First‐line therapy for post‐traumatic stress disorder: A systematic review of cognitive behavioural therapy and psychodynamic approaches

Background

Despite evidence supporting cognitive behavioural therapy (CBT)‐based interventions as the most effective approach for treating post‐traumatic stress disorder (PTSD) in randomised control trials, alternative treatment interventions are often used in clinical practice. Psychodynamic (PDT)‐based interventions are one example of such preferred approaches, this is despite comparatively limited available evidence supporting their effectiveness for treating PTSD.

Aims

Existing research exploring effective therapeutic interventions for PTSD includes trauma‐focused CBT involving exposure techniques. The present review sought to establish the treatment efficacy of CBT and PDT approaches and considers the potential impact of selecting PDT‐based techniques over CBT‐based techniques for the treatment of PTSD.

Results

The evidence reviewed provided examples supporting PDT‐based therapy as an effective treatment for PTSD, but confirmed CBT as more effective in the treatment of this particular disorder. Comparable dropout rates were reported for both treatment approaches, suggesting that relative dropout rate should not be a pivotal factor in the selection of a PDT approach over CBT for treatment of PTSD.

Conclusion/Implications

The need to routinely observe evidence‐based recommendations for effective treatment of PTSD is highlighted and factors undermining practitioner engagement with CBT‐based interventions for the treatment of PTSD are identified.     

A Negotiation Approach to Intake and Treatment Choice

Treatment choice is the decision process whereby the psychotherapeutic methods and the psychotherapist are determined when psychotherapy is recommended for a specific client. In this article the problem of treatment choice is situated within an integrative view of psychotherapy. A review of the literature confirms the usefulness of the following concepts for treatment choice: client preferences, client control of the situation of choice, and the mutual acceptability of differing views of therapists and clients. These research findings reveal the importance of four elements in the psychotherapeutic intake strategy: exploration of the client's perspective, informing the client, negotiation as a process of confrontation between the client's and the clinician's perspective, and the client's ultimate choice between alternative treatment proposals.     

Working with Families from the Indian Sub-Continent: An Indo-German Experience*

Whereas most Western European therapists and clients consider emotional distance and abstinence as desirable and conducive in the therapeutic process, this may not always be the case with clients from India. Cultural components such as the contrast between linear and cyclic world-views and the traditional view of the psychologist as an advisor in India present a challenge to professionals with a Western background. Some factors such as the situation of women in society and seemingly too close familiy ties can mean that a Western therapist fails to promote the changes an Indian client is desiring for his or her family. However, besides cultural awareness and caution, one of the most helpful tools in work across cultures is curiosity in its most positive sense and the readiness to be surprised by ones’ clients.I would like to thank all my Indian colleagues who supported and advised me in my work in India.     

Influence of Therapist and Client Behaviors on Therapy Alliance

This study considers the combined effect of therapist behaviors and couples interaction dynamics on therapeutic alliance because it seems to be a significant predictor of successful therapy outcomes. We measured therapeutic alliance using the Working Alliance Inventory, Observer Version (WAI-O), which includes three subscales: goals, tasks, and bond. We investigated the combined effect of therapist behaviors and couples interactions on therapeutic alliance. There were three significant findings: (1) the models better predicted therapeutic alliance for men clients than women clients; (2) combined consideration of partner behaviors and therapist behaviors provided the stronger prediction of therapeutic alliance; and (3) different variables predicted alliance for women clients versus men clients.     

The Relationship of the Self of the Therapist to Therapy Process and Outcome: are Some Questions Better Left Unanswered?

Gurman (1987) has challenged the field of marital and family therapy to answer questions concerning the relationship of the therapist to outcome. An examination of conceptual and empirical literature regarding the relationship of the self of the therapist to process and outcome in marital and family therapy discloses that empirical evidence for such relationship is not persuasive. The author constructs a crucible for the field of marital and family therapy.     

Race and Countertransference: Two “Blind Spots” in Psychoanalytic Perception

In this paper I propose an approach for the evocative use and resolution of racial and countertransferential manifestations in the treatment situation. When addressed with the interest they warrant, these phenomena can become powerful tools for the advancement of the treatment, rather than blind spots. The therapist's own treatment is offered as the most likely means through which the evocative and pernicious effects of race and countertransference can be mastered.     

Ethical Considerations in Psychotherapeutic Systems

Theoretical Medicine and Bioethics - In the process of individual psychotherapy, the client and the therapist work together towards clarifying the client's problems, unlocking vicious circles,...     

The effects of prior expectations and outcome knowledge on polygraph examiners' decisions

The present study deals with the question of whether judgments made by experts working in familiar contexts are affected by prior expectations and beliefs. Two experiments in which prior expectations were manipulated were designed to determine whether and to what extent polygraph examiners are affected by their prior expectations when analyzing and interpreting polygraph charts. Prior expectations affected the examiners' judgments when the polygraph charts did not include clear indications of guilt or innocence, but when the objective physiological evidence included strong indications which clearly contradicted the examiner's expectations, judgments were not affected by these expectations. Theoretical and practical implications of these results are discussed.     

Multiple-probe technique: a variation on the multiple baseline

Multiple-baseline and probe procedures are combined into a “multiple-probe” technique. The technique is designed to provide a thorough analysis of the relationship between an independent variable and the acquisition of a successive-approximation or chain sequence. It provides answers to the following questions: (1) What is the initial level of performance on each step in the training sequence? (2) What happens if sequential opportunities to perform each next step in the sequence are provided before training on that step? (3) What happens when training is applied? (4) What happens to the performance of remaining steps in the sequence as criterion is reached in the course of training each prior step? The technique features: (1) one initial probe of each step in the training sequence, (2) an additional probe of every step after criterion is reached on any training step, and (3) a series of “true” baseline sessions conducted just before the introduction of the independent variable to each training step. Intermittent probes also provide an alternative to continuous baseline measurement, when such measurement during extended multiple baselines (1) may prove reactive, (2) is impractical, and/or (3) a strong a priori assumption of stability can be made.     

Defense mechanisms in alcoholics attending outpatient treatment. Results from the MCT-test (Meta-Contrast Technique)

Defensive strategies were studied in 72 alcoholics participating in outpatient treatment by using, before the treatment started, the Meta-Contrast Technique, MCT, a percept-genetic method. Alcoholics had less often adaptive strategies than controls. A lack of adaptive defense strategies was related to a more impaired psychic status, more psychological benefits from drinking, and more psychiatric symptoms but not to severity of alcoholism or results of psychometric tests (intellectual level, field-dependence, spatial performance). It does not seem inconceivable that the MCT could be used as a diagnostic tool in treatment planning.