What many people imagine when thinking about psychotherapy or psychological treatment is psychoanalytic or psychodynamic treatment-the aloof and distant shrink sitting back, taking notes, and making interpretations of the products of the analysand's (the person being "psychoanalyzed") mental productions, thoughts, images, dreams, and so on. In some ways, associating psychological treatment with psychoanalytic or psychody-namic treatment is fair because it was one of the first, if not the first, therapy modalities and continues to be widely used to this day. Before we go on, however, let me clarify the issue of psychoanalytic versus psychodynamic therapy. Psychoanalytic typically refers to treatment and therapy methods that originated with Sigmund Freud and those who developed his ideas after him but stayed close to home and more strict in their adherence to Freud's ideas. Psychodynamic is a broader term and includes psychoanalytic therapy that uses psychoanalytic theory and its countless permutations as both theoretical and practice bases, including object relations theory, attachment theory, the neo-Freudians, the British school of psychoanalysis, and so on. From this point on, we will use psycho-dynamic to refer to the treatments in this chapter.
Psychodynamic psychotherapy is a form of therapy that utilizes the relationship between the therapist and client to elucidate the unconscious workings of the mind as they manifest in client behaviors, thoughts, dreams, and relationships. Specific attention is paid to the relationship dynamics between therapist and client, with issues of transference and countertransference representing the center of this focus. The clinical tool of interpretation of client behaviors and thoughts in light of the client's history and experience is used to bring awareness to connections between unconscious processes and current issues. This insight is used to alter behaviors and break the hold of the unconscious on current behavior, thought, emotions, and interpersonal dynamics. In addition to insight, the process of working through is used as a means of exploring the continuing role of the unconscious in ongoing experience. More interpersonally oriented psy-chodynamic therapies focus on what is called the corrective emotional experience, a form of relational learning that occurs as a therapist helps a client relearn relationship dynamics and function more effectively. In many ways, psychodynamic therapy is a form of behavioral and cognitive analysis within the context of a real relationship, the data from which is used for change. The ultimate goals of psy-chodynamic therapy, generally speaking, include furthering the development and maturation of personality, helping a patient become more fully aware of conflicts and his or her contributions to current issues, helping a patient become more fully aware of defenses and adaptations and that he or she distorts reality, helping the patient develop more mature defenses, helping the patient develop healthier ways and means to express impulses; and helping the patient gain a general increase in ego strength (Cash, 2002; Kudler, Blank, & Krupnick, 2000a, b).
There are numerous schools of psychodynamic therapy, and it would be impossible to touch on the nuances of each in this space. However, each of them has the elements in common mentioned earlier. Psychodynamic therapies for PTSD are also diverse, but they all have a psychodynamic formulation of patient symptoms and functioning as their base or core. In psychodynamic theory and therapy, a posttraumatic symptom is an adaptive attempt to manage the trauma (Kudler et al. 2000a, b). (For more on the psychodynamic theory of PTSD, see Chapter 7.) Trauma overwhelms us, and in response we engage in psychic defensive action and eventually will return to a state of balance between psychological resources and environmental demands (a situation that traumatic stressors obviously strain). Kudler et al. (2000a) state:
In PTSD, [mental] equilibrium has not been reestablished because the adaptive process, itself, has been overwhelmed. The defenses become entangled with the traumatic impressions against which they were meant to defend. The resulting complexes are symbolically represented as symptoms. (p. 181)
Specific psychodynamic psychotherapies have been developed, including the work ofJohn Briere, Mardi Horowitz, and J. Lindy. Before we get into the specific therapies, Kudler et al. (2000a, b) make some recommendations before engaging in psychodynamic therapy in general and with PTSD sufferers specifically. They cite Gabbard's (1994) list of nine patient and situational characteristics indicating the possible use of psychodynamic therapy:
1. Strong motivation to understand oneself.
2. Suffering that sufficiently interferes with life.
3. The ability to regress and give up emotional control and then to come back from this and reflect.
4. Tolerance for frustration.
5. A capacity for insight and psychological mindedness.
6. Intact reality testing.
7. Meaningful and enduring object relations.
8. Reasonably good impulse control.
9. Ability to sustain employment.
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