Controversies on psychoanalytic psychotherapies: Is Psychodynamic Psychotherapy Effective for the Treatment of PTSD?

Introduction

The search for understanding the symptoms of traumatic experiences began more than a century ago, and contributed to the development of one of the best-known theories of psychology: Psychoanalysis (Freud, 1893; 1913). The psychoanalytical technique and its theoretical foundations have their origins in the study and treatment of hysterical patients. “Viewed as the public expression of symptoms, hysteria was, from the outset, associated with traumatic experiences,

although some afterwards were revealed as fantasies” (Becker, 2017, p. 19). Through theories about hysterical phenomena (Freud, 1893), group psychology (Freud, 1921), signal and automatic anxiety (Freud, 1926), Freud developed the technique of the “talking-cure” (Cabaniss, Cherry, Douglas, & Schwartz, 2011, p. 4). From Freudian concepts, the Psychodynamic Psychotherapy (PDT) emerged, a therapy that uses un-covering and supporting techniques. As stated by Cabaniss et al. (2011, p. 6):

Psychodynamic psychotherapies that primarily use uncovering techniques are often called insight oriented, expressive, interpretive, exploratory, or psychoanalytic psychotherapies, while those that primarily use supporting techniques are often called supportive psychotherapies. Unfortunately, these are often seen as completely separate from one another. On the contrary, uncovering and supporting do not constitute separate therapies but rather they are two types of techniques that are used in an oscillating manner in all psychodynamic psychotherapies. One patient may benefit from a therapy in which a preponderance of uncovering techniques is used, while another may benefit from a therapy in which supporting techniques predominate, but all treatments use some of each at different points.

Despite the historical importance of Psychoanalysis, especially for the understanding of stress-related symptoms (Quartilho, 2016), studies on the efficacy of treatments based on this theory are scarce (Ben-Itzhak et al., 2012). As consequence of the lack of research, we have witnessed the gradual marginalization of psychoanalytic therapies. As stated by Busch and Milrod (2010, p. 1), “without more carefully conducted evaluations of efficacy that can be understood and accepted by clinicians and scientists outside the narrow discipline of psychoanalysis, psychoanalysis and related mental health interventions remain at risk of perishing as treatments for psychiatric and emotional disorders”. This study aimed at discussing PDT as a method of treatment of Posttraumatic Stress Disorder (PTSD), while recognizing the psychoanalytical approach not only as a means of explaining the origin of the symptoms, but also as a possibility of treatment.

Psychodynamic Psychotherapy & PTSD

“Psychoanalysis is a psychological theory, a therapeutic practice, and a research method on unconscious processes developed by Sigmund Freud. Through the treatment of his patients, Freud realized that the mind was an ever-changing system, and most of its activities took place outside consciousness” (Becker, Paixão, & Aragão-Oliveira, 2020, p. 97). As a means of treatment, psychoanalysis is based on the free association method. Through encouraging patients to say whatever comes into their minds, this method seeks to reveal associations and connections that might otherwise not go uncovered. Psychodynamic Psychotherapy (PDT), as beforementioned, was derived from psychoanalysis. It is a kind of therapy “that postulates that unconscious mental activity affects conscious thoughts, feelings, and behavior”, being its aim “to uncover unconscious material or support mental functioning in the way that will best help the patient” (Cabaniss et al., 2011, pp. 3-4).

In general, the first session is longer, consisting of an experimental therapy, or trial therapy, in which a psychodiagnostic evaluation can be performed. According to this method, the path to establishing therapeutic alliance is through overcoming resistances. The main therapeutic interventions, which aim to unlock the unconscious, include confrontation, clarification, challenge to resistance, head on collision, facilitation of emotional experiences and recapitulation (Becker, Paixão, Silva, Quartilho, & Custódio, 2019, p. 3).

As a product of Psychoanalysis, PDT focuses on “the emotional conflicts which are caused by the traumatic experience”, not focusing on symptoms alone, but on their meaning (Landolt & Kenardy, 2015, p.371).

PDT “concerns itself with identifying and addressing unconscious emotions and processes that result in a broad range of symptoms (anxiety, depression and, somatic) and character problems” (Abbass, Town, & Driessen, 2012, p. 97). “There is evidence for the efficacy of PDT in depressive disorders, prolonged or complicated grief, anxiety disorders, posttraumatic stress disorder, eating disorders, somatic symptom disorders, substance related disorders, and personality disorders” (Leichsenring, Klein, & Salzer, 2014, p. 119). According a comprehensive review conducted by Fonagy (2015), PDT has particularly benefitted patients who presented mental disorders as consequence of traumatic experiences. Specifically, regarding PDT for PTSD treatment, D'Andrea and Pole (2012, p. 438) defined it:

One of the earliest approaches to treating trauma, psychodynamic therapy seeks to foster insights about factors that create hypersensitivity to overt and covert trauma reminders. Thus, the goals of psychodynamic trauma therapy include bringing unconscious material into awareness; establishing a sense of meaning, purpose, and safety; examining affects such as guilt and shame; fostering insights into how threatening thoughts and feelings are kept from awareness in order to reduce hyperarousal; and examining the therapeutic relationship for symbolic reenactments of past trauma.

These activities have presented as providing many positive psychological benefits including improving emotion regulation (D'Andrea & Pole, 2012). Corroborating this, Levi, Bar-Haim, Kreiss and Fruchter (2015, p. 2) emphasized that “PDT also addresses the maladaptive defense mechanisms that are thought to fuel the symptoms of PTSD by helping patients come to terms with the idiosyncratic meaning of the traumatic event”. Summarizing the PDT approach, this technique considers the unconscious conflicts, failures and distortions of the intrapsychic structures, mental representations, transference and countertransference and makes use of confrontation, clarification and interpretation (Coderch, 1990). Through emotional exploration, identification of patters in the patients' life, confrontation of defensive functioning and interpretative interventions about intrapsychic conflicts, the treatments obtained favourable outcomes, with the reduction of symptoms and an increase in patients' quality of life (Becker et al., 2019).

“Clinical studies have shown that patients benefit from PDT, and that psychoanalysis-based psychotherapies have presented a continuous state of improvement in patients” (Becker et al., 2020, p. 93). However, the time length of psychoanalytic psychotherapies has been considered an obstacle to the proper investigation of its effectiveness, placing these therapies outside the first line of treatments for mental disorders (Becker et al., 2019).

Although PDT has presented similar effectiveness in comparative studies (D'Andrea & Pole, 2012; Levi et al., 2015; Sherman, 1998), the meta-analyses conducted by Sherman (1998), Tran and Gregor (2016), and Van Etten and Taylor (1998), including the same study about PDT (Brom et al., 1989), presented distinct positions regarding its efficacy. While Sherman (1998) suggested that PDT is comparable to Prolonged Exposure Therapy (PE), Van Etten and Taylor (1998) indicated Cognitive-behavioral Therapy (CBT) as the most effective psychotherapy and Eye Movement Desensitization and Reprocessing therapy (EMDR) as superior to PDT, placing PDT at the end of the list of effective treatments for PTSD. In contrast, Tran and Gregor (2016) began by mentioning PDT as non-trauma focused and therefore less effective than other therapies, but later designated PDT as non-categorizable for their study, which was focused on the comparisons between trauma focused treatments and non-trauma focused treatments.

In these three meta-analyses, the authors' assessments were based on the reduction of PTSD symptoms, including the comparison of effect sizes in the analyzed studies (Sherman, 1998), the clinical significance of the results between trauma focused treatments and non-trauma focused treatments (Tran & Gregor, 2016) and the effect

size across treatment conditions (Van Etten & Taylor, 1998). Additionally, although all of them concluded that cognitive-behavioral therapies were more effective in the treatment for PTSD, Sherman (1998) pointed out PDT as comparable to PE. The only study found in their search (Brom et al., 1989) that evaluated the effectiveness of PDT, hypnotherapy, and trauma desensitization (a behavioral therapy) in comparison with a waiting-list control group. The sample was consisted of 112 people (79% women with a mean age of 42 years old) who were diagnosed with PTSD resulting from traumatic events (bereavement, acts of violence, and traffic accidents). The assessment of the experimental group was taken in pre-treatment, post-treatment and 3-month follow-up, while the waiting-list group was measured before and after a waiting period of 4 months. This RCT (randomized controlled trial) concluded that at post-treatment assessment the effects of the PDT were fewest, but they were continuous when evaluated against the other therapies at follow-up assessments.

As highlighted by D'Andrea and Pole (2012, p. 438), “despite its long history and widespread use, psychodynamic trauma therapies are relatively understudied”, while “cognitive-behavioral therapies, on the other hand, have been widely studied”. Regarding the lack of studies on PDT in the treatment of PTSD, Levi et al. (2015, p. 1) stated:

Much research indicates that cognitive–behavioral therapy (CBT) approaches such as prolonged exposure (PE) therapy and cognitive processing therapy (CPT) have much to offer to PTSD patients. Much less research exists on psychodynamically oriented treatment approaches despite the fact that in real-world settings, psychodynamic psychotherapy (PDT) is still a common treatment for PTSD.

In Psychodynamic Psychotherapy, the patient “must reconcile the occurrence of the traumatic event and its meaning with his or her concept of the self and the world” (Sherman, 1998, p. 416), understanding “the effect of the traumatic event on his or her personality, embedding in the context of his or her current experience” (Levi et al., 2015, p. 2). The psychodynamic process “may be more effective for trauma survivors than commonly realized”, since the focus of the treatment is on raising awareness of unconscious thoughts and feelings associated with the traumatic event. Also, the goal of PDT is to reconstruct memories and meanings, which may slow down “automatic processing of trauma stimuli and enhanced emotion regulation” in the face of traumatic experiences (D'Andrea & Pole, 2012, p. 444). Through the processing of avoided emotions, the reexperiencing of affects within therapeutic relationship, and the replacement of inappropriate attitudes, expectations and behaviors with more adaptative ones, PDT seeks symptomatic relief, while helping patients to face traumatic memories, enhance self-understanding, and overcome their symptoms, which may allow them to maintain therapeutic improvements, or even to continue to improve after the end of treatment (Becker et al., 2020).

Levi et al. (2015) mentioned the Brom et al. (1989) study, highlighting that PDT, hypnotherapy and behavioral therapy appeared equally effective, and that the effect of PDT on PTSD is because this technique increases patients' ability to resolve emotional reactions related to trauma by improving his or her reflective capacity. Regarding the D'Andrea and Pole (2012, p. 442) study on the relation of the psychotherapy process to change PTSD symptoms, they found that PDT and Stress Inoculation Training (SIT) were significantly associated with greater reductions in PTSD symptoms, but only PDT was significantly associated with greater reduction in depression symptoms and marginally related to greater reduction in interpersonal sensitivity and anxiety. Although PE is touted as the first-line treatment for trauma survivors, this study found little evidence that this therapy is helpful. However, the author believes that their results were influenced by some characteristics of the sample, such as patients with complex trauma and multiple diagnoses, “resulting in a more distressed sample than

typically found in the literature”.

Corroborating the finding about the similarity of therapeutic processes outcomes, in the naturalistic study of Levi et al. (2015), the comparison between PDT (n=148) and CBT (n=95) indicated non-significant differences in remission of PTSD symptoms. The CBT was a combination of CPT and PE. While 35% of the patients in the CBT group presented remission, 45% of patients in the PDT group were in remission at the post-treatment assessments. At follow-up assessments, these numbers were 33% and 36%, respectively, providing evidence that both therapies remained in remission after 8-12 months of the treatments. Although both therapies induced significant reductions in PTSD symptoms and functioning level, Levi et al. (2015, p. 8) referred that CBT may be preferable to PDT “because it is shorter and more cost effective”.

“Time has proved to be an important factor, especially because it is considered an obstacle to scientific research aimed at validating the effectiveness of psychotherapies, which seems to be the main reason why PDT remains outside the front-line of treatments for mental disorders” (Becker et al., 2020, p. 114). However, the results of brief therapies are controversial.

According to a recent theoretical review , several authors have agreed that the application of a time limit is one of the features that enables an acceleration of therapeutic change, as it is believed that therapists and patients are encouraged to work harder and faster with the deadline in sight. On the other hand, the pressure of time can lead to the choice of an inappropriate focus, and work can be conducted superficially, without addressing crucial issues (Becker et al., 2020, p. 106).

Studying the effects of psychotherapies has been shown to be a critical issue, especially in the validation of long-term therapies. PDT have been the subject of empirical studies, presenting outcomes similar to other therapeutic approaches, and even superior in studies that cover post-treatment assessment measures (Becker et al., 2019). However, long-term treatments are not easily measured, being research on this technique complex and time-consuming (Levenson, 1995).

Conclusions

For the last years, we have conducted literature reviews and studies on the effectiveness of PDT in order to identify the obstacles and advantages of this technique. Our clinical experience has also been instrumental in verifying the benefits of PDT in the treatment of mental disorders, mainly those resulting from traumatic experiences. We have found that “despite being similar to other therapeutic approaches during treatment, this technique leads to long-term results, with patients maintaining their state of improvement after the end of their treatments” (Becker et al., 2020, p. 96). However, the effectiveness of PDT is questioned, mainly due to the impossibility of applying certain research methods, such as RCT – since it is a long-term therapy that does not strictly follow a manual by considering the specificities of each case, of each patient.

“Time has proved to be an important factor, especially because it is considered an obstacle to scientific research aimed at validating the effectiveness of psychotherapies, which seems to be the main reason why PDT remains outside the front-line of treatments for mental disorders” (Becker et al., 2020, p. 114). This paper emphasizes the need for studies that verify the effectiveness of PDT through the comparison with other therapies, and using an untreated control group. On the other hand, although RCTs have been considered a statistical credible mean of verifying the effect size of therapies, it may “mask an important heterogeneity that is often revealed by careful scrutiny of individual investigations” (Fonagy, 2015, p. 138). As stated by Brom et al. (1989, p. 612):

We should look for instruments that are capable of incorporating clinically relevant issues, such as different mechanisms within each of the therapeutic

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approaches… conclusions make it clear that the process of psychotherapy must be taken into consideration if we want to establish a more explicit link among theory, therapy, research methods, and disorders.