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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