A Proposal to Investigate the Effectiveness of Psychodynamic Psychotherapy for the Treatment of PTSD

Abstract

Post Traumatic stress disorder (PTSD) is a severe stress-related disorder that occurs following exposure to some traumatic event. PTSD is typically treated with medication, psychotherapy, or a combination of both. The empirical literature suggests that exposure therapies and other cognitive-behavioral therapies are the treatments of choice for PTSD. Psychodynamic therapy is typically viewed as a second-tier therapeutic treatment for PTSD due to the perception that empirical evidence for psychodynamic therapy is lacking; however, empirical research has indicated that psychodynamic therapy may be at least equally efficacious as cognitive behavioral therapy in the treatment of PTSD. The current research proposal discusses the new DSM – V conceptualization of PTSD, the etiology and clinical presentation of PTSD, empirical research regarding the treatment of PTSD, and empirical research regarding common factors in psychotherapy that contribute to positive outcomes. The study proposes comparing cognitive behavioral therapy and psychodynamic therapy in the treatment of anxiety and depression that occurs in PTSD with clinically validated measures of both as outcome measures.

A Proposal to Investigate the Effectiveness of Psychodynamic Psychotherapy for the Treatment of PTSD

Post Traumatic Stress Disorder (PTSD) is a syndrome that develops after a person is involved in, sees, or hears of a severe and extreme traumatic stressful event (typically defined as actual or threatened death, serious injury, or sexual violence; American Psychiatric Association [APA], 2013). The person reacts to the stressor with feelings of helplessness, fear, depression, avoidance of things that remind them of the event, and may persistently relive the event (APA, 2013). PTSD is a disorder that is often associated with combat veterans but can also be experienced by civilians undergoing extreme traumatic stress. This current study proposes to investigate the effectiveness of psychodynamic therapy in treating the anxiety and depression that occurs in patients with PTSD. Such a study is warranted due to a perceived relative lack of empirical research regarding the effectiveness of psychodynamic techniques in treating people diagnosed with PTSD. The current research hypothesis is that PDT will be at least as effective as CBT in the treatment of anxiety and depression in PTSD patients. This proposal will first briefly review the clinical features, subjective experience, physiology, and treatment of PTSD.

Etiology of PTSD and Cultural Factors Associated with a Diagnosis of PTSD

Of the different diagnoses and descriptions found in the DSM-V few refer to an etiology in their diagnostic criteria; however, PTSD is one diagnostic category that implies a causal agent. PTSD, acute stress disorder and the various adjustment disorders would result from some exposure to an environmentally based stressful event that surpasses one’s capacity to cope (APA, 2013). However, not everyone who will experience the same stressful event will develop PTSD, so a stressful event is not a sufficient cause of PTSD, but it is indeed a necessary cause (Campbell, 2008). Therefore, there must be a number of other significant risk factors that are associated with the predisposition for a person to develop PTSD.

The severity of the stressor is one of these potential risk factors as is the proximity of the stressful event to the onset of symptoms (APA, 2013). Other social and cultural risk factors that contribute to developing PTSD include poor family or peer support, having an external locus of control, and recent excessive alcohol use (Ozer, Best, Lipsey, & Weiss, 2008). A number of biological risk factors also appear to be associated with the development of PTSD including being female, a genetic vulnerability to psychiatric illnesses (which include a number of neurobiological and hormonal factors), and a diagnosis of certain personality disorder traits (Ozer et al., 2008).

The Presentation of People Diagnosed with PTSD

The current conceptualization of PTSD includes child and adult forms (APA, 2013); however, this proposal is concerned only with adults diagnosed with PTSD. The major facets of the clinical presentation of PTSD according to the DSM-5 now include four broad criteria: (a) painful re-experiences of the event (dreams, recollections, flashbacks, etc.); (b) patterns of avoidance and emotional numbing; (c) nearly constant hyperarousal; and (d) negative thoughts or mood such as depression, anxiety, memory lapses associated with the event, etc. (APA, 2013). One of the defining features of clinically significant PTSD is the intrusive re-experience of the trauma or traumatic event. These re-experiences are more than just memories, they are often experienced as distressing and invasive because the person has no control over when, how, or where they will occur. These experiences elicit strong negative emotions such as depression and anxiety associated with the initial trauma and any stimuli that remind the person of the trauma.

Pharmacotherapy Treatment for PTSD

There are no medications that are designed to treat PTSD specifically; however, some medications that are commonly used to treat anxiety disorders and depression have been found to be effective in helping people manage their PTSD symptoms. Selective Serotonin Reuptake Inhibitors (SSRIs) were developed as antidepressant medications. This group includes well-known medications like Prozac, Paxil, Celexa, Luvox, and Zoloft. There have been several studies that have found that SSRIs may be useful in the treatment of certain symptoms of PTSD such as hyperarousal, anxiety, depressive symptoms, and apathy (Shad, Suris, & North, 2011). In addition, sometimes improvements in memory and engaging in less avoidance of social situations are also observed with the administration of SSRIs. However, there have been studies that have shown that SSRIs may not address PTSD symptoms such as re-experiencing the event (Shad et al., 2011). In some cases, multiple SSRIs are used and for patients with high levels of arousal or extreme anxiety anxiolytic medications such as benzodiazepines are added. If the patient displays delusions or psychotic symptoms (such as may occur with flashbacks) antipsychotic medications such as Risperidol can be added (Shad et al., 2011). Of course one of the complications of taking these medications is their potential for side effects, which often results in ether more medications being added to control side effects or the patient discontinuing them.

Psychotherapy for the Treatment of PTSD

Cognitive-behavioral therapy. While the research has generally concluded that SSRIs and some other medications can be useful in controlling PTSD symptoms those findings still do not appear to be as robust as the findings in studies investigating types of cognitive-behavioral therapy (CBT) for PTSD (Cloitre, 2009). Studies comparing exposure therapies (where the victim re-imagines the trauma while in a state of relaxation), cognitive restructuring, or combinations of these have found robust effects for therapy compared to placebo (often relaxation training alone) or wait-list control groups (Cloitre, 2009; Resick, Monson, & Rizvi, 2008). The results for combinations of treatments versus a single intervention are mixed (Resick et al., 2008); however, many clinicians prefer to use some type of exposure therapy with other CBT techniques or cognitive processing techniques added, but exposure therapies should only be attempted by therapists trained in them (Cloitre, 2009). Other types of CBT applications such as cognitive restructuring are also effective (Cloitre, 2009). There is also evidence that group formats can also be effective for treating PTSD but no more effective than individual therapy (Resick et al., 2008).

Psychodynamic therapy. The current conceptualization regarding psychodynamic psychotherapy (PDT) as a treatment for PTSD indicates that at best psychodynamic therapy is a second-tier treatment recommendation for PTSD (Forbes et al., 2010). One of the reasons for this is that the gold standard for designating a treatment as an evidence-based treatment is the randomized clinical trial (RCT) and historically psychodynamic therapy research has been more concerned with publishing case studies and theoretical discourses (Shedler, 2010). Moreover, academics and clinical researchers have traditionally believed that the psychodynamic theory concepts are difficult to apply to empirical research and that other forms of treatment are superior to PDT (Shedler, 2010). Nonetheless, there is evidence that PTD can effectively treat the anxiety and depression-related symptoms that are associated with PTSD.

For instance, Benish, Imel, & Wampold (2008) performed a meta-analysis of RCT psychotherapy studies that compared at least two recognized psychotherapies in their effectiveness for treating PTSD. After reviewing the literature for RCTs that compared at least two treatments head-to-head, 17 studies utilizing CBT, PDT, and/or eye movement desensitization were selected for the meta-analysis. The researchers found that the effect sizes in the comparisons over all the studies hovered around zero indicating that all of the treatments in these RCTs were equally efficacious in treating the symptoms of PTSD. Benish et al. (2008) concluded that the common factors associated with each of the psychotherapies and not the specific therapeutic techniques that each particular style of psychotherapy utilizes were responsible for the improvements of the patients in the studies. Of course, this particular meta-analysis stirred some controversy; however, the finding that the common factors of psychotherapies are important in the efficacy of the therapy is not new (Shedler, 2010).

Nonetheless, Ehlers et al. (2010) commenting on the Benish et al. (2008) meta-analysis called for better-defined treatments that are considered to be bona fide treatments for PTSD in such studies and that Benish et al. (2008) may have arbitrarily excluded bona fide treatments in their analysis. Nonetheless, it appears that a good deal of the variance in RCTs utilizing different psychotherapies for PTSD is accounted for by therapist variables (Shedler, 2010).

Shared Attributes of PDT and CBT

Often students and even professors of clinical psychology or counseling are compelled to think that different schools of psychotherapy are vastly different in their approach; however, in the overall scheme of things, the different types of psychotherapies share much in common. For instance, CBT and PDT would appear to be quite different in their approaches; however, psychotherapy researchers have identified several core features that the two approaches share aside from obvious features such as primarily using verbal communication and the physical aspects of the therapeutic relationship (e.g., the therapist is an expert, client shares thoughts, feelings, etc.). It does not make sense to deal with minor similarities or differences of both techniques, but instead to look at the overall approach.

Shedler (2010) reviewed the research measuring the similarities between different therapies and noted that in the treatment of depression both PDT and CBT therapists shared nearly 50% of their intervention strategies. Shedler (2010) also noted that research has suggested specific CBT techniques were not responsible for outcomes in therapies, but that shared factors of therapies may be more effective. Other researchers have found major similarities in aspects of all of the different types of therapies (for a discussion see Sparks, Duncan, & Miller, 2008). There are several identified common psychotherapy variables that previous research has identified as being shared by PDT, CBT, and all psychotherapies (Sparks et al., 2008).

1. All psychotherapies involve a relationship between individuals that is charged emotionally, confiding, and may include the participation of a group. Sparks et al. (2008) note that with only a few minor exceptions previous research has indicated that a relationship with the therapist is necessary and very often sufficient for positive gains to be made in any kind of psychotherapy. It is well documented that clients and therapy often become very dependent on the therapist for help because of their confidence in the therapist's skills and desire to see the client do well. Such confidence is often reinforced by the quality of the training of the therapist.

2. All psychotherapies share a healing environment that utilizes at least two different therapeutic components. This aspect of all psychotherapies leads to an increased in the perception of the therapist's prestige and bolsters the client's expectation that they will be helped because the client views the therapist as a healer. This perception of the therapist as a healer is enhanced by the setting that may contain evidence of the therapist's expertise such as diplomas, books, certificates, etc.

3. There is a conceptual rationale that gives the patient a logical explanation for their difficulties and/or symptoms and offers a prescription or procedure that allows the patient to resolve or correct these difficulties. Sparks et al. (2008) note that older research has termed the rationale a conceptual myth and the explanation a ritual much in the same way that physicians and priests share these aspects of a healing relationship/environment.

4. There is a prescription or course of action that requires the participation of both the therapist and the client. This course of action is often expressed in scientific – type terminology; however, therapeutic courses of action and the reasoning behind their prescription are procedures that are not proven scientifically. When the course of action is deemed successful this is taken as evidence of its validity, whereas if the course of action is not successful this is often explained away.

In general, CBT will focus on the role of the therapist as being more directive and challenging. CBT therapists take the role of a facilitator often modeling appropriate behaviors, engaging in more role-playing, and challenging clients to help them learn more constructive thought and behavioral patterns. CBT focuses on thoughts and how thoughts affect emotions. Thus, emotions can be dealt with more indirectly by changing one’s cognitions thoughts and behavior (Shedler, 2010). In PDT the role of the therapist is often less directive at first and he/she spends more time interpreting what clients say, especially the transference. In this manner, the therapist helps the client gain insight into their feelings (emotions) which drive their behavior. Emotions are thought of as more directive in behavior. Moreover, PDT is more deterministic in nature; however, it is believed that insight into oneself can foster change by overcoming internal defenses to experiencing true feelings about one’s past and present (Shedler, 2010). Both therapies emphasize the need to demonstrate strong therapeutic alliances, empathy, and concern by the therapist for therapeutic outcomes to reach their greatest potential (Shedler, 2010). Thus, given a relative lack of research regarding how well PDT works for PTSD further comparison research between PDT and CBT for PTSD is warranted. Moreover, psychodynamic therapy also has good empirical support for its utility in treating clinical depression and anxiety-related disorders (Shedler, 2010).

Medication Combined with Psychotherapy

For purposes of the current proposal, it is also important to note that medications are often paired with psychological therapies in the treatment of PTSD. There is evidence that pairing them together may bolster the effectiveness of both (Cloitre, 2009). In patients who are both taking a medication like an SSRI and who are involved in psychotherapy, it can be difficult to ascertain the individual contribution of either treatment to the patient’s recovery, thus psychotherapy research studies of PTSD should endeavor to control for medication use.

Brief Psychodynamic Therapy

A good number of people who go into psychotherapy are not interested in being involved in therapy for long-term treatments and according to the available research nearly half of those people that enter psychotherapy are able to benefit from therapy in 10 sessions or less than 10 sessions, whereas somewhere between 15 to 30% are estimated to significantly benefit from psychotherapy that lasts more than 25 sessions (Asay & Lambert, 1999; Cummings & Cummings, 2000).

The goals of short term or brief psychodynamic therapy (BPDT) are aimed at making changes through the more rapid process than traditional Freudian and psychodynamic therapists follow. A central concept in brief psychodynamic therapy is there should be one major focus of the therapy sessions rather than the traditional Freudian notion of using free association to uncover many different personality issues, conflicts, etc. (Malan, 2013). In brief psychodynamic therapy, the focus for the therapy sessions is developed early in the first session or two and agreed upon by both client and therapist in contrast to traditional psychoanalysis’ use of prolonged periods of free association, the therapist as the director of the treatment, and a prolonged period of uncovering before insights are gained. This allows for the therapy sessions to be focused on the therapist to be much more directive and active than in traditional psychodynamic therapy (Malan, 2013).

The interpretive work that is often associated with BDPT is focused on a single problem in a brief period of time as opposed to the numerous issues and conflicts tackled in traditional psychoanalysis. The exact number of sessions that qualify for BPDT appears to be debatable depending on the issue being addressed and the therapist or researcher, but it is generally defined as being between 12-40 sessions (Malan, 2013).

There are several types of brief psychodynamic therapy developed for specific interventions such as personality disorders, panic disorder, etc (Malan, 2013). Despite the partitioning of brief psychodynamic therapy into various subtypes designed to treat specific techniques all of these brief psychodynamic therapies have more similarities than they have differences. Well-known psychodynamic therapists Franz Alexander and Thomas French acknowledged that all forms of brief psychodynamic psychotherapy are comprised of three components: (1) a therapeutic experience designed to put the client at ease, (2) the use of transference and, (3) production of flexible interpretations (Malan, 2013). The brief psychodynamic therapeutic process is approached as a corrective emotional experience designed to cope and repair the effects of traumatic past events and teach clients new ways of thinking, feeling, and behaving. Thus, brief psychodynamic therapy focuses on the therapeutic relationship, uncovering past events, and interpretations and more direct interventions by the therapist than traditional psychodynamic therapy. The streamlining of psychodynamic therapy into a briefer intervention has resulted in more conformity with existing psychotherapeutic models.

Empirical Evidence for the Utility of BPDT

The advancement of the practice of psychotherapy over the last several decades is evident in several ways. First, there has been a large proliferation of controlled treatment outcome studies and many professional journals now feature psychotherapy outcome research as the primary focus leading to even more research. Second, in addition to the quantity of outcome studies the quality of empirical psychotherapy research has also improved quite a bit spearheaded by the use of randomized controlled trials and other methodological features such as the assessment of clinical significance compared to just statistical significance, the use of treatment manuals, qualitative research, evaluation of follow-ups, etc. And finally, and perhaps most important, is the demarcation of evidence-based treatments leading to a basis for using a particular style of therapy (Nathan & Gorman, 2007). As a result, there have been many variations in psychotherapy techniques and many different integrations and applications of therapy.

There are a number of randomized controlled trials that have supported the efficacy of psychodynamic therapy for common conditions that other therapists often treat such as depression, panic disorder, normal anxiety, eating disorders, substance abuse, somatoform disorders, and personality disorders (Clarkin, Levy, Lenzenweger, & Kernberg, 2007; Leichsenring, 2005; Milrod et al., 2007; Westen, Novotny, & Thompson-Brenner, 2004). A brief discussion of the empirical literature regarding BPDT follows.

Abbass, Hancock, Henderson, and Kisely (2006) reviewed 23 different studies that used BPDT for the treatment of anxious, depressive, and somatic symptoms. The researchers generally found positive results that lasted well after the therapy was completed. Results were evaluated in the areas of symptom reduction and positive social adjustment. However, the researchers also noted that there was quite a bit of heterogeneity among the studies in terms of methodology and while BPDT appears to be effective in the majority of studies that they reviewed further research with tighter methodology was still needed.

Meta-analytic Research

Meta-analysis is a statistical technique that is able to combine numerous research studies that investigate a particular treatment or therapy in order to determine the treatments overall effectiveness as it relates to a particular condition or conditions (Nunnally & Bernstein, 1994). There are specific guidelines as to the parameters of the studies to be included regarding the homogeneity of the patients, methods, and outcome variables and the findings of the studies can vary greatly depending on the inclusion criteria. While there has been some criticism of the use of meta-analysis it is generally acknowledged that meta-analytic research has more statistical power than single studies and that meta-analysis, when performed properly, provides firmer evidence for the utility of a particular treatment and offers more generalizability than single studies including randomized controlled clinical trials (Stegenga, 2011).

Svartberg and Stiles (1991) performed a meta-analysis that included a total of 19 studies published between 1978 and 1988. The inclusion criteria included BDPT with a no-treatment control, an alternative treatment group, or both. In addition, there had to be a conceptually planned brief duration of treatment of fewer than 40 sessions. BDPT demonstrated a small but significant advantage compared to the no-treatment control condition at the end of treatment but disappeared by in those studies that included a one-year follow-up (however, these studies only averaged slightly over six sessions of treatment). BDPT was inferior to other forms of therapy such as CBT at post-treatment and at a one-year follow-up.

Crits-Christoph (1992) performed a meta-analysis of 11 studies using better selection criteria than Svartberg and Stiles (1991). This study only included studies utilizing manual-guided BPDT compared to waitlist control conditions, an alternative therapy, medication, or a non-psychiatric treatment(such as a self-help group, drug counseling, or low contact treatment); a minimum of 12 treatment sessions; and therapists experienced in BDPT. The outcome measures included the initial target symptoms, general level of psychiatric distress, and social functioning. The results indicated that BDPT demonstrated large effect sizes compared to waitlist controls but on slight nonsignificant superiority to the non-psychiatric treatments and was generally equivalent compared to other psychotherapies and to medication use.

Anderson and Lambert (1995) formed a meta-analysis of 26 studies (10 of which were included in the Crits-Christoph meta-analysis). Again BDPT was found to be superior to no treatment at all and equivalent to alternative therapies.

Luborsky et al. (2002) performed a meta-analysis of 17 meta-analyses comparing active treatments including BDPT with each other for general psychiatric distress. There was only a small and nonsignificant effect size (.20) due to treatment effect, which was reduced even further (.12) when corrected for the theoretical allegiance of the researcher (thus, controlling for experimenter bias).

Leichsenring, Rabung, and Leibing (2004) performed a meta-analytic study of BPDT utilizing 17 different clinical studies. The duration of the treatment was between seven and 40 sessions. The conditions being treated in these studies included personality disorders, substance abuse disorders (cocaine and opioid dependence), depression, PTSD, different anxiety disorders, and even eating disorders compared to no-treatment control conditions. The researchers found large effect sizes of 1.39 for the targeted symptoms of each particular study, .90 for the relief of general psychiatric symptoms over the studies, and .80 regarding the increase in social functioning. These findings were robust at follow-up periods and the targeted symptoms demonstrated an effect size of 1.57 follow-up, general psychiatric symptoms demonstrated an effect size of .95 follow-up, and social functioning demonstrated an effect size of 1.19 at follow – up. Thus, the researchers concluded that BPDT was not only effective in treating the psychiatric symptoms but produced lasting benefits.

There are a number of meta-analytic studies that review the utility of BDPT for specific psychological problems such as depression and panic disorder (but few good quality studies for PTSD). The vast majority of these studies report that BDPT is significantly more effective than a treatment control condition such as a waitlist control group and in studies where BDPT is compared to some other form of psychotherapy is either equal produces slightly lower effect sizes (e.g., Driessen et al., 2010). Nonetheless, a recent meta-analysis by Leichsenring and Rabung (2008) reported that short-term psychotherapy was not as effective as long-term psychodynamic psychotherapy; however, a reevaluation of these findings indicated that there were miscalculations in the effect sizes reported and that the analysis indicated that short-term therapy was just as effective as long-term therapy (Bhar et al., 2010). Juxtaposed between the ethical issues and the criticisms of traditional psychoanalysts are the criticisms of non- dynamically trained therapists who still believe that psychodynamic therapy lacks empirical validation. The overall research picture regarding the utility of BDPT is that it is more effective than doing nothing and is probably comparable to other forms of psychological treatment for specific conditions; however, not all of the conditions where BDPT it is effective have been defined (Hatfield, 2014).

BDPT treatment for PTSD

The empirical evidence that BDPT is effective for PTSD suffers from an empirically-validated specific approach specially designed for use with suffers from PTSD in the same way that there is a BDPT model specifically designed to address panic disorder (Hatfield, 2014). Thus, there are no treatment manuals specifically designed to guide therapists to use BDPT in the treatment of PTSD. Moreover, the empirical findings indicate that the use of BDPT for PTSD sufferers indicate that BDPT is probably better than no treatment at all but is not as effective as CBT (e.g., see Brom, Kleber, & Defares, 1989); Lindy, 1993; Resick et al., 2008; Schottenbauer, Glass, Arnkoff, & Gray, 2008; Tolin, 2010).

In a recent speculative review, Shottenbauer et al. (2008) hypothesized that the focus of psychodynamic therapies for PTSD typically attempts to analyze defense mechanisms and bring unconscious conflicts to the surface; however, the researchers offer no empirical evidence for the effectiveness of BDPT compared to other empirically – validated therapies for PTSD. Moreover, a 2010 meta-analysis of 25 studies found that CBT was superior for the treatment of PTSD in terms of treatment outcome and offer stronger therapist ratings of the therapeutic alliance (Tolin, 2010). Meta-analytic studies that have included BDPT for the treatment of PTSD are often criticized regarding the poor methodology used in these particular studies (Wittmann & Halpern, 2011).

While the evidence for the use of psychodynamic therapy and BDPT remains scant in the treatment of PTSD there are other approaches using BDPT approaches that appear to be promising. For example Carr (2011; 2013), a psychiatrist was also a veteran, has developed a specific form of BDPT designed to address clients with PTSD who are not helped by CBT that he calls intersubjective therapy. In this form of BDPT clients are encouraged to discuss the feelings of their traumatic experience freely with the therapist and process these feelings together. The therapy consists of twice-weekly sessions for about three months (Carr 2011; 2013). However, the empirical evidence for the effectiveness of this form of therapy consists primarily of case reports by Carr himself (Carr 2011; 2013).

Perhaps one issue regarding methodological issues with BDPT research for PTSD is the relative lack of studies using treatment manuals as part of the methodology. There are BDPT manuals for general therapeutic issues (e.g., Time-Limited Dynamic Psychotherapy, Strupp & Binder, 1984). The reluctance for psychotherapists to incorporate treatment manuals as a means of standardizing their procedure is not restricted to psychodynamic – oriented therapists alone (Town et al., 2012). The researcher could find no current treatment manual for the use of BDPT in the treatment of PTSD; however, treatment manuals for exposure therapy in the use of PTSD do exist and have been used in research (e.g., Resick et al., 2008). Treatment manuals in research studies are used to standardize the therapy across both therapists and clients (Lambert & Bergin, 1994). It is unclear whether the use of treatment manuals and research are adhered to in sessions not recorded by the researcher and whether studies that do use them lack external validity (Town et al., 2012). Thus, there appears to be no identified and agreed-upon formal structured approach to using BDPT to treat PTSD in both the research and in practice.

The Current Proposed Study

It is clear from a review of the research that continued empirical investigations of the effectiveness of short-term psychodynamic therapeutic techniques for PTSD is warranted. The current proposed study is designed to compare CBT and BDPT regarding their effectiveness for treating the general anxiety and depression associated with the diagnosis of PTSD in adults. It is hypothesized that BDTD will be equally efficacious or more efficacious compared to CBT in relieving anxiety and depression in adult patients with diagnosed with PTSD (thus this study has an atypical null hypothesis that CBT will produce superior treatment effects compared to PDT).

If the research hypothesis is supported and the results of the study indicate that both CBT and PDT are equally efficacious it could be concluded that perhaps the common factors of both techniques contribute significantly to the variance in treatment outcome of PTSD. In this case, further research on these common factors could be initiated to identify how they work. If CBT is found to be superior (research hypothesis not supported) or PDT is found to be superior (research hypothesis supported) it could be concluded that specific attributes of the particular therapy contributed to the outcome. In this case, further research could attempt to target which specific therapeutic attributes are responsible for positive outcomes in PTSD treatment. Potential interactions can also be interpreted in this general manner.

The current proposed study attempts to compare the outcomes of BDPT and CBT on the symptoms of anxiety and depression of individuals with a first-time diagnosis of PTSD. Limiting the study participants to first-time responders avoids confounds that are associated with participants who have prior treatment for their PTSD. Investigating the change in the symptoms of depression and anxiety levels of the participants allows for the use of empirically validated measures of the overall psychiatric distress in these individuals and allows for the strengths of BDPT and CBT such as their more direct focus on specific symptoms/issues to be evaluated and compared.

Method

Participants

Two therapists (one psychodynamically oriented and one cognitive-behavioral therapist) will be recruited for the study from Veterans Administration hospitals, battered women shelters, or from local private practices. Each therapist will have at least five years of experience in treating PTSD. Twelve adult patients diagnosed with PTSD from each therapist will also be recruited for the study by the therapist or by the researcher (N = 24). If both therapists can be recruited from the same site random assignment to the therapist may be possible; however, recruiting such dynamically opposed therapists from the same site may be difficult and could result in other complications regarding the assignment of cases, etc.

Only participants with a first-time diagnosis of PTSD will be eligible for inclusion in the study. Haugen, Evces, and Weiss (2010) concluded after their meta-analysis on the treatment of PTSD that the literature was amazingly sparse regarding treatment studies on individuals given a first – time diagnosis of PTSD, but that studies that include participants with long histories of treatment for PTSD may have several potential confounds including their expectations and experiences in treatment. In addition, an effort will be made to include participants whose primary diagnosis is PTSD. It may be difficult to include participants whose only diagnosis is PTSD due to the associated symptoms of substance abuse, depression, anxiety, etc. (APA, 2013). However, participants with a primary diagnosis that is not PTSD but are diagnosed with PTSD will not be included in the study.

All participants (both therapists and patients) will complete informed consent forms as an agreement to participate in the study. For the purposes of this study, the PTSD diagnosis will adhere to the DSM – 5 diagnostic criteria for adult PTSD (APA, 2013). Patients with the dissociative subtype of PTSD will not be eligible for inclusion in this study as this subtype of PTSD is newly defined and patients with it may have additional experiences that could complicate their scores on the outcome measures used in the study (APA, 2013). The diagnosis of PTSD will be made by the therapist or a consulting psychiatrist via the use of a clinically validated interview or clinically validated diagnostic tool.

Materials and Resources

As discussed in the literature review of this proposal there are no treatment manuals available for the use of BDPT in the treatment of PTSD. In addition, as mentioned in the literature review the use of treatment manuals in therapy research studies does not necessarily guarantee that the treatment provided is standardized and may actually decrease the external validity of the study; therefore, this study will not incorporate the use of treatment manuals as a means to standardize or operationalize the specific intervention.

Assessment and statistical analysis materials. The following measures will be used:

The Beck Depression Inventory – II (BDI-II; Beck, Steer, & Brown, 1996). In order to screen participants for depression, the patients will be administered the BDI-II. The BDI-II consists of 21 items read by the subject (or alternatively they can be read to the subject by the administrator). Each item is followed by four options (statements) that the respondent is required to endorse as they are related to their feelings over the prior two weeks including the day of the assessment. It can be used over multiple assessments and remains one of the most used measures of depression for both research and clinical uses.

The Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988). In order to measure the patient’s anxiety levels, the patients will be administered the PAI. The BAI is a 21-item inventory that self-administered (or alternatively the items can be read to the patient by an administrator). The BAI measures the severity of the patient's anxiety across several different domains. The BAI has demonstrated good reliability and validity in a number of research studies.

Other materials needed. A Lab top computer, SPSS statistical program software, notebooks, BDI-II and BAI record sheets.

Procedure

Participant recruitment. Following IRB approval the therapists/counselors will be recruited from several potential different venues including veteran’s hospitals and local therapy/counseling centers. Each therapist will be informed as to the general nature of the study to ensure their cooperation and ensured that confidentiality will be maintained for both them and their patients. Efforts will be made to recruit counselors that specialize in PTSD treatment, but as a minimum requirement selected counselors will be required to have a minimum of five years experience in treating PTSD.

Participant counselors will recruit patients for the study (or the counselor may choose to have the researcher recruit patients from their new patients). Each patient will complete informed consent forms before they are enrolled in the study. There will be an effort to balance the ages, genders, and educational backgrounds of the participants in both treatment groups. The patient and therapist names will not be used for identification. In order to maintain confidentiality, each therapist will be assigned an identification number and each patient will be assigned a participant number. The researcher will have no access regarding the identity of any patient in the study outside of their participation number.

Demographic information for each patient will be collected by the therapist and forwarded to the researcher. This information will include the patient's age, gender, level of education, marital status, ethnic background, types of medications, and general information regarding the traumatic event that has resulted in the patient's diagnosis of PTSD. As mentioned in the introduction many patients who suffer from PTSD are concurrently treated with medication and psychotherapy. An effort will be made to match patient groups up in the types of medications they receive; however, this may prove difficult due to the complex nature of PTSD and comorbid psychiatric diagnoses (APA, 2013). In order to control for confounding psychiatric issues and complicated medication regimes, an attempt will be made to recruit only patients with a diagnosis of PTSD, but it will most likely be difficult to limit the inclusion criteria to participants that only have a diagnosis of PTSD.

To control for other potential confounding demographic variables the researcher will also attempt to match participants in the BDP T and CBT group signed important demographic characteristics that may influence the outcome such as the participants’ age, gender, level of education, and any comorbid psychiatric diagnoses such as depression and substance abuse. In this manner, the researcher can control for major subject variables that can influence the outcome of the study (Haugen, et al, 2010; Resick et al., 2008).

Assessments. Prior to the beginning of their psychotherapy treatment, each patient will complete the BDI and BAI and each patient will complete both measures again following completion of 12 weeks of psychotherapy. The patients’ pre-and post-BDI – II and BAI scores will then be compared in order to determine the effectiveness of the treatment on relieving the patient's depression and anxiety. Records regarding the number of therapy sessions each patient has completed will be used to make sure that patients receive an equivalent number of sessions.

Design and analyses. The use of SPSS procedures descriptive statistics will compare differences in the demographic variables of the sample. The independent variable in this study is the type of psychotherapy received (either PDT or CBT). There are two dependent measures for this study. The first dependent variable is change in the level of depression the patients report pre-and post-treatment. The second dependent variable is the change level of anxiety the patients report pre-and post-treatment.

The data will be analyzed using a MANCOVA with therapy type as the independent variable and the post-test scores on the BDI – II in BAI as the dependent measures. The covariates will be the pretest scores on BDI – II and BAI. Using the pre-test scores as covariates results helps remove the potential confounds of different pre-test scores and treats the dependent post-test scores as if everyone scored equivalently on the pretest, thus reducing potential error (Tabacnick & Fidell, 2012). Models using both the pre-test scores either the BAI and the BDI as covariates can also be analyzed in order to assess the outcome of one independent measure after the adjustment for the other can also be implemented. Appropriate post hoc tests will be implemented when necessary. The alpha level will be set at .05 for the analyses.

References

Abbass, A. A., Hancock, J. T., Henderson, J., & Kisely, S. (2006). Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Database Syst Rev, 4.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Beck, A. T., Brown, G., & Steer, R. A. (1996). Beck Depression Inventory II manual. San Antonio, TX: The Psychological Corporation.

Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: psychometric properties. Journal of consulting and clinical psychology, 56(6), 893-897.

Benish, S. G., Imel, Z. E., & Wampold, B. E. (2008). The relative efficacy of bona fide psychotherapies for treating post-traumatic stress disorder: a meta-analysis of direct comparisons. Clinical psychology review, 28(5), 746-758.

Bhar, S. S., Thombs, B. D., Pignotti, M., Bassel, M., Jewett, L., Coyne, J. C., & Beck, A. T. (2010). Is longer-term psychodynamic psychotherapy more effective than shorter-term therapies? Review and critique of the evidence. Psychotherapy and Psychosomatics, 79(4), 208-216.

Brom, D., Kleber, R. J., & Defares, P. B. (1989). Brief psychotherapy for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 57, 607–612.

Campbell, J. (2008), Causation in psychiatry. In K. Kendler and J. Parnas (Eds.), Philosophical issues in psychiatry: Explanation, phenomenology, nosology. Baltimore: Johns Hopkins University Press.

Carr, R. B. (2011). Combat and human existence: Toward an intersubjective approach to combat-related PTSD. Psychoanalytic Psychology, 28(4), 471-496

Carr, R. B. (2013). Two War-Torn Soldiers: Combat-Related Trauma through an Intersubjective Lens. American journal of psychotherapy, 67(2), 109-133.

Clarkin, J.F., Levy K.N., Lenzenweger, M.F., & Kernberg, O.F. (2007). Evaluating three treatments for borderline personality disorder: A multiwave study. American Journal of Psychiatry, 164, 922-928.

Cloitre, M. (2009). Effective psychotherapies for posttraumatic stress disorder: A review and critique. CNS Spectrums, 14(1), S1, 32-43.

Crits-Christoph, P. (1992). The efficacy of brief dynamic psychotherapy: A meta-analysis. American Journal of Psychiatry, 149, 151–158.

Cummings, N. A., & Cummings, J. L. (2000). The essence of psychotherapy: Reinventing the art in the new era of data. San Diego: Academic.

Driessen, E., Cuijpers, P., de Maat, S., Abbass, A. A., de Jonghe, F., & Dekker, J. J. (2010). The efficacy of short-term psychodynamic psychotherapy for depression: a meta-analysis. Clinical Psychology Review, 30(1), 25-36.

Ehlers, A., Bisson, J., Clark, D. M., Creamer, M., Pilling, S., Richards, D., ... & Yule, W. (2010). Do all psychological treatments really work the same in posttraumatic stress disorder? Clinical Psychology Review, 30(2), 269-276.

Forbes, D., Creamer, M., Bisson, J. I., Cohen, J. A., Crow, B. E., Foa, E. B., ... & Ursano, R. J. (2010). A guide to guidelines for the treatment of PTSD and related conditions. Journal of traumatic stress, 23(5), 537-552.

Hatfield, R. C. (2014). The everything guide to panic disorder. Avon, MA: Adams.

Haugen, P. T., Evces, M., & Weiss, D. S. (2012). Treating posttraumatic stress disorder in first responders: A systematic review. Clinical psychology review, 32(5), 370-380.

Lambert, M. J., & Bergin, A. E. (1994). The effectiveness of psychotherapy. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed., pp. 143–189). New York: Wiley.

Leichsenring, F. (2005). Are psychodynamic and psychoanalytic therapies effective? International Journal of Psychoanalysis, 86, 841-868.

Leichsenring, F. & Rabung, S. (2008). Effectiveness of long-term psychodynamic psychotherapy: A meta-analysis. JAMA, 300, 1551–1565.

Leichsenring, F., Rabung, S., & Leibing, E. (2004). The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: A meta-analysis. Archives of General Psychiatry, 61(12), 1208-1216.

Lindy, J.D. (1993). Focal psychoanalytic psychotherapy of posttraumatic stress disorder. In J. P.Wilson & B. Raphael (Eds.), International handbook of traumatic stress syndromes (pp. 525–536). New York: Plenum Press.

Luborsky, L. (1984). Principles

Luborsky, L., Rosenthal, R., Diguer, L., Andrusyna, T. P., Berman, J. S., Levitt, J. T., Seligman, D. A., & Krause, E. D. (2002). The Dodo Bird verdict is alive and well—mostly. Clinical Psychology: Science and Practice, 9, 2–12.

Malan, D. H. (Ed.). (2013). A study of brief psychotherapy (Vol. 8). New York: Routledge.

Milrod, B., Leon, A.C., Busch, Z.F., Rudden, M., Schwalberg, M., Clarkin, J., Aronson, A., Singer, M., Turchin,W., Klass, E.T., et al. (2007). A randomized control trial of psychoanalytic psychotherapy for panic disorder. American Journal of Psychiatry, 164, 265-272.

Nathan, P.E., & Gorman, J.M. (Eds.). (2007). A guide to treatments that work (3rd ed.). New York: Oxford University Press.

Nugent, N.R., Tyrka, A.R., Carpenter, L.L., & Price, L.H. (2011). Gene-environment interactions: Early life stress and risk for depressive and anxiety disorders. Psychopharmacology, 214(1), 175-196.

Nunnally, J. C. & Bernstein, I. H. (1994). Psychometric theory (3rd ed.). New York: McGraw-Hill.

Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D. S. (2008). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological trauma: Theory, research, practice, and policy, Vol S(1), 3-36.

Resick, P. A., Monson, C. M., & Rizvi, S. L. (2008). Posttraumatic stress disorder. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: A step by step treatment manual (pp. 65-122). New York: Guilford Press.

Shad, M.U., Suris, A.M., & North, C.S. (2011). Novel combination strategy to optimize treatment for PTSD. Human Psychopharmacology, 26, 4-11.

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98-109.

Schottenbauer, M. A., Glass, C. R., Arnkoff, D. B., & Gray, S. H. (2008). Contributions of psychodynamic approaches to treatment of PTSD and trauma: A review of the empirical treatment and psychopathology literature. Psychiatry: Interpersonal and Biological Processes, 71(1), 13-34.

Sparks, J. A., Duncan, B. L., & Miller, S. D. (2008). Common factors in psychotherapy. In J. L. Lebow (Ed.) Twenty-first century psychotherapies: Contemporary approaches to theory and practice (pp. 453-497). Hoboken, NJ: Wiley.

Strupp, H. H., & Binder, J. L. (1984). Psychotherapy in a new key: A guide to time-limited dynamic psychotherapy. New York: Basic Books.

Tabachnick, B. G., & Fidell, L. S. (2012). Using multivariate statistics (6th Ed.). New York: Harper Collins.

Tolin, D. F. (2010). Is cognitive–behavioral therapy more effective than other therapies?: a meta-analytic review. Clinical psychology review, 30(6), 710-720.

Town, J. M., Diener, M. J., Abbass, A., Leichsenring, F., Driessen, E., & Rabung, S. (2012). A meta-analysis of psychodynamic psychotherapy outcomes: Evaluating the effects of research-specific procedures. Psychotherapy, 49(3), 276 - 290.

Westen, D., Novotny, C.M., & Thompson-Brenner, H. (2004). The empirical status of empirically supported psychotherapies: assumptions, findings, and reporting in controlled clinical trials. Psychological Bulletin,130, 631–663.

Wittmann, L. & Halpern, J. (2011). Prolonged exposure and psychodynamic treatment for posttraumatic stress disorder: Comments on an article by E. Gilboa-Schechtman et al. Journal of the American Academy of Child Adolescent Psychiatry, 50, 521-522.