authors warn that unaddressed relational complications can derail treatment. [source: Cierpka 2010; Cierpka et al. 2007] [synthesis: operationalising step IV of Grande's formulation as an in-session strategy]
Steps:
1. Keep the relationship-dynamic formulation at hand.
2. Before responding to a strong pull, ask whether your response would be what others do in step III.
3. Choose a response that is neither the expected one nor its opposite, and stays with the task.
4. Address the pattern explicitly when the patient can use it (B1/B2 or B3/B4).
Example language (illustrative): “I notice I'm being invited to tell you what to do. I'd rather we find out together what you think.”
Watch for: rigidity in avoiding every enactment. Some enactment is inevitable and useful when it is worked through.

B9. Team relationship-focus conference (inpatient or day-clinic)

Purpose: align a multiprofessional team's stance using one shared relationship-dynamic focus. An inpatient study found better interpersonal outcomes and shorter stays, though symptom outcomes were not better. [source: Cierpka et al. 2007; OPD-2 Leseprobe]
Steps:
1. Present the formulation in the team.
2. Collect each member's countertransference and the roles they have been cast in.
3. Agree how staff will respond to the typical offer.
4. Review it in later conferences.
Example language (illustrative, to the team): “He tends to make us into strict controllers. Let's agree that we keep the rules but explain them, rather than tightening or giving in.”
Watch for: staff splitting along the pattern's poles. That is itself confirmation of the focus.

B10. Axis I–guided preparation and motivation work

Purpose: when Axis I shows low readiness, a somatic illness concept or strong obstacles, prepare the patient before focal work. [source: OPD-2 Leseprobe; Cierpka et al. 2006 Spanish review] [synthesis: the specific steps]
Steps:
1. Start from the patient's own illness concept.
2. Link symptoms to concrete life situations the patient has described.
3. Offer a trial of exploratory sessions.
4. Address external obstacles and any secondary gain openly.
5. Re-rate Axis I before committing to the focal plan.
Example language (illustrative): “You've noticed the pain is worse after visits to your mother. Would you be willing to look at that with me for a few sessions and see if it helps?”
Watch for: pushing a psychological model too early (dropout). It is working when the patient brings in links of their own.

5. Handling problems

The OPD sources address problems mainly through the conflict/structure distinction and countertransference (Grande 2007). Most of the responses below are therefore marked [synthesis].

Stuck client (the HSCS focus stays at 1–3 for months).
- Re-check the focus: is it really maintaining the symptoms, and is it phrased in the patient's language? [source: Dagnino 2012 on revising foci]
- Re-check the perspective: a “conflict” that never moves may be a structural incapacity being interpreted as motive. Switch to B3–B5. [source: Grande 2007]
- Repeat the OPD interview, or use a second rater on the video. [synthesis]
Resistance to the formulation or foci.
- Treat the way the patient rejects the feedback as an instance of the relationship pattern, and reformulate jointly.
- Keep the defended part as a hypothesis and look for it in later episodes rather than insisting. [synthesis, following Grande 2007's defence-first principle]
Overwhelm or affect flooding during interview or treatment.
- Stop mobilising affect, move to observing and reconstruction (B4), and give more structure. [source: Grande 2007]
- In the interview, shift to structured, concrete questions and shorten the session. Finish risk assessment with the standard tools. [synthesis]
- Re-rate structure: flooding under mild pressure suggests a lower level than rated.
Non-adherence, missed sessions, dropout risk.
- Read missed sessions first against the relationship focus (e.g. withdrawal in a dependency/autonomy pattern), then against Axis I (low motivation, external obstacles). Discuss them openly. [synthesis]
- If Axis I readiness is low, go back to preparation (B10). [source: OPD-2 Leseprobe on readiness]
Ruptures.
- Expect them where the relationship formulation predicts. Use B2 if the patient is conflict-mode and well-integrated. Use B4 and B6 (repair, slow reconstruction, steady presence) if integration is low. [synthesis drawing on Grande 2007]
- Acknowledge your own part non-defensively. [synthesis]
Strong countertransference (urge to retaliate, rescue or withdraw).
- Sort shared from idiosyncratic reactions. A strong urge to fight back often signals being drawn into the patient's overwhelm or defence: step back and reflect before acting. [source: Grande 2007]
- With offensive coping, recall the underlying vulnerability to regain empathy (B7). [source: Grande 2007]
Patient sexualises or tests boundaries.
- Hold the boundary clearly and confront in calibrated doses, linking the behaviour to the preceding threat (B7). Seek supervision and document. [source: Grande 2007 case type 4; synthesis for documentation]
Mixed pictures: unsure whether a phenomenon is conflict or structure.
- Ask Grande's guiding question (is the structure basically intact?). If unclear, start structure-oriented, because it is safer, then test small interpretive steps and see whether the patient uses them or deteriorates. [source: Grande 2007; synthesis for “start structural”]
Severely impaired patient: is conflict work irrelevant?
- No: OPD-3 explicitly rates conflicts at all structural levels. Keep the conflict theme in the formulation even while technique stays structure-focused. [source: Thieme 2025]
Rating problems: unreliable or idiosyncratic ratings.
- Rate from video with a second trained rater, check against the manual anchors, and attend refresher or advanced courses. Reliability depends on training and the quality of the material. [source: OPD-2 Leseprobe; ÖAGG curriculum]
Interview time runs out or the material is thin.
- Schedule a second interview session. Mark unratable items rather than guessing. Note that very thin self- and object-descriptions are themselves structural data. [synthesis]
Patient wants only symptom relief or medication.
- Record this as an Axis I finding. Respect the patient's concept, offer a limited trial (B10), and coordinate with the medical treatment. [synthesis] (No drug dosing is covered here.)
Ward team split over the patient.
- Hold a relationship-focus conference (B9), and treat the split as a re-enactment of the pattern. [source: Cierpka et al. 2007]
Suicidality or self-harm emerging.
- Interrupt the focal plan, carry out a standard structured risk assessment and safety planning according to local protocols, and resume focal work only once risk is managed. [synthesis]
Version confusion (OPD-2 vs OPD-3 forms, ratings and training).
- State the version on every report. Do not mix OPD-2 and OPD-3 axis numbering: disorders are Axis V in OPD-2 and part of Axis I in OPD-3. [source: Cierpka 2010; ÖAGG OPD-3 curriculum]

Sources

Sources

Further reading (not drawn on in full)

Arbeitskreis OPD (Ed.) (2006). OPD-2 – Operationalisierte Psychodynamische Diagnostik: Das Manual für Diagnostik und Therapieplanung. Bern: Huber.
OPD Task Force (Ed.) (2008). Operationalized Psychodynamic Diagnosis OPD-2: Manual of Diagnosis and Treatment Planning. Cambridge, MA / Göttingen: Hogrefe & Huber.
Arbeitskreis OPD (Ed.) (2023; 2nd rev. ed. 2024 with C. Benecke). OPD-3 – Operationalisierte Psychodynamische Diagnostik: Das Manual für Diagnostik und Therapieplanung. Bern: Hogrefe.
OPD Task Force (Ed.) (2001). Operationalized Psychodynamic Diagnostics (OPD-1): Foundations and Manual. Seattle: Hogrefe & Huber.
Rudolf, G. (2004; later editions). Strukturbezogene Psychotherapie. Stuttgart: Schattauer.
Rudolf, G., Grande, T., & Oberbracht, C. (2000). Die Heidelberger Umstrukturierungsskala. Psychotherapeut, 45, 237–246.
Grande, T. (2007). Wie stellen sich Konflikt und Struktur in Beziehungen dar? Zeitschrift für Psychosomatische Medizin und Psychotherapie, 53, 144–162.
Cierpka, M., Grande, T., Rudolf, G., von der Tann, M., Stasch, M., & OPD Task Force (2007). The Operationalized Psychodynamic Diagnostics System. Psychopathology, 40, 209–220.
Grande, T., et al. (2009). Structural change as a predictor of long-term follow-up outcome. Psychotherapy Research, 19, 344–357. [uncertain: cited for HSCS level wording]
Stiles, W. B., et al. (1990s). Assimilation of Problematic Experiences Scale (APES). [uncertain: cited as the model for the HSCS]

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