Cognitive Behavioural Therapy (CBT) is a widely recognized psychological intervention used to treat a variety of mental health disorders and is often the most straightforward and appropriate intervention following a personal injury such as a road traffic accident. However, CBT may not always be the most appropriate intervention to deal with accident-related trauma in some cases.
The Role of CBT in Psychological Interventions Post-Accident
CBT is a form of therapy that focuses on changing negative thought patterns and behaviours. It is often used to treat conditions such as depression, anxiety, and post-traumatic stress disorder (PTSD), as recommended by NICE guidelines. The primary goal of CBT is to help individuals develop coping strategies to deal with stressful situations, thereby reducing symptoms and improving quality of life.
The NICE guidelines also recommend eye movement desensitisation and reprocessing (EMDR) for trauma. This can be used in combination with CBT and can be particularly useful for addressing stressful memories and nightmares. It involves recalling distressing events while simultaneously focusing on an external stimulus, such as side-to-side eye movements, hand tapping, or audio tones.
Limitations of CBT in Trauma Treatment
Despite its widespread use, CBT (and EMDR) are not always effective in treating trauma. This could be due to a variety of reasons, such as the individual’s resistance to change, lack of motivation, or intense emotional reactions.
Moreover, CBT and EMDR primarily focus on the present and future, rather than delving into past experiences. This can limit effectiveness when dealing with traumas that have deep roots in an individual’s past, particularly those related to attachment issues.
The Place for Dynamic Psychotherapy
NICE guidelines emphasize a stepped-care approach, starting with the least intrusive interventions first, and progressing to more intensive treatments if necessary. CBT and EMDR, due to the reasons outlined above, would lie on the least intrusive end of treatments. According to NICE guidance, Dynamic Psychotherapy should particularly be considered for individuals with complex or chronic issues, or those who have not responded to other treatments. Dynamic Psychotherapy is more ‘intrusive’ due to the level of depth of exploration. Unlike CBT, it delves into an individual’s past to uncover and address deep-seated issues that may be contributing to their current distress.
For instance, when an incident brings up attachment-related trauma, dynamic psychotherapy can help the individual explore their early relationships and how these might be influencing their current reactions to trauma. This approach can provide a deeper understanding of the individual’s emotional responses and help them develop healthier ways of relating to others.
Intensive Short-Term Dynamic Psychotherapy (ISTDP) is a unique form of psychotherapy designed to help individuals overcome internal resistance and deal with attachment trauma. The therapy focuses on the unconscious emotions that drive a person’s behaviour, particularly those that have been suppressed or avoided due to their intensity or discomfort. In the context of an accident, these could be feelings of anger/rage, fear, guilt, or states of helplessness and dissociation. ISTDP uses techniques such as identification, clarification, and challenge of defence mechanisms (avoidance behaviours) to help patients face these emotions, understand their impact, and learn to manage them effectively.
For dealing with attachment trauma, ISTDP can be particularly beneficial. It helps patients explore their emotional attachments and the pain associated with any disruption or loss of these attachments, which may have been triggered by the accident. The therapist works closely with the patient to identify and understand patterns of attachment, detachment, and defence mechanisms that may have developed. By bringing these patterns to conscious awareness, the patient can begin to address and resolve their attachment trauma, leading to improved emotional health and well-being. This process can help individuals recover from traumatic events and lead more fulfilling lives.
The author has both recommended ISTDP treatment for such patients and treated such patients. In one illustrative example, a patient had a car accident in which she had been trapped and felt that onlookers had ‘loomed over’ her. This resulted in intense reactions of helplessness, which had given rise to past traumata of emotional and sexual abuse resurfacing. The therapeutic work involved helping her to identify her punitive attitude towards herself, which was maintaining her helplessness and neglecting her anxiety. Recognising that she was in fact repeating the cruelty of past abusers towards herself was vital in helping her to turn against this and towards a compassionate, loving attitude towards herself; resolving the anxiety in travel and other situations. In the author’s opinion, this was only possible with such ‘intrusive’ and deeper methods such as ISTDP. Without making the deeper insights, the individual’s resistance to change and intense emotional reactions (maintained by punitive self-neglect) would not have been addressed.
Conclusion
While CBT is a valuable tool in the treatment of many psychological disorders, it is not always the most appropriate intervention for dealing with trauma, particularly when the trauma is rooted in past experiences or attachment issues. In such cases, dynamic psychotherapy may offer a more effective approach. Therefore, in medicolegal psychological reporting, it’s crucial to consider the individual’s unique circumstances and needs when deciding on the most appropriate therapeutic intervention. Sometimes, however, such issues only become apparent during the course of the first attempted treatment and the options for alternative treatments should then be considered.
References
1: Beck, A. T., & Alford, B. A. (2009). Depression: Causes and Treatment. University of Pennsylvania Press.
2: Shapiro, F. (2018). Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic Principles, Protocols, and Procedures. Guilford Press.
3: Beck, J. S. (2011). Cognitive Behavior Therapy: Basics and Beyond. Guilford Press.
4: National Institute for Health and Care Excellence (NICE). (2018). Post-traumatic stress disorder. NICE guideline [NG116].
5: Shapiro, F. (2018). Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic Principles, Protocols, and Procedures. Guilford Press.
6: Shapiro, F. (2018). Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic Principles, Protocols, and Procedures. Guilford Press.
- Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive Therapy and Research, 36(5), 427-440.
- Shedler, J. (2010). The Efficacy of Psychodynamic Psychotherapy. American Psychologist, 65(2), 98-109.
- National Institute for Health and Care Excellence (NICE). (2018). Post-traumatic stress disorder. NICE guideline [NG116].
- Beck, J. S. (2011). Cognitive Behavior Therapy: Basics and Beyond. Guilford Press.
- Shedler, J. (2010). The Efficacy of Psychodynamic Psychotherapy. American Psychologist, 65(2), 98-109.
- Fonagy, P., & Bateman, A. (2006). Mechanisms of change in mentalization-based treatment of BPD. Journal of Clinical Psychology, 62(4), 411-430.
- Davanloo, H. (2000). Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, MD. Wiley.