Treatment of Posttraumatic Stress Disorder (PTSD): Psychodynamic and Cognitive-Behavioural Therapies

posttraumatic stress disorder treatmentA variety of therapeutic interventions have been applied in the treatment of PTSD, including psychodynamic therapy, cognitive-behavioural therapy, family therapy and group therapy. Regardless of the orientation used, two factors appear to be critical for the success of psychotherapy with PTSD clients: 1) therapy should start soon after the traumatic experience, and 2) therapy should be brief and focused (Schawz & Prout, 1991).

The primary focus of psychodynamic therapy for PTSD is not on the symptoms of the disorder but on the underlying meaning which the trauma carries for the individual. This includes how it affects their views of themselves, others, as well as the external world. It also aims at understanding the basic assumptions which have been overturned by the trauma and the obstacles to psychological integration of the event (Krupnick, 2002). In order to provide clients with the benefits of traditional psychoanalytic therapy without the extensive time commitment necessary for such treatment, brief psychodynamic therapy has been used successfully. Brief trauma focused therapy  has received much attention from Horowitz and his colleagues (Horowitz et al., 1997, cited in Krupnick, 2002) who proposed a 12-session treatment model for PTSD. Included in this are four phases: a pre-treatment phase and three treatment phases. The main purpose of the pretreatment phase is to assess the severity of the client’s symptoms and to determine if a time-limited approach is the best approach for the individual in question. [showmyads]

The purpose of the initial phase (sessions 1-4) is to establish a therapeutic alliance and a sense of security in the client so that he feels comfortable telling his story. Unlike friends and relatives, the therapist encourages the client to tell and retell his story with as many details as possible and does not get bored or annoyed. The individual therefore comes to understand that he can relate the event without driving away, distressing or overwhelming the self or others. The purpose of this is to encourage  catharsis which in itself can be therapeutic. Techniques used in this phase include free association, exploration, clarification and provision of support.

The middle phase of therapy (sessions 5-8) is the working through phase. As symptoms become less pervasive, the therapist takes on a more interpretive role, focusing on the underlying beliefs and attitudes which prevent the individual from integrating the trauma. The therapist addresses any signs of negative self-image which may have resulted from the trauma and helps clients to revise their rigid expectations of self.

In the final phase of therapy (sessions 9-12), the therapist prepares the client for termination and works through the sense of loss which may be reactivated in trauma victims as a result of this. Both client and therapist revise what has been accomplished in therapy and what is left for the client to explore and address after the therapeutic relationship has ended. Long term psychodynamic therapy may be required if the trauma was particularly severe, if the person experienced more than one stressor, if there was a long delay between the appearance of symptoms and the time formal treatment was sought, and if further problems develop following brief psychotherapy.

Despite the usefulness of psychodynamic interventions, cognitive-behavioural therapy has been found to be the most effective psychological treatment for PTSD (Whitney, 2002). It provides a more structured environment than psychodynamic therapy and this in itself proves helpful for victims of severe trauma who may feel as if their lives are out of control. It also produces much quicker results. Two main techniques used in this form of therapy are exposure and cognitive restructuring. As the name suggests, exposure therapy involves gradually exposing clients to thoughts, memories and situations related to the trauma which produce anxiety. This can be done through imaging techniques or by gradually engaging in activities, or approaching places, that trigger anxiety (a technique known as systematic desensitization).

Cognitive restructuring rests on the premise that the way in which one thinks about an event, and not the event itself, results in psychopathology. It involves identifying irrational beliefs relating to the trauma and helping the client to replace them with more rational and positive thoughts, which in turn will result in new emotional and behavioural responses.

As with all forms of treatment, both psychodynamic and cognitive-behavioural therapies have advantages as well as disadvantages. It is up to the client to investigate available treatment options and make an informed decision as to the treatment choice that would be most appropriate. Once a choice has been made, clients must then remain committed to the therapeutic process in order to achieve the best possible outcome.

References

Krupnick, J. L. (2002). Brief psychodynamic treatment of PTSD. Journal of Clinical Psychology, 58, 919-932.

Shawz, R. A., & Prout, M. F. (1991). Integrative approaches in the treatment of posttraumatic stress disorder. Psychotherapy, 28(2), 364-373.

Whitney, D. (2010). Post traumatic stress disorder. Retrieved February 12, 2012, from http://www.wsiat.on.ca/english/mlo/post_traumatic.htm

Photo courtesy of Ambro / FreeDigitalPhotos.net

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