Phase 2

This chapter provides an overview of the central psychodynamic techniques of the middle phase of TFPP. Core intrapsychic conflicts that contribute to PTSD symptoms are identified and actively addressed. Interpretation of defenses aids in the elucidation of conflicts. A prominent defense in PTSD, identification with the aggressor, is described in more depth. Exploration of the transference is discussed with attention to the ways in which core conflicts emerge with the therapist. Patients with PTSD trigger particularly intense countertransference reactions, knowledge of which furthers the therapeutic process. The technique of working through is articulated, in which the therapist and patient elucidate how various conflicts and defenses emerge across a range of symptoms, contexts, and relationships. Case vignettes are used to illustrate these approaches.

Introduction and Overview

This chapter provides an introduction to efficacious treatments for posttraumatic stress disorder (PTSD). Despite efficacy of these treatments, many patients do not respond to them or experience persistent symptoms. Efficacious psychotherapies for PTSD used at the Veterans Administration (VA), including prolonged exposure therapy and cognitive processing therapy, are described. While these treatments can be helpful, many patients are avoidant of trauma processing and homework. Furthermore, both treatments tend to focus on one central trauma, to which exposure exercises are targeted, whereas most Veterans experience multiple traumas. An overview of the development and framework of trauma-focused psychodynamic psychotherapy (TFPP), a PTSD-symptom focused brief psychodynamic therapy, is presented. A brief background of psychoanalytic and psychodynamic literature and thinking about trauma is provided to further frame the place of TFPP

Some Techniques of Psychodynamic Psychotherapy as They Apply to Treatment of Post-Traumatic Stress Disorder

This chapter provides descriptions and clinical examples to illustrate core psychodynamic techniques as they are adapted to the work of trauma-focused psychodynamic psychotherapy (TFPP): clarification, confrontation, interpretations, and utilization of patient dreams. Clarification aids the patient in gaining distance and objectivity. Confrontation is designed to help patients recognize contradictory thoughts and feelings. Interpretations tie observed behaviors or thought patterns to the emotional dynamic factors that may give rise to them. Because a core symptom of post-traumatic stress disorder (PTSD) involves re-experiencing traumas through dreams, a focus on the approach to dreams is particularly relevant in this population, and TFPP is the only operationalized psychotherapy for PTSD that makes active use of dreams to gain an understanding of emotional causes of distress. The chapter also illustrates the use of the transference and its interpretation and describes common countertransference constellations that arise. Due to the nature of the impact of trauma, transference and countertransference reactions can be particularly intense and ways that the therapist can effectively use these reactions to guide the treatment are discussed.

Core Psychodynamic Factors in PTSD

After briefly reviewing the psychoanalytic view of mental life, including the influence of the unconscious on mental life and symptoms, this chapter describes the impact of trauma from the psychodynamic viewpoint. Disruptions in narrative coherence, repetition and re-experiencing, intrapsychic conflicts, dissociation, defenses, intense negative affects, and disruptions in trust that result from trauma are described. Clinical examples are presented to illuminate these factors. In addition, the relevance of the patient’s pretrauma history, their attachment style and mentalization skills, and the specific nature of traumatic experience on the impact of trauma and associated symptoms is elaborated.

Extended Example of TFPP Treatment

This chapter provides an extended case example of a 21 session treatment of a patient with TFPP. Pablo, a 27-year-old mixed Latino male Army Veteran who served in Afghanistan, presented with generalized anxiety, severe separation anxiety, and PTSD. In addition to his severe anxiety, panic attacks, hypervigilance, nightmares, and intrusive memories, Pablo complained of being in a “fog.” Symptoms began when a Humvee exploded next to Pablo. The therapist noted the patient’s description of feeling “trapped in a foxhole” with his painful memories of abuse and neglect in childhood and anger in current relationships. The therapist helped Pablo understand that he directed this anger toward himself, seeing himself as bad or inadequate, accepting his attackers’ view of him. The therapist linked the emotional impact of the Humvee explosion to a familiar set of anxieties and concerns following certain childhood experiences, and helped Pablo see how the pain of his early relationships and losses shaped his current fears and relationship choices. In the course of TFPP, Pablo became more comfortable expressing his anger and fears about his childhood, his military trauma and his current relationships. Symptoms and defenses and their origins and meanings were understood in the context of the relationship Pablo’s with his therapist (the transference). At termination Pablo was significantly improved; he no longer met DSM criteria for PTSD or other anxiety disorders. He felt much less affected by the “fog” and more capable of addressing problems in his life and moving forward with his goals and desires.

Phase 1 (Continued)

One of the key differences between TFPP and more open-ended psychodynamic psychotherapy is its specific focus on symptoms of PTSD throughout the treatment. This chapter outlines ways in which the therapist can focus psychodynamic psychotherapy on specific PTSD symptoms. These include difficulties with trust and paranoia, symptoms of re-experiencing the trauma(s), dissociation and avoidance, and guilt and a sense of “badness.” Approaches for fostering insight into these symptoms through a psychodynamic lens are all accompanied by illustrative clinical examples. Development of a psychodynamic formulation for the patient with PTSD is then articulated by linking symptoms, their precipitants, their meanings in the context of early and more recent relationships understood through the lens of the transference, and their defensive functions. The clinical vignettes show how the evolution of a more cohesive and positive self-narrative permits further self-exploration and access to memories, and the possibility of more flexibility in the patients’ life choices.

Phase 1

This chapter examines the initial approach to PTSD symptoms using TFPP. Symptoms serve as a lens through which to explore and address contributory emotions, conflicts, and defenses. Symptoms may express or function to ward off intolerably painful emotions generated by the trauma. The therapist works to link the symptoms to relevant traumatic events, which patients have often avoided via dissociation or other defenses. The therapist is empathic with patients’ distress in describing trauma and also works with patients’ reactions to better understand the impact of trauma. Exploration of the context, emotions, and meanings of symptoms helps patients to gain a clearer understanding of past and present precipitants and the reasons that symptoms continue. The therapist additionally explores how developmental experiences, including early traumatic events, affect patients’ reactions to subsequent trauma.

Phase 3

This chapter highlights the importance of the termination phase to the practice of TFPP. Attachment dysregulation and feelings of abandonment and rage come to the fore within the therapeutic relationship during termination. Careful handling of this process is crucial in helping the PTSD patient move past symptoms to effect therapeutic change. Issues that commonly arise during termination are feelings of loss and mourning, anxiety surrounding separations, aggravation of mistrust and anger, and fantasies and fears of helplessness. Feelings of pride and gratitude may also emerge. Termination is a challenging time in TFPP, and this chapter also focuses on common countertransference concerns and ways of avoiding pitfalls. Clinical vignettes of TFPP terminations are provided.

The Treatment Framework of TFPP and Initial Interventions

This chapter outlines core symptoms and mental states common to many patients with PTSD. The symptoms and their meaning, which necessarily will have individual variations, are presented and described through a psychodynamic lens. Fundamental elements of TFPP are described, Common approaches and pitfalls are presented all with clinical descriptions. Central difficulties that patients with PTSD commonly have in engaging in psychotherapy are outlined, including disruptions in narrative coherence, core problems of trust, and feelings of shame, guilt and alienation, that necessarily affect the way therapy can proceed. Approaches to these problems are highlighted, including ways to help build a safe therapeutic environment.

Update in the World of COVID-19

This brief chapter incorporates some of our team’s observations about practicing TFPP during the COVID-19 pandemic. For many of our patients, access to care became more fractured, whereas for other patients, session attendance became easier and even resulted in better access to their inner lives. The impact of the necessity to switch to telehealth is discussed, as well as the effects of isolation on the one hand and tensions surrounding quarantine situations on the other. The chapter discusses one case of a Vietnam war Veteran for whom the experience of the lockdown exacerbated anger and mistrust he had experienced during the war. In a second case the patient experienced being infected with COVID as yet another experience of abuse, and struggled with his angry response. Patients’ responses are necessarily filtered through their developmental histories, traumatic experiences, and individual dynamics. TFPP helps to delineate how patients’ symptoms and relationships are affected, creating opportunities for further therapeutic work.