Psychodynamic Assessment and Treatment of Traumatized Patients

Abstract

This article describes how psychodynamic assessment and treatment of traumatized patients can improve clinical acuity. The author describes an ego psychological, psychodynamic approach that involves 1) assessing the impact of trauma on the patient's ego defensive functioning and 2) elucidating the dynamic meaning of both the patient's presenting symptoms and the traumatic events that precipitated them. Clinical descriptions illustrate the ways in which psychodynamic psychotherapy may be particularly useful with patients whose acute symptoms develop following specific events. The author points out the advantages of an ego psychological, psychodynamic approach for her patients and the limitations of more symptom-based diagnostic assessments and treatments.

Since 1980, there has been a resurgence of psychiatric interest in the impact of trauma on children and adults. This literature has recently been comprehensively reviewed by van der Kolk and colleagues in their book Traumatic Stress.¹ The DSM-IV diagnosis of posttraumatic stress disorder (PTSD), derived from evolving research, requires exposure to an event involving “actual or threatened death or serious injury, or a threat to the physical integrity of self or others,” and a response involving “intense fear, helplessness, or horror” (pp. 427, 428). DSM-IV lists a series of symptoms as necessary evidence that the event continues to be reexperienced (and/or avoided) and that it continues to evoke symptoms of increased physiologic arousal.²

Yehuda and McFarlane³ have shown that psychological trauma does not necessarily lead to PTSD but may precipitate other symptoms and syndromes. They propose that factors not yet well understood determine the variability of individual responses to trauma. Numerous DSM-IV diagnoses in addition to PTSD have been identified in traumatized patients. These include major and minor depressive syndromes, panic and generalized anxiety, dissociative disorders, borderline personality, and substance abuse.^4–10 van der Kolk et al.¹¹ have demonstrated that PTSD rarely occurs alone, and they suggest that a range of trauma-related psychological problems, not fully captured in the DSM-IV framework of PTSD, occur together, requiring a more comprehensive approach.

Psychoanalytic ego psychology can provide such a comprehensive approach to trauma. Using the ego psychological framework described below, a variety of pathological states caused by a given traumatic event (or events) may be understood. This framework assists the clinician who is attempting to select and implement effective treatment in two ways. First, it provides parameters for evaluating the impact of potentially traumatic events on the patient's ego functioning (the intrapsychic capacity to synthesize and master the emotional impact of both external events and internal stimuli).¹² Second, it orients the clinician toward investigating in depth the dynamic meaning of both the patient's presenting symptoms and the traumatic events that precipitated them.

In this article I will focus on patients who come to treatment with acute symptoms following specific recent experiences and who have functioned at a relatively high level prior to the onset of these symptoms. Although the ego psychological approach to treating patients who complain of severe, chronic symptoms is beyond the scope of this article, the same approach can be clinically useful in understanding such patients.

Currently, the symptom-oriented organization of the Diagnostic and Statistical Manual¹³ and the increasing availability of medications and behavioral approaches to treat symptoms directly may deflect clinicians from exploring the meaning of recent precipitating events and the complex relationship of such events to their patients' symptoms. Pharmacologic treatments, while often very helpful, are limited by side effects, incomplete results, and lack of acceptance by those patients who prefer to solve problems more definitively in psychotherapy.¹⁴ Cognitive-behavioral therapies, although reported to be efficacious in Vietnam veterans and rape victims,¹⁵ consist of discrete treatments for specific symptoms and do not easily lend themselves to application in more complex clinical situations. In addition, there has been little systematic investigation of what works best in whom.¹⁶ As with pharmacotherapy,some patients refuse to participate, and others may find such treatments ineffective or insufficient. At the other end of the spectrum, inexperienced clinicians armed with the PTSD diagnosis may overzealously explore traumas psychodynamically without adequate attention to the vulnerable state of the patient's ego functioning,¹⁷ thus overwhelming the patient's capacity to cope.

Despite difficulties studying psychodynamic treatments, a controlled study demonstrated that psychodynamic psychotherapy was as effective as hypnotherapy and trauma desensitization for PTSD when treated patients were compared with wait-listed control subjects.¹⁸ Patients treated with psychodynamic psychotherapy showed symptomatic improvement somewhat later than other treated patients, but they showed unexpected, and comparably greater, beneficial changes in personality traits.

Recent reports document that posttraumatic reactions may be long lasting if not treated effectively. Rose,¹⁹ surveying the literature, found that brief supportive psychotherapy for adult survivors of sexual assault had frequently been inadequate to deal with persistent symptoms, even in patients with no preexisting psychopathology. Nader et al.²⁰ described the considerable degree to which children remained symptomatic 14 months following an acute disaster. Terr²¹ prospectively studied children exposed to a day-long schoolbus kidnapping that involved no physical harm. The children showed symptoms of posttraumatic stress 4 years later, despite brief psychotherapy. Kessler et al.²² found that although treated patients fared better than others initially, one-third of all people with an index episode of PTSD failed to recover even after many years. These data suggest a pressing need for further research into the efficacy and methodology of psychodynamic psychotherapy with traumatized patients.

Ego Psychological Approach

Freud has been accused by current trauma theorist Judith Herman of denying women's reality when he abandoned his hypothesis that his patients' symptoms were invariably caused by seduction during childhood.²³ Subsequently, he developed a structural theory that gave rise to the concepts of the three functional divisions of the mind: the ego, id, and superego.²⁴ Simon²⁵ has reviewed the history of this change in theory and the problems that have evolved in its wake despite the tremendous advantages of the new theory for understanding clinical data. The structural theory marked the beginning of ego psychology and was necessary to account for the multiple factors, including trauma, intrapsychic conflicts, and other vulnerabilities, that contribute to the development of psychopathology. Without this theory, it is more difficult to understand the meaning that patients attribute to traumatic events, the effect that these events have on patients' functioning, and the array of symptoms that traumatized patients develop. However, Freud's abandonment of the seduction hypothesis is often misunderstood to signify that Freud, and subsequently his followers, deny the reality, importance, and impact of external trauma.²⁶

It is beyond the scope of this article to review the history of ego psychology since Freud, except to say that Freud's later theory has been continually revised in the light of new analytic and neurobiologic evidence.^27–31 The 1967 volume Psychic Trauma³²contains several landmark papers in the evolution of the ego psychological view of trauma, including Anna Freud's “Comments on Trauma,” discussed below. Inderbitzin and Levy,³³ in a paper exemplifying ongoing recent revisions, question the common conceptualization that reliving a trauma is an attempt at mastery by “repetition compulsion.” They illustrate the degree to which episodes of reliving contain elements of defense against aggression mobilized by trauma.

Currently, the concept of the “ego” refers to a complex dynamic system of internal, and often unconscious, defenses and functions that mediate between the physiological and emotional needs of the self, such as for food, nurturing, or erotic gratification, and the demands of the external world. Perception, motor capacity, intelligence, thinking, language, and memory are among the many, relatively mature, functions of the ego.¹²

Psychoanalysts with an ego psychological orientation continue to define trauma as an external event, or series of events, that specifically overwhelms ego defenses, causing the traumatized person to regress to earlier modes of functioning.^34,35 For example, following a traumatic event, a child who has been successfully toilet trained and has been sleeping alone for many years may be unable to maintain bowel or bladder control or to fall asleep without mother present. Similarly, following a rape, a previously independent and highly functioning adult who characteristically used humor to cope with adversity may have difficulty concentrating at work and may revert to uncharacteristically primitive defenses, such as projection, to cope with anger.

Anna Freud suggested reserving the term trauma for situations in which there is concrete evidence that the ego has been overwhelmed and is unable to perform its usual functions, using its usual defenses.³⁶ Her view is consistent with DSM-IV, if we consider the intrusive, avoidant, and hypervigilant symptoms (listed under subheadings B, C, and D of the PTSD diagnosis) as concrete evidence of an overwhelmed ego.² Anna Freud, unlike DSM-IV, includes cases of cumulative³⁷ and strain³⁸ trauma (where lesser events have an additive effect) when there is symptomatic evidence that the ego, at a certain point, has become massively overwhelmed by the accumulated impact of events. Partial trauma, in which some defenses have been mobilized, often combines with other influences to confuse the clinical picture. Where childhood trauma and/or genetic factors have interfered with ego development, patients often present with a particularly extensive and perplexing array of symptoms and pathologic character traits.^36,39–41

Most analysts do not expect to fully know whether, and how, an event has been traumatic until treatment has clarified the meaning of the trauma and the patient's associated response. Therefore, unlike treatments where a definitive diagnosis is required at the start, psychodynamic treatment will not preclude cases in which an event's impact is not yet clear or conscious, or in which the effects of trauma have become obscured by other symptoms and experiences.

Initial psychodynamic assessment usually takes place during approximately three 1-hour sessions. While exploring the patient's current problems, past treatment, early development, and social relationships, the interviewer also assesses mental status both indirectly and, when necessary, by asking direct questions. Although keeping in mind areas to cover, the interviewer is not limited in advance to prestructured questions and leaves time for problems and reactions to emerge spontaneously. In addition to focusing on specific symptoms or behaviors such as those listed in DSM-IV, the interviewer attends to patterns of symptom occurrence and recurrence. Using this information, as well as concurrent observations of the patient's behavior and affects, the interviewer evaluates the patient's past and current ego functioning. When the symptom picture suggests acute regression from a relatively high level of functioning but the relationship of symptoms to recent events remains obscure, an extended evaluation, combined with a trial of psychodynamic therapy, may be necessary for more definitive diagnosis and treatment.

Psychodynamic assessment and treatment can be uniquely helpful in clarifying the meaning and influence of traumatic events, as well as the relationship of these events to presenting symptoms. For those patients who have become symptomatic following recent events, who have functioned at a much higher level prior to these events, and whose trauma is no longer ongoing, psychodynamic psychotherapy is often extremely effective and may be relatively short term. Confidentiality is a critical condition for full disclosure from patients (and one that may be compromised by current demands for information from insurance companies).

Factors Affecting Outcome of Trauma

Anna Freud delineated five factors that influence the outcome of trauma. These, when updated with current findings from research, can provide a framework within which to understand the impact of traumatic events on ego functioning, as well as the meaning these events can acquire for the patient. After reviewing Anna Freud's five factors, and a sixth added by van der Kolk more specifically for the assessment of adults,⁴² I will illustrate how I used this framework to understand and treat two patients seen in my private office.

The Nature and Intensity of the Event (Factor 1):

Certain experiences, such as living in a concentration camp, are so overwhelming that they seem to cause symptoms in most people.³⁰ Chronic childhood abuse is similarly detrimental.^43,44 However, other potentially intense and devastating experiences have a more variable effect.⁴⁵ The effect often depends on the meaning of specific details of the experience.⁴⁶

Sensitization due to Prior Trauma (Factor 2):

Sensitization can create a situation where a secondary event, not so obviously unusual as to meet DSM-IV criteria, precipitates a delayed onset of symptoms. Although such symptoms are accounted for in DSM-IV (Specifiers: With Delayed Onset), the clinician may miss the diagnosis when the patient is not consciously aware of prior trauma or when the patient is reluctant to reveal upsetting experiences to the interviewer. (See the case of Ms. B., described below.)

Hereditary and Congenital Factors that Affect the Level of Defensive Functioning (Factor 3):

Inherited and/or congenital vulnerabilities may provide substrates on which external stimuli and intrapsychic conflict act. For example, the recently identified cognitive deficits that underlie vulnerability to schizophrenia⁴⁷ may make the schizophrenic patient less able than others to cope with external stress and internal conflict, leading to more extreme decompensation. Rats can be bred to become increasingly susceptible to learned helplessness.⁴⁸ Genetic factors increase the vulnerability of individuals to the depression-inducing effect of stressful life events.⁴⁹ In bipolar, depressed, and anxiety-prone individuals, we still know relatively little about exactly what traits are inherited or how they predispose to future illness. Nor can we fully explain protective factors such as those found by Maziade et al.,⁵⁰ who studied children ages 3 to 8 with “extremely adverse” temperaments (low adaptability, withdrawal in the face of new stimuli, intense emotional reactions, negative mood, and low distractibility). These children had a much higher incidence of behavioral difficulties and clinical disorders in adolescence than did children with other temperaments, but no children with such adverse temperaments developed difficulties if they were living in the most highly functioning families.⁵⁰

Chronological Age and Developmental Stage at the Time of the Trauma (Factor 4):

The individual's age and stage of development influence the effect that trauma will have on ego development. As Anna Freud notes, “The young child's task of building up . . . a defensive organization is made immeasurably more difficult if traumatic experiences have to be endured during the critical period of maturation and development, just as the supporting walls of a house are more open to damage during building operations than after completion”³⁶ (p. 225). See Tyson and Tyson⁵¹ for a recent, thorough description of the specific phases of ego development.

The child often attributes meaning to a traumatic event that is consistent with the child's stage of development and age-appropriate fantasies. For example, potentially traumatic events during the oedipal period (ages 3–6) frequently become linked with sexual conflicts: Glenn described 3 patients who developed severe masochistic symptoms in response to experiencing their painful and frightening surgeries as punishment for sexual fantasies and wishes.⁵²

Recent research by van der Kolk et al.¹¹ confirms prior findings of a relationship between the age at the time of trauma, the nature of the experience, and the clinical outcome.

Environment at the Time of Trauma (Factor 5):

Environment can influence the impact of adverse experiences on both children and adults. A supportive parent can provide considerable protection to the vulnerable ego of a child exposed to trauma. In contrast, children living in chronically dangerous and/or abusive environments may cope by means of distorted ego development (including numbing and dissociative states).⁴¹ Traumatized adults are also affected by the extent to which support is available from family members and society.⁵³

Preexisting Personality (Factor 6):

Character traits, more fully consolidated by adulthood, further affect the outcome of adult trauma, leaving some individuals more susceptible to protracted PTSD reactions than others.⁴⁵ Character traits formed in the process of resolving childhood conflicts may be reactivated by adult trauma, influencing the symptomatic picture.

Clinical Cases

Case 1. Ms. A., a married photographer with two young children, came to me with panic attacks. She suffered from palpitations, feelings of impending doom, difficulty sleeping, and nausea, all of which led her to fear she was going crazy. She was tearful, hopeless, and convinced that she had brain damage as a result of a hallucinogen she had ingested 4 years before.

Ms. A. had been treated by two different psychiatrists over a period of 4 years. Her difficulties began when she was given the hallucinogen at a party, without her knowledge. She experienced depersonalization and became convinced that she was dying. A psychiatrist hospitalized her briefly, treating her with anti-anxiety medication (oxazepam and diazepam). He then maintained her on small doses of medication and weekly supportive therapy for a period of 2 years. She recovered from the physiological effects of the drug but continued to feel intermittently anxious, worrying that the drug had damaged her brain. During the second year, therapy was interrupted when Ms. A. and her children were forced to move because their safety was jeopardized through risks that developed in her husband's work as a criminal lawyer. When this work was over and he joined them, Ms. A. was surprised to find that her symptoms continued and that she began to feel even more depressed.

I saw Ms. A. the following year, after she had been treated by a second psychiatrist for several months. He had given her small doses of anti-anxiety and antidepressive medication (clonazepam 2 mg bid, fluoxetine 20 mg qd) and weekly therapy sessions focused on explaining the physiologic basis for her panic attacks. Ms. A.'s anxiety initially decreased, but she subsequently stopped both medications, claiming that medicines doctors insisted on giving her were making her worse.

Although Ms A. fulfilled DSM-IV criteria for panic attacks, generalized anxiety, and dysthymia, the significance of her symptoms was not initially clear. Nor could I rule out an organic component to her symptoms. But she had experienced obvious stress, and neither of the prior psychiatrists had addressed the impact of her potentially traumatic experiences directly.

Ms. A. had grown up in a relatively stable family. Although childhood conflicts resulted from her interactions with a strict father and a somewhat self-centered mother, there was no clear evidence for severe ego vulnerabilities that were due to genetic factors, prior trauma, or major early environmental deficits. However, she was relatively unaware of many of her feelings and impulses, and there was a brittle quality to her defenses. Her relationship with her children appeared basically sound, despite her symptoms, but some discontent with her husband (experienced, at the time, as mild) had predated the events of the past several years.

I saw Ms. A. in an extended evaluation twice a week over a period of 1 month before I could correctly diagnose her posttraumatic stress reaction. We clarified how she had misinterpreted mild antidepressant side effects, mild benzodiazepine withdrawal symptoms, and the physiologic accompaniments to panic attacks as signs of brain damage. While Ms. A. attempted to engage me in treating her “brain damage,” she simultaneously worried that I might further harm her. Although I considered restarting Ms. A.'s antidepressant, it became increasingly evident that medically oriented treatment, rather than alleviating her symptoms, had reinforced her conviction that she was suffering from brain damage. This idea might have been overcome with interpretation, but medication proved unnecessary: she responded with decreased anxiety once we began to understand the meaning of her symptoms and experiences. By observing her reactions over time, we noticed how her symptoms intensified whenever she was confronted with experiences that revived memories and thoughts about the events of the past 4 years: her conviction that doctors were giving her drugs that made her sick was fueled by unexpressed anger at her husband, who had taken her to the party where she ingested the hallucinogen, and the first doctor, who had further plied her with medications without helping her with her experiences. Feeling herself mistreated by insensitive psychiatrists and locked in a crazy spiral of interactions from which she could not extricate herself, she recalled similar feelings that had accompanied threats to her husband and the family in connection with her husband's legal case.

Ms. A. recovered over a period of 5 months. In addition to regaining her pretraumatic equilibrium, she was able to confront her husband about his tendency to misjudge the character of his friends (such as the one who had given the party where she had received a hallucinogen) and to deny the riskiness of his cases. Inhibition had prevented her from doing this earlier, although she felt his trait had contributed to their recent difficulties. The couple planned to begin marital therapy in the near future.

Ego regression, induced by her recent traumatic experiences, seemed the most important determinant of Ms. A.'s symptoms. At the time of her hallucinogen ingestion, although she no doubt experienced physiologic effects of the drug, Ms. A. had also been faced with a glimpse into her unconscious life for which she was emotionally unprepared. (For example, it seemed likely that her conviction that she was dying derived from unacknowledged anger at her husband for exposing her to risks that both he and she had ignored.) Subsequent dependence on her first psychiatrist, and on medication, further weakened her coping capacity while still keeping her unaware of her anger. The additional risks that developed in connection with her husband's job exerted further stress on an already compromised ego. Ms. A.'s second psychiatrist, using a symptom-oriented approach, compounded her problems by ignoring her trauma, failing to recognize the dynamic significance of her interactions with him, and inadvertently confirming her fears of brain damage.

Childhood conflicts pertaining to her relationship with a domineering father probably contributed to Ms. A.'s marital choice, her brittle defenses against her anger, and her inhibitions in assertiveness. More intensive dynamic work to familiarize her further with her unconscious life and the childhood antecedents of her current conflicts might have been useful. However, she was not interested in such exploration at the time—possibly because she retained some anxiety about her inner life, but also because her gains in treatment had been substantial and marital work took precedence.

Case 2. Ms. B., a married decorator, came to me complaining of several months of increasing tearfulness, suicidal ideation, difficulty sleeping, hopelessness, phobic anxiety about leaving her house, and fear for the safety of her 6-month-old baby. She met DSM-IV criteria for a major depressive episode, and additional components of the clinical picture did not emerge until we proceeded with an extended evaluation and began psychodynamic psychotherapy. She could date her distress from the time of her long, painful labor and delivery. After the birth of a healthy baby, she could not rid herself of the feeling that she had been mistreated and ruined by those who had cared for her. She blamed her husband, who had selected the small suburban hospital through contacts in his medical supply business. Although she had received some supportive therapy following childbirth, she never fully recovered and believed her symptoms were becoming worse again. The intensity of her reaction to the childbirth and her evasiveness about a hospitalization following an adolescent suicide attempt suggested possible trauma. (The childbirth experience alone was not severe enough to meet DSM-IV criteria.)

When Ms. B. was an infant, her mother had developed an unspecified emotional illness. Her father, who was often absent at work, had provided most of her nurturing. Ms. B. reported that during grade school she had been bullied by children in the neighborhood and never felt comfortable. Although she had abused alcohol during adolescence and had subsequently become involved in several self-destructive relationships, she had established emotional stability during the 5 years preceding the birth of her child. She had become competent in her career and had married a nonabusive husband. She was particularly upset with herself because of her feelings toward her formerly loved husband and because tearfulness, anger, and distress left her feeling unable to care for her baby.

In addition to Ms. B.'s obviously overwhelmed ego functioning, her family history of mental illness and stormy past personal history suggested that she might have underlying ego vulnerabilities. She experienced intense anxiety in response to some of my exploratory questions. This response, and the extent of her vegetative symptoms and difficulty coping at home, suggested that she was too distressed to engage in psychotherapy without medication. These factors also suggested she was at risk for further regression at a time when her availability to her baby was crucial. However, her responsiveness to my questions connecting her current symptoms with the feelings, memories, and fantasies stirred up while she was giving birth, and her subsequent revelation of further pertinent information, indicated her receptiveness to psychodynamic treatment and some capacity for insight.

I saw this patient long before the era of media interest in sexual abuse. However, once she was convinced that I would listen to her, rather than accusing her of being irrational or insisting on treating her with medication alone, she revealed that, while in labor, she had remembered a long-forgotten incident of sexual abuse. (Her father, who had intervened to end the abuse, had been unable to talk to about it to his then 5-year-old daughter.) Ms. B. also told me of a later sexual assault. This she had always remembered, but because she knew she had made herself vulnerable and was convinced that she would be blamed, she never told anyone. Several weeks of careful attention to her evasiveness about her adolescent suicide attempt passed before she told me the details. Despondent because a boyfriend had rejected her, she had joined a group of unsavory boys for a picnic. They had taken her to a deserted park and gang raped her. The complicated childbirth, in which a number of doctors and nurses gathered around her, watching her pain, vividly revived her sensations during the gang rape as well as her memories of the childhood abuse.

Ms. B. responded well to a combination of psychotherapy and antidepressant medication (doxepin 150 mg, decreased to 75 mg after 3 months). Medication alleviated her symptoms sufficiently for her to talk to me about the rapes and childhood abuse without feeling completely overwhelmed. Understanding the relationship of her symptoms to guilt about her early abuse, subsequent rapes, and more recent death wishes toward her baby proved crucial for her eventual recovery. We were able to determine that the death wishes toward her baby derived primarily from her anger at her own mother's inability to nurture her. Ms. B. remained in treatment for approximately 10 months and was able to taper and discontinue medication several months before terminating therapy. Although she described some minor conflicts with her husband, her affectionate feelings toward him returned, and she no longer felt fearful about, or unable to care for, her baby. Remembering her nurturing father and turning to his religion contributed to her recovery. On follow-up several years later, I learned that she went on to have a second baby without recurrent symptoms.

Remarkably, despite severe symptoms throughout her life, Ms. B. had achieved many years of stability before her child was born. Under the stress of pregnancy and a childbirth that elicited sensations similar to the ones she experienced during rape and abuse, she recalled her earliest experience. Had Ms. B. come to treatment at another time, when engaged in self-destructive behavior but without memories of the abuse or motivation to understand her relationship with her mother, she would probably have required more lengthy and intensive treatment.

Ms. B.'s sexual abuse at age 5 had been an isolated incident, rather than ongoing trauma inflicted by a close relative or caretaker. Mother's unavailability had made her vulnerable to an abusive neighbor. The abuse, in the context of her ambivalent relationship with mother, greatly intensified Ms. B.'s conflicts about autonomy and sexuality, making it difficult for her to resolve these conflicts through the usual positive identifications with mother. Father's failure to talk with her about the abuse further increased her vulnerability. She dealt with subsequent difficulties, such as bullying in grade school and rejection by a boyfriend in high school, by becoming a victim.

Her experience illustrates the reverberations trauma may have at several stages of life, and the complexity of its reenactments. For example, when Ms. B. went with the unsavory group of boys who subsequently gang raped her, she had been abandoned by a boyfriend, as she had felt abandoned by her parents in childhood. Again, as in the childhood abuse experience, she felt vulnerable to anyone who showed an interest in her. In allowing herself to accompany the boys she knew to be unsavory, she repeated aspects of the repressed abuse but also punished herself for anger at the abandoning boyfriend (representing both mother and father) and for the then-unconscious sexual feelings that had been aroused by the childhood abuse.

It is not surprising that Ms. B.'s symptoms arose again during childbirth, when unresolved conflicts with mother tend to be revived. Pathological identification with her emotionally unavailable mother left Ms. B. feeling inadequate and withdrawn, and this required our attention before she could feel confident in her own mothering. Fortunately, she was able to make use of her identification with her nurturing and supportive father in recovering her capacity as a parent.

Ms. B. might have been genetically vulnerable to depression (since her mother may have suffered from it), and medication alone may have benefited her symptomatically. However, medication would also have left her vulnerable to further traumatic reenactments, continued difficulties in mothering, and recurrent postpartum depression. Since she had already withheld important information from several mental health professionals, it seems unlikely that Ms. B. would have been able to reveal her traumatic experiences in a more symptom-oriented treatment where her defenses and underlying guilt were not specifically addressed. However, she did need the support of medication in order to tolerate the feelings aroused by exploring her experiences.

Discussion

Those traumatized patients who suffer the acute onset of symptoms following specific events or experiences may become aware of the full impact and meaning of these events only during the course of dynamically oriented treatment. Ms. A. and Ms. B. were both seen during periods of acute decompensation. Two consecutive traumatic events (a hallucinogen given to her without her knowledge and subsequent risks to the physical safety of her family) had overwhelmed Ms. A.'s formerly adequate ego defenses. She became increasingly symptomatic as she attempted to cope with the stress of protecting herself and her children and, simultaneously, with her unconscious anger at her husband. Complications during the birth of Ms. B.'s first baby revived memories of childhood trauma (an isolated instance of child abuse in the context of neglectful mothering) and overwhelmed her already vulnerable ego defenses. She became increasingly symptomatic in her attempt to cope with the stress of caring for her baby and the revived memories of emotional pain, death wishes, and guilt, which now were directed toward her husband, her baby, and herself. Diagnostically, it was important 1) to recognize the extent to which specific events had led these patients to regress in their capacity to cope with internal and external stimuli, 2) to determine their more usual coping capacities, and 3) to understand developmental and hereditary factors contributing to their ego strengths and vulnerabilities.

Both patients responded to psychodynamic treatment that helped them understand the meaning of their symptoms without further compromising their ego functioning. Ms. A. had ascribed an ominous meaning to the combination of her panic symptoms and medication side effects (that they indicated brain damage), but she had the capacity to make use of dynamic psychotherapy without medication. Because Ms. B. had more ego vulnerabilities due to developmental and possibly genetic factors, she required medication to tolerate the exploration of her childhood sexual abuse, her ambivalent relationship to her mother, and the repetition of her then-unconscious childhood trauma during adolescence. Once she understood and faced her feelings and memories in psychotherapy, Ms. B. was able to discontinue medication and remain symptom free during a second pregnancy several years later.

These cases illustrate the potential for dynamically oriented assessment and therapy to identify and remove obstacles to recovery through clarification and interpretation, resolving the multiple and confusing symptoms of some traumatized patients. Like Ms. A. and Ms. B., such patients may not readily respond to other forms of treatment. They may remain unnecessarily dependent on medication and/ or remain vulnerable to recurrent symptoms. In an era of intense pressure from managed care to reduce treatment, focus on short-term goals, and use medication as a primary form of treatment, the potential efficacy of psychodynamic psychotherapies may be overlooked.

The focus of this article has been on patients who come to treatment suffering from acute symptoms and who are responding to recent events. However, modern analysts continue to effectively treat those traumatized patients who present with multiple chronic symptoms and/or who suffer from more severe, protracted trauma.^54–56 Although such patients can be particularly challenging, much progress has been made, since Freud, in elucidating the impact of trauma on ego development and in differentiating those patients who respond well to psychoanalysis from those who are better treated with other forms of psychotherapy. Combination dynamic-supportive treatments, sometimes including medication and targeted cognitive-behavioral therapies, may be useful when ego vulnerabilities predispose patients to extreme regression.⁵⁷ Serotonergic antidepressants, not yet available at the time I treated Ms. B., may be particularly effective in modifying intense affects sufficiently to allow therapeutic work to proceed.⁵⁸ Techniques such as hypnosis or direct suggestion have been used to help patients with dissociative symptoms and fragile ego functioning cope with overwhelming affects and avoid self-destructive behavior.⁵⁹ For those traumatized patients with borderline personalities who function at a relatively high level, analytically oriented psychotherapy is often very useful.⁶⁰ Psychodynamic assessment of past and present ego functioning aids the clinician in determining the patient's suitability for psychodynamic psychotherapy or psychoanalysis, as well as the need for adjunctive medication or other forms of therapy. Psychodynamic treatment, if appropriately selected, will invariably lead to further elucidating the impact and meaning of traumatic events.

Treating traumatized patients can be very challenging for the therapist. Such patients tend to live out their experiences in action and have difficulty putting them into words. Like Ms. B., they often regress when a trauma is touched upon directly, and considerable clinical skill is required to determine when support, or further exploration, is indicated. Like Ms. A., such patients sometimes make defensive use of traumatic experiences to avoid recognizing other conflicts. Moreover, patients may be able to induce the therapist either to reenact the trauma or to become punitive and critical. In addition, the therapist listening to the experiences of a severely traumatized patient may feel overwhelmed and be at risk for withdrawing empathy, avoiding further exploration, or discharging the patient prematurely.

Conclusion

Traumatized patients benefit from an ego psychological approach to assessment and treatment in two ways. First, assessment of ego functioning provides information about the patient's vulnerabilities and strengths. It guides the clinician in determining both the patient's suitability for psychodynamic treatment and the need for adjunctive medication or other forms of therapy. Second, focus on the meaning of the patient's symptoms helps to identify traumatized patients who have repressed or avoided discussing upsetting experiences at the onset of treatment. This focus may elucidate the formerly obscure relationship of symptoms to traumatic events, as well as the dynamic meaning attributed to these events by the patient.

Patients who have become acutely symptomatic following specific events, who have some capacity for insight, and whose vulnerabilities are taken into account in treatment planning may respond quite rapidly to psychodynamic psychotherapy. By addressing the intrapsychic components to trauma, often missed in other therapies, psychodynamic treatment has the potential for clarifying and resolving the multiple and confusing symptoms that often characterize traumatized patients.