G. Psychodynamic Therapy

BACKGROUND

In 1895, Joseph Breuer and Sigmund Freud based their Studies on Hysteria on the proposition that traumatic life events can cause mental disorder (Breuer & Freud, 1955). This principle, radical for its time, grew in scope and application over the next century and strongly influenced military psychiatry in World War I (Kardiner, 1941; Rivers, 1918) and World War II (Grinker & Spiegel, 1945). Psychodynamic principles were later applied to the psychological problems of Holocaust survivors (Krystal, 1968; De Wind, 1984), Vietnam veterans (Lindy, 1996), rape survivors (Rose, 1991), adult survivors of childhood sexual trauma (Courtois, 1999; Roth & Batson, 1997; Shengold, 1989), and survivors of other traumatic events (Horowitz, 1997). Psychodynamic ideas have also helped providers manage the sometimes complex issues that may surface in the relationship between survivor and psychotherapist (Pearlman & Saakvitne, 1995; Wilson & Lindy, 1994). The following statements summarize the basic elements of psychodynamic psychotherapy:

• Based on the assumption that addressing unconscious mental contents and conflicts (including those that may have been blocked from consciousness as part of a maladaptive response) can help survivors better cope with the effects of psychological trauma
• Explores psychological meanings of posttraumatic responses by sifting and sorting through fears, fantasies, and defenses stirred up by the traumatic event
• Spans a continuum ranging from supportive to expressive but usually includes a mixture of both
• Transference and countertransference are recognized and managed by the therapist but may or may not be brought to the patient’s attention
• Approached within the context of a therapeutic relationship that emphasizes safety and honesty and which is, in itself, a crucial factor in the patient’s response

Course of Treatment for psychodynamic therapy:

• Most commonly involves one to two meetings per week and can be relatively short term (10 to 20 sessions) and focal or long term (lasting years) and open ended
• Sessions usually last 45 to 50 minutes and, although they average once a week, may be held more or less frequently depending on the patient’s needs and tolerance
• Can be conducted individually, in groups, or in family settings on an inpatient or outpatient basis

DISCUSSION

Individual case reports comprise the bulk of the psychodynamic literature on the treatment of psychological trauma, but a small group of empirical investigations and case series with controlled variables and validated outcome measures are available to support recommending psychodynamic therapy as a treatment option for PTSD.

Controlled investigations of the efficacy of psychodynamic therapies are few.  Individual case reports comprise the bulk of the psychodynamic literature on the treatment of psychological trauma, but a small group of empirical investigations and case series with controlled variables and validated outcome measures support recommending psychodynamic therapy as a treatment option for PTSD

Brom and colleagues (1989) conducted a RCT that compared psychodynamic psychotherapy to hypnotherapy, trauma desensitization, and a wait list control group in the treatment of patients with PTSD. They found that symptoms of intrusion and avoidance improved significantly in each of the treatment groups but not in the control group. Psychodynamic psychotherapy was more effective than the other treatments in terms of improved coping ability and greater self-esteem. Subjects in the psychodynamic psychotherapy group showed more improvement in the post-termination phase than did subjects in the other two treatment groups. Participants in all three treatment conditions were more improved than those in the wait-list condition (10 percent improvement), but no differences across the three treatments were observed, with 29 percent improvement for those in psychodynamic therapy, 34 percent for hypnotherapy, and 41 percent for desensitization (Rothbaum, 2001).

While research evidence and clinical experience suggest that psychodynamic psychotherapy can be effectively combined with other forms of psychotherapy and with psychopharmacological interventions for depression (DiMascio et al., 1979; van Praag, 1989), this approach has not been sufficiently researched in work with PTSD.

Psychodynamic ideas have, in some instances, been misapplied in clinical work with trauma survivors giving rise to concern about the creation or elaboration of so-called false memories (Roth & Friedman, 1997). It may be that trauma survivors are particularly prone to this phenomenon given their tendency towards dissociation. It is important that clinicians be properly trained before undertaking psychodynamic treatment of trauma survivors.

Because of its focus on basic problems in interpersonal relationships, psychodynamic psychotherapy may be useful in working with patients with complex PTSD. Clinical case studies suggest that psychodynamic psychotherapy may be of particular value in work with adult survivors of childhood sexual abuse (Courtois, 1999; Roth & Batson, 1997; Shengold, 1989). Psychodynamic psychotherapy may be also useful in treating patients suffering complex PTSD stemming from other stressors but there is, as yet, little research evidence to support this recommendation.