Comparison of therapeutic approaches to treating Post-Traumatic Stress Disorder

From the Multidisciplinary Association for Psychedelic Studies:

In November 2004 the American Psychiatric Association (APA) published Practice Guidelines for the treatment of PTSD (1). The three psychotherapeutic interventions recommended for established PTSD are:

  • Cognitive and behavior therapies
  • Eye movement desensitization and reprocessing (EMDR)
  • Psychodynamic psychotherapy

Although the APA endorses the above therapies in their Practice Guidelines, it is noteworthy that they also imply the need for research into more effective treatment techniques, with their statement that “there is a paucity of high-quality evidence-based studies of interventions for patients with treatment-resistant PTSD….” (1). The APA practice guidelines state that the goals of PTSD treatment “include reducing the severity of … symptoms…(by) improving adaptive functioning and restoring a psychological sense of safety and trust, limiting the generalization of the danger experienced as a result of the traumatic situation(s) and protecting against relapse.” It goes on to say that “…factors that may need to be addressed in patients who are not responding to treatment include problems in the therapeutic alliance; the presence of psychosocial or environmental difficulties; the effect of earlier life experiences such as childhood abuse or previous trauma exposures…” (1) Despite significant differences between these types of therapy, including MDMA-assisted therapy, they all share some important theoretical underpinnings. Moreover, some of the therapeutic experiences that occur with any of these approaches are very similar. This is not surprising, since each approach, in its particular way, is stimulating universal, innate healing mechanisms. For instance, the nondirective approach of MDMA-assisted therapy often leads to the spontaneous occurrence of many of the kinds of experiences that are more directly elicited and thought to be therapeutically important in these other approaches. As noted previously in this treatment manual, the therapists’ role is first to prepare participants for this likelihood by encouraging a non-controlling and open attitude toward experiences that arise and then to support the unfolding and the subsequent integration of these experiences. MDMA can act as an important catalyst to this process.

Table 1 briefly compares the major therapeutic approaches for treating PTSD, including the therapeutic elements discussed in the APA guidelines, in Dr. Edna Foa’s excellent manual of cognitive-behavioral therapy for PTSD (2), and in the protocol outlined in this treatment manual.

Table 1. Comparison of Therapeutic Approaches for PTSD

Therapeutic Element Cognitive Behavioral Therapy EMDR Psychodynamic Psychotherapy MDMA-Assisted Psychotherapy
Prolonged exposure (either in vivo exposure or trauma reliving in therapy) For in vivo exposure, develop a hierarchy list of situations, and assign specific homework involving exposure to these situations. For imaginal exposure, ask the patient to describe the trauma in detail in the present tense. This is done repeatedly over a number of visits. A target image related to the trauma is used as a starting point, with a non−directive approach to what follows. Patient is encouraged to “let whatever happens happen.” Discussions with the therapist are intermittent. The traumatic events are discussed, but the specific approach of prolonged exposure is not included. (In practice psychodynamic psychotherapy and cognitive behavioral therapy are often combined.) Non−directive approach to the way trauma comes up and is processed, with encouragement to stay present rather than distracting from difficult memories and emotions. Discussions with the therapists are intermittent. (Note that a contract is made before the session that if the trauma does not come up spontaneously the therapist will bring it up, but thus far trauma has always come up spontaneously; in effect, prolonged exposure happens spontaneously.
Cognitive restructuring − Identify “negative thoughts and beliefs/cognitive distortions. − Challenge them using Socratic method. − Modify them by arriving at rational response. Cognitive restructuring often occurs spontaneously and may be catalyzed by therapist’s adding “cognitive interweave,” if needed. Focus on the “meaning of the trauma for the individual in terms of prior psychological conflicts and developmental experience and relationships…” (1) Cognitive restructuring often occurs spontaneously, with minimal therapist intervention in this regard. Elements of both cognitive-behavioral and psychodynamic approaches may be used in follow-up integration sessions, but always in response to the way the experience is continuing to develop for the subject rather than according to a predetermined structure.
Anxiety management training (AMT), including stress inoculation training (SIT) Relaxation skills are often taught at outset of treatment, such as breathing exercises, deep muscle relaxation, imagery. EMDR protocol includes establishing an effective relaxation method at outset — often guided visualization. Not a specific element of psychodynamic therapy, but clinically is often combined. Subjects are taught relaxation, often using diaphragmatic breathing.
Increased awareness of positive experiences, including present safety May be part of cognitive restructuring, or may occur spontaneously after prolonged exposure. Often occurs spontaneously, most often toward end of session. May occur as a result of examining present and past relationships and experiences. Typically happens later in therapy. Usually occurs spontaneously, often early in the first MDMA session. May provide a sense of safety and well-being that provide a platform for deeper processing of painful experiences later in the session or in a subsequent session.
Clearing of tension in body and other somatic symptoms Therapist directs attention to the body. Therapist directs attention to the body. Not generally considered as part of psychodynamic psychotherapy. Mentioned in preparatory sessions and treated as an important therapeutic component that may be inadequately addressed in usual talking therapies. MDMA-assisted psychotherapy tends to bring this somatic component to awareness and allows for its release, often spontaneously and sometimes by: the therapist directing attention to body symptoms (as is done in Dr. Foa’s examples of imaginal exposure p.167), or by using the kind of focused body work described in Appendix B.
Transference and countertransference issues Not a focus, but therapists should be aware of them. Not a focus, but therapists should be aware of them. Interpretation of transference may be important part of the intervention. Not a focus, but therapists should be aware of them and the fact that they can be heightened in non-ordinary states such as that induced by MDMA. Should be addressed openly and honestly and inquired about if there seems to be a significant unspoken dynamic. Therapists are self disclosing and collaborative. Transference is addressed early rather than letting it build, as can happen in psychodynamic therapy.
Difficulties with therapeutic alliance − a possible obstacle to successful treatment Time and attention are given to developing alliance, with some limitations in time- limited therapeutic protocols (Dr. Foa recommends 9 sessions with the possibility of 3 more and mentions that, “there is a point of diminishing returns” with patients who have not responded to that course of treatment.) Time and attention are given to developing alliance. Time and attention are given to developing alliance. Time and attention to are given to developing alliance. Both the set and setting of the treatment model and the effects of MDMA promote a sense of trust and therefore development of a therapeutic alliance in a relatively short time.
“The effect of earlier life experiences such as childhood abuse or previous trauma exposures…” (1) as complicating factors that may cause treatment resistance May be addressed in cognitive restructuring. May come up spontaneously in EMDR sessions. Discussing this may be a focus of psychodynamic psychotherapy. Early experience of abuse or lack of support often comes up spontaneously in MDMA sessions, typically with insight about connections between this early experience and PTSD. This insight and the concomitant emotional connection and processing often occur with little or no intervention from the therapists.

References

  1. Urasano J et al, American Journal of Psychiatry Supplement, v 161, n. 11, November 2004
  2. Foa E and RothbaumB, Treating the Trauma of Rape, Cognitive-Behavioral Therapy for PTSD, The Guilford Press, New York, NY, 1998
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3 Responses to “Comparison of therapeutic approaches to treating Post-Traumatic Stress Disorder”

  1. Micky Says:

    About 3 years ago I dropped into a black hole – four months of absolute terror. I wanted to end my life, but somehow [Holy Spirit], I reached out to a friend who took me to hospital. I had three visits [hospital] in four months – I actually thought I was in hell. I imagine I was going through some sort of metamorphosis [mental, physical & spiritual]. I had been seeing a therapist [1994] on a regular basis [and had just finished a year of EMDR], up until this point in time. I actually thought I would be locked away – but the hospital staff was very supportive [I had no control over my process]. I was released from hospital 16th September 1994, but my fear, pain & shame had only subsided a little. I remember this particular morning waking up [home] & my process would start up again [fear, pain, & shame]. No one could help me, not even my therapist [I was terrified]. I asked Jesus Christ to have mercy on me & forgive me my sins. Slowly, all my fear has dissipated & I believe Jesus delivered me from my “psychological prison.” I am a practicing Catholic & the Holy Spirit is my friend & strength; every day since then has been a joy & blessing. I deserve to go to hell for the life I have led, but Jesus through His sacrifice on the cross, delivered me from my inequities. John 3: 8, John 15: 26, are verses I can relate to, organically. He’s a real person who is with me all the time. I have so much joy & peace in my life, today, after a childhood spent in orphanages. God LOVES me so much. Fear, pain, & shame, are no longer my constant companions. I just wanted to share my experience with you [Luke 8: 16 – 17]. EMDR was the icing on the cake, for me. I wanted to live and was prepared to do anything to RECOVER that “Little Boy”, who was lost for all those desperate, and lonely years. God helps those who help themselves.
    Thank you, Jesus for being with me in my LONG DARK NIGHT OF THE SOUL!! What I experienced was nothing compared with what you did for mankind – YOU died on a cross for our sins. I love you so much Jesus, because you LOVED me first. I was lost and was found.
    PEACE BE WITH YOU
    MICKY

  2. whig Says:

    Thanks for your testimony, Micky.

  3. psychotherapy schools Says:

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    You definitely know how to bring a problem to light and make it important.

    More and more people ought to look at this and understand this side of your story.
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