To refer back to Bromfield’s comment on the “rich and intriguing” nature of psychoanalytical approaches to PTSD, Freud and his following early psychoanalysts Freud, A., DATE, Klein, DATE, Bowlby, DATE, Lacan, DATE) paved the way for research into the multiplex diagnosis which is PTSD and provided many questions and possibility for future research. However, case studies may not be enough evidence to prove its success, and when dealing with an individual’s psyche and psychological welfare, to use safer option of treatment such as CBT may be more ethically sound. It must be noted that psychoanalytical treatment cannot be discounted entirely, it is the lack of research into the area, rather than the treatment itself which is at fault in this instance. Although the need for treatment for PTSD is understood, a standardised form of treatment for all sufferers is not.
On the other hand, children, as individuals who are still developing psychologically, may need an integrated approach involving research from cognitive behavioural, educational, neurological and biological psychiatric theorists and therapists alongside psychoanalytical therapy in order to create a tailor made treatment. Child therapy, especially for PTSD, is complex, and needs to be finely balanced in order for individuals to receive optimum treatment and stand better changes of progression and recovery.
Although PTSD is a disorder which has been treated for many years with varying levels of success, the scarcity of research, combined with high rates of co-morbidity (van der Kolk, 1996) means that there may be individual factors which are not yet fully understood may impact on the patient’s response to trauma and severity and complexity of symptoms, which means that there may not be a blanket treatment (Yehuda and Macfarlane, 1995). With this in mind, perhaps for adults, approaches such as psychoanalytic theory may provide a more comprehensive approach, as they work from the ground up in order to treat underlying unconscious issues in addition to surface symptoms. As adults have, through time and self-exploration and reflection, have a better understanding of their psyche than children, this means that psychoanalytical treatment may have a larger impact and therefore effect upon them.
There is a growing argument that in order to define an optimum treatment for PTSD, the definition itself must be adapted and revised. Some academics argue that the drastic changes made in the DSM-5 have resulted in “excessively complex criteria, and generating unacceptable levels of diagnostic discordance” (Weathers, 2017, p. 122) whereas others have responded by pointing out the years of group work, literature research, debates and secondary analyses that went into the APA approved the substantial criteria and diagnostic changes (Pai et al., 2017). Despite criticisms, it has been acknowledged that the new diagnosis of PTSD is, whilst not perfect, a positive step in the right direction which is, in turn, a step towards a recognition of the most efficient method of treatment.
Whilst psychoanalytical therapy for children is a “rich and intriguing” area (Bromfield, 2003, p.13), it can be argued that without the scientific empirical backing to support this, it is a time, money and energy consuming process which is emotionally and psychically difficult for both parent and child, which may not end with any significant progress, depending on the child. When attempting to help young traumatised children who are still developing a conscience and understanding of insight, it may be more prudent to use the more ‘tried and tested’ route of TF-CBT beforehand.
It could be argued that psychoanalytic therapy, particularly for children, is notoriously difficult to study on an empirical basis, due to the fact that a very complex form of therapy, and is also difficult to standardise, because of the importance of the unique connection between the therapist and child, child and parent and also the parent and therapist playing out alongside to each other (Bromfield, 2003).
With regards to RCTs for psychoanalytical therapy for child PTSD, one study compared thirty sessions of psychoanalytic psychotherapy to eighteen sessions of group psychoeducation (Trowell et al., 2002) and found higher rates of success for the psychoanalytical psychotherapy, however it could be argued that this was not a strong enough control group to draw assumptions from, as it is unclear if the indicative factor was the amount of sessions, the format of treatment (group therapy versus one on one), or the treatment itself. Also, Cohen et al. (2005) made the point that these RCTs have low generalisability, due to their small sample sizes.
Also like adult psychoanalytical therapy for PTSD, psychoanalytical play therapy for trauma has scarcely been studied on an empirical basis. CBT has been the subject of several studies regarding trauma-centred therapy for children (Cohen and Mannarino, 1997; King et al., 2000). One such study by Deblinger, Lippmann and Steer (1996, 1999) showed that children receiving therapy for sexual abuse who received Trauma-Centred Cognitive Behavioural Therapy (TF-CBT) either with our without a non-offending parent experienced a significant reduction in PTSD symptoms, in comparison to children receiving standard community care. In a further study (Deblinger et al., 2001) it was also shown to have a high level of efficacy in a group setting for children aged two to eight years old.
Whilst more recent studies of adult psychoanalytic therapy has begun to recognise the importance of bringing other individuals close to the patient into the healing process (Cukor et al., 2010), play therapy has recognised the importance of working in parallel to parents since its conception, at the same time as pointing out parents shortcomings or failures which need to be rectified in order to support their child’s treatment.
Similarly to adult psychoanalytic therapy for trauma, the aim of psychoanalytical play therapy is to overcome trauma and adjust to major life events by changing more than just surface symptoms. The overarching goal is for the child to resume healthy psychological development without the disruption of ego development that can occur as a result of trauma. The relationship between therapist and child is equally, if not more important than the relationship between the therapist and an adult PTSD sufferer, as the therapy is designed to provide a safe physical and psychological atmosphere in which the child can unconsciously explore their thoughts, feelings and emotions and if necessary, communicate these through transference with the therapist and utilise the therapist to ‘psychologically hold’ the child (Winnicott, 1945, 1975), in order to relieve some of the stress that the child cannot deal with internally. By allowing the child to re-enact painful and traumatic experiences through play, the child can take control of a situation that they previously felt powerless in, understand the feelings which made a tormenter act the way they did, and also to project difficult feelings without internal conflict or fear of consequences, making it a more concrete reality which is more comfortable and easily understandable (Jacobsen, 1954).
When treating trauma with psychoanalysis, a slightly different approach is taken with children, as opposed to adult patients. After Sigmund Freud’s earlier work into adult psychoanalysis, there were two main psychoanalysts who developed Freud’s work into becoming applicable for use with children. Klein (1932, 1975), drew comparisons between play therapy and free associations used in adult psychoanalytical therapy, as she believed that this was “the vehicle to making interpretations directly to even very young children’s conscious” (Bromfield, 2003, p. 1). The other psychoanalyst vredited with continuing and modifying his work in order for psychoanalysis to become applicable to children his daughter was Sigmund Freud’s daughter, Anna Freud (Freud, A., 1941). Part of the way she adapted previous psychoanalysis was to create a chronological timeline of the psychosexual stages of development in order to empirically measure normal psychological growth and development. This meant that if specific aspects of development were progressing at a slower pace than normal, or had regressed, for example, toilet training, there was a definitive symptomatic evidence that trauma had occurred.
Another method of treatment is cognitive behavioural therapy (CBT), which consists of a range of therapeutic techniques used to change distressing emotions by changing the individual’s thoughts, beliefs and behaviour, and has been shown to be successful when treating a wide range of anxiety disorders (Barlow and Lehman, 1996). However, this has been criticised when used to treat PTSD as it arguably only targets specific symptoms and is not applicable in what is perceived to be severe or complex trauma (Greally, 2013). Also, within the DSM-5, PTSD is now categorised under Trauma and Stressor-related Disorders, as opposed to the previous category of anxiety disorders, due to the additional emotions attached to the disorder such as guilt, shame and anger. This suggests that there is a need to adjust treatment accordingly and to move away from cognitive behavioural approaches to treatment (Pai, Suris, North, 2017).
There are several treatment paths which can be taken by clinicians in an attempt to treat trauma patients, however many are flawed or restricted in their approach. For example, pharmalogical options are often helpful, however they have both mental and physical side effects, and can be rejected by patients who prefer to deal with the underlying causes rather than surface symptoms. Furthermore, it is argued that patients who do accept pharmalogical help, only receive a temporary reprieve from symptoms, and if this is used as a long term measure rather than a window in which to allow patients to consider other treatments, it can lead to a dependency and addition that contradict the popular belief that PTSD victims need to regain control of their own lives as part of their recovery (Green, 2003).
This case illustrates the need for a psychoanalytical approach to dealing with adult trauma, as a purely symptom-oriented approach towards Ms. A.’s treatment by her first psychiatrist resulted in added issues; she became dependent on her psychiatrist, and the drugs prescribed, whilst these two factors kept her unaware of her anger towards her father and husband, therefore not allowing her to deal with the unconscious issues which worsened her post traumatic stress symptoms and anxiety. One the other hand, although there are many case reports detailing successful psychoanalytical and psychodynamic treatments of PTSD, there are very few empirical studies of the efficacy of this type of treatment (Gaskell, 2005). In a review of existing treatments, for PTSD in adults, Gaskell only found one randomised clinical trial (RCT) by Brom (1989). Whilst positive, this indicates a need for further research in order to support the findings in this particular RCT.
One clinical case which Chertoff uses to illustrate this point is that of ‘Ms. A.’, who was treated by Chertoff for panic attacks, citing symptoms such as a sense of “impending doom, difficulty sleeping and nausea”. She is described in the case study as being convinced that she had brain damage as a result of a hallucinogen that she had ingested without her knowledge, at a party which her husband took her to. Chertoff asserted that the extent of Ms. A.’s trauma symptoms were exacerbated both by her psychiatrist at the time immediately prescribing a pharmalogical course of treatment with anti-anxiety medication, and also her repressed anger towards her husband for his choice in friends, and the situation which he put her in by taking her to the party. Chertoff argues that ego regression appeared to be the main determinant of Ms. A.’s symptoms, as her domineering father had disrupted her ego development and become a source of trauma for her in childhood, contributing to her choice in husband, and lack of assertiveness, which became apparent in her repressed anger towards her husband.
Although adults suffering from trauma may suffer from PTSD as a result of their childhood, it may also be a result of trauma that has occurred in later life. Chertoff (1998) studied the use of psychoanalytic ego psychology in patients who have acute symptoms of trauma as a consequence of a specific experience in adulthood. In ‘Psychodynamic Assessment and Treatment of Traumatized Patients, Chertoff used Anna Freud’s (1967) five factors, and van der Kolk’s additional sixth (1987) in order to provide a framework for assessing the impact of trauma on an adult patient and subsequently the most efficient treatment method. The second of these factors is ‘sensitisation due to prior trauma’. This takes into account Freud’s repetition compulsion (Clark and Crawley, 2002, Freud, 1920). However, Chertoff (1998) accepts the criticism that it can be easy for a clinician to miss this delayed onset of symptoms, as the patient themselves may not be consciously aware of the previous trauma. Therefore, in depth long term psychoanalytical treatment is recommended in order to treat patients. Rose (1986) found that short term psychodynamic therapy for adult survivors of sexual assault was often inadequate to treat persistent symptoms, even in patients who presented no previous psychopathology. Likewise, Kessler et al. (1995), found that although patients who were treated shortly after the traumatic event showed signs of improvement, one third of patients with an index episode of PTSD failed to recover from the symptoms in the long run.
Psychodynamic therapies with regards to PTSD are described by as seeking to “re-engage normal mechanisms of adaptation by addressing what is unconscious, and in tolerable doses, making it conscious” (Kudler et al., 2000, p. 339). Through sessions with a clinician, psychoanalysis is used to resolve unconscious conflicts and issues which were provoked by the traumatic event, using techniques such as transference, and an exploration of desires, fantasies and fears.
Ego-psychology oriented psychoanalysts define trauma as “an external event, or series of events, that specifically overwhelms ego defences, causing the traumatised person to regress to earlier modes of functioning” (Chertoff, 1998). An example of this would be an adult who previously used humour to diffuse tense situations, who suffered a severe trauma then became irritable and aggressive in subsequent similar scenarios. Initial psychoanalytical assessment would usually take place over approximately three sessions, each session lasting one hour in length. Whilst exploring the patient’s previous and current problems, and early and recent social relationships and development, the therapist would also assess the patient’s mental health state.
In later psychoanalytical study of trauma, early studies into ego development and attachment theory have been referenced (Loevinger, 1976, Gold, 2000, Marx, Heidt and Gold, 2005), particularly in relation to trauma as a result of childhood sexual abuse. Freud believed that early childhood trauma, between the ages of three and five years old, had a direct impact on the development of the ego, which operates as a mediator between external situations and circumstances, the id, and the superego. Freud hypothesised that this disruption of ego development could lead to the individual having difficulty in impulse inhibition, in particular impulses that could lead the individual to harm. Following from this, an individual with impaired or disrupted ego development would not be able to stop themselves from repetition compulsion, and furthermore, stop themselves from controlling impulses later in life which may lead to further traumatic experiences.
By studying the criterion set out by the DSM-V, it begins to become clear how Psychodynamic theorists and practitioners relate trauma back to early Psychoanalysis, and can develop treatment of the symptoms of trauma for both children and adults based on this early Psychoanalysis. Often hailed as the founder of Psychoanalysis, and the subsequent Psychodynamic therapies that followed, Freud’s work focused greatly on trauma, and how his talking-therapies could manage and relieve the symptoms that come from severe trauma, whether repressed childhood trauma or a significant traumatic event later in life. Freud believed that patients having experienced trauma unconsciously re-visit the traumatic event through what he termed as ‘repetition compulsion’ (Clark and Crawley, 2002), in which patients re-enacted the experience in several ways. He noted that patients often re-lived the experience through dreams, and also through acting out repressed experiences. An example of this used in his essay ‘Beyond the Pleasure Principle’ (Freud, 1920), was that patients tended to use transference during therapy, and that although the patient may not remember being defiant of his parents’ authority, he was likely to act that way towards his doctor in an effort to retaliate against his parents in an earlier stage of life. This caused conflict with some of Freud’s own earlier work, as he struggled to reconciliate this notion with the fact that the repetition of a distressing experience went against the pleasure principle, in which the individual is constantly aiming for gratification and pleasure in all acts that he carries out.
Although trauma can also be physical, psychoanalysis aims to counteract psychical trauma, which can, but does not always, go hand in hand with physical trauma. Since 1980, there has been a renewed interest in psychoanalytic applications to psychological trauma, and its impact upon both children and adults. The DSM-V definition of post-traumatic stress disorder (PTSD) involves the person in question being exposed to actual or threatened injury, death or sexual violence, whether that is by witnessing the event, direct or indirect exposure. Other criterion include persistent re-experience of the traumatic event and avoidance of stimuli related to the event, accompanied by negative thoughts or feelings (DSM-V, 2013). Trauma centred Psychoanalysis is often carried out on the basis that “(1) trauma is relational, (2) trauma is a complex phenomenon involving both a shattering experience and efforts at restoration, and (3) trauma goes hand in hand with dissociation” (Brothers, 2009, p. 51). Psychoanalysis has been used for several decades in the treatment of trauma, particularly Post Traumatic Stress Disorder in war veterans. Whilst the reasoning behind psychoanalysts understanding of trauma can be complex, in recent years a framework has been developed in order to make Psychoanalysis an empirically evidenced method of combating trauma and the after effects, both in childhood and in later years.