March 05, 2014 at 12:18 PM
What makes trauma treatment work? And what can make it work better? This is the first in an irregular series of posts focusing on key elements of trauma treatment.
A person’s trauma history can take up so much of the visual field that her primary sense of identity may be as a trauma victim or survivor. After healing has occurred, she’ll typically say something like, “Okay, it’s too bad [the trauma] happened, but it no longer defines me. I am much more than that; my life is much more than that.”
I once viewed this broader life perspective as an outcome of trauma healing. I have long taught to include the really-over-ending as part of the trauma narrative, so that the bad part of the story could be connected to when it was over, allowing the client to “get” that it was actually over (Greenwald, 2005). But I did not fully appreciate the implications.
Then I learned about narrative exposure therapy (NET; Schauer, Neuner, & Elbert, 2011). Early in the course of NET, the therapist guides the client in constructing a time line of his life, from birth to the present and into the future, and marking key negative and positive moments on the time line. In subsequent sessions, the client does an exposure session on each traumatic memory, in chronological order. NET has been used with children and teens, as well as challenging adult clients who would have been screened out of standard prolonged exposure (PE) treatment; and NET has achieved good results with some efficiency. (Note that NET and PE have not been directly compared; I’m making these statements by extrapolating from the existing literature.)
Some years ago I spoke with a group of researchers who were very excited about their study of using PE with teens. This was a well-funded project with leading PE experts on board as investigators and consultants. And the research therapists said, “Oh, teenagers can’t actually do PE – it’s too much of an ordeal for them!”
Since NET is basically a series of PE sessions, why should NET be so well-tolerated and so efficient? The main difference is that in NET the broader life perspective is structured in, up front, by creating the time line of the client’s life. This time line becomes the context in which each trauma memory is processed. I strongly suspect that structuring in the broader life perspective makes a big difference.
We do something similar with progressive counting (PC; Greenwald, 2013). In PC the client is asked to visualize a “movie” of the trauma story, from beginning to end, while the therapist counts aloud. In preparing the client for this procedure, we guide the client to identify a beginning that is well before anything bad happens; and an ending that is well after the bad part is over. This incorporates the broader life perspective into the trauma narrative, which may help the client to tolerate the exposure as well as integrate the memory.
In the most recent comparison (Greenwald, McClintock, Jarecki, & Monaco, 2014), PC was about as effective as eye movement desensitization & reprocessing (EMDR) while being rated by participants as less difficult than EMDR. Also, whereas EMDR is the most efficient of the well-established trauma treatments (Greenwald, McClintock, Siebel et al, 2014), in this comparison study PC was 37% more efficient than EMDR.
Could the structuring-in of the broader life perspective be one reason for NET’s as well as PC’s performance? Might it be worthwhile to structure the broader life perspective into other trauma treatments?
Greenwald, R. (2005). Child trauma handbook: A guide for helping trauma-exposed children and adolescents. New York: Haworth.
Greenwald, R. (2013). Progressive counting within a phase model of trauma-informed treatment. New York: Routledge.
Greenwald, R. & McClintock, S. D., Jarecki, K., & Monaco, A. (2014). A comparison of eye movement desensitization & reprocessing and progressive counting among therapists in training. Manuscript submitted for publication.
Greenwald, R., McClintock, S. D., Siebel, S., Doss, J., Halvorsen, L., Lamphear, M. L., Priest, E. G., & Gray, A. K. (2014). A meta-analytic comparison of EMDR to other trauma treatments: Effectiveness, efficiency, and acceptability to clients. Manuscript in preparation.
Schauer, M., Neuner, F., & Elbert, T. (2011). Narrative exposure therapy: A short-term treatment for traumatic stress disorders. Göttingen, Germany: Hogrefe
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Most pertinent to this blog post is a particular assignment that has often had lasting positive impact on many young people I have worked with. The assignment: to research a specific job/career of interest to the individual student. This may be done by shadowing someone on the job for a day; by interviewing people who have the job of interest; and/or by reading about it.
Many young people have told me, even many years after such an assignment, that they have kept this career in mind as something they plan on doing. Thus this assignment can help traumatized individuals to harbor some realistic hope and plans for their future. This broader life perspective can indeed help them to hang in there, working towards that better future.