Psychoanalytic Psychotherapy

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Psychodynamic techniques elicit emotional

engagement in complex post-traumatic stress
disorder

Brian M. Henley

To cite this article: Brian M. Henley (2023) Psychodynamic techniques elicit emotional
engagement in complex post-traumatic stress disorder, Psychoanalytic Psychotherapy, 37:3,
231-242, DOI: 10.1080/02668734.2023.2231059

To link to this article: https://doi.org/10.1080/02668734.2023.2231059

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Psychoanalytic Psychotherapy, 2023
Vol. 37, No. 3, 231–242, https://doi.org/10.1080/02668734.2023.2231059

Psychodynamic techniques elicit emotional engagement in

complex post-traumatic stress disorder
Brian M. Henley*

Downtown Mind Wellness, Los Angeles, USA

(Received 17 January 2023; accepted 5 June 2023)

Therapies based on an exposure model have been shown to be effective in

the treatment of uncomplicated Post-Traumatic Stress Disorder (PTSD), but
less effective when used to treat Complex Post-Traumatic Stress Disorder
(CPTSD), because an essential first step in the exposure model is a patient’s
emotional engagement with traumatic material. This engagement is pre­
vented by a suppressive/dissociative reaction typical of CPTSD. Several
methods of overcoming this suppressive/dissociative reaction have been
investigated, but have proved impractical. Familiar psychodynamic techni­
ques appear to circumvent the suppressive/dissociative response and elicit
the required emotional engagement in standard clinical settings.
Keywords: psychodynamic psychotherapy; post-traumatic stress disorder;
complex post-traumatic stress disorder; exposure therapy; cognitive beha­
vioral therapy

Introduction
The effectiveness of therapies for Post-Traumatic Stress Disorder (PTSD)
founded on the exposure model has extensive empirical support, and these
therapies, which include Cognitive Behavioral Therapy, trauma-focused
Cognitive Behavioral Therapy, and Eye Movement Desensitization and
Reprocessing, have become first-line interventions for the treatment of traumatic
stress (Benight & Bandura, 2004; Ehlers et al., 2013; Rothbaum et al., 1999).
The effectiveness of these interventions is greatly reduced, however, when they
are used to treat Complex Post-Traumatic Stress Disorder (CPTSD) (Ehlers
et al., 2013; Lanius et al., 2010). The unique suppressive/dissociative features
of CPTSD interfere with affective engagement, which is a crucial first step in the
exposure model (Ehlers et al., 2013; Foa & Kozak, 1986; Rauch & Foa, 2006;
Rothbaum et al., 1999; Spermon et al., 2010). Several methods of counteracting
this response are under investigation, but to date none have found widespread
application (Nielson & Megler, 2014; Rothbaum et al., 1999; Scurfield et al.,
1992). Psychodynamic techniques already in widespread use appear to elicit the

*Corresponding author. Email: henley_b@hotmail.com

© 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-
NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use,
distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered,
transformed, or built upon in any way. The terms on which this article has been published allow the posting of the
Accepted Manuscript in a repository by the author(s) or with their consent.
232 B.M. Henley
requisite emotional engagement in patients with CPTSD in standard clinical
settings.

PTSD and CPTSD: treatment considerations

PTSD vs. CPTSD
PTSD can be described as a persistent, pathological, emotional and physiologi­
cal dysregulation attributable to trauma (Lanius et al., 2010). In PTSD, trauma-
related stimuli both external (aspects of the environment reminiscent of the
traumatic scene) and internal (memories, sensations or feeling-states related to
the traumatic event), trigger an emotional and physiological event typified by
hyperarousal. Hyperarousal includes physiological symptoms such as rapid
pulse, hyperventilation and restlessness; as well as emotional symptoms such
as wariness, fear, panic, and irritability (American Psychiatric Association,
2022).
CPTSD can be similarly described as a persistent emotional and physiolo­
gical dysregulation attributable to trauma (Lanius et al., 2010). In CPTSD,
however, trauma-related stimuli elicit an emotional and physiological event
typified by suppression and disassociation. Suppression/dissociation includes
physiological symptoms such as decreased heartrate, slowed respiration, and
stillness; as well as emotional symptoms such as emotional modulation,
expressive suppression, and dissociation (Gross & John, 2003; Lanius et al.,
2010). CPTSD also has a more variable presentation, and a more global effect
on functioning and personality, which are discussed further below (Herman,
1992).

Emotional processing theory and the exposure model

Exposure-model therapies for PTSD trace their theoretical roots to Emotion
Processing Theory (EPT), as described by Foa and Kozak (1986). In EPT,
traumatic stress is conceptualized as a product of pathological fear structures.
Fear structures are cognitive collections of associated stimulus, response and
meaning elements. A knife, for instance, could be a stimulus element associated
with a specific meaning element, such as danger, and relevant responses, such as
flight or panic. Pathological fear structures are distinguished from adaptive fear
structures by three factors: they involve an excessive response element, do not
accurately reflect reality, and are resistant to modification (Foa & Kozak, 1986).
Rectifying pathological fear structures requires two necessary conditions:
activation of the fear structure, and the integration of information incompatible
with the fear structure (Foa & Rauch, 2006). In other words, first the patient
must be feeling, to some extent, the emotions associated with the traumatic
experience (fear, loss, humiliation) before integration can occur. In the exposure
model this is accomplished by exposing the patient to trauma-related stimuli,
such as reciting a trauma script or imagining the incident. Second, with this
 Psychoanalytic Psychotherapy 233
emotional engagement achieved, information incompatible with the fear state is
presented, usually aimed at restoring a more realistic assessment of threat and
personal agency. In this manner the emotion is processed, and the fear structures
modified (Foa & Rauch, 2006).

Challenges in CPTSD: the suppressive/dissociative reaction

It is in the first step of this two-step process, that of activation, that
CPTSD presents unique challenges. Whereas in uncomplicated PTSD,
trauma-related stimuli elicit hyperarousal, in CPTSD the opposite is true
(Lanius et al., 2010). Traumatic reminders spur an over-modulation of
expressed and felt emotion, often through voluntary emotive suppression,
but in some cases involuntarily, and sometimes to the point of profound
disassociation (Gross & John, 2003; Herman, 1992; Lanius et al., 2010).
This is referred to here as the suppressive/dissociative reaction. Functional
Magnetic Resonance Imaging of this process in action reveals high activa­
tion of the brain’s regulatory structures, coupled with suppressed activity in
areas responsible for emotional experience (Lanius et al., 2010). This
renders the feeling states relevant to the trauma inaccessible, and prevents
the activation of the fear structures that is prerequisite in the exposure
model. Numerous studies evaluating exposure-model treatments have noted
the seeming intractability of CPTSD, leading to its frequent labels of
‘treatment resistant’ or ‘chronic’ PTSD (Rothbaum et al., 1999; Scurfield
et al., 1992).

Overcoming the suppressive/dissociative reaction

Several methods have been proposed and studied as solutions to this problem
of emotional engagement. These methods can be sorted into two categories:
stimulus enhancement and pharmacological. Methods in the stimulus
enhancement category operate on the premise that more immersive, evocative
or specific trauma-related stimuli might overpower the suppressive/dissocia­
tive response. These consist of virtual reality and in-vivo exposures to
scenarios that resemble scenes of trauma. Examples include computer-
generated military convoys through Iraq (Rizzo et al., 2014), or real flights
in Vietnam-era helicopters, intended to elicit emotional activation in combat
veterans (Scurfield et al., 1992). By contrast, pharmacological interventions
hope to use the natural disinhibiting properties of psychoactive substances,
such as psilocybin, ayahuasca and 3,4 Methylenedioxymethamphetamine, to
ease the accession and processing of difficult emotions (Nielson & Megler,
2014).
Results of these studies indicate that these methods may hold some promise,
but the drawbacks are numerous. Virtual reality relies on a great deal of
specialized equipment and operator know-how, while in-vivo exposure is
234 B.M. Henley
impractical and potentially hazardous (Rizzo et al., 2014). Pharmacological
interventions can be unpredictable, and are contraindicated for patients with
comorbid diagnoses that involve mania or psychosis (Nielson & Megler,
2014). Until these drawbacks can be addressed, what is called for is a reliable
method for eliciting emotional engagement that can be applied in a standard
clinical setting.

Psychodynamic technique in CPTSD

Psychodynamic approaches are suited to CPTSD due primarily to the pri­
macy of the unconscious in psychodynamic theory. In uncomplicated PTSD,
the generative trauma and resultant symptoms are comparatively circum­
scribed. The generative trauma is most commonly an anomalous event,
a disaster or an attack or an accident, that stands out as being dramatically
different from the accustomed day-to-day experience. Resultant PTSD symp­
toms are likewise anomalous events. The intrusive thoughts, avoidant beha­
viors and stress reactions tend to center around stimuli directly attributable to
the trauma and its context. As frequent and debilitating as these symptoms
may be, they are recognizable as intrusions upon an established identity
(Herman, 1992).
This is not the case in CPTSD. CPTSD has been linked to prolonged trauma,
such as imprisonment or childhood abuse, and resultant symptoms pervade the
personality and manifest in ‘protean sequelae’ (Herman, 1992, p. 2) that impact
every facet of life. Traumatic stress is not an intrusion, but instead has been
incorporated into, and in fact comprises portions of, the identity and sense of
self. Its manifestations are therefore frequently unconscious, and often undistin­
guished from simple habits, preferences, aesthetics, idiosyncrasies, and all the
other myriad components of personality (Herman, 1992).
Psychodynamic techniques aimed at calling attention to these unconscious
manifestations of traumatic stress, and bringing them to conscious awareness,
have the effect of eliciting the emotional engagement – the activation of the fear
structures – requisite for emotional processing to occur without provoking the
suppressive/dissociative reaction. The crucial difference appears to be that in
using these techniques, the therapist is not invoking the trauma (which triggers
the well-documented suppressive/dissociative response), but is instead inviting
the patient to witness its operation already underway.
The psychodynamic techniques most heavily recruited in this endeavor are
transference interpretation and process analysis. These two lend themselves
especially because they are ‘present tense’ interventions. Due to the fact that
the intention is to have the patient witness trauma’s influence as it is operating,
the patient needs to be ‘caught in the act’, so to speak, and transference
interpretation and process analysis can be applied to emerging thoughts and
behaviors at the moment of occurrence.
 Psychoanalytic Psychotherapy 235
Transference as a concept has of course been a mainstay of psychodynamic
theory almost since its inception. Transference is defined as a patient’s thoughts
and feelings about the therapist that have as much or more to do with the
patient’s previous experience of significant others than with anything presented
by the therapist (Suszek et al., 2015). A patient might experience a therapist as
hostile, for example, or seductive or maternal, based more on prior interactions
with others than on the therapist’s observed behavior. The purpose in interpret­
ing transference is to allow modifications to be made to the transference reaction
through awareness and understanding, that can then be generalized to other
relationships, thereby creating a more flexible and adaptive approach to relation­
ships (Suszek et al., 2015).
Process analysis refers to the analysis of the dynamic reactions of the patient
in therapy (Cotter, 2021). Practically any spontaneous reactions – twitches, gaits,
shifts in posture, glottal stops, elisions, abbreviated gestures, winces, etc. – fit
under the category of process, and constitute a rich and vital source of material
that can be explored and interpreted to therapeutic effect (Bromberg, 2009).
Process analysis calls conscious attention to the otherwise autonomic behaviors
used to modulate emergent emotional pressures. Pressures can then be articu­
lated and addressed directly, and behaviors modified through awareness and
understanding (Fukao et al., 2007).
The following case excerpts illustrate the implementation of transference and
process interventions with patients diagnosed with CPTSD, and demonstrate the
resultant emotional engagement that permits processing of traumatic material.

Case examples
Case 1
Ann (a pseudonym), a 20 year-old woman, sought therapy because she was
mystified and alarmed by symptoms she could not explain. Ann reported having
frequent dissociative episodes, usually preceded by a feeling of panic and
despair. During these episodes, Ann said the panic and despair were still present,
but somehow distant. Her surroundings would likewise seem present yet distant
or unreal, and she would simultaneously crave the comfort of friends and find
their presence terrifying. These episodes occurred frequently, sometimes several
times a day. One particularly distressing episode occurred when Ann attended
a protest against sexual assault. Ann felt a growing sense of unease as several
survivors of sexual assault shared their stories with the crowd, and she began to
dissociate from her surroundings. Ann remembered seeing a picket sign that
read, ‘She was drunk, she was flirting, she was wearing a skimpy dress: there is
no excuse for rape!’ and then needing to flee. Processing this later in session, she
explained that the sign had particularly upset her because, ‘there isn’t anything
you can do to prevent it. It’s just completely out of your control’.
Ann did not have a history of sexual assault that she could remember. Her
father, who she loved very much, died of cancer when Ann was 10 years old, but
236 B.M. Henley
aside from this loss Ann reported a relatively happy childhood. Ann felt that her
symptoms pointed to some early traumatic sexual incident, but could find
nothing in her life to fit that description.
Ann could not, however, remember significant portions of her childhood.
She had solid, episodic memories from about fourth grade onward, but only bits
and pieces before that. In addition, she had vivid and disturbing dreams, and
what she called ‘flashes’: brief, intrusive images and sensations. Both her
dreams and her flashes, she said, involved her father. In the dreams she shared
in session, Ann was at her childhood home, but it was ‘bigger than it should
have been’, and she was busy trying to hide her father’s corpse from visiting
relatives. The ‘flashes’ she could not describe, because every time she tried to
focus on them she immediately dissociated.
In session Ann was terse, still and vigilant. She sat tense and poised at the
edge of her seat, and watched the therapist closely. The following excerpt began
during a protracted silence, when the therapist noticed Ann bouncing her foot.
Ann saw the therapist notice, and immediately stopped the bouncing. This
conversation occurred after nine months of weekly sessions, and was a pivotal
moment. Subsequent to this interaction Ann relaxed her vigilance in sessions
and began to display facets of her personality she had kept hidden previously.
She laughed and joked and chided. She also reported a dramatic drop in
dissociative episodes, from several per day to one or two per week.

Patient: What?

Therapist: (imitating her) ‘I will not let him see me bounce my foot. I will not
betray any emotion’.

P: (laughing) Yeah.

T: What does it do for you, not letting me see? How does that keep you safe?

P: It keeps people from seeing a vulnerability and using it against me.

T: (thinking)

P: What?

T: I’m imagining that. It sounds really manipulative. Someone would have to

read your body language and think ‘Ooh she really wants that’, and then
think ‘I could use that to get her to do something’. And then you’d learn that
you had to hide your wants, or else you’d be taken advantage of.

P: (nods)
 Psychoanalytic Psychotherapy 237
T: How am I going to use what I notice about you against you in here?

P: You’re not.

T: Well, that’s rationally true, but what about the fear? What are you worried
I’m going to do?

P: I don’t know. (Thinking, then changing her answer) I know but I can’t say.

T: I would take some sexual advantage?

P: Yeah.

T: Do you feel anything in that?

P: (nods)

T: Anything you can tell me?

P: Really sad. And a tightness in my throat like nausea.

Case 2
Beth (a pseudonym) was a 21 year-old college student who sought therapy for
her panic attacks and anxiety. Her anxiety had become such a problem that she
had failed several classes and had to change her major. In the first session, she
informed her therapist that she had been sexually assaulted as a child, but
refused to discuss the incident any further. In subsequent sessions it became
clear that the perpetrator was either a family member or someone integral to the
family, and Beth was certain that her admission would destroy the family
system. She had never told anyone about the incident, and endeavored to keep
it out of her own mind as well.
Exploring this, Beth came to understand that her silence was intended to
protect her as much as her family. By leaving the assault unacknowledged, Beth
was trying to keep it from ever having happened, and she expended constant and
unsustainable energy in attempts to counteract its effects as they cropped up in
the various facets of her life. Her original major, for instance, in an extremely
difficult subject, had represented an opportunity to prove to herself and others
that she was healthy and unimpeded.
For the first four months of once-weekly therapy, attempts made by the
therapist to approach her trauma directly were met with a deliberate and
steadfast refusal to entertain the topic or anything related to it, and a retreat
into willful catatonia. When not evincing this resolute avoidance, Beth would
adopt a ‘cutesy’ persona; speaking in a high, soft voice, cocking her head
238 B.M. Henley
girlishly to one side, and sitting with her hands in her lap and her toes
pointed inward. The following excerpt came from a session conducted over
Zoom, and began with Beth’s admission that she constantly checked the ‘self
view’ window during remote sessions and Zoom meetings to assess her
appearance. It represents the first time Beth acknowledged the psychic cost
of keeping her trauma at bay. Naming the perpetrator and discussing the
trauma openly would take another 10 months, at which point she switched to
twice-weekly sessions.

Therapist: What are you checking for?

Patient: I don’t know. My hair, lumps in my clothes, smoothing it out.

T: What don’t you want people to see?

P: I don’t know, I just don’t want to look weird.

T: It’s interesting to me, that this seems to be internal as well as external. Like,
you’re worried about how you look to an observer, like the camera is right
there, right in your face. But at the same time I doubt you’ve ever had any
really explicit feedback, as in I doubt anyone has ever said, ‘Your hair looks
weird’, or ‘Your clothes are lumpy’. So the standards you’re trying to meet
are internal. They’re coming from you.

P: That’s true. I’m the one who’s always worried about how I seem.

T: What I hear in this, what I hear in all of this, is, ‘I don’t want anyone to be
able to tell that I’m damaged’.

P: (heatedly) No, that’s not it. I’m not walking around thinking that everyone
can tell I’ve been hurt. It’s just that, society demands I be functional. Life
demands that I be functional. If I’m not okay, I don’t go to school. I don’t
work and make money. I don’t do any of the things I want to do.

T: I want to take a moment and acknowledge how hard you’ve tried to be okay.

P: (begins to cry)

T: What is coming up for you?

P: Nobody knows how hard I try to be okay.

 Psychoanalytic Psychotherapy 239
Case 3
Casey (a pseudonym) was a 40 year-old woman who sought therapy for
PTSD symptoms and relationship issues. Casey said her trauma started as
early as she could remember. She explained that from when she was
a toddler until she was in her late teens, her father was her absolute favorite
person, but he was also terrifying. Although he was never diagnosed, Casey
came to believe that a personality disorder was the only thing that could
account for her father, a man who ‘could be so charming, nobody could
make you feel as good’, but who also had ‘black rages, where his eyes would
go black like a shark’s’. He once chased Casey’s mother through their house
with a gun, firing the weapon at the ceiling. Casey remembered doting on
him, and monitoring his mood obsessively, hoping to head off the next
explosion before it started. In addition to this there were alarming boundary
violations, such as her father showering with her when she was eight years
old, and giving her instructions on how to perform fellatio once she got
a boyfriend. Casey was also molested as a pre-teen by a babysitter, and never
reported the assault.
In initial sessions Casey was loud, brash, hostile and combative. She
described her history of trauma freely and fluently, with no observable affective
engagement, and said she was proud of her ability to do so. Attempts made by
the therapist to question her further about any of these incidents were met with
anger or dismissal.
Casey’s therapist interpreted her anger and hostility in these early sessions as
an expression of her fear of a developing emotional intimacy, but did not share
this interpretation with her, reasoning that it would be inaccessible and poten­
tially alienating until further work was done. Instead he began sharing his
reactions with her in a clear, non-accusatory manner. If she insulted him, he
told her he felt hurt. When she was visibly angry, he said that he felt frightened.
Casey received these as accusations, hearing them as ‘you are hurtful’, and ‘you
are frightening’, but was struck by the contrast between how she felt (powerless,
desperate) and how she was experienced. This phase of treatment lasted three
months. During these three months Casey began to feel safer with the therapist,
and she was able to see meaning in the contrast between how she felt and how
she was experienced, and she recognized the fear that prompted her anger. The
following excerpt is taken from a session during this second phase of treatment.

Therapist: I’m frightened when you get like that.

Patient: I know, I know. Oh my god. I don’t want to be frightening.

T: What do you think is going on there?

P: (pressing on her abdomen) I feel it . . . here. Right here. (sobbing violently)

I’m scared of you. I’m so scared of you.
240 B.M. Henley

T: (nodding)

P: I always felt it here.

T: Yeah?

P: Sex trauma. It was sex trauma. I feel disgusting all the time.

Discussion
In the mainstream, exposure model of PTSD treatment, the traumatic material is
approached explicitly. Patients recite trauma scripts, or describe or imagine their
trauma, or are otherwise exposed to trauma-specific stimuli. This provides
a face-valid, common-sense assurance that whatever emotions arise are asso­
ciated with trauma, and not attributable to other factors. This assurance is
diminished when the traumatic material is approached circuitously as outlined
above. The notion that it is traumatic stress that is accessed when what is
ostensibly under discussion is the agitated bouncing of a foot, or a habit of
checking one’s appearance, is based on the assertion that, in CPTSD, survivors
develop ‘protean sequelae’, which include global characterological and person­
ality deformations. The aftermath of trauma is thereby present in gesture and
habit, and vulnerable to analysis. This notion is primarily supported by clinical
observation, as opposed to purely experimental evidence, which may cast some
prudent doubt on the claim that here is an answer to the problem of emotional
engagement in CPTSD.
In this psychodynamic approach, the assurances that the emotions accessed
are associated with trauma are mainly contextual. Trauma was either reported or
implicated early in each case, and formed a backdrop for all subsequent discus­
sions. The tense vigilance of one patient, the girlish persona of another, and the
loud hostility of a third might be attributable to temperament, but given the
context of trauma they become relevant and interpretable. Also arguing in favor
of this approach is the fact that powerful emotions and somatic sensations were
accessed through discussions of these relatively innocuous happenings. It is
difficult to explain otherwise why an investigation into a bouncing foot, an
admission of self-consciousness, or expressions of anger yields up sadness,
tears, nausea, and feelings of disgust and violation.
Each method of eliciting emotional engagement discussed here has draw­
backs. Some methods, such as enhanced traumatic stimuli, remain impractical.
Others, such as pharmacological interventions, are unpredictable or contraindi­
cated for some patients. The psychodynamic techniques described here have
their drawbacks too. Chief amongst them is that they cannot readily be manua­
lized. The activity of the therapist in this approach is guided largely by intuition,
in that the therapist needs to have some sense of the potential significance of
 Psychoanalytic Psychotherapy 241
what is observed. This leaves the intervention susceptible to human factors, such
as experience, perspicacity and skill. The efficacy of this approach might there­
fore vary depending upon the practitioner, more so than with other methods.
These psychodynamic interventions merit consideration, however, for two rea­
sons. One, they are routine and trusted techniques that can be applied in existing
clinical settings without recourse to elaborate equipment or unpredictable psy­
chotropics. And two, if these psychodynamic methods work as they appear to,
psychology as a field might be expending a great deal of energy trying to find
answers to a problem it already solved.

Disclosure statement
No potential conflict of interest was reported by the author(s).

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