When one tool is not enough: An integrative psychotherapeutic approach to treating complex PTSD

Complex posttraumatic stress disorder (CPTSD) is a term representing the psychopathological implications of exposure to chronic, inter-personal trauma. These include the main symptoms of PTSD, as well as changes in identity, emotion regulation, and inter-personal relationships. Self-harm and dissociation (i.e., disintegration of mental processes) are also quite common in CPTSD. Considering this complex and often severe clinical picture, mental health professionals often find it difficult to effectively treat CPTSD. In this paper, we present an integrative approach to the treatment of CPTSD based on a combination of techniques from several psychotherapy approaches. The case described here illustrates the need for therapeutic flexibility and eclecticism when treating individuals exposed to chronic trauma. We show the advantages of flexible therapeutic attunement, which enables the therapist to respond to the changing need of the patient, as well as her fluid clinical picture and symptom manifestation. The case also illustrates how interventions taken from psychodynamic therapy, Dialectical behavior therapy, and Eye Movement Desensitization and Reprocessing may be applicable in various stages of treatment, alleviating the patient's distress in several psychological and physical domains.

Homework assignments in relational psychoanalytic treatment of personality disorders: A case study of a patient with narcissistic personality disorder

Homework assignments, or specific tasks patients are asked to engage in or complete between sessions, are a controversial topic among psychoanalysts. While many argue these interventions contradict psychoanalytic principles, others believe they can help address problems and promote coping skills. We propose that homework can be a legitimate aspect of relational psychoanalysis when used in a way that is attuned to the patient's experience and that homework may be an important component of treating personality disorders (PD). We present the case of a man diagnosed with narcissistic PD. He often felt superior to and reported that he despised others, though the core self-image was of fragile. He embraced the role of the omnipotent caregiver, which came with boredom and anger and lack of satisfaction in his social life. The patient tried to control therapy, asserting that he could psychoanalyze himself. As a result, therapy was stalled and progress was limited. At this point, the therapist asked him to complete homework assignments that encouraged him to refrain from his compulsive caregiving to better understand what motivated this behavior. Through this process, the patient came to realize he acted out of avoidance, as he did not want to disclose his own vulnerabilities and flaws. At that point he was able to experience relationships while adopting different stances and finding new meanings. We argue that homework can be fully integrated into the relational psychoanalytic repertoire to improve self-reflection and foster change in patients with PD.

The Functions of Safety in Psychotherapy: An Integrative Theoretical Perspective Across Therapeutic Schools

Objective

There is a certain consensus in the psychotherapeutic literature that safety plays a central role in human development and psychotherapy and that lack of safety undermines mental health. However, the role of safety in psychotherapy has not yet been thoroughly examined. In this article, we identify and integrate the diferent functions of safety in psychotherapy on a theoretical basis.

Method

We made a panoramic overview of the concept of safety across some of the main psychotherapeutic schools that represent major paradigms in contemporary psychotherapy (psychodynamic, cognitive-behavioral, humanistic). We then analyzed, compared, and synthetized the findings to identify the common functions that safety plays both in ontogenesis and in clinical practice across different therapeutic orientations.

Results

Our analysis showed that safety is indeed rightly prioritized across psychotherapy schools because of its developmental value in promoting change and adaptation both in ontogenesis and clinical settings. The findings suggest that the main functions of safety are to secure survival, facilitate restoration, promote exploration, sustain risk-taking, and enable integration, with these functions being complementary and dependent on the context. However, safety seems to be in a dialectical and paradoxical relationship to psychotherapy and human development. Adequate ontogenetic development and treatment progress do not appear to require continuous maintenance of maximum possible safety. Rather, they seem to require enough safety, adequately and timely modulated according to developmental needs and treatment phases.

Conclusions

Although safety provides the necessary basis that enables restoration, fuels exploration, and facilitates treatment progress, safety's misdosage (e.g., lack, excess), misconstruction (e.g., misattunement, misinterpretation), or misuse (exploitation, idealization) may hinder the healthy development of attachment, identity, autonomy, self/co-regulation as well as the ability to tolerate and cope with dangers, risks, insecurities, or frustrations. Future research is suggested to further explore the role of safety in psychotherapy.

Reformulated Object Relations Theory: A Bridge Between Clinical Psychoanalysis, Psychotherapy Integration, and the Understanding and Treatment of Suicidal Depression

In contrast to the fruitful relationship between psychoanalysis/psychoanalysts and the humanities, institutionalized psychoanalysis has been largely resistant to the integration of psychoanalysis with other empirical branches of knowledge (infant observation, psychotherapy research, psychological and neurobiological sciences), as well as clinical ones [primarily cognitive-behavioral therapy (CBT)]. Drawing from two decades of theoretical and empirical work on psychopathology, psychotherapy, and psychoanalysis, the author aims to show how a reformulation of object relations theory (RORT) using (neuro-)psychological science may enhance a clinical-psychoanalytic understanding and treatment of suicidal depression, which constitutes one of the most formidable health challenges of our time. Specifically, he rewrote the notion of Melanie Klein positions-primarily the depressive position-using extant knowledge of structure of emotions, the centrality of mental representations of the future ("prospection") and the toxic nature of criticism-based emotions. This reformulation enables a dialog between clinical psychoanalysis and other therapeutic schools of thought and sheds light on the understanding and treatment of suicidal depression.

Bayesian Approach to Psychotherapy Integration: Strategic Modification of Priors

Integrative psychotherapies have become the mainstay in mental health care. The most researched therapy, CBT, being integrative itself, continues to integrate such new elements as mindfulness, spirituality, and experiential techniques. There is no commonly accepted strategy for psychotherapy integration. New elements are sometimes added on a trial and error basis with a following post-hoc theoretical and empirical justification. Other times, they are incorporated based on an ad-hoc theoretical premise, and empirical studies follow to support or invalidate it. Nevertheless, four main integrative strategies have been identified as technical eclecticism, common factors integration, principle-based assimilative integration, and theoretical integration (Norcross, 2005). Strategies outside of these four have also been suggested. Recently, a principle of nested hierarchy has been proposed as a way of integrating different strategies into a general roadmap for building an integrative therapy (Krupnik, 2018). The nested hierarchy principle does not, however, offer a strategy for theoretical integration at the top of its hierarchy. In this report, I suggest using the Bayesian theory of psychopathology for such strategy. I propose to apply Bayesian framework to psychotherapy integration and discuss a possibility of using it as a universal strategy called Strategic Modification of Priors (SMOP). I illustrate SMOP's application with a synopsis of a clinical case.

Is countertransference a valid source of clinical information? Investigating emotional responses to audiotaped psychotherapy sessions

The study aimed to test whether countertransference reactions contain valid information about the patient. The authors examined whether a significant part of the variance in emotional, cognitive, and motivational responses to recorded therapy sessions is attributable to the patient. Six student raters listened to 605 audiotaped sessions of 81 patients with major depression treated by 19 therapists and indicated their reactions using a modified version of the Countertransference Questionnaire. The relative amount of variance in countertransference reactions due to differences between patients, ranging from 2% to 16%, was significant for most of the countertransference dimensions. Reactions were influenced by type of treatment and severity of depression but not by comorbid personality disorder or interpersonal problems. The relative amount of variance due to differences between raters was large, averaging at 23%. The authors conclude that-albeit having a relatively low "signal-to-noise ratio"in raters without psychotherapy training-countertransference reactions contain valid clinical information.

Treating anxiety disorders by emotion-focused psychodynamic psychotherapy (EFPP)-An integrative, transdiagnostic approach

Anxiety disorders are characterized by high levels of anxiety and avoidance of anxiety-inducing situations and of negative emotions such as anger. Emotion-focused therapy (EFT) and psychodynamic psychotherapy (PP) have underscored the therapeutic significance of processing and transforming repressed or disowned conflicted or painful emotions. Although PP provides sophisticated means of processing intrapsychic and interpersonal conflict, EFT has empirically tested a set of techniques to access, deepen, symbolize, and transform emotions consistent with current conceptualizations of emotions and memory. Based on our clinical experience, we propose that an integrative emotion-focused and psychodynamic approach opens new avenues for treating anxiety disorders effectively, and we present a transdiagnostic manual for emotion-focused psychodynamic psychotherapy. The therapeutic approach takes into account both the activation, processing, and modification of emotion and the underlying intrapsychic and interpersonal conflicts. The short-term treatment is based on the three phases of initiating treatment, therapeutic work with anxiety, and termination. Emotional poignancy (or liveliness) is an important marker for emotional processing throughout treatment. Instead of exposure to avoided situations, we endorse enacting the internal process of generating anxiety in the session providing a sense of agency and access to warded-off emotions. Interpretation serves to tie together emotional experience and insight into the patterns and the nature of underlying intrapersonal and interpersonal conflict. Treatment modules are illustrated by brief vignettes from pilot treatments.

Psychotherapy Is Chaotic-(Not Only) in a Computational World

Objective: The aim of this article is to outline the role of chaotic dynamics in psychotherapy. Besides some empirical findings of chaos at different time scales, the focus is on theoretical modeling of change processes explaining and simulating chaotic dynamics. It will be illustrated how some common factors of psychotherapeutic change and psychological hypotheses on motivation, emotion regulation, and information processing of the client's functioning can be integrated into a comprehensive nonlinear model of human change processes.

Methods: The model combines 5 variables (intensity of emotions, problem intensity, motivation to change, insight and new perspectives, therapeutic success) and 4 parameters into a set of 5 coupled nonlinear difference equations. The results of these simulations are presented as time series, as phase space embedding of these time series (i.e., attractors), and as bifurcation diagrams.

Results: The model creates chaotic dynamics, phase transition-like phenomena, bi- or multi-stability, and sensibility of the dynamic patterns on parameter drift. These features are predicted by chaos theory and by Synergetics and correspond to empirical findings. The spectrum of these behaviors illustrates the complexity of psychotherapeutic processes.

Conclusion: The model contributes to the development of an integrative conceptualization of psychotherapy. It is consistent with the state of scientific knowledge of common factors, as well as other psychological topics, such as: motivation, emotion regulation, and cognitive processing. The role of chaos theory is underpinned, not only in the world of computer simulations, but also in practice. In practice, chaos demands technologies capable of real-time monitoring and reporting on the nonlinear features of the ongoing process (e.g., its stability or instability). Based on this monitoring, a client-centered, continuous, and cooperative process of feedback and control becomes possible. By contrast, restricted predictability and spontaneous changes challenge the usefulness of prescriptive treatment manuals or other predefined programs of psychotherapy.

Combining Cognitive Therapy With Acceptance and Commitment Therapy for Depression: A Group Therapy Feasibility Study

Cognitive therapy (CT) and acceptance and commitment therapy (ACT) have been shown to be effective in treating depression. Although integrating ACT with CT is used for the treatment of anxiety, there is a paucity of integrated CT and ACT treatments for depression and/or dysthymia. The purpose of this study is to determine the feasibility of integrating CT and ACT into a manualized group therapy treatment for depression and/or dysthymia. Over a period of 2 years, 4 consecutive groups were held at a community clinic, with 24 completing the 15-week treatment. Posttreatment and follow-up data revealed satisfaction with the treatment, significant decreases in depression severity, and significant increases in quality of life over the 5 time points. The results support the acceptability and feasibility of a manualized integrated CT/ACT group therapy program for depression and dysthymia.

Embodied simulation in exposure-based therapies for posttraumatic stress disorder-a possible integration of cognitive behavioral theories, neuroscience, and psychoanalysis

Exposure to the trauma memory is the common denominator of most evidence-based interventions for posttraumatic stress disorder (PTSD). Although exposure-based therapies aim to change associative learning networks and negative cognitions related to the trauma memory, emotional interactions between patient and therapist have not been thoroughly considered in past evaluations of exposure-based therapy. This work focuses on recent discoveries of the mirror-neuron system and the theory of embodied simulation (ES). These conceptualizations may add a new perspective to our understanding of change processes in exposure-based treatments for PTSD patients. It is proposed that during exposure to trauma memories, emotional responses of the patient are transferred to the therapist through ES and then mirrored back to the patient in a modulated way. This process helps to alleviate the patient's sense of loneliness and enhances his or her ability to exert control over painful, trauma-related emotional responses. ES processes may enhance the integration of clinical insights originating in psychoanalytic theories-such as holding, containment, projective identification, and emotional attunement-with cognitive behavioral theories of learning processes in the alleviation of painful emotional responses aroused by trauma memories. These processes are demonstrated through a clinical vignette from an exposure-based therapy with a trauma survivor. Possible clinical implications for the importance of face-to-face relationships during exposure-based therapy are discussed.