Psychodynamic techniques elicit emotional engagement in complex post-traumatic stress disorder

Abstract

Therapies based on an exposure model have been shown to be effective in the treatment of uncomplicated Post-Traumatic Stress Disorder (PTSD), but less effective when used to treat Complex Post-Traumatic Stress Disorder (CPTSD), because an essential first step in the exposure model is a patient’s emotional engagement with traumatic material. This engagement is prevented by a suppressive/dissociative reaction typical of CPTSD. Several methods of overcoming this suppressive/dissociative reaction have been investigated, but have proved impractical. Familiar psychodynamic techniques appear to circumvent the suppressive/dissociative response and elicit the required emotional engagement in standard clinical settings.

Keywords:

• psychodynamic psychotherapy
• post-traumatic stress disorder
• complex post-traumatic stress disorder
• exposure therapy
• cognitive behavioral therapy

Introduction

The effectiveness of therapies for Post-Traumatic Stress Disorder (PTSD) founded on the exposure model has extensive empirical support, and these therapies, which include Cognitive Behavioral Therapy, trauma-focused Cognitive Behavioral Therapy, and Eye Movement Desensitization and Reprocessing, have become first-line interventions for the treatment of traumatic stress (Benight & Bandura, 2004; Ehlers et al., 2013; Rothbaum et al., 1999). The effectiveness of these interventions is greatly reduced, however, when they are used to treat Complex Post-Traumatic Stress Disorder (CPTSD) (Ehlers et al., 2013; Lanius et al., 2010). The unique suppressive/dissociative features of CPTSD interfere with affective engagement, which is a crucial first step in the exposure model (Ehlers et al., 2013; Foa & Kozak, 1986; Rauch & Foa, 2006; Rothbaum et al., 1999; Spermon et al., 2010). Several methods of counteracting this response are under investigation, but to date none have found widespread application (Nielson & Megler, 2014; Rothbaum et al., 1999; Scurfield et al., 1992). Psychodynamic techniques already in widespread use appear to elicit the requisite emotional engagement in patients with CPTSD in standard clinical settings.

PTSD and CPTSD: treatment considerations

PTSD vs. CPTSD

PTSD can be described as a persistent, pathological, emotional and physiological dysregulation attributable to trauma (Lanius et al., 2010). In PTSD, trauma-related stimuli both external (aspects of the environment reminiscent of the traumatic scene) and internal (memories, sensations or feeling-states related to the traumatic event), trigger an emotional and physiological event typified by hyperarousal. Hyperarousal includes physiological symptoms such as rapid pulse, hyperventilation and restlessness; as well as emotional symptoms such as wariness, fear, panic, and irritability (American Psychiatric Association, 2022).

CPTSD can be similarly described as a persistent emotional and physiological dysregulation attributable to trauma (Lanius et al., 2010). In CPTSD, however, trauma-related stimuli elicit an emotional and physiological event typified by suppression and disassociation. Suppression/dissociation includes physiological symptoms such as decreased heartrate, slowed respiration, and stillness; as well as emotional symptoms such as emotional modulation, expressive suppression, and dissociation (Gross & John, 2003; Lanius et al., 2010). CPTSD also has a more variable presentation, and a more global effect on functioning and personality, which are discussed further below (Herman, 1992).

Emotional processing theory and the exposure model

Exposure-model therapies for PTSD trace their theoretical roots to Emotion Processing Theory (EPT), as described by Foa and Kozak (1986). In EPT, traumatic stress is conceptualized as a product of pathological fear structures. Fear structures are cognitive collections of associated stimulus, response and meaning elements. A knife, for instance, could be a stimulus element associated with a specific meaning element, such as danger, and relevant responses, such as flight or panic. Pathological fear structures are distinguished from adaptive fear structures by three factors: they involve an excessive response element, do not accurately reflect reality, and are resistant to modification (Foa & Kozak, 1986).

Rectifying pathological fear structures requires two necessary conditions: activation of the fear structure, and the integration of information incompatible with the fear structure (Foa & Rauch, 2006). In other words, first the patient must be feeling, to some extent, the emotions associated with the traumatic experience (fear, loss, humiliation) before integration can occur. In the exposure model this is accomplished by exposing the patient to trauma-related stimuli, such as reciting a trauma script or imagining the incident. Second, with this emotional engagement achieved, information incompatible with the fear state is presented, usually aimed at restoring a more realistic assessment of threat and personal agency. In this manner the emotion is processed, and the fear structures modified (Foa & Rauch, 2006).

Challenges in CPTSD: the suppressive/dissociative reaction

It is in the first step of this two-step process, that of activation, that CPTSD presents unique challenges. Whereas in uncomplicated PTSD, trauma-related stimuli elicit hyperarousal, in CPTSD the opposite is true (Lanius et al., 2010). Traumatic reminders spur an over-modulation of expressed and felt emotion, often through voluntary emotive suppression, but in some cases involuntarily, and sometimes to the point of profound disassociation (Gross & John, 2003; Herman, 1992; Lanius et al., 2010). This is referred to here as the suppressive/dissociative reaction. Functional Magnetic Resonance Imaging of this process in action reveals high activation of the brain’s regulatory structures, coupled with suppressed activity in areas responsible for emotional experience (Lanius et al., 2010). This renders the feeling states relevant to the trauma inaccessible, and prevents the activation of the fear structures that is prerequisite in the exposure model. Numerous studies evaluating exposure-model treatments have noted the seeming intractability of CPTSD, leading to its frequent labels of ‘treatment resistant’ or ‘chronic’ PTSD (Rothbaum et al., 1999; Scurfield et al., 1992).

Overcoming the suppressive/dissociative reaction

Several methods have been proposed and studied as solutions to this problem of emotional engagement. These methods can be sorted into two categories: stimulus enhancement and pharmacological. Methods in the stimulus enhancement category operate on the premise that more immersive, evocative or specific trauma-related stimuli might overpower the suppressive/dissociative response. These consist of virtual reality and in-vivo exposures to scenarios that resemble scenes of trauma. Examples include computer-generated military convoys through Iraq (Rizzo et al., 2014), or real flights in Vietnam-era helicopters, intended to elicit emotional activation in combat veterans (Scurfield et al., 1992). By contrast, pharmacological interventions hope to use the natural disinhibiting properties of psychoactive substances, such as psilocybin, ayahuasca and 3,4 Methylenedioxymethamphetamine, to ease the accession and processing of difficult emotions (Nielson & Megler, 2014).

Results of these studies indicate that these methods may hold some promise, but the drawbacks are numerous. Virtual reality relies on a great deal of specialized equipment and operator know-how, while in-vivo exposure is impractical and potentially hazardous (Rizzo et al., 2014). Pharmacological interventions can be unpredictable, and are contraindicated for patients with comorbid diagnoses that involve mania or psychosis (Nielson & Megler, 2014). Until these drawbacks can be addressed, what is called for is a reliable method for eliciting emotional engagement that can be applied in a standard clinical setting.

Psychodynamic technique in CPTSD

Psychodynamic approaches are suited to CPTSD due primarily to the primacy of the unconscious in psychodynamic theory. In uncomplicated PTSD, the generative trauma and resultant symptoms are comparatively circumscribed. The generative trauma is most commonly an anomalous event, a disaster or an attack or an accident, that stands out as being dramatically different from the accustomed day-to-day experience. Resultant PTSD symptoms are likewise anomalous events. The intrusive thoughts, avoidant behaviors and stress reactions tend to center around stimuli directly attributable to the trauma and its context. As frequent and debilitating as these symptoms may be, they are recognizable as intrusions upon an established identity (Herman, 1992).

This is not the case in CPTSD. CPTSD has been linked to prolonged trauma, such as imprisonment or childhood abuse, and resultant symptoms pervade the personality and manifest in ‘protean sequelae’ (Herman, 1992, p. 2) that impact every facet of life. Traumatic stress is not an intrusion, but instead has been incorporated into, and in fact comprises portions of, the identity and sense of self. Its manifestations are therefore frequently unconscious, and often undistinguished from simple habits, preferences, aesthetics, idiosyncrasies, and all the other myriad components of personality (Herman, 1992).

Psychodynamic techniques aimed at calling attention to these unconscious manifestations of traumatic stress, and bringing them to conscious awareness, have the effect of eliciting the emotional engagement – the activation of the fear structures – requisite for emotional processing to occur without provoking the suppressive/dissociative reaction. The crucial difference appears to be that in using these techniques, the therapist is not invoking the trauma (which triggers the well-documented suppressive/dissociative response), but is instead inviting the patient to witness its operation already underway.

The psychodynamic techniques most heavily recruited in this endeavor are transference interpretation and process analysis. These two lend themselves especially because they are ‘present tense’ interventions. Due to the fact that the intention is to have the patient witness trauma’s influence as it is operating, the patient needs to be ‘caught in the act’, so to speak, and transference interpretation and process analysis can be applied to emerging thoughts and behaviors at the moment of occurrence.

Transference as a concept has of course been a mainstay of psychodynamic theory almost since its inception. Transference is defined as a patient’s thoughts and feelings about the therapist that have as much or more to do with the patient’s previous experience of significant others than with anything presented by the therapist (Suszek et al., 2015). A patient might experience a therapist as hostile, for example, or seductive or maternal, based more on prior interactions with others than on the therapist’s observed behavior. The purpose in interpreting transference is to allow modifications to be made to the transference reaction through awareness and understanding, that can then be generalized to other relationships, thereby creating a more flexible and adaptive approach to relationships (Suszek et al., 2015).

Process analysis refers to the analysis of the dynamic reactions of the patient in therapy (Cotter, 2021). Practically any spontaneous reactions – twitches, gaits, shifts in posture, glottal stops, elisions, abbreviated gestures, winces, etc. – fit under the category of process, and constitute a rich and vital source of material that can be explored and interpreted to therapeutic effect (Bromberg, 2009). Process analysis calls conscious attention to the otherwise autonomic behaviors used to modulate emergent emotional pressures. Pressures can then be articulated and addressed directly, and behaviors modified through awareness and understanding (Fukao et al., 2007).

The following case excerpts illustrate the implementation of transference and process interventions with patients diagnosed with CPTSD, and demonstrate the resultant emotional engagement that permits processing of traumatic material.

Case examples

Case 1

Ann (a pseudonym), a 20 year-old woman, sought therapy because she was mystified and alarmed by symptoms she could not explain. Ann reported having frequent dissociative episodes, usually preceded by a feeling of panic and despair. During these episodes, Ann said the panic and despair were still present, but somehow distant. Her surroundings would likewise seem present yet distant or unreal, and she would simultaneously crave the comfort of friends and find their presence terrifying. These episodes occurred frequently, sometimes several times a day. One particularly distressing episode occurred when Ann attended a protest against sexual assault. Ann felt a growing sense of unease as several survivors of sexual assault shared their stories with the crowd, and she began to dissociate from her surroundings. Ann remembered seeing a picket sign that read, ‘She was drunk, she was flirting, she was wearing a skimpy dress: there is no excuse for rape!’ and then needing to flee. Processing this later in session, she explained that the sign had particularly upset her because, ‘there isn’t anything you can do to prevent it. It’s just completely out of your control’.

Ann did not have a history of sexual assault that she could remember. Her father, who she loved very much, died of cancer when Ann was 10 years old, but aside from this loss Ann reported a relatively happy childhood. Ann felt that her symptoms pointed to some early traumatic sexual incident, but could find nothing in her life to fit that description.

Ann could not, however, remember significant portions of her childhood. She had solid, episodic memories from about fourth grade onward, but only bits and pieces before that. In addition, she had vivid and disturbing dreams, and what she called ‘flashes’: brief, intrusive images and sensations. Both her dreams and her flashes, she said, involved her father. In the dreams she shared in session, Ann was at her childhood home, but it was ‘bigger than it should have been’, and she was busy trying to hide her father’s corpse from visiting relatives. The ‘flashes’ she could not describe, because every time she tried to focus on them she immediately dissociated.

In session Ann was terse, still and vigilant. She sat tense and poised at the edge of her seat, and watched the therapist closely. The following excerpt began during a protracted silence, when the therapist noticed Ann bouncing her foot. Ann saw the therapist notice, and immediately stopped the bouncing. This conversation occurred after nine months of weekly sessions, and was a pivotal moment. Subsequent to this interaction Ann relaxed her vigilance in sessions and began to display facets of her personality she had kept hidden previously. She laughed and joked and chided. She also reported a dramatic drop in dissociative episodes, from several per day to one or two per week.

Patient:

What?

Therapist:

(imitating her) ‘I will not let him see me bounce my foot. I will not betray any emotion’.

P:

(laughing) Yeah.

T:

What does it do for you, not letting me see? How does that keep you safe?

P:

It keeps people from seeing a vulnerability and using it against me.

T:

(thinking)

P:

What?

T:

I’m imagining that. It sounds really manipulative. Someone would have to read your body language and think ‘Ooh she really wants that’, and then think ‘I could use that to get her to do something’. And then you’d learn that you had to hide your wants, or else you’d be taken advantage of.

P:

(nods)

T:

How am I going to use what I notice about you against you in here?

P:

You’re not.

T:

Well, that’s rationally true, but what about the fear? What are you worried I’m going to do?

P:

I don’t know. (Thinking, then changing her answer) I know but I can’t say.

T:

I would take some sexual advantage?

P:

Yeah.

T:

Do you feel anything in that?

P:

(nods)

T:

Anything you can tell me?

P:

Really sad. And a tightness in my throat like nausea.

Case 2

Beth (a pseudonym) was a 21 year-old college student who sought therapy for her panic attacks and anxiety. Her anxiety had become such a problem that she had failed several classes and had to change her major. In the first session, she informed her therapist that she had been sexually assaulted as a child, but refused to discuss the incident any further. In subsequent sessions it became clear that the perpetrator was either a family member or someone integral to the family, and Beth was certain that her admission would destroy the family system. She had never told anyone about the incident, and endeavored to keep it out of her own mind as well.

Exploring this, Beth came to understand that her silence was intended to protect her as much as her family. By leaving the assault unacknowledged, Beth was trying to keep it from ever having happened, and she expended constant and unsustainable energy in attempts to counteract its effects as they cropped up in the various facets of her life. Her original major, for instance, in an extremely difficult subject, had represented an opportunity to prove to herself and others that she was healthy and unimpeded.

For the first four months of once-weekly therapy, attempts made by the therapist to approach her trauma directly were met with a deliberate and steadfast refusal to entertain the topic or anything related to it, and a retreat into willful catatonia. When not evincing this resolute avoidance, Beth would adopt a ‘cutesy’ persona; speaking in a high, soft voice, cocking her head girlishly to one side, and sitting with her hands in her lap and her toes pointed inward. The following excerpt came from a session conducted over Zoom, and began with Beth’s admission that she constantly checked the ‘self view’ window during remote sessions and Zoom meetings to assess her appearance. It represents the first time Beth acknowledged the psychic cost of keeping her trauma at bay. Naming the perpetrator and discussing the trauma openly would take another 10 months, at which point she switched to twice-weekly sessions.

Therapist:

What are you checking for?

Patient:

I don’t know. My hair, lumps in my clothes, smoothing it out.

T:

What don’t you want people to see?

P:

I don’t know, I just don’t want to look weird.

T:

It’s interesting to me, that this seems to be internal as well as external. Like, you’re worried about how you look to an observer, like the camera is right there, right in your face. But at the same time I doubt you’ve ever had any really explicit feedback, as in I doubt anyone has ever said, ‘Your hair looks weird’, or ‘Your clothes are lumpy’. So the standards you’re trying to meet are internal. They’re coming from you.

P:

That’s true. I’m the one who’s always worried about how I seem.

T:

What I hear in this, what I hear in all of this, is, ‘I don’t want anyone to be able to tell that I’m damaged’.

P:

(heatedly) No, that’s not it. I’m not walking around thinking that everyone can tell I’ve been hurt. It’s just that, society demands I be functional. Life demands that I be functional. If I’m not okay, I don’t go to school. I don’t work and make money. I don’t do any of the things I want to do.

T:

I want to take a moment and acknowledge how hard you’ve tried to be okay.

P:

(begins to cry)

T:

What is coming up for you?

P:

Nobody knows how hard I try to be okay.

Case 3

Casey (a pseudonym) was a 40 year-old woman who sought therapy for PTSD symptoms and relationship issues. Casey said her trauma started as early as she could remember. She explained that from when she was a toddler until she was in her late teens, her father was her absolute favorite person, but he was also terrifying. Although he was never diagnosed, Casey came to believe that a personality disorder was the only thing that could account for her father, a man who ‘could be so charming, nobody could make you feel as good’, but who also had ‘black rages, where his eyes would go black like a shark’s’. He once chased Casey’s mother through their house with a gun, firing the weapon at the ceiling. Casey remembered doting on him, and monitoring his mood obsessively, hoping to head off the next explosion before it started. In addition to this there were alarming boundary violations, such as her father showering with her when she was eight years old, and giving her instructions on how to perform fellatio once she got a boyfriend. Casey was also molested as a pre-teen by a babysitter, and never reported the assault.

In initial sessions Casey was loud, brash, hostile and combative. She described her history of trauma freely and fluently, with no observable affective engagement, and said she was proud of her ability to do so. Attempts made by the therapist to question her further about any of these incidents were met with anger or dismissal.

Casey’s therapist interpreted her anger and hostility in these early sessions as an expression of her fear of a developing emotional intimacy, but did not share this interpretation with her, reasoning that it would be inaccessible and potentially alienating until further work was done. Instead he began sharing his reactions with her in a clear, non-accusatory manner. If she insulted him, he told her he felt hurt. When she was visibly angry, he said that he felt frightened. Casey received these as accusations, hearing them as ‘you are hurtful’, and ‘you are frightening’, but was struck by the contrast between how she felt (powerless, desperate) and how she was experienced. This phase of treatment lasted three months. During these three months Casey began to feel safer with the therapist, and she was able to see meaning in the contrast between how she felt and how she was experienced, and she recognized the fear that prompted her anger. The following excerpt is taken from a session during this second phase of treatment.

Therapist:

I’m frightened when you get like that.

Patient:

I know, I know. Oh my god. I don’t want to be frightening.

T:

What do you think is going on there?

P:

(pressing on her abdomen) I feel it … here. Right here. (sobbing violently) I’m scared of you. I’m so scared of you.

T:

(nodding)

P:

I always felt it here.

T:

Yeah?

P:

Sex trauma. It was sex trauma. I feel disgusting all the time.

Discussion

In the mainstream, exposure model of PTSD treatment, the traumatic material is approached explicitly. Patients recite trauma scripts, or describe or imagine their trauma, or are otherwise exposed to trauma-specific stimuli. This provides a face-valid, common-sense assurance that whatever emotions arise are associated with trauma, and not attributable to other factors. This assurance is diminished when the traumatic material is approached circuitously as outlined above. The notion that it is traumatic stress that is accessed when what is ostensibly under discussion is the agitated bouncing of a foot, or a habit of checking one’s appearance, is based on the assertion that, in CPTSD, survivors develop ‘protean sequelae’, which include global characterological and personality deformations. The aftermath of trauma is thereby present in gesture and habit, and vulnerable to analysis. This notion is primarily supported by clinical observation, as opposed to purely experimental evidence, which may cast some prudent doubt on the claim that here is an answer to the problem of emotional engagement in CPTSD.

In this psychodynamic approach, the assurances that the emotions accessed are associated with trauma are mainly contextual. Trauma was either reported or implicated early in each case, and formed a backdrop for all subsequent discussions. The tense vigilance of one patient, the girlish persona of another, and the loud hostility of a third might be attributable to temperament, but given the context of trauma they become relevant and interpretable. Also arguing in favor of this approach is the fact that powerful emotions and somatic sensations were accessed through discussions of these relatively innocuous happenings. It is difficult to explain otherwise why an investigation into a bouncing foot, an admission of self-consciousness, or expressions of anger yields up sadness, tears, nausea, and feelings of disgust and violation.

Each method of eliciting emotional engagement discussed here has drawbacks. Some methods, such as enhanced traumatic stimuli, remain impractical. Others, such as pharmacological interventions, are unpredictable or contraindicated for some patients. The psychodynamic techniques described here have their drawbacks too. Chief amongst them is that they cannot readily be manualized. The activity of the therapist in this approach is guided largely by intuition, in that the therapist needs to have some sense of the potential significance of what is observed. This leaves the intervention susceptible to human factors, such as experience, perspicacity and skill. The efficacy of this approach might therefore vary depending upon the practitioner, more so than with other methods. These psychodynamic interventions merit consideration, however, for two reasons. One, they are routine and trusted techniques that can be applied in existing clinical settings without recourse to elaborate equipment or unpredictable psychotropics. And two, if these psychodynamic methods work as they appear to, psychology as a field might be expending a great deal of energy trying to find answers to a problem it already solved.

Disclosure statement

No potential conflict of interest was reported by the author(s).