Brief Psychodynamic Treatment of PTSD

Janice L. Krupnick
Georgetown University

This article describes a brief psychodynamic psychotherapy for adults suf-

fering from PTSD following exposure to a single traumatic event, such as
tragic bereavement, assault, or loss of a body part through surgery. It uses
a supportive therapeutic relationship to uncover what the specific event
and circumstances that follow mean to the individual and the obstacles to
normal psychological processing of these events. Using this 12-session
treatment model, therapists pay particular attention to the individual’s cur-
rent phase of response and the typical ways that the individual avoids
threatening information. Making links among the recent trauma, earlier
developmental experiences that may have rendered the individual vulner-
able to the development of PTSD, and ways that conflicts are reenacted in
the therapeutic dyad, dynamic therapists seek to help traumatized individ-
uals re-establish a sense of coherence and meaning in their lives. A case
illustration is provided to demonstrate the phases and techniques in this
approach. © 2002 Wiley Periodicals, Inc. J Clin Psychol/In Session 58:
919–932, 2002

Keywords: developmental history; psychodynamic therapy; recovery

environment; PTSD

Psychodynamic theorists and practitioners have long been interested in the psychological
consequences of trauma. For example, as early as 1917, Freud explored the differences
between “normal” grieving and “pathological” melancholia in response to loss. However,
because posttraumatic stress disorder (PTSD) did not enter the psychiatric nomenclature
as a formal diagnosis until 1980, dynamic treatments specifically designed to address the
constellation of signs and symptoms of this disorder, perforce, emerged only after that
time.
This article will describe one of the better-known and investigated psychodynamic
approaches to PTSD, that is, the brief trauma-focused psychotherapy elucidated by Horo-

Correspondence concerning this article should be addressed to: Janice L. Krupnick, Department of Psychiatry,
Georgetown University, 311 Kober-Cogan Hall, 3800 Reservoir Road, NW, Washington, DC 20007.

JCLP/In Session: Psychotherapy in Practice, Vol. 58(8), 919–932 (2002) © 2002 Wiley Periodicals, Inc.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.10067
920 JCLP/In Session, August 2002

witz and colleagues (Horowitz, 1997a; 1997b; Horowitz et al., 1997). This model, a
12-session individual treatment for adults who have experienced a single traumatic event
in the recent past, derives from both Horowitz’s early experimental work (e.g., Horowitz
& Becker, 1972) and treatment models developed by brief dynamic therapy proponents
such as Malan (1979), Mann (1973), Luborsky (1984), and Strupp and Binder (1984). It
incorporates key elements of general psychodynamic psychotherapy, for example, bring-
ing conflicts into conscious awareness, helping individuals gain insight into their diffi-
culties through scrutiny of the therapist–client relationship, with particular attention paid
to ways in which clients may react to their therapists on the basis of unresolved feelings
related to significant figures of the past, and analysis of how they keep threatening thoughts,
feelings, and impulses from awareness. What distinguishes this intervention model as a
PTSD treatment is its trauma focus and the attention devoted to the specific states of
mind, models of relationship and self-concept, and thematic contents that are particular
to individuals who have PTSD subsequent to the experience of trauma. As noted before,
this is a treatment model that was conceived as a therapy for survivors of a single trau-
matic event, such as tragic bereavement, assault, or loss of a body part through surgery.
It is not well suited to chronic or “complex” PTSD, where a longer-term or more-
comprehensive approach would be indicated.

Theoretical Foundations
Both experimental studies and clinical observations of survivors of trauma have shown
that individuals typically respond in characteristic ways to catastrophic events. It is com-
mon for survivors to experience an initial sense of shock and disbelief that gradually
gives way to episodes of intrusive thoughts, images, and feelings and a heightened sense
of physiological arousal, particularly in situations that are reminiscent of the trauma. In
the weeks to months that follow the stressful event, most individuals experience various
degrees of life disruption, often with intense psychological pain. Over time, however, and
repeated contemplation of what has occurred, interspersed with periods of turning away
from such a review, they gradually are able to incorporate the painful reality of what has
occurred. They make necessary psychological revisions in their view of the world, come
to terms with what they have experienced, and move on with their lives.
As numerous studies (e.g., Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995)
have shown, however, a certain percentage of individuals do not resume work, study, or
investment in relationships after trauma exposure. They become caught in excessively
prolonged or intense reactions, with unremitting symptoms of intrusion and/or hyper-
arousal, or they remain unable to confront the reality of what has occurred, becoming
emotionally numb, avoidant, withdrawn, or involved in substance abuse or risk-taking
behaviors.
Those who seek psychotherapeutic help typically do so because of intrusive thoughts
and heightened arousal. These individuals feel that their emotions are out of control and
that they cannot cope. It is not uncommon for survivors of traumatic life events also to
feel wracked by negative emotions, such as fear, anger, despair, shame, and/or guilt. In
contrast, those who become “stuck” in states of prolonged denial or avoidance may gen-
eralize their lack of response to all their emotions, avoiding pain, but also joy and the
capacity for intimacy and deep feeling. They may feel cut off from themselves and/or
take drugs or alcohol to maintain distance from feared emotional states.
The aim of the psychodynamic psychotherapist is both to identify the phase of trau-
matic response in which the individual seems to be caught and to formulate the aspects of
the event itself, the individual who experienced the event, and the pre- and post-event
 Brief Psychodynamic Treatment of PTSD 921

environment that interfere with normal psychological processing and integration of the
trauma. In the context of the therapeutic relationship, psychodynamic psychotherapy
seeks to uncover and help the traumatized individual confront what the specific event and
circumstances that follow mean for his/her life and well being. In doing so, the clinician
strives to help the individual reestablish a sense of purpose and meaning in life and hope
for the future in spite of the pain and loss incurred by the trauma.

Phases of Treatment
An important consideration before embarking on a brief uncovering intervention for
PTSD is determining whether a time-limited dynamic approach is the most suitable treat-
ment model for the individual in question. It is to be expected that someone who recently
has experienced a horrific event will be shaken and symptomatic. Functioning may be
compromised, as a good deal of emotional energy may be drawn into simply coping with
a vast array of disorganizing events and emotions. There should be evidence of pretrauma
emotional stability, however, because dynamically oriented PTSD treatment, although
offering structure and support, also can be painful and intense. Thus, careful evaluation
of the individual is essential for increasing the likelihood of therapeutic success.
In addition to inquiring about the nature and circumstances of the traumatic event,
including the events leading up to the trauma and the circumstances and reactions fol-
lowing it, it is essential to obtain a comprehensive developmental history. This includes
descriptions of important people in the individual’s past and current life, as well as the
quality of the individual’s relationships with these figures. Brief dynamic therapists such
as Malan (1976) have suggested that only individuals with a history of at least one prior
meaningful relationship be considered for this type of treatment. Owing to the brevity of
the intervention, individuals must come to treatment already possessing the capacity for
basic trust. However, the sense of trust in others may be tested severely as a consequence
of their recent trauma. The evaluating clinician also should ask about the individual’s
trauma history. For example, has the person previously sustained other stressful life events
or losses, and, if so, to what extent may there be unresolved feelings about those expe-
riences that may be reactivated under the stress of the recent trauma.
The evaluation also includes an assessment of the individual’s psychological strengths
and weaknesses. It addresses such issues as the person’s characteristic modes of coping
with the world and their emotional states. It assesses the individual’s capacity for psy-
chological thinking, perhaps through the use of a trial interpretation in order to get a feel
for the person’s facility in using psychological explanations for distress. A comprehen-
sive evaluation typically deals with issues pertaining to assertion and aggression, assess-
ing whether the individual has conflicts or difficulties in that area of functioning. Also of
interest is the person’s level of self-esteem and his/her basic self-image. Furthermore,
what is the person’s capacity for intimacy and engagement in a relationship? Does he/she
have a history of tumultuous relationships or satisfying, mutual attachments?
Finally, what is the person’s recovery environment like? Does he/she have friends,
family, and affiliations that provide support, or is the environment an additional source of
stress? Does the individual have a confidante with whom it is possible to share distressing
thoughts and emotions? Does the individual have adequate financial resources?
The initial evaluation can provide invaluable data across a range of domains, sug-
gesting the phase of response that is most problematic for this individual, identifying
relationship potentials that may be actualized during the treatment process, and elucidat-
ing problematic thematic contents that remain undigested and unresolved. The various
bits of information derived in the first session can be woven together to help the dynamic
922 JCLP/In Session, August 2002

therapist determine where and how to intervene, at which depth, and with which balance
of support versus exploration. Whereas the larger question of why this event caused this
response in this person awaits further exploration and elaboration, this vital preliminary
data should start the wheels turning.
This model of brief psychodynamic treatment can be conceptualized as composed of
three distinct phases, each with its own tasks and goals. The task of the pretreatment
evaluation phase is to determine whether a short-term dynamic approach is likely to
ameliorate—or at least significantly reduce—the individual’s symptoms of PTSD and to
provide an initial road map for intervention. In order to assess whether the individual
meets criteria for the PTSD diagnosis and to obtain a sense of the severity of the disorder,
the clinician can administer a structured scale designed for diagnostic purposes, such as
the Clinician-Administered PTSD Scale (CAPS; Blake et al., 1990) or the PTSD module
of the Structured Clinical Interview for DSM-IV (SCID; Spitzer, Williams, Gibbon, &
First, 1990; APA, 1994). These and other PTSD measures, although providing useful
information about the frequency and severity of symptoms in the individual client, also
allow the therapist to compare the client to others with the PTSD diagnosis.
The dynamic treatment of PTSD is concerned not only with symptoms, however; its
primary emphasis is the understanding of the meanings of the trauma to individuals in
terms of how they view themselves, others, and the world in which they live. It seeks to
uncover whether basic assumptions have been shattered as a consequence of the trauma
(Janoff-Bulman, 1992) and the obstacles to integration of the event(s).
One of the chief tenets of client selection for brief dynamic therapy is that the clini-
cian and client should be able to arrive at a mutually agreeable focus for the work ahead.
Whereas the client’s recent experience of trauma and the responses that follow may make
him/her more vulnerable and perhaps wary of others, the trauma also serves to organize
and focus the treatment. Confronting and working through the meanings of the traumatic
event places boundaries around the treatment that make it particularly amenable to a
focal approach. In contrast to longer-term treatments, the goal is not personality trans-
formation, although aspects of personality certainly enter into the way that a given indi-
vidual will perceive, interpret, and respond to experiences. Nuances of personality may
determine the nature of the individual’s support system and the ways in which the person
avoids taking in threatening information. Thus, attention to the client’s personality style
provides clues about how to phrase interventions and suggests ways that the individual
may construe the therapeutic relationship.

The Initial Phase

Tasks of the initial phase of treatment (Sessions 1– 4) entail establishing a sense of safety,
forging a therapeutic alliance, and allowing the person to tell his/her trauma story. In
contrast to many others in the person’s environment, the therapist is neither bored nor
overwhelmed by hearing the details of traumatic events. Rather than telling the person
that he/she should try to put intrusive thoughts out of mind, as some others might do, the
clinician encourages the telling and retelling of events, having the person add as many
relevant details as possible. Seeing the therapist tolerate the story and the emotions it
instigates provides a powerful message that the trauma can be explored without driving
away, injuring, or overwhelming either the self or the therapist. Traumatic events may
convey a sense of danger, but the therapeutic encounter should engender a sense of safety.
Before the client risks further disclosure, he/she needs to know that the therapist is
concerned, compassionate, and nonjudgmental.
 Brief Psychodynamic Treatment of PTSD 923

Part of ensuring the sense of safety includes conveying the message that the medicine—
that is, the treatment—will be administered in tolerable doses. This means that the ther-
apist will not let the client waste his/her time in treatment, but also, at the same time, will
be respectful of the client and that person’s coping style. The therapist should not force
the client to go any faster or deeper than that person can tolerate. Clients tend to experi-
ence a tremendous sense of relief when they realize that the therapist will not force them
to take on anything that they are not ready to handle. Thus, avoidances based on the fear
of being overwhelmed can be set aside. As the client develops the conviction that the
therapist is not only concerned and interested in him/her, but also competent to help with
his/her problems, the client also develops the sense of trust that is necessary to venture
forth into anxiety-laden territory. Techniques traditionally used in psychodynamic psy-
chotherapy, such as exploration, clarification, and provision of support, most commonly
are used in this phase of treatment as the therapeutic dyad forge their collaborative bond.
The therapist is attuned particularly to the client’s symptoms in the initial phase of
treatment. For those whose experiences are primarily in the domains of intrusive mem-
ories and hyperarousal, the clinician may help the client structure his/her time, advise
reducing external demands and pressures, and might recommend the use of anti-anxiety
or antidepressant medication to help the client with sleep problems or to achieve a greater
sense of emotional control. Gentle exploration and reassurance about the step-by-step
plan of action encourages individuals who appear to be fixated in states of numbness or
over-control to relax their guard to some degree so that they can begin to experience some
of the thoughts and emotions they effectively have sealed off.

The Middle Phase

The middle phase of treatment (approximately Sessions 5–8) marks the “working-
through” phase of therapy. As symptoms subside or cease to occupy center stage, thera-
pist and client can focus more on the underlying beliefs, attitudes, and thematic contents
that have made the particular trauma so difficult to integrate. Knowing the particular
constellations of thought and emotion that commonly emerge in survivors of trauma
(Krupnick & Horowitz, 1981) can help the therapist anticipate and identify salient issues
as they emerge in the treatment context. The therapist also can address the methods that
are used by the client to keep from awareness those personally unacceptable impulses,
wishes, or feelings. Being mindful of tact and timing, the therapist employs a more-
interpretive mode in this phase of therapy, permitting the client to complete trains of
thought that previously were stymied.
During this phase of treatment, the therapist also explores maladaptive models of
negative self-images and interpersonal relationships that may have emerged as a conse-
quence of the trauma experience. For example, individuals who place great value on
being able to control their emotions and their capacity to endure life’s adversities might
see themselves as weak and vulnerable when they cannot control their tears after a violent
assault. Helping them revise their expectations of themselves under such circumstances
and clarifying that the therapist, as well as most others, would not be critical of someone
for this behavior can help such individuals review and revise their own rigid self-
demands. Making links between relationship patterns that develop between therapist and
client, aspects of the trauma and earlier developmental experiences point to ways that the
client may be reacting to current events with attitudes and perceptions based on earlier
experiences. Helping clients distinguish between real versus distorted meanings of events
(e.g., a parent who feels responsible for his child’s suicide because he had once wished to
924 JCLP/In Session, August 2002

remain childless) usually reduces exaggerated feelings of shame or guilt and provides
them with permission to carry on with their lives. Helping individuals clarify the sequence
of events that led to the trauma and its aftermath can provide a sense of control and
coherence to individuals who felt only chaos and disorganization.

The Final Phase

Focus on termination in the final sessions (9–12) of treatment activates the sense of loss
that is inherent in any trauma situation. Whether the individual has lost a significant
other, a body part, or even a previously held fantasy of invulnerability, sadness and loss
must be confronted in any survivor of personal tragedy with PTSD. In contrast to losses
incurred as a consequence of the traumatic experience, however, the loss of the therapy
and therapist can be anticipated, planned, and approached with a sense of mastery. Client
and therapist may review what realistically has been achieved in their time together, as
well as what remains for the client to explore, to try to modify, and/or to reinforce after
the treatment is completed. Clients are encouraged to express whatever anger and sadness
they may feel regarding disappointments in the therapy and encouraged to continue work-
ing on the issues that initially brought them to treatment. The losses inherent in termina-
tion are linked to those pertaining to the trauma and, where appropriate, to earlier endings,
separations, losses, and deprivations. Clients are helped to anticipate a natural period of
mourning after the therapy is completed, with possible exacerbations of symptoms on
anniversaries of the trauma.

Case Illustration
Presenting Problem/Client Description

Susan, a 54-year-old African-American woman, sought treatment for symptoms of PTSD

five months after her husband Tom’s death in a plane crash. Tom, a computer sales rep-
resentative, had been returning from a business trip when his plane exploded in midair,
leaving no survivors. Susan was notified of her husband’s death by airline officials who
also requested Tom’s dental records, as most of the bodies were burned beyond recognition.
Susan’s first reaction to the news of her husband’s death was shock and disbelief. He
had been in perfect health only days before and now she would never see him again.
Furthermore, it was difficult to feel that the corpse she had buried was really her husband
because the body parts returned to her bore no real resemblance to Tom. The suddenness
of the death and the strangeness of the circumstances provided a surreal quality to events.
Susan could not believe that her husband was dead. She kept expecting him to call,
apologizing for having missed his flight, and promising to take the next plane out.
After her husband’s death, Susan entered a denial phase in dealing with her grief. Her
friends had remarked on the extent to which she appeared strong and capable of coping
with her feelings, but Susan knew from early on that she felt more dazed than strong.
Soon after the funeral, Susan returned to her job as a manager at a retail store. She spent
an inordinate amount of time at her office, leaving little time to contemplate her feelings
about, and reactions to, the death. This behavior served the purpose, at least for a while,
of keeping her so busy that she was able to postpone feelings of grief that seemed too
overwhelming.
In the weeks before seeking treatment, however, this strategy was no longer working.
Susan began to experience episodes of intrusive thought and emotion, comparing the
feeling to going to the dentist and having the Novocain wear off. She found herself
 Brief Psychodynamic Treatment of PTSD 925

snapping at coworkers and, once she arrived home, experiencing episodes of uncontrol-
lable sobbing. Susan felt tense much of the time and started having nightmares about
explosions and burning bodies. She learned after the crash that Tom had not been required
to make this particular trip, but he had insisted on going. Susan now felt angry with him
for that decision.
Susan’s developmental history revealed that, although she got along well with her
father, her relationship with her mother had always been a source of tension. Her mother
had been severely depressed while Susan was growing up, and Susan had felt neglected
and abandoned by her. In response to Susan’s traumatic bereavement, her mother again
seemed preoccupied and self-absorbed.

Case Formulation

The therapist viewed Susan as a good candidate for brief dynamic therapy for PTSD. She
met criteria for the PTSD diagnosis by virtue of having had a traumatic experience, as
well as multiple symptoms of intrusion, avoidance, and hyperarousal. Although she had
not been present at the scene of the crash, she was called upon to view her husband’s
remains. Images of this grotesque sight repeatedly came to mind, causing her consider-
able anxiety and feelings of disgust. Susan replayed the scene of what she thought Tom’s
last few moments of life must have been like over and over again in her mind. She felt
guilty that she had not been with him, and she imagined how frightened he must have felt.
She also was flooded with feelings of overwhelming sadness punctuated by anger toward
her husband for having taken this unnecessary trip. At one level, she blamed him for
dying because he had not really needed to go. Susan also was infuriated with airline
officials whom she regarded as negligent and incompetent in determining the cause of the
crash. It seemed likely that pilot error was involved, but airline personnel had been less
than forthcoming in their responses, and they were dragging their heels in their promised
settlement to the families of crash victims. In addition to the nightmares that she had
begun to have about the crash, Susan acutely was aware of reminders of Tom’s death. She
found herself tensing up each Sunday at 4 pm, the day and time of the accident.
Susan tried to avoid thinking about her loss by throwing herself into her work with a
vengeance, yet she was having increasing difficulty in concentrating on the tasks at hand.
She was having difficulty staying asleep and was beginning to feel “hung over” due to
exhaustion. She had always been an impatient woman, but her persistent irritability and
intolerance of others was reaching a new level, and her support system at work was
beginning to show signs of strain. Susan felt detached from others whom she felt could
not understand what she was going through. She resented their feeble attempts to comfort
her and envied their perceived carefree lives.
An initial formulation of Susan’s problems suggested that she was an intelligent,
hard-working woman who was motivated for treatment. She was seen as primarily having
difficulties at the outset of therapy with symptoms of intrusion and hyperarousal that
made her feel as if she were losing her mind. These symptoms were particularly trouble-
some for her because of her markedly obsessional personality structure. She was a woman
who was used to having her life and her feelings under tight control.
Whereas Susan clearly had a number of emotional strengths, including the capacity
to tolerate the anxiety and sadness that the therapy might evoke, she also was assessed as
having a number of conflicts that could be addressed in a brief focused treatment. The
primary difficulty in the grief process appeared to be a feeling of unresolved anger toward
her husband. She blamed him for stubbornly taking a trip that she herself had advised
926 JCLP/In Session, August 2002

against, although she alternately said that she could understand his wish to deal with his
client in person, and she admired his perseverance and dedication to his work. After all,
she too was someone who derived a good deal of satisfaction from doing her job well.
Susan displayed a tendency to idealize her husband and their relationship despite her
acknowledgement of some marital problems earlier in their relationship. She displaced
her ambivalent or negative feelings onto the incompetent pilot of the plane, airline offi-
cials, and others who had not experienced this undeserved fate.
Although Susan presented as a feisty, independent individual, the therapist surmised
that she had conflicts in dependence–independence based on her history of deprivation in
her relationship with her mother and in an almost too heavy emphasis on her lack of need
of others’ support. She also seemed to feel guilty about her anger toward her husband,
reflected in her tendency to idealize him and their relationship. Although she complained
about the greedy airline managers and their reluctance to pay the survivors in a timely
fashion, she felt uneasy about profiting from her husband’s death. It did not seem right
that she should look forward to indulging herself when Tom’s life had been cut short
prematurely.
Susan did not want to spend the rest of her life alone, but she was uneasy about even
contemplating another romantic attachment somewhere down the line. She had received
a breast-cancer diagnosis and had had a radical mastectomy 10 years earlier, and she had
significant concerns about her appearance and desirability.
When the therapist shared her diagnosis of PTSD with Susan and suggested that they
embark on a time-limited treatment that would focus on her problems in coping with the
traumatic loss of her spouse, Susan agreed. She expressed eagerness to begin, and a
treatment contract was discussed, including 12 weekly sessions.

Course of Treatment
The initial sessions of therapy were spent in a retelling of the events leading up to, and
following, Susan’s notification of the crash, including a description of the reactions that
she was having at the present time. Susan noted that her ulcer had been acting up lately,
necessitating her taking time off from work to visit her physician, in addition to the time
she had to take to come to therapy. She did not know how she would keep up with all that
she had to do in light of all this time away from the office. The therapist responded that
this was not an ordinary time and she could not be expected to keep up in an ordinary
way. It was all right to give herself some time and space to take in all that had happened
to her. She had emotional work that needed to be taken care of, as well as the work at her
office. The therapist also explored Susan’s ambivalence about starting treatment, despite
the initial enthusiasm she had shown at the evaluation. Susan acknowledged that at the
time of the evaluation, therapy had seemed like a good idea. She had known a few people
who had been in therapy, and they had found it helpful. Now that she was actually start-
ing herself, however, she had mixed feelings. She feared what she might learn about
herself. Suppose she found that she really did not like herself all that well? Furthermore,
in the last few days, she found that she was forgetful and disorganized. She was forgetting
meetings at work, failed to return important phone calls, and she had misplaced a neck-
lace that Tom had bought her for their last wedding anniversary. She could not afford to
get more disorganized than this. The therapist acknowledged Susan’s anxiety, but sug-
gested that psychotherapy was more likely to help her gradually sort things out rather
than make her fall apart.
Susan also talked about her anger toward the pilot and the uncaring airline officials
who did not assess regularly the competence of their personnel. She railed at fate for
 Brief Psychodynamic Treatment of PTSD 927

selecting her for a punishment she did not deserve. She had been a good person; it was not
right and it was not fair. The therapist expressed empathy, agreeing that, indeed, it was
not fair. She also addressed what she thought might be an underlying anxiety for Susan,
that is, would the therapist be like the pilot of her husband’s plane, an incompetent indi-
vidual on whose watch it was inadvisable to journey into unfamiliar territory? Susan
acknowledged that she was anxious about beginning treatment. She had never before
tried psychotherapy, and she did not want to “crash and burn” emotionally.
The early sessions of treatment were spent building a relationship between therapist
and client. Susan tested the therapist’s capacity to tolerate hearing about the horrific
sights she saw at the crash site, including the distraught faces of other victims’ family
members. Susan was very tuned in to the therapist’s facial expressions and nonverbal
behaviors, as if she were studying the therapist’s responses to her reports. The therapist
provided reassurance that Susan’s reactions were common; these were typical responses
to an abnormal situation, not a cause for shame or self-disgust.
As Susan settled into treatment and the structure of her weekly time to confront the
horror of what had occurred, she began to feel less scattered and jumpy. The therapist’s
efforts to reconstruct events in a sequential manner, from the days before Tom left until
the present, helped Susan feel more organized and in control. With the therapist’s bless-
ing, she gave herself permission to reduce her workload temporarily, explaining to her
supervisor that she needed to take some sick leave. In contrast to the reproach that she
had expected from him, he was supportive and understanding.
As the therapy progressed, the focus shifted from Susan’s immediate emotional states,
which were increasingly better modulated, to a deeper exploration of the ways in which
she had difficulty in being supportive and understanding of herself. Susan revealed that
she and Tom had an argument the morning he left. She had been angry that he had
expressed reluctance to accompany her to the annual company picnic that was coming up
because he felt uncomfortable around her colleagues. Because of Tom’s social discom-
fort, Susan had held back from social engagements outside work with colleagues. She
had experienced that as a loss and resented Tom for it. She berated Tom for his social
inadequacy as well as his stubborn insistence on taking this trip, which she had deemed
unnecessary.
Wishing to make up before he left, he told Susan that he would take an earlier flight
home than the one he originally had planned so that they could go out to dinner together
that evening. Susan had been gratified that he was making an effort to please her at the
time, but now she felt guilty. It was because of her that he decided to take the fatal flight.
Had she not made such a fuss, he would have come home later and he would be alive. He
was not socially inadequate; it was she who was unreasonable and demanding. Susan felt
guilty now for criticizing Tom in any way. She felt that she was being disloyal and
betraying him, and she wished that she had never started an argument with him in their
last interaction. The therapist empathized with her feelings of guilt and responsibility, but
also pointed out that there was no way that Susan could have known that that morning
would be their last, or that the plane to which Tom had changed would crash.
Themes that were explored in the treatment included Susan’s anger at Tom for depriv-
ing her of a more-satisfying social life, contempt for his inflexibility, and shame about his
interpersonal inadequacy. She felt guilty for having these feelings, and she felt guilty for
expressing them to Tom. After all, she was not perfect herself, and Tom had been extremely
supportive of her during her cancer treatment and surgery. The therapist pointed out
Susan’s difficulty with tolerating her own anger toward Tom and clarified that it is com-
mon for survivors to feel angry at people who abandon them by dying. Although they
know that the person did not die deliberately to hurt them, it can feel that way emotion-
928 JCLP/In Session, August 2002

ally. The therapist also noted that it was not hurting Tom when she expressed her feelings.
In fact, he probably would have been very much in favor of her doing whatever it took for
her to deal with his death.
Although Susan realized intellectually that Tom died because of his presence on a
plane that crashed, that he chose to take that flight, and that there was no way that either
of them could have known in advance that that flight would be any less safe than the ones
before or after it, she felt responsible for his death at an unconscious level. She some-
times had entertained thoughts, particularly in the earlier years of their marriage, about
how she would be better off without him when he had balked about getting together with
others. Now she was free of him. Although she consciously was not aware of it, Susan felt
that her hateful thoughts had marked Tom for extinction. She also felt like an inflictor of
harm vis-à-vis her beleaguered, vulnerable spouse by yelling at him in their last conver-
sation. In this model of relationship, she saw herself as powerful and destructive and Tom
as weak and helpless. Because this image of herself gave rise to guilty feelings, it was
intolerable for her to stay with this set of ideas. Soon after embarking on this train of
thought, she would switch to another set of thoughts and images. In this alternate view,
which served the psychological purpose of reducing her anxiety about being an evil
perpetrator, Susan saw herself as a bereft waif who deliberately was abandoned by her
selfish stubborn husband. This relationship model was primed by her early experiences
with her mother, whom she also had seen as a willful abandoner, someone who did not
care how she felt because she was so involved with her own thoughts and feelings. This
view, which aroused her anger, equally was intolerable, and thus had to be avoided.
As the therapist got to know and observe Susan, she clarified to Susan the patterns
she observed. She said that she thought that Susan’s main difficulties in integrating the
trauma had to do, in part, with the suddenness and horrific nature of the death itself. In
addition, however, she thought that Susan had some predisposing characteristics and
experiences that made an event of this type particularly difficult for her. Susan seemed to
have had some experiences regarding loss that left her vulnerable, and she also had
certain patterns of perceiving and interpreting information that made her vulnerable to
the development of PTSD. For example, Susan’s characterological tendencies toward
perfectionism and her need for emotional control made it very difficult for her to accept
her rage toward Tom for dying. She did not feel that she was entitled to these feelings, and
she feared that she would lose control of her aggression, causing herself or others serious
harm. At the same time, she could not bear her feelings of helplessness, both about recent
events and about her emotional responses. Thus, Susan found it threatening to pursue
trains of thought about her anger toward Tom for changing his plans and for leaving her,
her anger toward others such as the pilot and airline officials whom she also held account-
able for her loss, and anger toward almost everyone else in the world who never had, and
probably never would have, to endure the misery that she currently was experiencing.
Acknowledging the full extent of her rage made Susan perceive herself as a vindictive,
vengeful person with exaggerated responsibility for destructive power. To avoid immer-
sion in these negative images of herself, Susan switched to a gentler view of herself, yet
one that was equally threatening. In this scenario, she was the innocent victim of hurtful
others and a random, destructive fate over which she had no control. This view served the
purpose of eliminating the image of herself as powerful and destructive, but left her
feeling alone and helpless, a feeling she knew from her childhood and could not tolerate.
The therapist interpreted these inferred states of mind and internalized relationship
and cognitive models to Susan, using as examples statements that Susan had made during
treatment. Links between Susan having felt ignored and abandoned by her mother when
she was a child and her response to the recent trauma also were explored and interpreted.
 Brief Psychodynamic Treatment of PTSD 929

Susan acknowledged the similarity in her mind to the two sets of losses. She added that
the abandonment by her mother, which the therapist had felt made Susan especially
vulnerable to the development of PTSD, was not just an experience of the past. Although
Susan’s parents initially had said that they would come to visit after Tom’s death, her
mother was now saying that she did not feel up to the travel that the visit would involve.
As had frequently been the case, Susan’s mother would not be there for her when she
needed her.
The other prior loss that was linked to Susan’s PTSD response was her history of
breast cancer and the loss of her breast. Although Tom had been available and supportive
throughout her ordeal, Susan continued to feel physically vulnerable and unattractive. As
long as Tom was alive and healthy, however, he could provide comfort and reassurance.
With his death, it became clear that he too was physically vulnerable, and Susan criticized
herself for recoiling at the grotesque sight of what had remained of his corpse. Tom had
never displayed horror at the vision of her scars. Again, the therapist tried to normalize
her response, pointing out that the burned remains of her husband had been a horrific
sight that would make anyone, and most of all someone who had cared about him, flinch.
Her reaction was not a sign of weakness, but rather a sign of being human. Furthermore,
Tom apparently had still loved her with only one breast. Why should it be impossible for
someone else to feel that same way?
As might be expected, Susan anticipated that the therapist would see her as she saw
herself, that is, as extremely powerful and destructive or as extremely weak and help-
less. Furthermore, as her mother had found her unworthy of attention and adequate
care, the therapist likely might be neglectful and abandoning. Opportunities to explore
these reactions came to the fore most clearly after the therapist returned from a one-
week vacation after the fourth therapy session and again during the termination phase
of the therapy. Although the therapist had informed Susan from the outset that the treat-
ment would be interrupted for a week because of the previously scheduled break, Susan
experienced the therapist’s absence as neglect and the impending termination as aban-
donment. The therapist explored Susan’s reactions to both the vacation and the impend-
ing loss of therapy and made the links between her reactions to termination and her
reactions to Tom’s death and her mother’s withdrawal. The therapist reassured Susan
that she was ending therapy not because she was undeserving and burdensome, but
because that had been their agreement all along, and because Susan was now ready to
move on. In contrast to her self-image as weak and vulnerable, the therapist pointed out
that Susan, in fact, had shown herself to be a bright and capable woman. She was no
longer a small, vulnerable child who needed her mother’s caretaking, a destructive Am-
azon who held the power of life and death, or an undesirable woman whom only Tom
could love.
Termination provided a number of opportunities for the therapist and Susan to sort
out emotional fantasies from objective realities. The therapist was able to identify Sus-
an’s worry that termination was a relief for the therapist, who must have felt bombarded
by the intensity of Susan’s rage. The therapist pointed out that although Susan saw her
anger as overwhelming, she, the therapist, had been neither depleted nor injured by it.
Just as Susan’s private thoughts and not-so-private words had not killed Tom, they had
not devastated the therapist. Furthermore, it had never been Susan’s appearance, needs,
or personality that had caused her mother to withdraw from her. The therapist clarified
what Susan knew intellectually, but had never integrated emotionally: Her mother suf-
fered from depression and always had been, and continued to be, preoccupied with her
own personal problems. Her withdrawal and unavailability were painful for Susan, but
they had not been reactions to Susan as an individual.
930 JCLP/In Session, August 2002

When the therapist explored Susan’s feelings about termination, Susan initially denied
that she felt angry or sad about treatment ending. Not that she meant to diminish or
devalue the therapist, but this loss was nothing compared to the loss of her husband,
especially the way that she had lost him. The therapist agreed that the ending of the
12-week therapy relationship was indeed a pale comparison to the 28-year marital rela-
tionship that had been taken from her without warning or preparation. Nevertheless, it
had been an important source of support to her at a time when Susan had been feeling
desperate, and she should not be surprised if she found herself aware and perhaps feeling
somewhat sad at this time for the next few weeks. The therapist praised Susan for the hard
work she had done in treatment and identified some areas that Susan might continue to be
aware of in herself, such as her tendency to think in black-and-white terms rather than
recognizing the shades of gray in many situations, the ease with which she slipped into
self-criticism and self-denial, and her proclivity toward perfectionism. Susan expressed
gratitude for the help she had received and agreed to come in for a follow-up visit in 4 to
6 months.

Outcome and Prognosis

Susan returned to therapy for two follow-up sessions. At the first follow-up session,
approximately 6 months after the completion of therapy, Susan was considerably more
realistic and accepting of her husband’s death. She still missed him and wished that she
had him back, but she no longer felt responsible for his death. She continued to feel
somewhat angry with her husband for making the unnecessary trip that ended his life, but
she understood that he believed that what he was doing was important for his job, and
perhaps he was right.
Susan had made strides in expanding her social contacts. She had formed a support
network, including three other widowed women, and she felt somewhat able to express
her feelings to these women. She had not actually dated by this time, but was open to the
possibility of this option in the future. She also was less pessimistic than she initially had
been about her prospects in this area.
Susan continued to experience some PTSD symptoms, including sensitivity to remind-
ers of the death. At times she avoided looking at her husband’s photograph because it
made her feel too sad. However, in spite of some continued symptomatology, Susan
reported feeling much better, and she no longer met diagnostic criteria for PTSD.
Susan was very positive about her therapy experience, stating that it had been par-
ticularly helpful to learn that in some ways she was more upset by her relationship with
her mother than her prior conflicts with her husband. For the first time, she was able to
express long-held feelings of resentment toward her mother, which was a liberating expe-
rience. Susan felt that the therapist had given her permission to be angry without judging
or condemning her. When the therapist did not express criticism of her for criticizing her
mother or Tom, she was able to reconsider her criticism of herself. Susan seemed to be
more accepting of her husband’s death and more accepting of herself.
Susan’s second follow-up session was 2 years after her husband’s death, approxi-
mately 1.5 years after the end of her brief PTSD therapy. At this point, Susan indicated
that she was feeling good. She was enjoying her work, finding that it provided her with
both intellectual stimulation and a good source of friendship.
Occasionally, she continued to feel very sad about losing her husband, but her thoughts
were no longer of an intrusive or distressing nature. She thought about places they had
gone together and about how Tom would encourage her to do what she enjoyed. She tried
 Brief Psychodynamic Treatment of PTSD 931

to keep the calming, permission-giving part of Tom with her, making those characteris-
tics part of herself. She was no longer depressed or seriously anxious; she now slept well
and felt in control of her life. She was involved in a romantic relationship with someone
both she and her husband had known prior to Tom’s death. She was not sure where this
relationship would go, but, in the meantime, she was enjoying the man’s companionship.
Overall, Susan reported that she did not think about her husband’s death that much
anymore, as she was quite busy with her work and new relationships. She also had become
quite involved in a variety of community activities that occupied her time and energy. She
was able to recall her husband in both positive and negative terms. She was sorry that
they would never have the opportunity to grow old together, but she was able to conclude,
philosophically, that this was their fate.
The therapist felt that Susan continued to have an obsessional personality style, but
she was pleased to see that the intensity of her symptoms had attenuated considerably.
Susan had become far less self-critical, more caring toward herself and others, and less
tense and anxious. She was now sometimes tolerably sad rather than overcome with
despairing grief, and she was able to focus her energies on current relationships and
activities.

Clinical Issues and Summary

The implications of this treatment approach confirm the utility of the brief dynamic
method for PTSD. This method particularly is effective for previously well-functioning
individuals interested in pursuing a treatment that involves introspection, self-analysis,
and the exploration of meanings that lie beneath the surface.
Susan’s PTSD reactions were conceptualized as a response to both the sudden and
horrific nature of the loss she experienced in combination with her pre-existing emotional
conflicts and loss experiences. The therapist hypothesized that because Susan had grown
up with a neglectful depressed mother and earlier had experienced mutilating surgery,
Susan particularly was sensitive to interpersonal loss and bodily disfigurement. Both the
unexpected and visually distressing aspects of her husband’s death played into that dual
vulnerability, causing her to have difficulty in fully integrating the experience on her own
or even in the company of supportive others. Furthermore, not everyone in her post-event
environment was supportive. Once again, her mother promised to be there for her, but
could not actually bring herself to follow through. This was a painful reminder to Susan
of what she had lost and what she had never had. Both the early and the more-recent
experiences with her mother reactivated feelings of rage over abandonment.
This case showed how a trauma-focused dynamic therapy helped an obsessional
woman follow incomplete trains of thought and emotion to completion. Key in this endeavor
was the repeated identification of Susan’s defensive pattern of switching to another image
of herself and another constellation of thought whenever she came within what she per-
ceived to be an emotional danger zone. The therapist pointed out this pattern, encouraged
Susan to become aware of it, and had her focus attention on what she was thinking and
talking about before she switched topics. By repeatedly bringing this pattern to Susan’s
attention and exploring her fears about pursuing her current train of thought, Susan came
to see that it could be safe to follow her thoughts and fears. Understanding that her worst
fears would not be realized (i.e., that her thoughts and feelings would neither kill her nor
the therapist, nor would she be left alone and defenseless in the world), Susan’s anxiety
decreased and her confidence and sense of well being improved.
Within the context of a supportive therapeutic relationship, Susan learned that she
consciously could contemplate her wishes to be rid of her husband and, at an earlier time,
932 JCLP/In Session, August 2002

her mother without having caused physical or emotional harm to either one. Furthermore,
she could explore her own dependency wishes and frustrations without losing her auton-
omy or exploding with rage. Although it would be unrealistic to expect a major transfor-
mation in a client’s self-concept or personality style in a brief therapy, active intervention
in clarifying the implicit meanings of traumatic events, exploration and interpretation of
characteristics of past relationships that the client projects onto the therapist and current
relationships, and identification of the wishes and fears that the client avoids can be
useful strategies in modifying symptoms and identifying maladaptive patterns. It also is
useful to identify and interpret the typical ways clients use to keep threatening wishes and
meanings from conscious awareness, as it is the unknown, yet powerful interpretations of
events that may continue to plague individuals long after events have occurred.

Select References/Recommended Readings

American Psychological Association. (1994). Diagnostic and statistical manual of mental disorders
(4th ed.). Washington, DC: Author.
Blake, D.D., Weathers, F.W., Nagy, L.M., Kaloupek, D.G., Klauminzer, G., Charney, D., & Keane,
T. (1990). A clinician rating scale for assessing current and lifetime PTSD: The CAPS-1.
Behavior Therapy, 18, 187–188.
Freud, S. (1917). Mourning and melancholia. In J. Strachey (Ed.), The standard edition of the
complete psychological works of Sigmund Freud (Vol. 14, pp. 243–258). London: Hogarth
Press & Institute for Psychoanalysis.
Horowitz, M.J. (1997a). Formulation as a basis for planning psychotherapy. Washington, DC: Amer-
ican Psychiatric Press.
Horowitz, M.J. (1997b). Stress response syndromes (3rd ed.) Northvale, NJ :Aronson.
Horowitz, M.J., & Becker, S.S. (1972). Cognitive response to stress: Experimental studies of a
“compulsion to repeat trauma.” In R. Holt and E. Peterfreund (Eds.), Psychoanalysts and
contemporary science, (vol. 1). New York: Macmillan.
Horowitz, M.J., Marmar, C., Krupnick, J., Wilner, N., Kaltreider, N., & Wallerstein, R. (1997).
Personality styles and brief psychotherapy (2nd ed.). New York: Basic Books.
Janoff-Bulman, R. (1992). Shattered assumptions: toward a new psychology of trauma. New York:
Free Press.
Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. (1995). Posttraumatic stress
disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048–1060.
Krupnick, J., & Horowitz, M. J. (1981). Stress response syndromes: Recurrent themes. Archives of
General Psychiatry, 38, 428– 435.
Luborsky, L. (1984). Principles of psychoanalytic psychotherapy: A manual for supportive expres-
sive treatment. New York: Basic Books.
Malan, D.H. (1979). Individual psychotherapy and the science of psychodynamics. London, UK:
Butterworth.
Mann, J. (1973). Time-limited psychotherapy. Cambridge, MA; Harvard University Press.
Strupp, H.H., & Binder, J.L. (1984). Psychotherapy in a new key: A guide to time-limited dynamic
psychotherapy. New York: Basic Books.
Spitzer, R.L., Williams, J.B.W., Gibbon, M., & First, M.B. (1990). Structured clinical interview for
DSM-III-R (SCID). Washington, DC: American Psychiatric Press.