Over the past years, the notion of trauma has become central to therapy and national well-being, as the publicity and awareness campaigns for mental health currently draw attention to the mental state of the population. For example, speaking of young adults only, Lewis (2019) estimated that nearly every third UK resident experienced a traumatic event by the age of 18. Later, more than half of this population was exposed to the complications of the posttraumatic stress disorder (PTSD) (Lewis, 2019). Hence, the issue of trauma and abuse is prevalent in American society.
However, while everyone has a vague understanding of trauma, the definition of this term is sometimes unfamiliar even to the ones the experienced it. Thus, according to Hardy (2020), despite the existing debate, the broadest definition of trauma would be ‘any event that a person interprets as representing a significant physical or psychological stress to the self’ (p. 224). In the International Classification of Diseases by World Health Organization (2021), codes 6B40-6B4X stand for the mental disorders associated specifically with stress, varying from the range of regular human life experiences to the extremely harmful and shocking events that lead to PTSD.
Although these events can sometimes be anticipated, reducing potential harm, most of them are uncontrollable and have unique repercussions for every individual (De Haan et al., 2021). For this reason, psychological intervention and therapy are required in most cases when patients deal with trauma (Ginwright, 2018). In the present paper, both psychoanalysis and person-centered therapy will be analyzed on the matter of dealing with trauma. Considering the fact that both approaches have their flaws, the primary hypothesis concerns the idea that the patient-centered approach is rather challenging for patients potentially struggling with PTSD.
Manifestation of Trauma in Patients
The reaction to any shocking or traumatic experience is unique for every individual because the response depends on a series of factors, including prior experiences trauma and the presence of resiliency to a traumatizing event (Bateman and Fonagy, 2019). Moreover, the nature of the traumatic event is also important, as it can vary between impersonal trauma such as a natural disaster or accident, interpersonal trauma such as abuse or harassment from a stranger, and an attachment trauma that stems from the abuse of one’s closest surroundings (Bateman and Fonagy, 2019; Vickers and Moyer, 2020). As a result, a person’s predisposition to trauma, along with its peculiarities, defines the uniquely tailored approach to the treatment.
However, in most cases, when patients are faced with a harmful traumatic experience different from routine stressors such as relationships or socioeconomic status, the shocking event results in the development of PTSD. According to the American Psychiatric Association (2020), the symptoms of PTSD fall into four main categories: intrusion, avoidance, changes in cognition, and changes in reactivity. As a result, while some people may struggle with constant flashbacks and intrusive thoughts about their experience, others tend to entirely block the event and ignore any triggering memories (Fried et al., 2018). In some cases, the avoidance is related to the fact that patients are nearly incapable of describing the event due to the fact that at the moment of trauma, their cognition attempts to block or alter their perception. For example, in some cases, when people are exposed to a traumatic event, their Broca’s area, a part of the brain responsible for speech, becomes inactive, making it barely possible for the survivors to verbalize their experience (Giotakos, 2020). Hence, it may be concluded that trauma, at its core, is a psychological phenomenon that requires consideration for the patient’s reaction to the experience, environment, and peculiarities of trauma perception in general. To define what type of therapy can be utilized for this scenario, both psychoanalysis and person-centered therapy will be critically appraised.
For years, the approach to psychotherapy has been oriented towards the analysis of the human subconscious, treating every individual primarily as a patient. As a result, every mental disorder or traumatic event was perceived as a pathology rather than a life experience (Cook and Monk, 2020). As with every pathology, a traumatic experience was regarded through the lens of a condition that had etiology, possible contributing factors, and the need for clinical intervention. However, in the middle of the 20th century, Carl Ransom Rogers introduced a revolutionary client-oriented approach (Lietaer and Gundrum, 2018). The central hypothesis of the theory was that instead of analyzing the behavioral patterns of the client, a psychotherapist is expected to secure the environment that would empower an individual to find self-actualization resources within themselves (Hoffman, 2020). Hence, a patient-oriented approach tends to focus on the present rather than the past, encouraging the client to discover the inner strength to overcome the challenge.
Although the therapist-client communication paradigm is vital for every approach, person-centered therapy is especially dependent on this interaction. Indeed, according to Knight and Wheeler (2020), the primary objective of the therapist in this setting is to make sure that clients confide in the therapist enough to be truthful to themselves, as their genuineness is key to recovery. Apart from effective communication, Rogers also emphasized the importance of ‘congruence, unconditional positive regard, and accurate empathetic understanding’ (Knight and Wheeler, 2020, p. 42). Thus, the primary idea of this approach is to perceive human experience as a phenomenon indissociable from the human as a whole.
Application of the Approach
The person-centered approach is currently regarded as a universal way to conduct therapy, as the clients’ experiences may vary from normal range stressors to some mental issues like depression or anxiety. For example, Knutson and Koch (2018) present a model of person-centered interaction with transgender and gender-fluid individuals, whereas Lemisiou (2018) claims this therapy to be beneficial in terms of increasing emotional and social intelligence competency in the workplace (p. 6). The universal nature of this approach is closely associated with the autonomy given to patients.
When establishing contact with the client during a person-centered therapy session, the primary goal of the professional is to present minimum interference and commentary on the client’s narrative. Conversely, therapists are encouraged to demonstrate active listening by mimicking their clients, reacting to their words, and summarizing the narrative to show engagement (Velasquez and Montiel, 2018; Murphy, 2019). Even in the setting where the client actively seeks answers to their problems, the therapist’s primary task is to make their client discuss the issue out loud. In such a way, they can hear their thoughts and find the answer with the therapist’s support, not active interference in the discussion.
Person-Centered Approach and PTSD
In the person-centered therapy setting, one of the main conditions of an effective session is letting the clients talk openly about their experience receiving empowerment and reassurance from the therapist as the third party. However, it was established earlier in the paper that such significant stressors as trauma and abuse lead to PTSD, limiting the person’s ability to verbalize their narrative. Moreover, even if they have the ability to describe the experience, the wording will be used in such a way so that memories of traumatic events would not be triggered.
In this case, empowering the clients to hear themselves talk may not be as productive as with the clients discussing normal range problems. According to Dimaggio (2019), even when more intensive than trauma-oriented therapies, a person-centered approach could not guarantee positive long-term outcomes for PTSD patients. As Foning (2019) recalls from a personal experience, anxiety, panic attacks, flashbacks, and disassociation are a few reasons why a person-centered approach can be a challenging endeavor when working with PTSD patients. Indeed, clients may find it difficult to self-reflect on the matter of trauma, as PTSD can augment their perception of the present as well as the past, including the moment of traumatic experience. Still, person-centered therapy may be a valuable additional tool for client reassurance (Hashemi Pour and Bahreinian, 2019). However, exposure to trauma and abuse requires more trauma-oriented approaches, such as prolonged exposure or present-oriented therapy.
Person-Centered Approach Critique
Despite the fact that the person-centered approach revolutionized the field of psychotherapy, its positive outlook has received a fair share of criticism over the years. Thus, for example, some researchers claimed the approach to be culturally insensitive due to its focus on the American archetype of an individual (Kim, 2018). The idea of self-actualization stands for the individual’s need to put the effort in order to discover their potential for realization in life (Gopinath, 2020). However, this idea revolves around the concept of individualism relevant to Western culture. A vast part of minority groups, especially in Eastern culture, rely greatly on the idea of collectivism and ‘interdependent self’ (Kim, 2018, p. 202). Thus, it is difficult for some cultures to resonate with this therapeutic approach.
Moreover, at the time, Roger’s theory presented a challenge to neoliberals in terms of its application. According to Joseph (2020), some critics implied that the therapy’s idea of self-actualization could eventually become a way to direct people into striving to achieve their organizational goals, leaving little to a person’s freedom. However, this critique was not well-grounded, as the intention behind a person-centered approach was to create a beneficial and flourishing space for every individual, encouraging the therapists and third parties not to involve (Gladding, 2021). Finally, over time, some researchers have begun to question the notion of directivity in the approach, as the therapist’s directive of non-intervention can be inefficient for clients willing to be guided or educated (Renger, 2020). For this reason, the person-centered approach requires a more flexible perspective in order to be able to deal with such challenging and unexpected phenomena like trauma and abuse.
Considering all the aspects, it may be concluded that the notion of person-centered therapy is based on the principles of empathy and minimum intervention on the therapist’s part. This idea, as opposed to psychoanalysis and psychodynamic theory, has modified the approach to therapy and interaction with the client. However, its area of application remains rather questionable due to the clients’ frequent inability to express their concerns in an insightful way.
Since the introduction of psychotherapy to the broad public, the process of therapeutic treatment has become closely associated with the image of psychoanalytic treatment. According to Safran and Hunter (2020), psychoanalysis is considered a precursor of therapy as a whole, being introduced by Sigmund Freud in 1896. According to the American Psychological Association (n.d.), psychoanalysis stands for ‘the assumption that much mental activity is unconscious and that understanding people requires interpreting the unconscious meaning underlying their overt, or manifest, behavior’ (para. 1). Hence, instead of manifesting the holistic approach to one’s personality, there is an evident division into the conscious and the subconscious.
The pillar of psychoanalysis is the division of human cognition into three major parts. According to Wang (2020), the id stands for the human’s immediate needs, such as the desire to eat or the feeling of anger when the needs are not met. Solms (2018) states that the id is the part that people obtain as soon as they are born, as it comprises the innate needs of an individual. On the other hand, one’s superego stands for the human conscience or moral compass that drives a person to abide by specific moral and social laws (Hattangadi, 2021). As a result, the id and the superego find themselves in an eternal conflict of interests, as one’s superego limits the id’s power over the mind. In this case, the ego stands for the reaction to the outside world and controls the id’s impulses (Wang, 2020). Hence, as long as these parts interact harmoniously, a person has an adequate perception of the world and normal self-esteem.
However, once one of the components, especially id, become hard to control and regulate, the person is likely to develop a defense mechanism. A defense mechanism can be defined as an ‘unconscious resource used by the ego to decrease internal stress’ (Bailey and Pico, 2021, para. 1). Hence, the defense mechanism is a reaction of the ego to a severe conflict between the id and the superego that tends to relocate the pressure of the conflict. According to Nortje (2022), the defense mechanisms include ‘projection, displacement, sublimation, repression, denial, identification, introjection, undoing, compensation, splitting, suppression, conversion, disassociation, avoidance, isolation, humor, and regression’ (para. 18). Since these processes happen unconsciously, in most cases, people are unaware that they use one of the aforementioned strategies, yet they feel anxious and depressed. Thus, the purpose of psychotherapy and psychoanalysis, in particular, is to identify the conflict between the conscious and unconscious minds and relieve the stressor (Laplanche and Pontails, 2018). By determining the id’s impulse desires, both the client and the therapist can find a way to replace it in a more controlled manner.
Application of the Approach
Currently, there are no direct guidelines that would identify the target population for the psychoanalysis. According to Civitarese and Ferro (2020), ‘the common factor that unites all who seek analysis is a certain degree of mental suffering’ (p. 6). For this reason, clients frequently address the professionals when they experience depression, anxiety, or any other manifestations of mental health problems. The procedure of psychoanalysis implies a sense of detachment from the therapist by making sure that the client does not see the professional during the session (Fayek, 2020). The therapist, however, establishes a trusting relationship with an individual by asking navigating questions and reacting to the client’s thoughts. However, instead of explicitly discussing the conscious reflections of the client, the therapist’s goal is to closely examine the subject on the matter of potential slips or inconsistencies, resorting to the client’s id (Busch, 2021). They can also utilize such strategies as visual tests, free association, and dream analysis to make the client compare their conscious thoughts to their immediate responses.
Psychoanalysis and Trauma and PTSD
For many years, the notion of psychoanalysis had been closely associated with the treatment of trauma and adverse neurosis. According to the researchers, the discovery of the defense mechanisms through one’s consciousness could assist in the analysis of the underlying trauma and the replacement of the existing impulses (Craparo et al., 2019). Pierre Janet, one of the pioneers in the psychotherapeutic treatment of trauma and PTSD, claimed the idea of rapport, or transference, to be one of the most efficient ways to heal from trauma, redirecting the painful and traumatizing experience on the therapist (Scalabrini et al., 2020). However, with time, the role of psychoanalysis has faded.
As of today, since the relevance of psychodynamic theory is questioned, its application to the treatment of trauma is not as popular. In 2020, the American Psychological Association claimed the absence of psychoanalytical practices in the guidelines for addressing PTSD nationwide (Dauphin, 2020). Although the notions of transference and self-awareness have been adopted by other treatment practices, psychoanalysis is no longer relevant in terms of treatment (Pagel, 2021). Hence, it can be concluded that despite bringing a series of benefits to the understanding of trauma within the professional community, the approach of the therapy itself is rarely embraced by the therapists.
Although many researchers respect psychoanalysis for its contribution to the emergence of psychotherapy in general, its principles are now regarded as outdated. Indeed, according to researchers, there are many factors that suggest psychotherapy is irrelevant, the main ones being lack of empirical evidence and sexist approaches (Critique of psychoanalysis, n.d.). Indeed, since the emergence of psychotherapy, Freud did not want to empirically test the efficiency of psychoanalysis, making it nearly impossible to justify the extent of its applicability. Another critique concerning psychoanalysis is the simplistic approach to human nature. In a commonly known case study about Dora, Sigmund Freud initiated the interpretation of the patient’s dreams as a manifestation of the subconscious (Barry, 2020b). Moreover, most of his conclusion was drawn on the basis of sexual desire as a driving force and the main id impulse for behavioral patterns (Gardiner, 2020a). These assumptions were later considered misogynistic and explicitly sexist, as they were all made from the male perspective (Barry, 2020a). Hence, the framework’s application is deemed inappropriate, especially when working with such trauma as sexual abuse.
Another important critique of the psychoanalysis perspective is the perception of the clients. Essentially, clients are perceived predominantly as patients with an articulated pathology (Ackerman, 2021). As a result, psychoanalysis is driven by the directly outlined guidelines of what behavior is natural and appropriate for an individual, claiming everything else a pathology that stems from a defense mechanism. Such a perspective of the existing socio-cultural complexity tends to undermine the differences and unique behavioral patterns of the individuals.
Undeniably, even in the modern context, there exist supporters of psychoanalysis as a technique. For example, Solms (2018) claims that despite the common belief of lack of empirical evidence, studies demonstrate that psychoanalytic therapy is not only effective but has an effect that lasts longer (p. 7). These suggestions, however, are based on empirical studies with relatively small samples compared to other research on therapy approaches.
Hence, considering the concept of psychoanalysis, it may be concluded that this approach to therapy is currently one of the most controversial. Being a pioneer in the field of psychotherapy, psychoanalysis has set the way for new, more client-oriented, and holistic approaches. As far as trauma is concerned, psychotherapy was long used to discover the defense mechanisms used by the client in order to detect transference and identify healthier patterns of coping with trauma. However, with years, the concept of psychotherapy was abandoned, yet the separate practices were integrated with other therapeutic approaches.
The concept of trauma is an extremely complex phenomenon, the recovery of which can never be complete and everlasting. When working with trauma, the primary objective of the therapist is to ease the complexity of emotional burden by demonstrating support and ways of gradual healing. In terms of the present paper, person-centered and psychoanalytic approaches were closely examined on the matter of their essence and interaction with trauma. The primary hypothesis was that the person-centered approach, with no direct intervention, was rather challenging for such patients, especially the ones developing PTSD symptoms. However, when examining the pillars of psychotherapy, it was also established that the approach was not programmed to emphasize the unique experience of the survivors. For this reason, when dealing with trauma, therapists can resort to the strategies of both approaches while combining them with other trauma-oriented techniques.
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