Pragmatic Case Studies in Psychotherapy

May 19, 2022 -- FROM THE EDITOR  

ANNOUNCING THE PUBLICATION OF OUR 63rd ISSUE (Vol. 18, Module 2)  

A Sequenced, Relationship-Based Approach to the Treatment of Complex Posttraumatic Stress Disorder (CPTSD): The Hybrid Case Study of “Chloe” 

*** Phoebe Shepherd, World Trade Center Mental Health Program, Icahn School of Medicine at Mount Sinai, New York, NY     

Commentaries 

*** Christine Courtois, Consulting and Training in Trauma Psychology and Treatment, Bethany Beach, DE; and Julian Ford, Department of Psychiatry, University of Connecticut, Farmington, CT   

*** Stephanie Lyon, Graduate School of Applied and Professional Psychology, Rutgers University—New Brunswick, NJ  

EDITOR'S NOTE

        In the hybrid case of “Chloe,” the patient’s history encompassed “adverse and potentially traumatizing experiences in childhood, including: father’s alcoholism; mother’s emotional instability and unavailability and ongoing threats of suicide; parental divorce at age 10 with custody awarded to Chloe’s mother; paternal abandonment post-divorce; and suggestions by grandparents that Chloe was responsible for her mother’s problems … [together with the grandparents’] lack of appropriate intervention on Chloe’s behalf. These adverse experiences resulted in Chloe’s mistrust of and detachment from others and emotional fragility, including a tendency towards isolation and depression” (from the Commentary by Courtois & Ford).

        Chloe’s major trauma occurred a year prior to the present treatment when Chloe interrupted her mother’s attempt to shoot herself in the head to commit suicide, the effects of which ultimately led Chloe to seek counseling. This specific traumatic event and Chloe’s associated presenting symptoms did meet the criteria of post-traumatic stress disorder (PTSD).

        Many therapists would have focused on Chloe’s PTSD reaction to interrupting her mother’s suicide, and would have treated her with one of the evidence-based, Cognitive-Behavior-Therapy-rooted exposure therapies—like Foa’s Prolonged Exposure Therapy or Resnick’s et al.’s Cognitive Processing Therapy. In contrast, author-therapist Phoebe Shepherd took into account Chloe’s long history of trauma and conceptualized her problems as involving the distinctive condition of Complex PTSD (CPTSD).

        Two of the major clinical theorists and senior practitioners in the area of CPTSD are Christine Courtois and Julian Ford. They have developed a model for treating CPTSD that includes, in part, some of the CBT exposure therapy approaches, but places these in a broader model that emphasizes two main components: (a) the role of a deep relationship between the therapist and the patient as a learning opportunity for the patient to experience a positive emotional attachment to contrast with the patient’s past attachment difficulties; and (b) placing exposure treatment for PTSD as the middle section of a sequence (not always linear) involving three phases. The three phases are: (1) safety, stabilization, and engagement; (2) trauma memory and emotion processing; and (3) consolidating therapeutic gains.

        The Case Study of Chloe describes in detail the successful application of Courtois and Ford’s sequenced, relationship-focused approach to Chloe’s complex PTSD. Following Courtois and Ford’s model, Shepherd incorporated not only a CBT approach, but also two other approaches: Fosha‘s Accelerated Experiential Dynamic Psychotherapy (AEDP), with a special emphasis upon Shepherd developing a deep therapeutic relationship with Chloe; and Ogden and Fisher’s Sensorimotor Therapy, with a special focus on the role of body-based, physiological experiences associated with processing emotional arousal.

        The first Commentary is by the developers of the Phase Model, Courtois and Ford, who discuss many ways in which Shepherd’s application of their theory was right on target, but other ways in which the approach might have taken different directions at certain clinical choice points.

        The second Commentary, by Stephanie Lyon, reflects one of the guiding principles behind the cases published in PCSP, namely that a crucial goal of a pragmatic case study is to describe and interpret what actually happened in the treatment of a particular client, not to only to confirm a particular theory, strategy, or intervention. As such, authors are encouraged to in part describe the complex clinical facts and processes of real-world cases in “ordinary language” that is not embedded in psychotherapy theory. The value of this tenet is reflected in Lyon’s Commentary as she persuasively demonstrates how Chloe’s problems, treatment, and improvement over the course of the therapy could be interpreted as the successful application of mentalization theory, which is distinctly different from the theories in which Shepherd conducted and interpreted Chloe’s case.

** Below Table of Contents: Click on the article title for the Abstract. Click on the pdf button for the pdf file.