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Schottenbauer, M.A. Arnkoff, D.B. Glass, C.R. Gray, S.H. (2005). Abstracts of the 2005 Poster Session of the American Psychoanalytic Association Winter Meeting: Approaches to Psychotherapy of Trauma: Differences Among Psychoanalysts, Psychodynamic Clinicians, and Cognitive Therapists. J. Amer. Psychoanal. Assn., 53(4):1315-1320.
Psychoanalytic Electronic Publishing: Abstracts of the 2005 Poster Session of the American Psychoanalytic Association Winter Meeting: Approaches to Psychotherapy of Trauma: Differences Among Psychoanalysts, Psychodynamic Clinicians, and Cognitive Therapists
(2005). Journal of the American Psychoanalytic Association, 53(4):1315-1320
Posttraumatic stress disorder (PTSD) is a response to extreme psychological stress that affects about 8% of the general population in their lifetime (American Psychiatric Association 2000). Randomized clinical
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trials (RCTs) have demonstrated the effectiveness of cognitive-behavior therapy (CBT) and Eye Movement Desensitization and Reprocessing, or EMDR (Chambless and Ollendick 2001). However, only one RCT (Brom, Kleber, and Defares 1989) has included psychodynamic treatment for PTSD (Roth and Fonagy 1996), despite research showing that more primary care patients report receiving psychodynamic interventions (30%) than cognitive-behavioral interventions (26%) or exposure (16%) for PTSD (Rodriguez et al. 2003).
Research suggests that clinicians’ theoretical orientations may not correspond in a predicable or obvious way with their interventions (Beutler, Machado, and Neufeldt 1994). When treating a PTSD patient, clinicians may alter their customary technique to address issues specific to PTSD (Herman 1997). To investigate this phenomenon, psychoanalysts, psychodynamic clinicians, and cognitive therapists were invited to participate in an online survey of therapeutic approaches to patients with PTSD in an effort to discover commonalties between, and defining characteristics within, each group of respondents.
Participants. Therapists identifying themselves primarily with psychodynamic/psychoanalytic and cognitive-behavioral practice were recruited from major professional organizations via announcements disseminated by e-mail. Those who expressed interest were directed to an internet-based survey approved by the CUA Human Subjects’ Committee.
Demographic/educational history questionnaire. The demographic questionnaire included questions about therapist background, such as highest professional degree and core professional identif ication. Participants were asked to select the approach that best represented their treatment of clients/patients and to rate their overall adherence to specif ic subtheories and approaches on a scale from 1 (not at all) to 7 (a great deal).
Q-sort. The Psychotherapy Process Q-set, or PQS (Jones l985), is a common way of delineating therapy process quantitatively and in theoretically neutral language. It uses 100 items that describe therapist and patient attitudes, experiences, and behaviors (Jones 2001). Participants sort the cards into piles on a Likert-type scale ranging from least characteristic (1) to most characteristic (9) of a specific type of therapy. The number of items that can be sorted into each pile is specified, so that
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Figure 1 Most highly ranked therapist functions
Figure 2 Significant disagreement among clinicians Functions valued by Cognitive but not by Dynamic Therapists
Figure 3 Valued therapist functions Significant agreement among clinicians (p < 0.01 or better)
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overall allocation of items in piles is normally distributed, permitting quantitative analysis.
Procedure. After providing informed consent, participants filled out the demographic questionnaire. Participants were then randomized to one of four case summaries and asked to indicate their conceptualization of an ideal treatment for that client/patient, using the PQS.
In this preliminary study, the responses of 32 psychoanalytic/psycho-dynamic and 28 cognitive-behavioral therapists were examined.
There were no differences in ratings of Q-sort items between psychodynamic clinicians who had completed psychoanalytic training (N = 10), those who were currently in psychoanalytic training (N = 8), and those who had never been in psychoanalytic training (N = 14), Wilk's Lamba =.003, F (2, 58) =.64, p =.78. They were combined into a single group in subsequent analyses.
The fourteen most highly ranked therapist functions are presented in Figure 1. Psychodynamic and cognitive clinicians differed significantly on three of them (see Figure 2) and had very significant agreement (p < 0.01 or better) on five (see Figure 3).
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The results of our preliminary study suggest that psychoanalysts and psychodynamic clinicians do not differ from each other in their psychotherapeutic approach to patients who have experienced trauma, but as a group they differ from cognitive-behavioral therapists in their preference for specific technical interventions. Psychodynamic clinicians endorsed a preference for empathic and nonjudgmental approaches, while cognitive-behavioral therapists gave their highest ranks to setting treatment goals and asking for information. Both groups gave high ratings to items reflecting a focus on the individual patient and items referring to clarity, coherence, and skill. For instance, “Therapist communicates with patient in a clear, coherent style” was ranked third by both groups. This and four other elements were notably common to the fourteen highest-ranked items in the two therapies. These included “Therapist adopts supportive stance,” “The patient's treatment goals are discussed,” “Therapist asks for more information or elaboration,” and “Therapist is sensitive to the patient's feelings, attuned to the patient, empathic.” The items “Patient experiences discomforting or troublesome (painful) affect,” and “Patient achieves a new understanding or insight” were also highly ranked by both groups. The significant agreement on specific items suggests that there are shared components in the treatment approaches to PTSD of psychoanalysts, psychodynamic clinicians, and cognitive-behavioral therapists.
This is the first study in a series that will explore and compare interventions for PTSD as reported by practicing clinicians of psychoanalytic, psychodynamic, and CBT orientations. Because clinician consensus indicates that psychodynamic psychotherapy may offer various benefits for treating patients with PTSD, especially those with interpersonal problems (American Psychiatric Association 2004), it is important to identify ideal interventions for PTSD as reported by psychodynamic clinicians, and to understand how psychodynamic paradigms differ from those reported by clinicians who adopt therapies that have already found empirical support (CBT and EMDR). The findings from these studies may support the development of a manual-directed, testable psychodynamic therapy of PTSD and, eventually, to another effective evidence-based treatment of this disorder.
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AMERICAN PSYCHIATRIC ASSOCIATION (2004). Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Am. J. Psychiatry 161 (Suppl). [Related→]
BEUTLER, L.E., MACHADO, P.P.P.S., & NEUFELDT, S.A. (1994). Therapist variables. In Handbook of Psychotherapy and Behavior Change, ed. A.E. Bergin & S.L. Garfield. 4th ed. New York: Wiley, pp. 229-269.
BROM, D., KLEBER, R.J., & DEFARES, P. B. (1989). Brief psychotherapy for post-traumatic stress disorders. Journal of Consulting & Clinical Psychology 57: 607-612. [Related→]
CHAMBLESS, D.L., & OLLENDICK, T.H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology 52: 685-716.
HERMAN, J. (1997). Trauma and Recovery. New York: Basic Books.
JONES, E.E. (1985). Manual for the Psychotherapy Process Q-set. Unpublished manuscript, University of California, Berkeley.
JONES, E.E. (2001). Therapeutic action: A new theory. Am. J. Psychother. 55: 460-474. [Related→]
JONES, E.E. & PULOS, S.M. (1993). Comparing the process in psychodynamic and cognitive-behavioral therapies. Journal of Consulting & Clinical Psychology 61: 306-316. [Related→]
RODRIGUEZ, B.F., WEISBERG, R.B., PAGANO, M.E., MACHAN, J.T., CULPEPPER, L., & KELLER, M.B. (2003). Mental health treatment received by primary care patients with PTSD. Journal of Clinical Psychiatry 64: 1230-1236.
ROTH, A., & FONAGY, P. (1996). What Works for Whom? A Critical Review of Psychotherapy Research. New York: Guilford Press.
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Schottenbauer, M.A., Arnkoff, D.B., Glass, C.R. and Gray, S.H. (2005). Abstracts of the 2005 Poster Session of the American Psychoanalytic Association Winter Meeting. J. Amer. Psychoanal. Assn., 53(4):1315-1320