In a ground-breaking clinical trial recently documented in the American Journal of Psychotherapy, psychodynamic psychotherapy — a form of depth psychology — was found to be effective in mitigating symptoms of post-traumatic stress disorder (PTSD) among LGBTQ individuals. Not only did the therapy reduce primary PTSD symptoms, but it also seemingly eased associated symptoms of depression and anxiety, fostering improved psychosocial functioning.
The study marks a promising leap toward a treatment approach specifically tailored to the nuanced needs and lived experiences of the LGBTQ community — a community disproportionately affected by PTSD.
John Keefe, the lead author from the Albert Einstein College of Medicine, and his co-authors emphasize the importance of therapists appreciating the broader picture of the individual’s identity and experiences beyond the immediate trauma.
“Some LGBTQ patients with PTSD may benefit from therapists who explicitly consider the role of identity factors or other potentially important and preoccupying developmental (e.g., family rejection, alienation) or contemporary experiences (e.g., internalized stigma) beyond the index trauma,” the authors write. “Application of trauma-focused therapy techniques may also require additional sensitivity toward the context and realities of different LGBTQ patients.”
Members of the LGBTQ community, research has shown, experience exposure to traumatic events, such as physical and sexual abuse, at higher rates than their cisgender and heterosexual counterparts. Such individuals, thus, bear a disproportionate burden of PTSD.
Additionally, the study underscores that this community confronts extra stressors, including minority stress, economic strain, and personal losses. These adversities may intensify the likelihood of developing PTSD and may challenge their ability to cope effectively. This new research provides a hopeful approach for effectively treating PTSD in this population, considering their specific needs and realities.
This aligns with studies conducted with other marginalized and oppressed populations. For instance, individuals from racial minority backgrounds are similarly more prone to experiencing traumatic events, and their exposure to racist violence exacerbates symptoms of traumatic stress. Within the LGBTQ communities, individuals belonging to racially minoritized groups face a heightened likelihood of being subjected to violent and traumatizing experiences.
Mainstream evidence-based psychotherapies for the treatment of PTSD, such as prolonged (PE) and cognitive-processing therapy (CPT), exhibit significant challenges in terms of participant retention (dropout rates ranging from 30% to 50%) and yield questionable clinical outcomes (with approximately 50% of individuals experiencing minimal or no symptom reduction).
Further, these approaches concentrate on addressing a single traumatic event, commonly referred to as the index trauma, without adequately contextualizing treatment to encompass the broader sociocultural, political, and economic factors that contribute to differential exposure to traumatic events and the subsequent development of PTSD. It’s hardly surprising that individuals belonging to marginalized and oppressed groups tend to discontinue trauma-focused treatment at higher rates.
During the last decades, psychodynamic psychotherapy has been granted the status of evidence-based treatment, particularly in addressing depression and other mood disorders, anxiety, panic disorders, somatic disorders, and so-called personality disorders. This therapeutic approach provides an alternative to behavioral and cognitive-behavioral therapies, such as PE and CPT respectively. The availability of various psychotherapy options is essential due to the low to moderate response rates of psychotherapy in general, but specifically, the high dropout rate and low clinical response of existing trauma-focused treatment. Additionally, it is crucial to acknowledge that a single treatment will unlikely be universally effective or applicable to all patients. Moreover, it is noteworthy that the efficacy of these treatments amongst LGBTQ individuals has not been thoroughly studied.
For these reasons, the researchers developed trauma-focused psychodynamic psychotherapy, a novel approach to psychodynamic psychotherapy specifically designed for working with PTSD. While being a manualized treatment, it was also designed to have the flexibility necessary for addressing LGBTQ polytrauma and other issues pressing for these communities. The aim of this affect- and attachment-focused treatment is, according to the authors, “to improve patient’s ability to tolerate, understand, and manage intense emotions that suddenly and unpredictably appear, a phenomenon related to patients’ tendency to reexperience traumatic events in the here and now, unexpectedly and when danger is not present.”
This is achieved by elucidating, tolerating, and working through conflicts, making meaning of PTSD symptoms and their relationship to traumatic events, and expressing previously unexpressed emotions. Moreover, according to the authors, patients have the opportunity to explore “the broader context of their symptoms and difficulties in their lives, including but not limited to LGBTQ identity and minority stress….”
In this clinical trial, 14 participants completed the initial intake assessment and were invited to begin the trial, composed of 24 twice-weekly sessions of trauma-focused psychodynamic psychotherapy. Ten participants were cisgender women, one cisgender man, one transgender woman, and two gender non-binary individuals. Nine identified as homosexual, and five identified as either bisexual or pansexual. Ten identified as Caucasian, three as Black, and one as Asian. Only one of the participants also identified as Hispanic or Latinx. One had a history of suicidal attempts. Eleven were on ongoing psychotropic medication.
The researchers measured PTSD symptoms by using the CAPS-5, which is the best-established measure for the diagnosis and assessment of PTSD. They also measured (1) complex PTSD symptoms by using the International Trauma Interview (ITI), (2) depression using the Hamilton Rating Scale for Depression (HRSD), anxiety using the Hamilton Anxiety Rating Scale (HARS), and psychosocial impairment using the Sheehan Disability Scale (SDS). These measures were used at baseline (before starting treatment), five weeks into treatment, at the termination, and three months after treatment. 14% (two) of the participants dropped out of treatment. One participant said they did not find the treatment helpful, and another could no longer attend therapy.
At termination, 71% of the participants experienced clinical response (which was defined as meeting at least a 30% reduction in their baseline CAPS-5 score), and 50% no longer met the criteria for PTSD. Patients’ PTSD symptoms continued to decrease three months after treatment, and there was no evidence of a recurrence of symptoms. In addition, patients’ depressive and anxiety symptoms decreased, and their psychosocial functioning improved during and after treatment.
The promising clinical response and a low dropout rate of this treatment suggest that psychodynamic psychotherapy might be an effective option for working with LGBTQ individuals who experience PTSD. Moreover, it is sensitive in addressing issues that are unique for this population while tailoring interventions to the individual’s personal experiences – which makes it stand out from other psychotherapeutic modalities (e.g., other trauma-focused treatments and affirmative therapies).
The pathologizing and individualizing effects of psychiatric diagnoses such as PTSD can cause harm to the individuals it attempts to aid. Therapists providing this kind of treatment should be aware of this issue, which might be appropriately addressed using other frameworks, such as the Psychodynamic Diagnostic Manual and the Power Threat Meaning Framework. These alternatives to the DSM and IDC are attempts to contextualize psychological distress and tailor treatment to the individual, aligning with the theory and practice of trauma-focused psychodynamic psychotherapy.
Keefe, J. R., Louka, C., Moreno, A., Spellun, J., Zonana, J. & Milrod, B. L. (2023). Open Trial of Trauma-Focused Psychodynamic Psychotherapy for Post-traumatic Stress Disorder Among LGBTQ Individuals. American Journal of Psychotherapy, Online First. (Link)