Beyond the Conditioned Fear Model: Narrative Reconstruction for a Woman With Posttraumatic Stress Disorder

Although fear is considered to be the dominant affect associated with posttraumatic stress disorder (PTSD), recent changes in diagnostic criteria have resulted in the addition of anger, guilt, and shame as significant emotional states linked with the disorder. The presence of these other emotions is associated with poorer prognosis, slower recovery, and more residual symptoms. However, treatment strategies for these other kinds of PTSD presentation have been less well explored than fear. Narrative reconstruction—an integrative treatment for PTSD—combines components of cognitive behavioral therapy, such as exposure and cognitive restructuring, alongside psychodynamic features. Incorporated psychodynamic elements include the expression of emotions, identification of recurring themes and patterns, interpersonal relationships, the influence of past experiences, and the integration of dissociated emotional schemas. During narrative reconstruction, the patient and therapist reconstruct an organized, coherent, and detailed written narrative of the patient’s traumatic experience. Narrative reconstruction employs psychodynamic elements to help identify and address the underlying feelings of shame, guilt, and anger. To illustrate how these other emotions are dealt with in narrative reconstruction, a case study is presented of a woman with chronic PTSD who previously had limited success with exposure-based treatment. Unprocessed shame, anger, and loneliness are discovered, and connections are made to past and current family situations. Pre to posttreatment, session-by-session, and follow-up data on clinician-administered and self-report measures demonstrate significant symptom reduction. Clinical vignettes and a case discussion demonstrate the therapeutic model and technique.