Structure-related psychotherapy for structural deficits

1. Introduction

Version followed: Gerd Rudolf, Strukturbezogene Psychotherapie. Leitfaden zur psychodynamischen Therapie struktureller Störungen, 3rd ed. (Schattauer 2013), read through Rudolf's CME paper (Psychotherapeut 2012), his indication paper (2016) and his practice book Psychodynamisch denken – tiefenpsychologisch handeln (2019). Structural diagnosis follows OPD-2 (Arbeitskreis OPD 2006; English: OPD Task Force 2008).

Sourcing caveat. The 2013 book and the full 2012 and 2016 papers are not drawn on directly. The abstracts, publisher excerpts, book reviews and one dissertation summary are used. Anything below that is not tagged with a source comes from the published literature as I know it and is marked [uncertain]. Check those points against the 2013 book before relying on them.

What it is. Structure-related psychotherapy (SP; also translated "structure-oriented") is a psychodynamic treatment for patients whose main problem is not an unconscious conflict but structural deficits. These are capacities for self-regulation and relationship-building that never fully developed: perceiving oneself and others, regulating impulses, affect and self-worth, communicating emotionally, and forming and loosening attachments [source: Rudolf 2012 abstract; Rudolf 2002 abstract]. Rudolf calls it a Leitfaden, "aber eben kein Manual". It guides the therapist's stance; it is not a session-by-session protocol [source: Hauten, foreword to Rudolf 2019]. So the guide below describes a framework and the techniques its author describes. Session-level operationalisations that I add are marked [synthesis].

How change happens. The patient cannot be expected to produce associations, memories or self-reflection that they do not yet have. Interpreting unconscious meaning therefore has little effect, because the inner space (Binnenraum) needed for self-critical reflection is missing [source: Rudolf 2019 excerpt; Ploeger 2005 review]. Change instead comes from a developmentally promoting, "parental-like" relationship. In it, the therapist first actively stabilises the patient and temporarily lends missing functions (Hilfs-Ich-Funktion). The therapist and patient then look together at the disorder as a "third thing". The patient practises the missing capacities on concrete experience and step by step takes over responsibility for their own self-regulation [source: Rudolf 2012 abstract; Rudolf 2019 excerpt]. Change is actively accompanied. It is not expected to arise spontaneously from the relationship [source: Rudolf 2016 abstract].

2. Framework

Indication. Use SP when structural problems of self-regulation and relationship formation dominate the clinical picture, for example severe personality disorders [source: Rudolf 2012 abstract]. Pure conflict or pure structural pathology is rare, so most patients have mixed pictures [source: Rudolf 2019 excerpt]. In OPD-2 terms, SP is the main approach at moderate to low structural integration (mäßig to gering integriert). At good integration, conflict-centred work is the default [uncertain: exact level thresholds as stated in the 2013 book not verified].

OPD-2 structural map that defines the work [source: OPD-2 / OPD Task Force 2008; Cierpka et al. 2006]. There are four dimensions. Each has a self-directed side and an object-directed side, and each is rated gut / mäßig / gering integriert / desintegriert.

Perception: self-reflection, affect differentiation and identity; self-object differentiation and a whole, realistic perception of others.
Regulation: impulse control, affect tolerance and self-worth regulation; protecting relationships, balancing interests and anticipating others' reactions.
Emotional communication: inward (experiencing affects, using fantasies, body self) and outward (making contact, communicating affect, empathy).
Attachment: to internal objects (internalising, using introjects, holding variable attachments) and to external objects (capacity for attachment, accepting help, letting go).

[uncertain: the 1st and 2nd editions of Rudolf's book used the older six-dimension OPD-1 scheme. The 3rd edition is understood to follow OPD-2's four dimensions.]

Phases. Rudolf names opening, working-through and ending phases. He gives the ending phase specific treatment in SP [source: Rudolf 2019 table of contents, sections 3.9 and 4.10]. The core sequence is to stabilise first, then hand over responsibility [source: Rudolf 2012 abstract]. Treatment can move to conflict-centred work once structure is stable [source: Ploeger 2005 review].

Phase	Goals	Typical content	Move on when
1. Diagnosis and agreement	OPD structural assessment; agree on a structural focus and goal	Taking in the complaints, life and relationship history, structural rating, psychoeducation [source: Rudolf 2016 abstract; Rudolf 2023 table of contents]	The patient can name the focus in their own words and accepts the working frame [synthesis]
2. Active stabilisation	Safety, a reliable relationship, reduced chaos	Hilfs-Ich, crisis structuring, the therapist standing "behind" the patient [source: Rudolf 2012 abstract; Rudolf 2019 excerpt]	Crises become less frequent or less dangerous, and sessions can hold reflective work [synthesis]
3. Structural work at the focus	Build the specific missing capacities	Function-specific interventions (Section 4), joint look at the disorder as a third thing, answering stance	Focus change is observable, for example progress on the Heidelberg Restructuring Scale (below)
4. Handing over responsibility	The patient regulates and shapes life themselves	The therapist steps back and the patient plans and evaluates [source: Rudolf 2012 abstract]	The patient handles focus-type situations largely alone [synthesis]
5. Ending	Separation as structural work; consolidation	Working through the ending, internalising the therapist as a good object [source: Rudolf 2019 table of contents 4.10; Rudolf 2002 abstract names separation]	Planned end of treatment
(optional) Conflict work	Neurotic conflicts once structure is stable	Use of transference, regression and resistance [source: Ploeger 2005 review]	—

Format. Outpatient SP is usually delivered within German tiefenpsychologisch fundierte Psychotherapie (TP): sitting face to face, about one session a week. A focus matters particularly in time-limited TP [source: Rudolf 2016 abstract]. SP was also developed in Heidelberg inpatient psychosomatic settings, and the 2016 paper covers modifications for adolescents and older adults [source: Rudolf 2016 abstract]. [uncertain: typical session totals are not specified in the sources. German statutory TP contingents (short-term 12–24 sessions; long-term up to about 60–100) are the practical frame, and severe structural disorders usually use the long-term contingent.]

Tracking movement: Heidelberger Umstrukturierungsskala (HUSS). This is a 7-point rating of how far the patient has restructured around a focus. It was developed by Rudolf, Grande and Oberbracht (2000), modelled on Stiles' assimilation (APES) scale, and recommended for treatment planning and evaluation [source: Rudolf, Grande & Oberbracht 2000 abstract; Hümmeler dissertation p. 35]. Stage names as I know them are listed below [uncertain].

Focus not perceived.
Unwanted preoccupation with the focus.
Vague awareness of the focus.
Acknowledgement and exploration.
Dissolution of old patterns.
Restructuring.
Resolution of the focus.

In practice, phase 3 is usually reached around stages 3–4, and handover of responsibility fits stages 5–6 [synthesis].

3. Guiding principles

Structure before conflict. Stabilise and build capacities first. Conflict interpretation comes later, if at all. Practical meaning: do not interpret unconscious motives to a patient who cannot yet reflect on them [source: Ploeger 2005 review; Rudolf 2012 abstract].
Developmentally promoting, "parental-like" (beelternde) stance. The therapist offers what development lacked: interest, mirroring, structure and encouragement. Practical meaning: be warm, active and engaged, not abstinent and silent [source: Rudolf 2012 abstract].
Answering instead of interpreting (antwortende Interventionen). Rudolf adopts the Göttingen "Prinzip Antwort" (Heigl-Evers and Heigl). Practical meaning: respond as a real person with a selective, authentic reaction rather than a meaning-interpretation [source: Hümmeler p. 27; Hauten foreword in Rudolf 2019; Streeck & Leichsenring 2015 excerpt].
Auxiliary ego (Hilfs-Ich). Temporarily provide the missing function, such as naming the affect, slowing down or anticipating consequences, until the patient can do it alone. Practical meaning: lend the function, then gradually withdraw it [source: Rudolf 2019 excerpt].
Three positions: behind, opposite, beside (hinter, gegenüber, neben). Behind means backing and supporting the patient. Opposite means being a real, answering other. Beside means looking together at the disorder. Practical meaning: choose your position consciously in each sequence [source: Hauten foreword in Rudolf 2019; detailed rules for each position are in Rudolf 2019 §4.6, so uncertain].
The disorder as a "third". Patient and therapist form a "we" that examines the vulnerability together, which makes the situation triadic rather than dyadic. Practical meaning: talk about "this pattern" or "your vulnerability", not "you" [source: Hauten foreword in Rudolf 2019; Ploeger 2005 review on the "Wir"].
Work at an agreed structural focus. Pick the most relevant limited functions, formulate them in the patient's language, and agree on them together [source: Rudolf 2016 abstract; Hümmeler p. 22].
Don't demand what is missing. Do not expect free association, rich memories or insight from a patient who lacks them [source: Rudolf 2019 excerpt].
Diagnose deficits precisely, and use resources. Precise structural assessment is a precondition for activating resources, not a deficit-oriented attitude [source: Wöller & Kruse 2018 excerpt, endorsing Rudolf]. Practical meaning: name the strengths alongside the gaps.
Active accompaniment of change. Track progress and steer. Do not wait for the relationship to cure by itself [source: Rudolf 2016 abstract].
Limit regressive transference; step out of it when it becomes destructive. Practical meaning: when the patient casts you in a bad-object role, speak as yourself and turn back to the patient's experience rather than deepening the transference [uncertain: given in the version hint and consistent with Rudolf's structure-before-conflict logic, but not verified].
Stabilise, then hand over responsibility. Practical meaning: as capacities grow, return tasks and decisions to the patient [source: Rudolf 2012 abstract].
Here and now, concrete over abstract. Work on current, specific situations and affects rather than reconstructing early childhood [uncertain: standard in Rudolf's teaching as I know it; not verified].

4. Intervention inventory

The items below are the interventions and working areas named in the sources: the Hilfs-Ich, answering interventions, mirroring description, the three positions, the disorder as a third, the agreed focus, stabilisation then handover, the HUSS, and work on affect differentiation, impulse control, empathy, emotional expression, attachment and separation. They also include the remaining OPD-2 structural functions that Rudolf's book organises its techniques around. Step sequences and wording are illustrative operationalisations [synthesis] unless tagged otherwise. All example language is my own wording (illustrative).

4.1 OPD-based structural assessment

Purpose / when: At the start, and again at reviews. Determines whether to use SP and which functions to target [source: Rudolf 2016 abstract; Rudolf 2023 table of contents ch. 2–3; Cierpka et al. 2006].
Steps: (1) Let the patient present their complaints openly, and note your own countertransference as data on structure (Rudolf 2023 §3.2 heading). (2) Take the illness, relationship and social history. (3) Ask for 2–3 concrete recent relationship episodes. (4) Rate each OPD-2 dimension, self and object side, from how the patient tells the story and how they behave with you. (5) Weigh conflict against structure (Rudolf 2023 §3.7 heading) and decide whether the main approach is structural or conflict-centred.
Example language (illustrative): "Tell me about the last time you got really upset with someone. What happened, step by step?" "When that happened, what did you notice inside yourself?"
Watch for: Thin, global affect words ("bad", "stressed"). Others described as all-good or all-bad. Action instead of reflection. Your own sense of being pulled into roles. These suggest structural limitation.

4.2 Formulating and agreeing on the structural focus

Purpose / when: End of the assessment phase. Gives the time-limited work a target [source: Rudolf 2016 abstract; Hümmeler p. 22: a focus is the central problem knot that causes and maintains the disorder, drawn from the patient's own material].
Steps: (1) Pick 1–3 functions that are most limited and most relevant to the complaints. (2) Translate them into everyday language tied to the patient's own examples. (3) Offer the formulation tentatively and revise it with the patient. (4) Agree a concrete goal ("what would be different"). (5) Write it down and revisit it every 10–15 sessions [synthesis for intervals].
Example language (illustrative): "It seems that when you are hurt, the feeling floods you so fast that you act before you know what you feel. Shall we make that our main project: noticing the feeling earlier and finding more ways to deal with it?"
Watch for: Agreement that is only compliant. A focus phrased as blame ("you can't...") rather than as a vulnerability.

4.3 Psychoeducation about structure and vulnerability

Purpose / when: Early in treatment, and repeatedly after crises. Turns the disorder into a shared "third" and lessens shame [source: Hauten foreword in Rudolf 2019 on the disorder as third; Streeck & Leichsenring 2015 excerpt on Aufklärung in a related approach; Rudolf's own explicit psychoeducation procedure: uncertain].
Steps: (1) Explain that certain capacities develop through early relationships, and that if those conditions were lacking the capacities stay vulnerable. This is not a moral failing. (2) Link this to the patient's examples. (3) Present symptoms such as self-harm, binges or rage attacks as attempted solutions that cost too much [synthesis]. (4) Explain the plan: stabilise, then practise the capacities, then the patient takes over. (5) Check what the patient understood.
Example language (illustrative): "Some abilities, like calming yourself or sensing what you feel, are learned with others early in life. If that learning was disrupted, they stay fragile. That's not a weakness of character. It's something we can practise here."
Watch for: The patient hearing "damaged". Counter this by naming resources. Over-intellectual uptake without any experiential change.

4.4 Active stabilisation

Purpose / when: Phase 2, and whenever crises recur. Creates enough safety for structural work [source: Rudolf 2012 abstract].
Steps: (1) Prioritise safety and current life threats. Use standard suicide and risk assessment when indicated. (2) Structure chaotic material: "one thing at a time". (3) Agree on concrete steps for the coming days. (4) Make the frame reliable: times, availability, how crises are handled. (5) Reduce stimulation in session. Avoid deep regressive exploration of trauma while the patient is unstable [synthesis].
Example language (illustrative): "A lot is happening at once. Let's choose the one thing that matters most for this week and look at that."
Watch for: The patient leaving more organised than they arrived. Crisis contacts becoming less frequent or less intense.

4.5 Hilfs-Ich (auxiliary-ego) function

Purpose / when: Whenever the patient cannot perform a function themselves, such as naming a feeling, anticipating consequences, or slowing an impulse [source: Rudolf 2019 excerpt].
Steps: (1) Notice which function is missing in the moment. (2) Perform it out loud for the patient, offered as a suggestion. (3) Invite the patient to check it against their own experience. (4) Next time, wait longer and ask before supplying it. (5) Fade your help as the patient takes over [steps 3–5: synthesis].
Example language (illustrative): "If I imagine myself in that situation, I might feel humiliated. Does that fit, or is it something else?" Later: "What would you call that feeling now?"
Watch for: Too much help can create dependency. Too little can feel like abandonment. A sign it is working is the patient using your words, then their own.

4.6 Answering intervention (antwortende Intervention, after "Prinzip Antwort")

Purpose / when: Instead of an interpretation, especially when the patient acts on you rather than reflecting [source: Hümmeler p. 27; Hauten foreword in Rudolf 2019; origin Heigl-Evers & Heigl, Göttingen].
Steps: (1) Register your emotional reaction to what the patient just did. (2) Choose a selective part of it that is helpful for the patient to know. Don't unload. (3) Say it briefly as your own reaction ("I"). (4) Link it to the effect on relationships outside. (5) Ask how the patient experiences hearing it.
Example language (illustrative): "When you said that so sharply just now, I noticed I wanted to pull back. I wonder if people around you sometimes react like that, without you knowing why."
Watch for: The reaction must be authentic and dosed, not retaliatory. It is working if the patient becomes curious about their effect on others.

4.7 Mirroring description (spiegelnde Beschreibung)

Purpose / when: To make visible behaviour and affect that the patient does not perceive themselves. It works on implicit, non-reflected patterns [source: Hümmeler p. 28; Rudolf 2023 excerpt on mirroring as central to developing an "ich"].
Steps: (1) Describe observable behaviour or expression concretely and without judgement. (2) Add how it reaches you emotionally, if useful. (3) Invite the patient's perspective.
Example language (illustrative): "You're smiling while telling me this, and your voice got very quiet. What's happening in you right now?"
Watch for: Shame reactions. Soften with warmth. It is working if the patient begins to notice these things unprompted.

4.8 Taking the three positions (behind, opposite, beside)

Purpose / when: Choose your position deliberately [source: Hauten foreword in Rudolf 2019; the full treatment in Rudolf 2019 §4.6 is not drawn on, so position-specific rules are uncertain].
Steps: Behind: back the patient, validate their effort, support coping (stabilisation, crises). Opposite: be a distinct real person who answers, sets limits and offers a different perspective (answering interventions, limit-setting). Beside: look together at the pattern as a third and examine it jointly (focus work). Move between them as the moment requires: behind when overwhelmed, beside for reflection, opposite when an answer or limit is needed [synthesis].
Example language (illustrative): Behind: "You got through that week. That took a lot." Opposite: "I see it differently." Beside: "Let's look at this pattern together, as if it were on the table between us."
Watch for: Getting stuck in one position. Staying only behind becomes over-protective. Staying only opposite becomes confrontational.

4.9 The disorder as a "third" (joint look)

Purpose / when: Throughout the work at the focus. It protects the alliance and builds an observing stance [source: Hauten foreword in Rudolf 2019; Ploeger 2005 review on the "Wir"].
Steps: (1) Name the vulnerability as a pattern with its own name, ideally the patient's own term. (2) Talk about how "it" shows up, what triggers it and what it costs. (3) Ask the patient to observe it between sessions. (4) Review it together as co-researchers [steps 1, 3 and 4: synthesis].
Example language (illustrative): "So 'the switch' flipped again on Saturday. Let's look at how it happened this time."
Watch for: The patient using the name to disown responsibility ("the switch did it"). Pair it with the handover of responsibility (4.20).

4.10 Stepping out of the transference

Purpose / when: When the patient casts you in a hostile, persecuting or idealised role and the relationship starts to repeat old damage instead of developing [uncertain: named in the version hint and in Rudolf's teaching as I know it; not verified. It is consistent with the point that SP limits transference and regression until structure is stable, per Ploeger 2005].
Steps: (1) Notice the role you are being pushed into, using countertransference as the signal. (2) Don't act the role out, and don't deepen it with transference interpretations. (3) Speak as the real person you are, about what you actually intend. (4) Turn attention back to the patient's experience and its triggers outside the room. (5) If useful, place it beside you both as the focus pattern (4.9) [synthesis for the sequence].
Example language (illustrative): "You feel I'm judging you, like others have. I'm not, and I'd like to understand what made it feel that way just now. When else does this feeling come up?"
Watch for: Escalation if the step comes across as denial of the patient's feeling. Validate the feeling first. It is working if the tension drops and the patient becomes able to reflect.

4.11 Self-perception: affect differentiation and self-reflection

Purpose / when: When the patient's inner life is undifferentiated ("bad", "tense", "nothing") or reflection is absent [source: Rudolf 2002 abstract names affect differentiation; OPD-2 sub-functions].
Steps: (1) Slow down at an affect-laden moment. (2) Ask about body signals first, then the feeling. (3) Offer a choice of feeling words (Hilfs-Ich). (4) Distinguish blended affects, such as anger and shame. (5) Link the feeling to its trigger and to what the patient did next. (6) Build a coherent self-picture by asking what this says about what matters to the patient [identity; synthesis].
Example language (illustrative): "Before you slammed the door, what was going on in your body?" "Was it more anger, or more shame, or both?"
Watch for: Intellectualised labelling with no felt sense. It is working if the patient brings in feelings they noticed during the week.

4.12 Object perception: self-object differentiation and a realistic, whole picture of others

Purpose / when: When others are seen as all-good or all-bad, or when the patient's own feelings are taken as the other's intentions [source: OPD-2; Rudolf 2002 abstract names empathy].
Steps: (1) Separate what the other actually did from what the patient assumed. (2) Ask what the other might have felt or wanted (perspective-taking). (3) Collect contradictory information about the same person to build a more whole picture. (4) Contrast "my feeling" with "their intention".
Example language (illustrative): "What did she actually say, word for word? And what did you take it to mean?" "How might it have looked from her side?"
Watch for: Premature perspective-taking used to excuse abusers, or felt as invalidation. Validate the patient's experience first.

4.13 Self-regulation: impulse control and affect tolerance

Purpose / when: Impulsive acting-out, rage, self-harm, binges or flooding [source: Rudolf 2002 abstract names impulse control; OPD-2].
Steps: (1) Reconstruct the escalation sequence: trigger, feeling, impulse, action, aftermath (see 4.21). (2) Find the earliest point where it could have been interrupted. (3) Gather the patient's existing ways of calming down (resources). (4) Agree a concrete alternative for that point. (5) Review it next session without moralising [steps 3–5: synthesis].
Example language (illustrative): "Where along the way was there a moment, even a tiny one, when you could still have chosen something else?"
Watch for: Shame after relapses. Treat them as information. Signs it is working are longer gaps between impulse and action and lower intensity.

4.14 Self-regulation: self-worth regulation

Purpose / when: When the patient swings between grandiosity and collapse, or is extremely sensitive to slights [source: OPD-2 sub-function; specific Rudolf technique not verified, uncertain].
Steps: (1) Identify slight-and-collapse episodes. (2) Name the self-worth drop as part of the focus pattern. (3) Explore what restores self-worth now and what costs it has. (4) Build more stable sources of worth, such as competence and values. (5) Offer realistic acknowledgement in session [synthesis].
Example language (illustrative): "After his comment it was as if you were suddenly worth nothing. What helped you get back up?"
Watch for: Your praise being devalued or needed constantly. Keep acknowledgement specific and realistic.

4.15 Regulating relationships: protecting relationships, balancing interests, anticipating

Purpose / when: When relationships keep breaking, one's own needs are imposed or abandoned, or others' reactions aren't foreseen [source: OPD-2 sub-functions].
Steps: (1) Before a relevant encounter, rehearse together how the other is likely to react. (2) Look for options that serve both sides. (3) After a conflict, ask what could repair the relationship. (4) Review the outcome [synthesis].
Example language (illustrative): "If you tell him that tomorrow in those words, how do you think he'll react? Is there a way to say it so you still get what you need?"
Watch for: Rehearsal turning into you managing their life. Hand back the choices (4.20).

4.16 Inner communication: experiencing affects, using fantasy, body self

Purpose / when: Alexithymic or psychosomatic presentations, an inner emptiness, or a body treated as an object [source: OPD-2 sub-functions; psychosomatic focus in Rudolf 2023 ch. 5; specific techniques uncertain].
Steps: (1) Invite attention to bodily sensations in a neutral, curious way. (2) Connect sensations with situations. (3) Invite small imaginings ("what would you have liked to say?") to open an inner space. (4) Tolerate silence briefly, but don't leave the patient in empty silence [synthesis].
Example language (illustrative): "When you mention your sister, where in your body do you notice something?"
Watch for: Flooding when blocked affects open up. Return to stabilisation (4.4).

4.17 Outer communication: making contact, expressing affect, empathy

Purpose / when: The patient can't show or say what they feel, can't make contact, or misreads others' signals [source: Rudolf 2002 abstract names emotional expression and empathy; OPD-2].
Steps: (1) Use the therapy relationship as a practice field. Notice and acknowledge when the patient expresses something directly to you. (2) Explore how they show feelings outside and how others respond. (3) Rehearse wording. (4) Practise reading faces and tone through concrete episodes [synthesis].
Example language (illustrative): "You just told me plainly that you were disappointed with me. That's exactly what we've been working on. How was it to say it?"
Watch for: Over-disclosure after a long silence. Help the patient dose it.

4.18 Attachment to internal objects: internalising and using good introjects

Purpose / when: The patient cannot soothe themselves, feels alone with no inner support, or is dominated by harsh inner voices [source: OPD-2; Rudolf 2002 abstract names attachment; Rudolf 2023 §4.3.1 heading "Bindung, Struktur"].
Steps: (1) Explore whether there were ever good, supportive figures. (2) Invite the patient to remember or imagine them in difficult moments. (3) Notice when the patient is already using the therapist internally ("I thought about what you'd say"), and value that. (4) Address harsh inner voices: whose are they, and do they still fit? [synthesis]
Example language (illustrative): "When you were alone that night, was there anyone, now or in the past, whose voice could have helped?"
Watch for: Grief about what was missing. That is part of the process, not a failure.

4.19 Attachment to external objects: accepting help and letting go

Purpose / when: The patient cannot ask for or accept help, clings, or cannot end relationships [source: Rudolf 2002 abstract names attachment and separation; OPD-2].
Steps: (1) Explore patterns of help-seeking and help-refusal, including in therapy. (2) Treat breaks and holidays as practice for separation: prepare in advance, plan for the gap, review afterwards. (3) Support building a wider network beyond therapy [synthesis].
Example language (illustrative): "I'm away for two weeks. Let's think now about what might be hard and what could help you."
Watch for: Crises clustered around breaks. Plan for them early.

4.20 Handing over responsibility

Purpose / when: As stabilisation holds and capacities grow, so the patient becomes the author of their own regulation and life [source: Rudolf 2012 abstract].
Steps: (1) Ask before offering ("what do you think?"). (2) Let the patient plan the next step. (3) Reduce Hilfs-Ich input. (4) Highlight what the patient did themselves. (5) Openly name the shift in roles [synthesis].
Example language (illustrative): "A few months ago I'd have suggested something here. What would you suggest to yourself?"
Watch for: Feeling dropped, regression, or crises. Slow the pace without reversing course.

4.21 Detailed episode analysis

Purpose / when: This is the main way into every structural function. Work on a concrete recent situation rather than on generalities [uncertain: Rudolf's emphasis on concrete scenes is as I know it from the book. The sources confirm only that patients cannot be expected to produce associations or reflection on their own (Rudolf 2019 excerpt), which implies a structured, therapist-guided inquiry].
Steps: (1) Choose a recent focus-relevant episode. (2) Go through it slowly, like a slow-motion replay: situation, perception, feeling, body, thought, impulse, action, other's reaction, aftermath. (3) At each point, notice which function failed or worked. (4) Identify one alternative to try. (5) Review it the next time [synthesis].
Example language (illustrative): "Let's replay Tuesday in slow motion. You came in the door. What did you see first?"
Watch for: Jumping to summaries ("it was the usual"). Gently return to detail. It is working if the patient starts telling episodes in this format unprompted.

4.22 Acknowledging resources and coping efforts

Purpose / when: Throughout. Balances the deficit assessment, strengthens the alliance and self-worth [source: Wöller & Kruse 2018 excerpt: precise deficit assessment is a precondition for resource activation, in a chapter shaped by Rudolf's approach].
Steps: (1) Ask what has helped them survive so far. (2) Recognise symptoms as costly but understandable attempts to cope. (3) Name the specific strengths you observe [steps: synthesis].
Example language (illustrative): "With what you went through, it makes sense that you learned to shut down. It protected you then. Now we can look at whether you need other options too."
Watch for: Hollow praise. Keep it specific and true.

4.23 Tracking progress at the focus (HUSS)

Purpose / when: Every few months, and for reports to the Gutachter (the reviewing assessor in German statutory therapy). Used to steer the treatment and to decide on phase transitions [source: Rudolf, Grande & Oberbracht 2000 abstract; Hümmeler p. 35].
Steps: (1) For each agreed focus, rate the current HUSS stage (1–7, see Section 2) from recent sessions. (2) Compare with the previous rating. (3) If there is no movement over a long stretch, revisit the focus formulation, the phase and your position (Section 5). (4) Optionally share a plain-language version with the patient [synthesis].
Watch for: Rating your hopes instead of the evidence. Base the rating on specific session material.

4.24 Ending phase as structural work

Purpose / when: The final months. Separation is itself a structural task in the attachment dimension [source: Rudolf 2019 table of contents §4.10 specific to SP; Rudolf 2002 abstract names separation].
Steps: (1) Announce the ending early and plan it together, possibly with lower session frequency. (2) Expect old patterns to return and name them as part of the ending. (3) Review what has changed and what the patient can now do alone, using HUSS and the focus. (4) Talk about what the patient takes along internally. (5) Agree how to handle future crises [synthesis].
Example language (illustrative): "It's understandable that the old feeling of being dropped comes back now. Let's look at how you handle it differently than a year ago."
Watch for: Acting out before the end, or premature ending to avoid the separation. Address it openly and keep the frame.

4.25 Transition to conflict-centred work (optional)

Purpose / when: Once structure is sufficiently stable and an underlying neurotic conflict, as defined by the OPD conflict axis, becomes relevant [source: Ploeger 2005 review: transference, regression and resistance are used only once structure is stable; Rudolf 2016 abstract on conflict-processing versus structure-promoting approaches].
Steps: (1) Check that the patient can reflect on their inner life and tolerate affect. (2) Discuss the change of focus openly. (3) Introduce clarification, then interpretation of the conflict, in small doses. (4) Return to structural work if destabilisation occurs [synthesis].
Watch for: Destabilisation after interpretations. That signals premature transition.

5. Handling problems

Most guidance in this section is my own synthesis built from the principles above, because the sources did not address these problems directly. Each item is tagged.

Acute crisis or suicidality. Switch to stabilisation (4.4) and standard suicide and risk assessment, with emergency and crisis plans and coordination with psychiatric care. Structural work pauses during acute danger [synthesis; general clinical standard]. Afterwards, review the episode as focus material (4.21).
Overwhelm or flooding in session. Move to the position behind (4.8). Slow down, use the present moment and orienting questions, and offer the Hilfs-Ich (4.5) to name and contain. Postpone deep material. Next time, dose the work more carefully and agree on a stop signal [synthesis].
Stuck: no movement at the focus. (1) Rate the HUSS (4.23). (2) Check whether the focus is too abstract, wrong, or only compliantly accepted, and reformulate it with the patient (4.2). (3) Check whether you are asking for capacities that are still missing ("don't demand what is missing") and go back to Hilfs-Ich work. (4) Check whether you are stuck in one position. (5) Consider whether an unaddressed conflict or trauma is blocking progress [synthesis; the principle in step 3 is from Rudolf 2019 excerpt].
Passivity: "you're the expert, you do it." Acknowledge the wish for help, provide some (behind). Then move beside: "what part can you take on?" Keep handing back small tasks (4.20) [synthesis].
Devaluation, hostility, negative transference. Validate the feeling, then step out of the transference (4.10) and answer as a real person (4.6). Set limits on abusive behaviour from the opposite position [synthesis; 4.10 itself uncertain].
Idealisation and dependency. Accept it without feeding it, and mark realistic limits of what you can do. Use breaks for separation practice (4.19). Strengthen the patient's own capacities and network [synthesis].
Ruptures, such as walking out or angry emails. Contact the patient in a calm, non-punitive way. In the next session, analyse the rupture together as an episode (4.21) and acknowledge your own share if there is one. Repairing ruptures is itself a structural experience: relationships can survive conflict [synthesis].
Missed sessions and non-adherence. Treat absences as material, not only as an administrative problem, and explore the episode. Agree on the frame clearly. Ask whether the work overwhelmed the patient [synthesis].
Over-intellectual "insight" without change. Shift from talking about to experiencing in the moment (4.11, 4.16). Ask for concrete behaviour changes between sessions [synthesis].
Therapist pitfalls specific to this modality. The parental-like stance can become infantilising, over-protective or rescuing. Your answering interventions can drift into self-disclosure for your own sake. Rudolf's later writing warns against interpretive urge as therapist self-display (Deutungslust as an Imponier-Moment) [source: Rudolf 2023 excerpt, Geleit]. Use supervision or intervision. Regularly check whether you are fading your Hilfs-Ich input [synthesis].
Mixed conflict and structure picture. Lead with whichever predominates. Many patients need structural work first, then conflict work (4.25). Destabilisation after interpretation means returning to structure [source: Rudolf 2019 excerpt on mixed pictures; synthesis for procedure].
Comorbid substance misuse, eating disorders or severe self-harm. Combine SP with symptom-specific measures and medical or psychiatric care. SP addresses the underlying structure, not acute symptom control [synthesis].
Limited session contingents. Agree on a narrow focus (one function) and plan the ending from the start. Use HUSS to justify extensions [synthesis; focus importance in time-limited TP: Rudolf 2016 abstract].
Adolescents and older adults. Rudolf 2016 describes age-related modifications, but these are not drawn on [uncertain].

Sources

Sources:

Further reading (not drawn on in full):

Rudolf, G. (2013). Strukturbezogene Psychotherapie. Leitfaden zur psychodynamischen Therapie struktureller Störungen (3rd ed.). Stuttgart: Schattauer. This is the version followed; 1st ed. 2004.
Rudolf, G. (2019). Psychodynamisch denken – tiefenpsychologisch handeln. Stuttgart: Schattauer.
Rudolf, G. (2023). Dimensionen psychotherapeutischen Handelns. Stuttgart: Schattauer.
Arbeitskreis OPD (2006). OPD-2. Operationalisierte Psychodynamische Diagnostik. Bern: Huber. English: OPD Task Force (2008). OPD-2: Operationalized Psychodynamic Diagnosis. Hogrefe & Huber.
Heigl-Evers, A., & Heigl, F. (Göttingen group): origin of the "Prinzip Antwort" and psychoanalytic-interactional method [uncertain: specific work].

Not drawn on: Europe PMC and PMC, ebook.de, Hugendubel and Klett-Cotta product pages, and the full texts of the Springer articles.

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