Wednesday, September 23, 2015

Brief Narrative Trauma Treatment with Survivors of Natural Disaster



    The need for a treatment model to address the consequences of disaster based trauma and other types of trauma is evident.  Research shows that PTSD and other mental health conditions are at times sustained for many years after disasters or large-scale traumatic events (Ursano, Grieger, & McCarroll, 2007; Oncu & Wise, 2010).   Immediate problems that disaster survivors encounter include having to live in harsh or stressful environments or being permanently displaced from their homes or geographical area.  Van der Velden, Wong, Boshuizen, & Grievink (2013) completed a longitudinal study among 1,083 Dutch participants who survived a large-scale disaster.  This study examined severe symptoms that emerged as a result of the disaster including PTSD, anxiety, depression, and sleep problems.  The authors discovered that 6.7% developed persistent PTSD symptoms during the 10 years after the traumatic event.  Anxiety prevalence was 3.8%, depression was 6.2%, and sleep problems were 4.8%.  High disaster exposure independently predicted persistent symptoms of PTSD, anxiety, and depression.  Results indicate that attention to the long-term effects of disaster-based traumatic events on overall mental health is required.  Brief and structured therapeutic interventions are necessary for the treatment of trauma and reduction of trauma-related symptoms.  
     The most commonly utilized methods for the treatment of PTSD are use some variation of Cognitive-Behavioral Therapy (CBT) and/or Exposure therapy.  Because these approaches are usually delivered in 10-12 sessions by professionals, they continue to be insufficiently brief for effective use after large-scale disasters where large numbers of people need assistance quickly (Zang, Hunt, & Cox, 2013).  This article examines the utilization of a six-session narrative model as a brief treatment of disaster trauma populations, offering an alternative to CBT. 

Review of the Literature
     The central idea animating narrative-based therapies in the behavioral and social sciences is that human beings make sense of their lives and their worlds through telling stories (Stewart & Neimeyer, 2007; Schauer, Neuner, & Elbert, 2011).  Furthermore, trauma experts have noted that developing a coherent narrative is vital for making sense of trauma (Briere & Scott, 2015).  From a coherent narrative, the person’s identity takes the form of an inner story, complete with setting, scenes, character, plot, and themes (Crossley, 2000).  Internalized life stories are based on biographical facts, but they go well beyond the facts as individuals appropriate aspects of their experience and construe both past and future to construct stories that make sense to the individual and their audiences.  This construction and reconstruction of stories help vivify and integrate life and make it more or less meaningful (Angus & McLeod, 2004). Several trauma-narrative approaches emerged in the literature that included the following: White’s Reauthoring Model, creation of linguistic representation, Narrative Exposure Therapy, developing an explanatory account, and identification of Posttraumatic Growth. 

White’s Reauthoring Model
     Michael White and David Epston (1990) created narrative therapy, in its reauthoring version, in the late 1980s and early 1990s.  It has developed into a variety of treatment psychotherapy applications and has turned into one of the most influential models in the narrative therapies.  From the model’s perspective, clients correct dysfunctional psychological processes by the construction of new narratives of life.  In this reauthoring model, it is posited that the identification and elaboration of unique outcomes (UOs) solidify one of the main processes through which therapy allows the construction of new life narratives.  UOs are narrative details outside of what White refers to as the dominant or problem-saturated story, which is a narrative reduced to a single theme (i.e. depression, trauma).  According to this theory, despite the redundancy of the dominant story, even severely disturbed clients experience UOs.  However, these UOs do not contribute to the emergence of an alternative story due to the problem-saturated narrative that becomes predominant and influences the person to devalue and minimize alternative accounts of the events.  The problem-saturated narrative blocks clients to alternative ways of thinking, feeling, acting, or behaving, and they often ignore or forget UOs. This process is similar to what cognitive therapists refer to as cognitive distortions (Matos, Santos, Goncalves, & Martins, 2009). 
     Likewise, clients often iterate traumatic events in a problem-saturated way that focuses on actions taken that are perceived as ineffective and actions not taken that are idealized.  Many other valuable actions were taken and not taken and yet these remain un-storied in the shadow of the problem-dominated trauma account.  This model proposes that therapeutic interventions address four quadrants of storied/un-storied actions/inactions in the following way: 1) Actions Taken and Storied (AT-S) as meaningless or unhelpful are rendered meaningful; 2) Actions Taken and Not storied (AT-N) are recognized; 3) Actions Not taken and Storied (AN-S) as ideal are deconstructed; 4) Actions Not taken and Not storied (AN-N) are explored and reinforced.  These quadrants must be systematically explored in therapeutic dialogue.  When actions in all quadrants are visible, it provides clients with a larger plethora of possible actions to consider in their development of meaning.  It is also more likely to make visible their actual ability to generate options, choose options that are congruent with their values, and engage in those actions that are more successful than initially stored.  When clients are able to observe all their actions and how those actions are congruent with their values, they are more likely to experience themselves as competent individuals despite the challenges of the trauma.  Through this narrative process, the traumatic event is externalized and therefore becomes disempowered of its identity-shaping ability with the focus shifting to internal choices and action in handling the crisis.  Clients are subsequently in a better position to separate from interpretations of traumatic memories that had eroded their preferred experience of self (Beaudoin, 2005). 
     Another important concept in White’s Reauthoring Model includes externalizing conversations.  This method could be beneficial in working with traumatized clients.  According to this method, people believe that their problems are internal to their self or the selves of others and that they are the problem.  This belief only plunges them further into the problems they are attempting to resolve (i.e. PTSD symptoms).  Externalizing conversations can provide an antidote to these internal understandings by objectifying the problem.  This method practices the objectification of the problem against cultural practices of objectification of people.  This makes it possible for people to experience an identity that is separate from the problem; in other words, the problem becomes the problem, not the person or their identity.  In the context of externalizing conversations, the client distances the problem and other options for successful problem resolution suddenly become accessible and visible (White, 2007; Beaudoin, 2005). 

Creation of Linguistic Representation
     Another trauma-narrative approach that exists is the creation of linguistic representation.  A growing body of literature exists and attests that posttraumatic symptomology is a failure of memory; particularly, it is a disruption in the conversion of sensory experience to verbal or linguistic memory.  This concept is important and corresponds with key concepts of narrative therapy.  Historical clinical accounts from Janet noted the fragmented and non-linguistic quality of clients’ trauma memories, and more recent evidence has demonstrated that traumatic memories are unique.  These memories are retrieved sensory fragments with no verbal component (Van der Kolk, 2014).  Kaminer (2006) further explains:
Within this literature, the creation of linguistic representation of fragmented images and sensory experiences – that is, the development of a coherent verbal trauma narrative that names and organises the affects, cognitions, behaviours and sensory experiences associated with the trauma – is the central process of recovery for trauma survivors. (pp. 485)
     Developments in neurophysiology have added another dimension to the understanding of the narrative processing disruption that identifies traumatic memories.  The amygdala is responsible for interpreting the emotional significance of incoming sensory information.  Additionally, the hippocampus is responsible for integrating and organizing this sensory information with preexisting information, which also includes the pre-frontal cortex and thalamus.  Van der Kolk (1996) states that extremely high levels of arousal “may prevent the proper evaluation and categorisation of experience of interfering with hippocampal functioning” (p. 295).  Therefore, emotional fragments often do not include the contextual time and space that hippocampal integration would allow (Kaminer, 2006). 
     This literature suggests that developing a coherent trauma narrative is vital to organizing split-off sensory and emotionally charged memories into narrative linguistic memories. Thus, developing this coherent narrative would reduce the intrusive memories that are hallmark symptoms of PTSD.  Therefore, a few primary tasks of the therapist would be to 1) assist the trauma client gradually to organize her memory fragments into sequential episodes; 2) to identify the characters involved in the story and their actions; and 3) help the survivor in identifying his or her emotions, sensations, and thoughts at different stages of the event (Kaminer, 2006). 

Narrative Exposure Therapy
     Increasing evidence exists that suggests the retelling of the trauma narrative in a safe environment may facilitate psychological recovery by “habituating” trauma survivors to the anxiety associated with traumatic memories.  Additionally, there is substantial evidence that Prolonged Exposure (PE) therapy is effective in reducing PTSD symptoms among trauma clients (Foa & Rothbaum, 1998).  However, PE may not be brief enough in large-scale disaster populations due to the aforementioned reasons.  Therefore, Narrative Exposure Therapy (NET) may be a viable alternative to traditional exposure therapy due to its brevity.  NET is a standardized short-term trauma-focused treatment developed originally to meet the needs of survivors of torture and war.  NET was derived from a combination of concepts based in exposure therapy, CBT, and testimony therapy.  In contrast to other exposure treatments for PTSD, the client does not identify a single traumatic event as a target in therapy.  Conversely, NET constructs a narrative that covers the client’s entire life.  The cognitive processing model asserts that PTSD symptoms are maintained through a distortion of explicit autobiographic memory about traumatic events and its detachment from the implicit memory.  This produces a fragmented narrative of the traumatic memories.  Furthermore, emotional processing theory suggests that the habituation of emotional responses through exposure precipitates a decrease in PTSD symptoms.  Zang, Hunt, and Cox (2013) conclude: “NET stresses the importance of both approaches: the habituation of emotional responding to reminders of the traumatic event and the construction of a detailed narrative of the event and its consequences” (pp. 2). 

Developing an Explanatory Account
     An additional trauma narrative method is to develop an explanatory account.  This process is important because the client must facilitate the development of a cognitively meaningful trauma account.  This involves a collaborative reconstruction of the trauma story by the client and the therapist, introducing the trauma narrative cognitive insights that have been missing.  Following a traumatic event, survivors are challenged to develop this explanatory model of themselves and others that can account for the trauma.  Failure to establish this account means that the trauma cannot be integrated into their cognitive map of the world. 
     In the psychodynamic orientation, an explanatory narrative is developed through exploring the unconscious processes that influence emotions, thoughts, and behaviors.  This helps the client to complete the ‘plot’ of his or her life story.  For example, the psychodynamic therapist may interpret a client’s depressive response to a recent traumatic event as being expressions of unconscious desires or anxieties rooted in early relationships.  These unconscious meanings gradually come to be integrated into the client’s conscious, verbal narrative of his or her traumatic experience (Kaminer, 2006). However, this orientation may not be practical for the immediacy and brevity needed among trauma disaster populations.

Identification of Posttraumatic Growth
     A final theme that emerged included the identification of posttraumatic growth when examining helpful trauma narrative methods.  Posttraumatic growth (PTG) refers to the positive change experienced as a result of the struggle with traumatic or highly stressful life experiences.  Tedeschi & Calhoun (2004) explained that the terms trauma, crisis, and highly stressful events are often used synonymously with each other when describing this concept.  They posited that posttraumatic growth is “manifested in a number of ways or 5 ‘domains of growth’ including an increased appreciation of life in general, more meaningful interpersonal relationships, an increased sense of personal strength, changed priorities, and a richer existential and spiritual life” (pp. 1).  Since spiritual growth is one of the domains of PTG, Shaw, Joseph, & Linley (2004) conducted a review of 11 empirical studies which examined the relationship between religion, spirituality, and PTG.  The authors reported three main findings between the three aspects of their review: 1) studies show that religion/spirituality are usually beneficial to people in dealing with the aftermath of trauma; 2) traumatic experiences can lead to a an enrichment or deepening of religion and spirituality; and 3) positive religious coping, readiness to face existential questions, religious participation, and religious openness are typically associated with PTG.  Tedeschi & Calhoun (2004) seem to suggest that it is possible that the development of a trauma narrative could either enhance or help facilitate spirituality and/or PTG.  They explain that as traumatized clients experience posttraumatic growth, these changes have a mutual influence on their life narrative in general.  As clients struggle with trauma, along with the possibility of PTG, this can result in a revised life story.  The development of the individual personal life narrative and PTG may directly influence each other.  Therefore, when utilizing narrative therapy with traumatized clients, it is important to assess and further process possible gains in the area of PTG.

A Brief Narrative Based Approach
     After the 2010 Haiti earthquake, national and international assistance was provided to address the needs of the Haitian people.  In response to the need for trauma treatment, Lane and Lane (2010) developed a brief narrative treatment model for addressing trauma symptomatology across cultures (Kamya, 2012).  Utilizing many of the research based features in the literature review, the model is designed to be used with groups, and is made to be easily understood and implemented by non-therapist trained volunteers and lay people.  The six sessions have the participants identify with a character from a story and relate their experiences to the story character’s experiences.  Four life stages are stressed:  1) The story of my life before the trauma; 2) My story of the traumatic event(s); 3) The story of my life since the trauma; and 4) Creating my story and defining my future.  Each of the six sessions uses multiple activities and exercises tied to storytelling and re-telling.  Participants begin the process of finding meaning in their experiences, reconnecting with their sense of self to reestablish wholeness, and writing or telling how their life story will proceed following the trauma, according to Narrative methodology.    
    The Gold Stone story addresses the major elements experienced during trauma, including death, profound loss of relationship, life-altering environmental changes, feelings of guilt and self-blame, rage, powerlessness, depersonalization and derealization, loss of a sense of self, and spiritual questioning.  Because large numbers of lay leaders may be easily trained to use the model by small numbers of professionals, it creates a force multiplying effect, promotes a strong sense of communities helping themselves, allowing intervention to take place immediately, with a goal of preventing the development of long term trauma-related pathology. 

Discussion
    Anecdotally, reports from use of the model with small groups (totaling 233 participants) were encouraging.  It would appear that a brief narrative based trauma treatment might be effective for relief of trauma symptomatology associated with natural disasters.  This model could prove useful for disaster agencies and workers dealing with large numbers of victims who need a structured, easily distributed method of providing service.  The materials have since been used with community workers in Newtown, CT, following the Sandy Hook School shooting, and in the Dominican Republic, Cambodia, Vietnam, Malaysia, Costa Rica, New Zealand, and in the Middle East.  Anecdotal reports are equally encouraging on the efficacy of the model. 
     The model drastically shortens the time needed to provide treatment, from an average of 10-12 sessions for CBT to a maximum of 6 sessions.  Due to the model’s structure and ease of use and training, many volunteers can be readily trained by a few professionals to use the model, providing a force multiplier in areas where professional resources are limited and the immediate need is greater than the available service.  In addition, the model utilizes a wide range of different elements from Narrative and trauma research to create a program that addresses the variety of issues resulting from disaster-related trauma, including the immediate shock of the trauma victim, grief and loss, the fragmentation of memory due to trauma, developing meaning from the trauma, religious/spiritual responses to trauma, and the construction of a new narrative for the victim’s life (Herman, 1997; Bowlby, 1980; Stewart & Neimeyer, 2007). 
     Trauma counselors may ask their clients to give detailed retellings of the trauma experiences without having a theoretically sound rationale for why they are doing so causing a potential ethical problem by risking re-traumatization in the story telling (Briere & Scott, 2015).  This reality creates a difficult ethical situation for clinicians.  Perhaps this could further support the utilization of brief standardized narrative therapy models with manualized guidelines such as Narrative Exposure Therapy (NET) or The Gold Stone
     Other recommendations for research in to address gaps in the literature include examining group trauma therapy approaches among disaster populations.  A common belief among clinicians is group therapy could provide an economic benefit since it is perceived to be more cost-effective than individual therapy.  Research is still lacking in this area.  Also, it seems that a group approach would lend itself to the brevity needed among post-disaster settings.  Future research needs to examine if these narrative approaches would be effective among other countries and cultural settings. 


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