Clinical Case Studies 2013 Abbas 145 56

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Supportive and Insight-Oriented Psychodynamic Psychotherapy for Posttraumatic

Stress Disorder in an Adult Male Survivor of Sexual Assault
Amineh Abbas and Jenny Macfie
Clinical Case Studies 2013 12: 145 originally published online 24 January 2013
DOI: 10.1177/1534650112471154
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471154 CCSXXX10.1177/1534650112471154Clinical Case StudiesAbbas and Macfie
Clinical Case Studies
Supportive and Insight-Oriented 12(2) 145156

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DOI: 10.1177/1534650112471154
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in an Adult Male Survivor of

Sexual Assault
Amineh Abbas1 and Jenny Macfie1
Abstract
This is a single case study of a middle-aged man with posttraumatic stress disorder (PTSD) and
Dissociative Disorder Not Otherwise Specified following sexual assault as an adult. Treatment
consisted of supportive psychodynamic psychotherapy, focusing on reintegrating the patient
into his community, followed by insight-oriented psychodynamic psychotherapy with an em-
phasis on processing trauma and decreasing PTSD and dissociative symptoms. Daily subjective,
self-report measures were used to track his symptoms over a 29-month period. Simulation
Modeling Analysis for time-series was utilized to assess the phase change from pretreatment
baseline phase to total treatment phase and also between supportive psychotherapy phase and
insight-oriented psychotherapy phase. Symptoms tracked included overall distress, preoccupa-
tion with the trauma, and dissociation. All symptoms significantly improved from the pretreat-
ment baseline phase to the total treatment phase. Overall distress and preoccupation with the
trauma significantly improved from the supportive to the insight-oriented psychotherapy phase.
Keywords
time-series, psychodynamic psychotherapy, posttraumatic stress disorder, sexual assault,
dissociation
1 Theoretical and Research Basis for Treatment

Male survivors of sexual assault, especially adult males, are less well represented in the empir-
ical literature than are females (Chapleau, Oswald, & Russell, 2008), perhaps due to the lower
occurrence of rape in males versus females and to the relative unwillingness of males to report
it or seek treatment (Walker, Archer, & Davies, 2005). Nevertheless, 3% to 8% of adult
American or British men report having been sexually assaulted as an adult (Elliott, Mok, &
Briere, 2004). Furthermore, males report similar symptoms to females: fear, anger, depression,
somatic complaints, problems with relationships, and sexual dysfunctions (Koss & Harvey,
1986). There is no current literature on the prevalence of posttraumatic stress disorder (PTSD)
1
University of Tennessee, Knoxville, USA
Corresponding Author:
Amineh Abbas, University of Tennessee, 227 Austin Peay Building, Knoxville, TN 37996-0900, USA
Email: aabbas@utk.edu

146 Clinical Case Studies 12(2)
in adult male rape victims (Turchik & Edwards, 2012). However, in an early study, 94% of rape
victims (male and female) reported symptoms associated with PTSD one week following the
rape (Foa & Rothbaum, 1989): re-experiencing of the traumatic event, avoidance of stimuli
associated with the trauma, numbing of general responsiveness, and increased arousal (American
Psychiatric Association [APA], 2000).
Dissociation may also result from the experience of severe trauma, including rape.
Dissociative symptoms characterize individuals who develop PTSD (Bremner, Scott, Delaney,
& Southwick, 1993; Marmar, Weiss, Schlenger, & Fairbank, 1994), and dissociation may be
considered an avoidance symptom (APA, 2000). Spiegel (1986) theorized that dissociation is a
defense mechanism activated in response to overwhelming pain and helplessness following
trauma. He suggests that dissociation is different from other defense mechanisms. Rather than
protecting an individual from unconscious desires and drives, he thought that dissociation
would shield an individuals psyche from immediate traumatic experiences. However, fragmen-
tation of ones sense of self may then occur, and dissociation may become part of the persons
emotion regulation strategy, reactivated when exposed to future stress (Spiegel, 1986).
Psychodynamic Psychotherapy and PTSD

As with exposure therapy for treating PTSD (Foa, Rothbaum, Riggs, & Murdock, 1991), psycho-
dynamic psychotherapy encourages the patient to confront his trauma to diminish and alleviate
symptoms. However, psychodynamic psychotherapy additionally focuses on the creation of
meaning by integrating the trauma into the individuals sense of self, the other, and the world
(Solomon & Johnson, 2002). Horowitz (1976) first conceptualized the traumatized individuals
response to trauma as vacillating between an intrusive phase and an avoidance phase, and he
devised a brief psychoanalytic treatment for each (Horowitz, 1976). However, Horowitz (1997)
later acknowledged that these phases may overlap, consistent with a current diagnosis of PTSD.
Therefore, in this study, Horowitzs approach to treatment is slightly modified in terms of a
lengthier treatment and in terms of treating the intrusive and avoidance symptoms concurrently.
When an individual experiences intrusive/obsessive thoughts, nightmares, and flashbacks, the
therapist encourages the patient to regulate affective responses to memories and thoughts that are
disturbing and/or triggering the posttraumatic stress symptoms of hyperarousal. This emotion
regulation is fostered through a supportive and safe therapeutic atmosphere, the transmission and
acquisition of anxiety-management and coping skills, and potentially medication. When the indi-
vidual is experiencing avoidance symptoms, such as emotional numbness, selective inattention,
withdrawal, frantic overactivity, being dazed, or even having partial or complete amnesia for
the traumatic incident, the patient is attempting to manage the overwhelming distress of the
trauma. Therefore, the therapist encourages the patient to confront traumatic memories, any
associations or triggers, and the related emotions, thoughts, and behaviors. Subsequently, the
overwhelming affect is diminished and the therapist then puts an emphasis on obtaining under-
standing and meaning behind the patients various posttraumatic stress symptoms. The purpose
of this is for the patient to gain a sense of mastery over the trauma and, thus, restore the previous
level of functioning and self-efficacy in the patients life (Horowitz, 1976, 1997).
Treatment Outcome Research of Rape Victims Who Develop PTSD

There is currently no treatment outcome research for adult male rape victims with PTSD,
because adult male rape victims are rarely studied (Ratner et al., 2003), and there are rela-
tively few of them (Walker et al., 2005). There are, however, numerous treatment outcome
studies regarding adult female rape victims with PTSD, which support the efficacy of

Abbas and Macfie 147
cognitive-behavioral approaches (e.g., stress inoculation therapy, prolonged imaginal

exposure, systematic desensitization, cognitive processing therapy) in treating adult
female rape victims with a diagnosis of PTSD (Foa et al., 1991; Leiner, Kearns, Jackson,
Astin, & Rothbaum, 2012; Resick & Schnicke, 1992; Taylor & Harvey, 2009; Vickerman
& Margolin, 2009). Furthermore, supportive counseling is effective in treating PTSD
symptoms in adult female rape victims (Foa, Rothbaum, & Steketee, 1993; Foa, Zoellner,
& Feeny, 2006), although less effective than many of the cognitive-behavioral approaches
(Resick, Jordan, Girelli, & Hutter, 1988; Taylor et al., 2009; Vickerman et al., 2009). In
meta-analyses conducted by Sherman (1998) and Taylor et al. (2009), cognitive-behavioral
therapy approaches to treatment of PTSD are overwhelmingly more effective than many
other types of treatment for PTSD.
There is a lack of treatment outcome research on insight-oriented psychodynamic
psychotherapy with rape victims with a diagnosis of PTSD. However, there are treatment
outcome studies investigating insight-oriented psychodynamic psychotherapy for treating
PTSD generally, but not for rape victims with a diagnosis of PTSD specifically (Brom,
Kleber, & Defares, 1989; Sherman, 1998; Solomon et al., 2002). These studies found that
insight-oriented psychodynamic psychotherapy is as effective as is exposure therapy (Brom
et al., 1989). Finally, studies that compared active treatment (cognitive-behavioral, sup-
portive, or insight-oriented psychodynamic) to a wait-list control group found that indi-
viduals in active treatment had more improvement than their wait-list counterparts (Brom
& Kleber, 1989; Foa et al., 1991; Foa et al., 1993).
To have a clearer picture of treatment efficacy for individuals with PTSD, more research
needs to be conducted using various treatment modalities and theoretical orientations.
More attention needs to be paid to less visible victims of severe trauma, specifically adult
male rape victims. This case study utilizes a time-series methodology to assess the efficacy
of supportive and insight-oriented psychodynamic psychotherapy for an adult male sexual
assault survivor. Time-series longitudinal data supplement the clinical case study
material.
Single Case Studies,Time-Series Design, and Phase Change Analysis

A relatively new design has received attention for its ability to monitor a patients progress
during the course of therapy and for assessing clinically significant improvement in the
individuals self-identified distressing symptoms. Quantitative research of patient-rated
symptoms in a single-subject (N = 1) design (Borckardt & Nash, 2008; Borckardt et al., 2008;
Nash, Borckardt, Abbas, & Gray, 2011) tracks symptoms daily and provides a detailed and rich
picture of the patients change (or lack thereof) over time (Nash et al., 2011).
2 Case Introduction
Mr. V was a single, 29-year-old Caucasian male who lived at home with his retired parents.
He was on medical leave from his job as a server at a restaurant, due to informing his boss
that he had been supposedly diagnosed with cancer and needed surgery. This was in fact
untrue, but used as a cover for his distress following the disclosure a few months earlier of
a female friend who had experienced a sexual trauma, whereupon Mr. V was flooded by
intrusive memories, nightmares, and flashbacks of his own sexual assault that had occurred
eight years prior. Mr. V was referred for psychotherapy and was prescribed 50 mg of ser-
traline approximately one week prior to intake by his primary care physician to treat symp-
toms of PTSD (309.81) and Dissociative Disorder Not Otherwise Specified (300.15).

Details of the assault were revealed at intake. At age 21, Mr. V was invited to the home of a
middle-aged, self-identified homosexual male friend of the family under the pretense of attend-
ing a party. When he arrived, he found no other guests there and began to feel uneasy but con-
vinced himself of his own safety with this man whom he had known his whole life. After some
time had passed and no other attendees arrived, Mr. V attempted to leave, whereupon the perpe-
trator emerged from the kitchen naked, threw Mr. V away from the front door onto the floor, and
began to anally rape him. Mr. V reported becoming completely immobilized and silent, which
has been termed tonic immobility or the last-ditch defense against entrapment by a predator
(Lima et al., 2010, p. 225). In addition to the involuntary immobility, it also includes analgesia
and near complete unresponsiveness to the external stimuli (Gallup, 1974; Lima et al., 2010).
3 Presenting Complaints
Mr. V presented with posttraumatic stress and dissociative symptoms. His posttraumatic stress
symptoms included intrusive/obsessive thoughts, nightmares, flashbacks of the sexual assault,
and avoidance of triggers that reminded him of the trauma (the word rape; images or conver-
sations in person, on TV, or in movies relating to rape; any contact with or even mention of
perpetrator; interest and/or participation in any romantic or sexual relationship); hypervigilance;
sleep disturbance; detachment and isolation; and eventually refusal to leave his home. His dis-
sociative symptoms included losing time or blacking out in which he had no recollection of
his activities; fabricating detailed stories (such as his diagnosis of cancer and his need for sur-
gery); spending large sums of money on credit cards he did not recall doing; and a general sense
of numbing and dissociation at times when reminded of the trauma.
4 History
Mr. V lived with his biological mother and father in a city of approximately 200,000 in an
upper-middle socioeconomic status home until he was 1-year-old when his parents
divorced. He then lived with his mother and had only sporadic contact with his father. At
the age of 5, his mother remarried to a man who eventually legally adopted him. Mr. V
referred to this man as his dad. He reported that his adoptive father was an alcoholic
when his mother married him and physically abused Mr. V at age 6 while intoxicated. Mr.
Vs mother took the child and left her new husband until he agreed to end his alcohol
abuse. Following this incident, his adoptive father became sober and did not physically
abuse Mr. V again. Nevertheless, Mr. V reported continued verbal and emotional abuse:
being called stupid or dumb, which made him feel as if he was not good enough.
Furthermore, Mr. Vs biological father was largely absent from his life. When Mr. V was
18, his biological father told him that as he had not been in his life up until this point, he
did not think he should be in his life in the future. Mr. V reported being devastated and that
this was the last time he spoke to his biological father.
Mr. V did not report a history of alcohol or substance use, abuse, or dependence. He reported
no previous therapy, use of psychotropic medications, hospitalizations, or legal history. He did
not have any major accidents, illnesses, neurological problems, or deaths in the family as a child.
Mr. V reported that he had been diagnosed as a child with a learning disorder, was placed in
remedial classes, and graduated with a special diploma. Since high school, Mr. V had a series of
unskilled restaurant and retail jobs. He always lived with his parents and had difficulty managing
his finances even prior to the rape and subsequent dissociation. He had never been married, had
no children, reported being heterosexual, and had one serious romantic relationship at age 19. He
stated that prior to his traumatic memories being triggered, he had several friends and numerous

acquaintances. He had no history of suicidal/homicidal ideation, auditory/visual hallucinations,

or delusions.
5 Assessment
To identify symptoms to be tracked over time, Mr. V completed an intake interview in which he
was asked, How would you know you were getting better during treatment? Therapist and
patient collaboratively identified overall distress and preoccupation with the trauma. These were
rated on a 9-point Likert-type scale, where 1 indicated not at all feeling distressed or thinking
about the trauma and 9 indicated feeling extremely distressed or thinking about the trauma all
day. The therapist decided at intake that Mr. Vs dissociative symptomatology would also be
monitored by administering the Dissociative Experiences Scale (DES; Bernstein & Putnam,
1986) at the beginning of each therapy session. The DES is a self-report measure assessing dis-
sociation on a continuum. His initial score on the DES was 38. A score of 20 to 30 is considered
a high score on the DES.
Following the intake interview, Mr. V was found to be non-emergent, non-suicidal, and non-
psychotic allowing him to be eligible to participate in the time-series study. At that time, his
case was sent to be staffed and was assigned to the intake therapist for individual psychother-
apy. Prior to beginning treatment, Mr. V completed additional psychological testing as well as
40 days of daily symptom tracking during the initial pretreatment baseline phase. Throughout
this phase, Mr. V had access to his therapist as well as a 24-hour clinic crisis line. It is important
to assess whether a pretreatment baseline phase is appropriate for each patient on an individual
case-by-case basis, bearing in mind the criteria stated above regarding the individuals mental
status at the time of the intake interview.
The total treatment phase was 28 months of individual psychotherapy in which the first
24 months were conducted weekly and the last four months were switched to biweekly sessions.
Mr. V rated his symptoms daily. During the total treatment phase, four months of supportive
psychodynamic psychotherapy occurred, to reintegrate Mr. V into his community. A subsequent
24-month period of insight-oriented psychodynamic psychotherapy followed to process the
trauma and to decrease his level of distress, PTSD symptoms, and dissociative symptoms.
6 Case Conceptualization
Mr. V was conceptualized as someone prone to approval-seeking and unconditional compliance
with male authority figures following abandonment by his biological father and a strained rela-
tionship with a critical adoptive father. Following the rape, Mr. V refused to tell anyone due to
feeling that he would be judged, that his masculinity would be compromised, and his sexuality
questioned especially by the men in his life. However, after his friends disclosure of her own
sexual assault, Mr. Vs need for emotional support following the trauma manifested itself in a
way that he perceived as being immune from harsh judgment. He began losing time and story
telling that he had been diagnosed with cancer and would need surgery. This elicited the sym-
pathy and compassion that Mr. V so desperately needed following his rape that he was unable
to acknowledge. However, these large-scale stories were impossible to sustain. Mr. Vs stories
were discovered by his parents, which prompted him to reveal that he had been raped and to
subsequently seek medical and psychological treatment.
Treatment was designed to address Mr. Vs posttraumatic stress symptoms of hyperarousal,
intrusive thoughts and nightmares, and withdrawal in addition to his dissociative symptoms of
losing time, emotional numbing, and story telling. Supportive psychodynamic psychotherapy
would address the consequences of Mr. Vs overwhelming intrusive symptoms.

That is, supportive psychodynamic psychotherapy addressed his drastic decrease in daily life
functioning, his reintegration into withdrawal from his community, and his strained interper-
sonal relationships by encouraging him to confront each of these overwhelming situations after
obtaining anxiety-management and other coping skills while purposely deemphasizing the
trauma to foster emotion regulation and stabilization. Insight-oriented psychodynamic psycho-
therapy addressed his resistance, his losing time, the stories, as well as his PTSD symptoms
to allow him to create meaning in relation to the trauma and integrate that meaning into his
self-concept.
7 Course of Treatment and Assessment of Progress

Overview
Mr. V participated in once weekly individual psychotherapy for 24 months of treatment. Due
to his highly dependent traits and previous experiences of separation anxiety that Mr. V dis-
played in his relationships, the remaining four months of therapy were switched to biweekly
sessions in preparation for termination. In the theoretical literature, Pistole (1999), among oth-
ers, stated that termination can evoke previous losses and separation anxiety for patients, which
can be induced by the loss of the current attachment figure, that is, the therapist (Graybar &
Leonard, 2009). Furthermore, Mr. Vs dependency issues surrounding his transference toward
of the therapist as an attachment figure and his proneness to seek approval may have played a
significant role in the patients consistent treatment attendance and adherence to daily symptom
tracking. Thus, transitioning from weekly to biweekly therapy was a vital factor in readying the
patient for termination.
Following the pretreatment baseline phase, supportive psychodynamic psychotherapy began,
followed by insight-oriented psychodynamic psychotherapy. The primary goal of the treatment
was to establish a safe and comfortable space for Mr. V and to create a strong therapeutic
alliance. Obviously, this goal is important with any patient in any psychotherapeutic context;
however, it is particularly important when working with traumatized individuals whose illusion
of safety in the world has been shattered.
During supportive psychodynamic psychotherapy, the therapist encouraged Mr. V to
deemphasize his focus on the trauma to foster emotion regulation and stabilization through
the use of various approaches, including antidepressant medication prescribed by his physi-
cian, a supportive and safe therapeutic atmosphere and alliance, psychoeducation about
posttraumatic stress and dissociative symptoms, and a focus on the use of anxiety-manage-
ment and coping skills. The choice to deemphasize the trauma rather than process it during
this phase of treatment was due to the extensive destruction and reactivity the intrusive
symptoms had recently caused (i.e., flooding, dissociative episodes of losing time, com-
plete withdrawal from relationships, loss of job). Through the use of supportive psychody-
namic psychotherapy, Mr. V decided to reveal to his community that he had not been
diagnosed with cancer and that he was seeking psychological treatment, following a period
of extended isolation and inability to work. This enabled Mr. V to reintegrate into his com-
munity by reestablishing previous relationships, rejoining his church, and initiating a job
search. Thus, following this reintegration into his community, the transition to insight-ori-
ented psychodynamic psychotherapy occurred.
During insight-oriented psychodynamic psychotherapy, the emphasis was on processing
Mr. Vs trauma and decreasing his level of distress, PTSD symptoms, and frequency and degree
of dissociative symptoms. Therefore, during this phase of treatment, Mr. V was encouraged to
confront his traumatic memories, any associations or triggers, and his related emotions,

Table 1. Means and Standard Deviations for Daily and Weekly Measures
Baseline Supportive Insight-oriented Total treatment

(n = 8) (n = 22) (n = 145) (n = 167)
Daily measure M SD M SD M SD M SD
Overall distress 5.13 1.10 4.54 0.90 2.60 0.78 2.86 1.03
Preoccupation with the 8.60 0.40 4.89 1.02 2.65 0.82 2.95 1.14
trauma
Baseline Supportive Insight-oriented Total treatment
(n = 5) (n = 15) (n = 104) (n = 119)
Weekly measure M SD M SD M SD M SD
Dissociative Experiences 33.43 5.07 16.00 1.12 15.34 1.97 15.42 1.89
Scale
thoughts, and behaviors. Subsequently, his overwhelming affect was diminished, and the thera-
pist then put an emphasis on obtaining understanding of unconscious and conscious meaning of
Mr. Vs various posttraumatic stress symptoms. The purpose of this was for Mr. V to gain a
sense of mastery over his trauma and, thus, restore his previous level of functioning and self-
efficacy (Horowitz, 1976).
Throughout the treatment, each session began by discussing Mr. Vs tracked symptoms and
the level of distress they created during the previous week. This discussion shaped the remain-
der of the session and allowed the patient a sense of control. Thus, Mr. Vs treatment consisted
of more than symptom reduction and improving his level of functioning. As other therapeutic
issues emerged, they were processed. Many of which were interpersonal in nature revolving
around abandonment and dependency issues with regard to an absent and emotionally unavail-
able biological father, an abusive, critical adoptive father, and an enmeshed mother. Therefore,
the patients autonomy (or lack thereof) was a recurring theme. Moreover, the patients story
telling was processed with varying degrees of depth throughout the course of treatment. This
brought up feelings of shame, embarrassment, self-loathing, and depression, which were pro-
cessed and resolved. Also the patients level of intellectual functioning slowed the progress of
treatment as his ability to articulate his thoughts and emotions as well as his ability to be abstract
and symbolize was limited and needed to be practiced and refined over time. Finally, in response
to these aspects of Mr. Vs treatment and in the tradition of psychodynamic psychotherapy, tim-
ing of termination was generally initiated by the patient (Murdin, 2000) and an end date was
mutually agreed upon through the collaboration of patient and therapist (Graybar et al., 2009).
Assessment of Progress
Simulation Modeling Analysis (SMA; Borckardt, 2006) for time-series data was used to analyze
each daily and weekly measure to assess for phase-effect. This approach compares phases of
treatment while accounting for the autocorrelation of the data stream. That is, the program
accounts for the autocorrelation, which is the lack of independence of the sequential (daily or
weekly) observations of each data stream. Then, an effect size and a significance level are com-
puted and the mean scores of the two data streams are compared. When investigating phase-
effect, significant effect sizes indicate statistically significant change in the measured symptom.
The valence of the effect size indicates which phase is significantly higher or lower.

Table 2. Autocorrelations for Nontruncated and Truncated Data
Daily measure Nontruncated data (n = 875) Truncated data (n = 175)

Overall distress 0.802 0.841
Preoccupation with the trauma 0.891 0.914
Note: Paired samples t-test = 3.88; p = .161.
9
8
7
Daily Ratings
6
5
4
3
2
1
0
120
150
180
210
240
270
300
330
360
390
420
450
480
510
540
570
600
630
660
690
720
750
780
810
840
870
30
60
90
0
Days in Treatment
Figure 1. Daily ratings of preoccupation with the trauma: Baseline through treatment phases
Note:= Phase marker between baseline and supportive psychotherapy treatment.
= Phase marker between supportive and insight-oriented psychotherapy treatment.
To use the SMA program, which only allows for 200 data points, and still be able to
analyze the full length of treatment, the original data stream was truncated. Days were col-
lapsed into 5-day means of consecutive daily measures. Subsequently, there were 8 points
(40 days) in the pretreatment baseline phase and 167 points (835 days) in the total treatment
phase. For the weekly measure of the DES, there were 5 points in the pretreatment baseline
phase and 119 points in the total treatment phase. See Table 1 for number of data points in
each phase of treatment analyzed.
To assess and ensure that the integrity of the model was not compromised by truncating
the data, the autocorrelations of the truncated data were compared with the autocorrelations
of the original data stream using a Paired Samples t-test. The two sets of autocorrelations
were not significantly different, t(1) = 3.88, p = .161. This implies that the phase-effect
analyses in SMA would be valid when using the truncated data. Thus, all analyses of daily
measures were calculated using the truncated data. See Table 2 for the autocorrelations.
Overall distress, preoccupation with the trauma, and dissociation (DES scores) were all
examined to assess whether there was a significant decrease of symptomatology from the pre-
treatment baseline phase to the total treatment phase. These symptoms were also examined to
assess whether there was a significant decrease of symptomatology from the supportive psycho-
dynamic psychotherapy treatment phase to the insight-oriented psychodynamic psychotherapy
treatment phase. See Table 1 for the means and standard deviations of the various phases of
treatment. Also see Figures 1 and 2 for Mr. Vs daily symptom tracking and dissociation (DES
scores) over the 28-month course of treatment.
There were significant phase-effects from the pretreatment baseline phase to the total treat-
ment phase for overall distress (r = .42, p = .002), preoccupation with the trauma (r = .73,
p = .0001), and dissociation scores (r = .86, p = .0001). There were also significant phase-
effects between the supportive psychodynamic psychotherapy treatment phase and the insight-
oriented psychodynamic psychotherapy treatment phase for overall distress (r = .64, p =

40
35
Weekly Ratings
30
25
20
15
10
5
100
104
108
112
116
120
12
16
20
24
28
32
36
40
44
48
52
56
60
64
68
72
76
80
84
88
92
96
0
4
8
Weeks in Treatment
Figure 2. Weekly ratings of Dissociative Experiences Scale: Baseline through treatment phases
Note:= Phase marker between baseline and supportive psychotherapy treatment.
= Phase marker between supportive and insight-oriented psychotherapy treatment.
.002) and preoccupation with the trauma (r = .67, p = .001). However, Mr. Vs dissociation
scores did not significantly change between the supportive psychodynamic psychotherapy
treatment phase and the insight-oriented psychodynamic psychotherapy treatment phase (r =
.12, p = .207).
8 Complicating Factors
A complicating factor in Mr. Vs treatment was his low level of daily functioning and borderline
intellectual functioning that were present prior to treatment and prior to the rape. First, during
the supportive psychodynamic psychotherapy treatment phase when reintegrating into his com-
munity and regaining his former level of functioning was the primary focus of treatment, basic
life skills were needed. For instance, Mr. V could not balance a checkbook and had been avoid-
ing paying his credit card bills due to feeling overwhelmed. With the help of his parents, Mr. V
was able to master these and other independent living skills, which provided the foundation
necessary to delve into the sensitive material related to the trauma. Second, Mr. Vs level of
dependence on his mother and adoptive father did not foster a sense of autonomy, or competence
in his ability to take care of himself or trust his own judgment. This manifested itself in treatment
as Mr. V insisted that all decisions regarding his treatment or capability to function in the world
be made with his parents present. As treatment continued, this dynamic was explored with
Mr. V and his reliance on it decreased drastically. Finally, Mr. Vs borderline intellectual func-
tioning further complicated treatment by making articulation of the traumatic event challenging.
This also affected his capacity for symbolization and creation of meaning.
9 Access and Barriers to Care

There were no managed care considerations or access/barriers to care in this particular case.
Mr. V was charged on a sliding fee schedule and therapy could continue as long as was deemed
necessary.
10 Follow-Up
Mr. V was not asked to complete follow-up measures. However, in the six months following
termination, Mr. V contacted the therapist twice by phone to share positive events in his life and
inform her that he was continuing to function effectively in his community.

11 Treatment Implications of the Case

All of Mr. Vs daily or weekly tracked symptoms, including overall distress, preoccupation with
the trauma, and dissociation, improved significantly from pretreatment baseline phase to total
treatment phase (i.e., supportive psychodynamic psychotherapy followed by insight-oriented
psychodynamic psychotherapy). Moreover, overall distress and preoccupation with the trauma
improved significantly from the supportive psychodynamic psychotherapy treatment phase to
the insight-oriented psychodynamic psychotherapy treatment phase. This demonstrates the
effectiveness of insight-oriented psychodynamic psychotherapy above and beyond the improve-
ment that generally occurs simply by the individual entering treatment.
The improvement that occurs during insight-oriented psychodynamic psychotherapy is the
gaining of mastery over the trauma and regaining of mastery over ones life. Reintegration occurs
when the creation of meaning surfaces and the trauma victim can incorporate the trauma into his
or her self-concept. This is not only the alleviation of symptoms but is also thought to be a trans-
formation of ones perception of self, the other, and the world. The insights that Mr. V gained
throughout treatment helped illuminate his long-standing issues with men and allowed him to
interact interpersonally with men, even with his adoptive father and other male authority figures
(e.g., his boss), in a more assertive and confident manner. In addition, these insights allowed Mr.
V to forgive himself for not trusting his judgment prior to the rape and continuing to remain at
the perpetrators home despite his feelings of uneasiness and impending doom.
Mr. Vs dissociation score improved significantly between the time before therapy and his
average dissociation score during therapy. However, dissociation did not change significantly
between the supportive psychodynamic psychotherapy treatment phase and the insight-oriented
psychodynamic psychotherapy treatment phase. This is likely due to a floor effect as dissociation
had almost completely disappeared by the end of the supportive psychodynamic psychotherapy
treatment phase. The significant decrease of dissociation demonstrates the necessity of treating
individuals with supportive psychodynamic psychotherapy prior to insight-oriented psychody-
namic psychotherapy in order to stabilize the individual, strengthen adaptive coping skills, and
bolster self-efficacy before dismantling the individuals resistance and defenses.
12 Recommendations to Clinicians and Students
This study focused in a unique way on various aspects of treatment outcome that have been
neglected in the empirical literature. First of all, it focused on an adult male rape victim. Second,
it focused on the psychodynamic treatment of rape victims with PTSD, which was also lacking
in the current treatment outcome literature. In addition, it focused on the decrease of dissociation
as a primary goal of treatment for individuals with PTSD, which is unavailable in the PTSD
treatment outcome literature, including in the cognitive-behavioral treatment tradition. Finally,
a time-series single-subject (N = 1) design (Borckardt et al., 2008; Nash et al., 2011) tracked
patient-rated symptoms across baseline and intervention phases. It is important to note that even
though a time-series design can only measure one individuals therapeutic outcome at a time and
has no control group, a time-series design has one advantage over the large-N designs, such as
randomized controlled trials (RCTs). That is, due to the time-series daily tracking of symptoms,
a detailed and rich picture of the patients change (or lack thereof) over time is captured in a way
that can be transmitted easily to other clinicians and researchers.
Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or pub-
lication of this article.

Funding
The authors received no financial support for the research, authorship, and/or publication of this
article.
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Bios
Amineh Abbas, MA, is a graduate student in the clinical psychology doctoral program at the University
of Tennessee in Knoxville. Her clinical interests include dimensions and subtypes of trauma, dissociation,
and psychodynamic psychotherapy.
Jenny Macfie, PhD, is an associate professor at the University of Tennessee, Knoxville. She graduated
from the University of Rochester with a PhD in clinical psychology in 1999 and was a postdoctoral fellow
at the Center for Developmental Science at the University of North Carolina, Chapel Hill, from 1999 to
2002.

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