October 29, 2014 at 8:21 AM
The medical model has historically been promoted as the foundation of the psychotherapy approach, despite being a poor fit for psychotherapy (Wampold, 2010). In medicine one can actually provide a specific treatment for a properly diagnosed disorder and thereby effect a cure. However, mental health diagnoses are largely behaviorally defined rather than based on underlying dynamics or etiology, and the evidence for the superiority of a particular treatment for a given diagnosis is dubious (Wampold, 2010). Therefore common factors researchers have long been advocating a focus on good therapy applied to a wide range of clients and presenting problems.
More recently the call for transdiagnostic treatment approaches is also coming from the CBT community, which has previously focused on developing diagnosis-specific treatments (Clark & Taylor, 2009). This is because in practice, clinicians are unlikely to learn a large number of specific treatments for various diagnoses. Also, whereas specific treatments are typically developed and validated in laboratory studies with individuals who only have the targeted diagnosis without co-morbid conditions, practicing clinicians are unlikely to encounter many such clients. This makes treatment fidelity a problem, in that treatments may have to be substantially altered to work with more complex clients with multiple diagnoses; also, which specific treatment would one select? Furthermore, more symptom features are shared across a wide range of diagnoses than are distinct (Harvey, Watkins, Mansell, & Shafran, 2004). A transdiagnostic treatment approach that addresses these common features, and that can be applied with some flexibility without violating treatment fidelity, would have a greater chance of being learned well and applied in clinical practice (McHugh, Murray, & Barlow, 2009). In short, a transdiagnostic treatment approach would be quite practical, if it works.
Several transdiagnostic approaches have been developed, typically addressing those mechanisms (e.g., interpretational bias, emotional dysregulation, avoidance, etc.) seen as being key to the maintenance of the presenting problems (Mansell, Harvey, Watkins, & Shafran, 2009). Although some such approaches are promising (e.g., Ellard, Fairholme, Boisseau, Farchione, & Barlow, 2010), this focus on mechanisms may be, in essence, replicating the field’s traditional error of relying on the medical model’s diagnosis-centered approach. That is, the same basic mind-set and counteractive (symptom-treating) approach previously applying treatment to diagnoses are now being applied to mechanisms. But what if these mechanisms, that purportedly serve to maintain symptoms across a range of diagnoses, are actually themselves symptoms of something deeper?
Indeed, these so-called mechanisms are readily recognized as common outcomes of trauma exposure. Trauma, broadly defined to include loss and other significant adverse life experiences, has been implicated as routinely causing or contributing to nearly every type of diagnosis (Anda et al, 2006; Fairbank, Putnam, & Harris, 2007; van der Kolk, 2007). The evidence of trauma being at the root of many problems has been reinforced by trauma treatment outcomes, which consistently feature mitigation or elimination of those post-traumatic symptoms identified as maintenance mechanisms in the transdiagnostic treatment literature (see Greenwald, 2013).
The phase model of trauma-informed treatment (e.g., Bloom, 1997; Greenwald, 2013; Herman, 1992; Shapiro, 2001) is arguably the ideal transdiagnostic treatment approach. A good phase model can incorporate the common factors, as well as implement any particular symptom-specific intervention that may be needed in a given case. And the trauma resolution component of such a treatment approach can help the client to heal from the trauma, which is what tends to lead to the most profound and lasting improvement (Ecker, Ticic, & Hulley, 2012) – regardless of diagnosis.
Note: An earlier version of this piece was published in: Greenwald, R. (2013). Progressive Counting Within a Phase Model of Trauma-Informed Treatment. NY: Routledge.
Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C., Perry, B. D., Dube, S. R., & Giles, W. H. (2006). The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology. European Archives of Psychiatry and Clinical Neuroscience, 256, 174-186.
Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Toward a unified treatment for emotional disorders. Behavior Therapy, 35, 205–230.
Bloom, S. L. (1997). Creating sanctuary: Toward the evolution of sane societies. New York: Routledge.
Clark, D. A., & Taylor, S. (2009). The transdiagnostic perspective on cognitive-behavioral therapy for anxiety and depression: New wine for old wineskins? Journal of Cognitive Psychotherapy, 23, 60-66.
Ecker, B., Ticic, R., & Hulley, L. (2012). Unlocking the emotional brain: Eliminating symptoms at their roots using memory reconsolidation. NY: Routledge.
Ellard, K. K., Fairholme, C. P., Boisseau, C. L., Farchione, T. J., & Barlow, D. H. (2010). Unified protocol for the transdiagnostic treatment of emotional disorders: Protocol development and initial outcome data. Cognitive and Behavioral Practice, 17, 88-101.
Fairbank, J. A., Putnam, J. A., & Harris, W. W. (2007). The prevalence and impact of child traumatic stress. In M. J. Friedman, T. M. Keane, & P. A. Resick (Eds.), Handbook of PTSD: Science and practice, pp. 229-251. New York: Guilford Press.
Greenwald, R. (2013). Progressive counting within a phase model of trauma-informed treatment. New York: Routledge.
Harvey, A. G., Watkins, E. R., Mansell, W., & Shafran, R. (2004). Cognitive behavioural processes across psychological disorders: A transdiagnostic approach to research and treatment. Oxford: Oxford University Press.
Herman, J. L. (1992). Trauma and recovery. New York: Basic Books.
Mansell, W., Harvey, A., Watkins, E., & Shafran, R. (2009). Conceptual foundations of the transdiagnostic approach to CBT. Journal of Cognitive Psychotherapy, 23, 6-19.
McHugh, R. K., Murray, H. W., & Barlow, D. H. (2009). Balancing fidelity and adaptation in the dissemination of empirically-supported treatments: The promise of transdiagnostic interventions. Behaviour Research and Therapy, 47, 946-953.
Perry, B. D., Pollard, R. A., Blakley, T. L., Baker, W. L., & Vigilante, D. (1995). Childhood trauma, the neurobiology of adaptation and use-dependent development of the brain: How states become traits. Infant Mental Health Journal, 16, 271-291.
Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2nd ed.). New York: Guilford Press.
van der Kolk, B. (2007). The developmental impact of childhood trauma. In L. J. Kirmayer, R. Lemelson, & M. Barad (Eds.), Understanding trauma: Integrating biological, clinical, and cultural perspectives, pp. 224-241. New York: Cambridge University Press.
Wampold, B. E. (2010). The research evidence for common factors models: A historically situated perspective. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy, 2nd edition, pp. 49-81. Washington, DC: APA.
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More broadly, what your post raises is that even if trauma resolution work is essential in a given course of therapy, it may not be sufficient. In our own comprehensive phase model of trauma-informed treatment, we routinely incorporate whatever interventions may be called for in a given situation, potentially including motivational work, attachment work, parent training, self-management skills, etc. Often such interventions are required to enable the client to be able to do the trauma work; and the interventions may have independent value as well. Not to negate the main point of the blog post, but reality is a bit more nuanced.