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Symptoms often persist after first-line PTSD treatments, highlighting the need for additional approaches.

Trauma-related symptoms often persist because they serve psychological functions in reaction to the trauma.

Early experiences shape how trauma is interpreted, influencing views of self and others, and relationships.

Linking symptoms to trauma, conflict, and defenses can help patients attain more lasting psychological change.

The most recommended psychotherapies for Posttraumatic Stress Disorder emphasize exposure-based approaches (Foa and Rothbaum, 1998; Resick and Schnicke, 1993), encouraging patients to recount and reexperience traumatic events. Exposure treatments have helped many people, but a significant number of patients drop out of them, in part because directly focusing on traumatic experiences can be intolerably painful (Steenkamp et al., 2020). Additionally, these treatments often focus narrowly on an “index trauma,” ignoring other traumatic experiences that may be emotionally relevant. They also typically do not address the deeper psychological meanings of trauma or explore how childhood adversity shapes the impact of later traumatic events. Moreover, even with current best treatments, about two-thirds of patients still have enough symptoms to meet a PTSD diagnosis (Shalev et al., 2017). Clearly, we need additional ways of understanding and treating trauma.

One such approach is Trauma-Focused Psychodynamic Psychotherapy (TFPP) (Busch et al., 2021), a form of Problem-Focused Psychodynamic Psychotherapy (Busch, 2022) adapted for PTSD. Rather than focusing on retelling the traumatic event (although this is sometimes important), TFPP explores how traumatic and early life experiences have affected the individual’s emotions, self-assessments, expectations of others, and relationships. Additionally, this approach describes how we use this information to address posttraumatic symptoms.

Traumatic experiences can disrupt memory, identity, and emotional regulation. People often report alternating clarity and haziness in recalling events, difficulty forming a coherent narrative, and emotions that feel unpredictable or overwhelming. A central psychodynamic idea is that trauma may be repeated unconsciously (Freud 1920). These reenactments are not intentional but are often a way the mind attempts to master feelings of helplessness associated with the traumatic event. In inadvertently repeating a trauma, the individual attempts to control it and hopes for a different outcome. For example, a person who experienced emotional abandonment in childhood by caregivers may become overly controlling to keep a friend or partner close to them, inadvertently driving the other person away.

In addition, people who have experienced trauma often feel as if the traumatic experience is occurring in the present. For instance, a veteran returning to civilian life may sit in a restaurant turned toward the door to monitor if someone dangerous is entering. Nightmares, flashbacks, and even some relationship patterns can be seen as ways of reexperiencing trauma. For instance, one woman with a background of significant childhood trauma was convinced that her boyfriend was being abusive even as it became clear (through couples therapy) that he was making significant efforts to respond to her concerns and only demonstrated normal range empathic failures.

Conflict, Defenses, and Dissociation

As with other psychodynamic psychotherapies, TFPP emphasizes identifying and addressing intrapsychic conflicts—the internal struggles triggered or exacerbated by trauma. Common conflicts include:

Rage at perpetrators triggering guilt about having angry or retaliatory wishes

A desire for closeness causing terror of betrayal or rejection

Longing for protection leading to anxiety about being vulnerable to harm

To manage these conflicts, the mind deploys defenses, ways of attempting to cope or manage with painful feelings, thoughts, and memories, though often with a cost. One of the most common reactions to trauma is dissociation. Dissociation involves a breakdown in the integration of thoughts, feelings, and memory. For example, a person may describe horrific events while feeling emotionally numb. Numbing, a form of dissociation, is an unconscious attempt to avoid unbearable pain. Other defenses include repression, in which painful feelings and memories are kept out of awareness, which unfortunately leaves them undealt with.

Counterphobic behavior is another defense, denying vulnerability by confronting danger (for example, someone exposed to violence repeatedly engaging in risky confrontations). Identification with the aggressor is a defense in which the individual unconsciously aligns with the power of the perpetrator to avoid feeling like a helpless victim. But this identification often triggers pain and guilt about fantasies of harming innocent victims. These defenses can reduce anxiety in the short term but often perpetuate suffering.

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Trauma and Attachment

Insecure attachment, especially early experiences of neglect, abuse, or inconsistent caregiving, can intensify the impact of later trauma, heightening the risk of the development of PTSD. TFPP explores how these early adverse experiences combine with trauma to intensify negative self-assessments and expectations of others. After traumatic events, individuals may see themselves as highly vulnerable, fundamentally damaged, or dangerously enraged. Others may be experienced as untrustworthy, controlling, and/or abusive. Relationships can become fraught based on negative views of oneself and others, including a tendency toward mistrust. The woman described above, who experienced her boyfriend as behaving abusively, is an example of these expectations, relieved by her boyfriend’s efforts in couples therapy to recognize and address how she was feeling.

Symptoms as Attempted Solutions

Another central idea in TFPP is that symptoms serve an emotional purpose. Rage may protect against helplessness. Numbing may shield against humiliation. Self-blame may create an illusion of control (if I had done something differently, the trauma wouldn’t have occurred). For example, one patient repeatedly demeaned his wife when he felt criticized by her. Growing up, he had a history of humiliation and abandonment by caregivers. His aggression temporarily made him feel strong, but it worsened his guilt and threatened the relationship he most feared losing.

Another patient unconsciously tested others’ loyalty, recreating experiences which she perceived as betrayal. She would give others expensive gifts but felt betrayed when she did not get the intense gratitude she was seeking. The repetition gave her a sense of control, even as it reinforced her rage and disappointment. Recognizing the meanings of symptoms is often crucial for relieving them.

TFPP is a step-by-step manualized approach to the consequences of trauma. The therapist looks to identify links between current symptoms and traumatic events, helping patients recognize where their symptoms derive from. By session three or four, therapist and patient collaboratively build a psychodynamic formulation—a working map of how trauma, early life history, self-assessments and expectations of others, conflicts, and defenses interact to produce current symptoms.

Follows the patient’s associations and emotions

Identifies patterns linking present symptoms to past trauma

Identifies negative self-assessments and expectations of others, conflicts, and defenses that contribute to symptoms

Addresses mistrust and relational fears as they emerge in and outside of the therapeutic relationship

An important goal of TFPP is integration. As patients connect feelings to memories and understand the function of their symptoms, they regain a sense of coherence along with a more stable and compassionate sense of self.

By identifying how symptoms are linked to trauma, relevant childhood experiences, conflicts, and defenses, and self-views and expectations of others, and integrating dissociative experiences, TFPP seeks to restore narrative continuity and emotional stability. Trauma causes the mind to fragment in order to survive. Psychodynamic work aims to help it come back together, to regain a sense of narrative and purpose. In a field understandably focused on measurable symptom reduction, we should not lose sight of a larger aim: helping individuals reclaim their full psychological lives.

Busch, F.N. (2022). Problem-Focused Psychodynamic Psychotherapy. Arlington, VA, American Psychiatric Press, 2022.

Busch, F.N., Milrod, B.L., Chen, C., & Singer, M. (2021). Trauma-Focused Psychodynamic Psychotherapy. New York, NY: Oxford University Press, 2021.

Foa, E. B., Rothbaum, B.O. (1998). Treating the trauma of rape: Cognitive-behavioral therapy for PTSD. New York, NY: Guilford Press.

Freud, S. (1920). Beyond the pleasure principle. J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 18, pp. 7-64). London: The Hogarth Press, 1955.

Shalev, A., Liberzon, I., & Marmar, C. (2017). Post-traumatic stress disorder. New England Journal of Medicine, 376, 2459–2469.

Steenkamp, M.M., Litz, B.T., & Marmar, C.R. (2020). First-line Psychotherapies for Military-Related PTSD. Journal of the American Medical Association, 323. 656-657.

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