Generic Trauma Therapy: a Common Factors Approach

1. Generic Trauma Therapy: a Common Factors Approach James Keim, msw | Puebla, November 24, 2013

2. Jim’s Background • Co-author of the book, The Violence of Men, and contributor of chapters to over ten edited psychotherapy books • Served as Director of Training for Jay Haley and Cloe Madanes at the Family Therapy Institute of Washington DC • Project Director and Archivist at MRI in Palo Alto • Current Director of the Oppositional and Conduct Clinic at the Institute for the Advancement of Psychotherapy and participant in the Best Pharmaceuticals for Children Act discussions at the National Institutes of Health • Trains clinicians in treatment of victims of human trafficking in Southeast Asia, currently a Fulbright Specialist Roster Candidate, Vietnam

3. This presentation is available at www.generictraumatherapy.com

4. Workshop Outline • What do we mean by common factors? • Common Factors in Successful Therapy • Common Factors suggesting Therapy Imitates Life • The Funeral as a model for Trauma Therapy • Generic changes that characterize successful processing (KEIM) • Memory Reconsolidation and Distracted Recall as unifying concepts • A Generic Approach to Exposure – What EMDR, CBT, and all the others have in common

5. Defining “Common Factors”

6. What Is a “Common Factors” Approach?

7. The “lens” of generic factors does not attempt to describe all aspects of all therapies, but rather attempts to describe common structures and elements. One might compare this to looking at similarities between skeletons of various animals.

8. Basic Assumptions • The basic curative elements in the successful processing of trauma are the same in clinical and non-clinical contexts.

9. Basic Assumptions • These common factors in the successful processing of trauma, both in and outside of therapy, manifest in a wide range of individual, group, and cultural forms.

10. Basic Assumptions • Investigating these common factors may demystify these processes, may facilitate the evolution of psychotherapy approaches, and may lead to a greater appreciation for the ways that humans have dealt with this problem for thousands of years.

11. Basic Assumptions • A better understanding of the generic aspects of trauma therapy may also facilitate their modifications to meet the needs of different cultures and contexts.

12. Nine Generic Factors in the Resolution of Trauma 1) Development of a linear narrative This describes the evolution of the trauma memory from a cloud-like, disorganized set of thoughts and perceptions into a more organized form (Ahlers, Hackman, & Michael, 2004). Keim describes the process as the conversion from a disorganized, unsequenced memory to a linear narrative with a beginning, middle, and end (Keim, 2013).

13. Nine Generic Factors in the Resolution of Trauma 2) Interpersonal processing of trauma (part a) The successful processing of trauma is characterized by the individual’s perception that increased social support is needed and then received (Robinaugh, Marques, Traeger, Marksa, & Sung, 2011). Perhaps the single most important part of the processing of trauma is this social dimension.

14. Nine Generic Factors in the Resolution of Trauma 2) Interpersonal processing of trauma (part b) The processing of trauma may involve hundreds or even thousands of retellings of a story to a supportive social circle.

15. Nine Generic Factors in the Resolution of Trauma 2) Interpersonal processing of trauma (part c) “Poor social support following a traumatic event is among the greatest risk factors for posttraumatic stress disorder (PTSD) across types of trauma” (Robinaugh, Marques, Traeger, Marksa, & Sung, 2011, p. 1072).

16. Nine Generic Factors in the Resolution of Trauma 2) Interpersonal processing of trauma (part d) Brewin noted in that “Of 14 separate risk factors for PTSD investigated in a recent meta-analysis, including trauma severity and gender, social support was shown to have the strongest effect size” (Brewin & Holmes, 2003, p. 339)

17. Nine Generic Factors in the Resolution of Trauma 3) Perspective control: This is characterized by the evolution from a memory that pulls one back into the victim perspective to an ability to visit the memory while maintaining a present perspective (Zimbardo, 2012)

18. Nine Generic Factors in the Resolution of Trauma 4) Emotional control: This is the evolution from an inability to control the strength and specific emotions associated with a memory to an ability to modulate (choose) the emotions and emotional intensity evoked by the memory (Jaycox, Zoellner, & Foa, 2002).

19. Nine Generic Factors in the Resolution of Trauma 5) Neuroendocrine control (part a): This describes the evolution from a reflexive neuroendocrine stress response (in its stronger forms, this is called a "fight/freeze/flight" response) to a modulated, preferred physical response that does not impair intrapersonal or interpersonal processing of the trauma experience (Keim, 2013; Dass-Brailsford, 2007; Barrett, 2012)

20. Nine Generic Factors in the Resolution of Trauma 5) Neuroendocrine control (part b): The neuroendocrine response to trauma, if unregulated, can impair the very parts of the brain that are needed to process trauma. “Each replay, however, distresses the traumatized individual, who may inhibit thought processes to modulate the active processing of traumatic information.” (Dass-Brailsford, 2007)

21. Nine Generic Factors in the Resolution of Trauma 6) Somatic integration, part a: Strong emotions have the potential to make us feel disconnected from our bodies, and the successful processing of trauma is characterized by a reconnection and regaining of comfort with the way the body responds to stress.

22. Nine Generic Factors in the Resolution of Trauma 6) Somatic integration, part b: Beyond the body’s vital role in the processing of emotions, trauma can involve a particular problem in which one’s own body can become a trigger for trauma memories. Trauma can thus create a disconnection between body and sense of self, and if this has occurred, the reintegration of these two is part of successful processing (Rothchild, 2000).

23. Nine Generic Factors in the Resolution of Trauma 6) Somatic integration, part C: Beyond the body’s vital role in the processing of emotions, trauma can involve a particular problem in which one’s own body can become a trigger for trauma memories. Trauma can thus create a disconnection between body and sense of self, and if this has occurred, the reintegration of these two is part of successful processing (Rothchild, 2000).

24. Nine Generic Factors in the Resolution of Trauma 7) From avoidance to confident revisiting Avoidance is one of the defining qualities of more severe trauma. In healthy processing, one moves from fear that the trauma memory is going to be recalled (and the avoidance of contexts that might trigger such a recall) to confident revisiting, the ability to decide when and when not to revisit a trauma memory and the confidence that one can regulate the emotional experience of this revisiting.

25. Nine Generic Factors in the Resolution of Trauma 8) Overcoming Cognitive/Philosophic Dissonance This describes the evolution from a sense that the traumatic experience is a violation of one's understanding of life to a schema that allows for the co-existence of the traumatic event with one’s current life schemas (Jaycox, Zoellner, & Foa, 2002).

26. Nine Generic Factors in the Resolution of Trauma 9) Addressing Blame or Guilt, part a Trauma seems to regularly evoke issues of blame or guilt, and the resolution of these is characteristic of successful processing (Kubany, 1998).

27. Nine Generic Factors in the Resolution of Trauma 9) Addressing Blame or Guilt, part b For example, a person may experience and feel “survivor’s guilt” despite the fact that, on an intellectual level, that person does not believe that there is a factual basis to the guilt. This type of blame or guilt is often a focus of conversation in the successful social support of a trauma victim.

28. Memory Consolidation as a Unifying Concept • Memory reconsolidation describes the changes in memory that happen when an event is recalled and remembered again (Siegel, 2012). One of the most common types of psychotherapy intervention is to have a client recall a traumatic memory while they are supported by a therapist in staying very self-regulated. The reconsolidated memory, when retrieved in the future, then is associated with a lower level of emotional activation.

29. Memory Consolidation as a Unifying Concept • Distracted recall is a specific type of memory-reconsolidation intervention. Distracted recall techniques have the client revisit the trauma while they are simultaneously asked to pay attention to distracting stimuli such as rhythmic tapping, finger waving, or the therapist’s counting out loud.

30. Memory Consolidation as a Unifying Concept • Asked to pay careful attention simultaneously to their own story and the therapist’s distraction, a client is challenged to additionally pay attention to anxiety symptoms and often experiences a reduction in experienced anxiety. This process is repeated until the anxiety resolves sufficiently.

31. Memory Consolidation as a Unifying Concept • An explanation for how distracted recall works is offered by Van den Hout (van den Hout, Eidhof, Verboom, Little, & Engelhard, 2013). Their research suggests that distracted recall works by blurring of emotional and non-emotional memories by taxing working memory during recall.

32. Memory Consolidation as a Unifying Concept • the reconsolidation of memory that then takes place during this type of intervention resets the emotions associated with the memory at a lower level of vividness during future recall. Van den Hout’s model may offer us a unifying model to understand how the distracted recall (exemplified by EMDR and numerous other trauma-specific interventions) works.