tulburari posttraumatice

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A CONVERSATION WITH DONALD MEICHENBAUM

Following is a condensation of a conversation between Donald Meichenbaum and Michael F. Hoyt which tookplace in San Francisco on May 4, !!4, where Meichenbaum was conducting a two"day workshop on #$reating%atients with %ost"$raumatic Stress Disorder# for the &nstitute for 'ehavioral Healthcare. $he full conversation

will appear in Constructive Therapies 2, edited by Hoyt and forthcoming from (uilford.

Hoyt:How did you come to think of treating PTSD as a narrative constructive endeavor?Meichenbaum:& became fascinated with how people describe their e)perience and how their accounts changedover time. *hen something bad happens to you, when some natural or man"made disaster occurs, when someform of victimi+ation e)perience occurs to you or to your family, ordinary language and everyday vocabularyseem inadeuate to describe your e)perience and reactions. &n their own ways, these #victimi+ed# individualsbecame #poets,# using metaphors to describe their e)periences. $hey conveyed their e)periences by using

phrases such as, #this is like...#- #& feel like a...#- and so forth. $he #victimi+ed# individual may describe herselfas a #prisoner of the past,# as a #doormat,# a #whore,# as a #time"bomb ready too e)plode,# and the like. ustimagine the impact on yourself and on others if you go about describing your e)periences in such metaphoricterms/ 0s a result of these initial clinical impressions, & undertook the task of analy+ing the nature of themetaphors and the narrative accounts that clients offered over the course of their therapeutic sessions. 'asedupon both clinical analysis and a literature review, & came to appreciate the heuristic value of a constructive

narrative perspective.

Hoyt:When someone becomes a victim has a horrib!e trauma how does that affect them? What changesespecia!!y in terms of their wor!d view?Meichenbaum:$hat depends on which piece of the pu++le you look at. 1learly there is increasing evidencethat something changes physiologically. $his is especially true of chronic, prolonged e)posure or what arecalled $ype && stressors 2e.g., abuse, domestic violence, holocaust victim3. Such e)posure leads too what are

called Disorders of )treme Stress that affect one5s sense of trust in family and beliefs about self and the world.$raumatic events can #shatter# your basic assumptions about the world and can violate and invalidate your corebeliefs. 0nother thing that trauma does is overly sensiti+e you to trauma"related cues and this hypervigilancefeeds into, and is in turn, affected by the ruminations, flashbacks, and avoidance behaviors that characteri+e%$SD.

Hoyt:"s this primari!y a protective mechanism# $" need to be on a!ert so it won%t happen again$?

Meichenbaum:& think there are functional and adaptive values in such behavior. $o become vigilant and toover"respond after e)posure to a trauma can be adaptive initially. 'ut, what happens to the people who havedifficulty recovering is that they continue to behave in ways that may be no longer #necessary.# %eople get#stuck# using techniues such as dissociation that were at one time effective in order to deal with trauma such asincest, or rape, or combat. &t is my task, as a therapist, to help clients understand and appreciate the adaptivevalue of how they responded. 'ut, & also help them appreciate the #price# of continuing to respond in this

fashion, when it is no longer needed. $his approach helps clients reframe their reactions as adaptive strengths,rather than as signs of mental illness. *e work together to help them not only change their behavior, but also totell their #stories# differently.& go beyond understanding, to nurturing the client5s discovery process by using Socratic uestioning. &encourage clinicians to use strategically their bemusement, their befuddlement- & want them to be collaborators.$he goal is to help the client in the initial phase of stress inoculation to better understand what they have been

through, how are things now, how would they like them to be, and what can wedo, working together, to helpthem achieve their goals/ $he educational phase of S&$ lays the groundwork whereby the client can come tosay, #6ou know, &5m stuck.# 0 related ob7ective of this initial phase is to help clients move from globalmetaphorical accounts of their e)perience and reactions to behaviorally prescriptive descriptions that lead tochange and nurture the #sense of hope# to undertake this change.

Hoyt:"n essence " think you%re saying that as c!inicians we%re trying to he!p c!ients reauthor their narrativesrather than undertake the ro!e of correcting their accounts&Meichenbaum:1orrect. $he metaphors that describe my therapeutic approach include rescripting, reauthoring,helping clients generate a new narrative, being a coach. & don5t 7ust record the clients5 accounts- rather & helpthem alter their personal stories. 0 second way is to help them engage in #personal e)periments# in the presentthat provide them with #data# that they can take as #evidence# to #unfree+e# the beliefs they hold about

themselves and the world. $he results of such ongoing e)periments that occur both within and outside of thetherapeutic setting provide the basis for the client to develop a new narrative. $his co"constructive process isone that emerges out of e)perientially meaningful efforts by the client. &n terms of #strengths# and copingefforts, & help people who have post"traumatic stress disorder to appreciate that their intrusive thoughts,hypervigilance, denial, dissociation, dichotomous thinking, moments of rage, each represent coping efforts, andmetaphorically reflect the #body5s wisdom.# For e)ample, intrusive thoughts may reflect ways of making sense
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of what happened, as attempts to #finish the story,# to answer #why uestions.# Denial may be an attempt to#dose oneself# dealing with limited amounts of stress at a given time, a way to take a #time out.# Hypervigilancemay be seen as being on continual #sentry duty# when it is no longer needed. &n other words, it is not thatpeople get an)ious, angry, or depressed per se- those are natural human emotions. 8ather, it is what people sayto themselves about those conditions that is critical.

$he collaborative process of therapy is designed to help the client #say# different things to herself, as well as, to

others. 0 key element of cognitive behavioral interventions is that an effective way of having people to talk tothemselves differently is to have them behavedifferently. $hus, a critical feature of cognitive behavioralinterventions, such as stress inoculation training, is to encourage and even challenge clients to perform personale)periments, in vivo so, as & mentioned, they can collect data that will #unfree+e# their beliefs about themselvesand about the world. 1ognitive behavioral therapy is not 7ust a #talking cure,# it is a proactive, enabling form of

intervention, that fits an #evidential# theory of behavior change. 'ut such change is notenough. &t is critical forclients to take credit for the changes that they have brought about. $here is a need for the therapist to ensure thatthe clients take #data# resulting from #personal e)periments# as #evidence,# and thus, assume a greater sense ofresponsibility for the changes that they have brought about. $his process of #ownership# is evident in the newnarratives that clients relate. & listen careful to the clients5 stories. & listen for their spontaneous use ofmetacognitive self"regulatory verbs as part of their new accounts. &mprovement is evident when clients use such

verbs as #& noticed...caught myself...interrupted...used my plan...felt & had options...patted myself on theback...became my own coach...anticipated high risk situations...tried my other options.# *hen clients

incorporate these e)pressions into their narratives, then they have become their own therapists, and truly havetaken 2appropriated3 the clinician5s #voice# with them.

Hoyt:This is the power of new experience not 'ust e(p!anation of what%s wrong but disconfirming the

e(pectations with a new e(perience&Meichenbaum:'ut for meaningful change to occur it has to be #affectively"charged.# & am referring to thetime"honored concept of #corrective emotional e)perience.# %eople can readily dismiss, discount, dissuadethemselves of the #data.# $hey don5t really accept data as #evidence,# and it is critical therapeutically to workwith clients in order to ensure that they take the #data# they have collected as evidence to unfree+e their beliefs,to get into the nature of the clients5 belief system and to nurture an internal dialogue that they would find most

adaptive, as compared to being #stuck# in maladaptive patterns of thinking and behaving.Hoyt:Watching you work "%m a!ways impressed by how much caring and effort goes into deve!oping atherapeutic a!!iance and a co!!aborative re!ationship with the c!ient& "t appears to be the vehic!e that carries the

rest of your work&Meichenbaum:& agree. & think the therapeutic relationship is theg!uethat makes the various therapeuticprocedures work. Some of the things that & try to highlight for a clinical audience watching my video tapes is

how often & #pluck# and reflect the client5s key words, use Socratic uestioning, and often over the course of thesession, & let the client finish my sentences. 6ou need to encourage clients to tell their stories, at their own paceand to be in charge. 'ut out of the telling of their stories, out of the narrative sharing""and there5s a lot oftherapeutic value in sharing one5s story""new stories emerge that also reveal strengths and resources. 1lients5stories are filled with e)pressions of hopelessness and helplessness. $hey often convey a tale of having been#victimi+ed# and it is my 7ob, as the therapist, to not only hear their stories and empathi+e with them, but also to

help them appreciate what they have done to survive and to cope with their feelings, namely, help them attendto #the rest of the story.# For #the rest of the story# is often the tale of remarkable strengths. 9eep in mind thatthe story of how people cope with stressful events is inherently the story of resilience and courage. ven in theworst scenarios people evidence remarkable strengths. 0s a therapist, & need clients to attend to that part of their

stories. $hus, the #bad things# that happened to people are only one chapter in their life stories.Hoyt:)ften times therapists rush past the painfu! materia! trying to reframe or restructure so *uick!y that the

person doesn%t fee! heard of va!idated& Do you think there%s a!so++maybe fo!!owing from ,ristot!e++a need for

catharsis and abreaction?Meichenbaum:$he uestions about differential forms of treatment is comple). How one should proceedtherapeutically is dependent upon the target group. &f you are treating people who have e)perienced traumasthat are brief, sudden, yet life"threatening, such as automobile accidents, robberies, rape, and sudden disasters,or what have been characteri+ed as $ype & stressors. 6es. $he data suggest that having clients go through re"

e)periencing procedures as a means of #coming to terms# with what happened, is therapeutic and beneficial.&ndeed, there are a variety of very creative clinical techniues, including direct therapy e)posure, guidedimagery procedures, graded in vivo procedures, and the like, that are helpful. $hey fit your 0ristotelian catharsismodel and provide a means of #inde).html#working through# that can prove valuable.

Hoyt:What about peop!e with more pro!onged trauma?

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Meichenbaum:*hen, however, you are treating post"traumatic stress disorders that are chronic""and thetraumatic events occurred many years ago""the treatment decision to undertake #memory work# of havingclients #go back# may not be the most effective treatment strategy. Having clients recount and re"e)periencetraumatic events, even in the area of incest, may not be the most therapeutic approach. 'ecause in the attempt toconduct so"called #memory work,# there is the danger that the therapist can inadvertently, unwittingly, and,

perhaps, even unknowingly, help clients co"create memories. *ith such prolonged traumas that have a number

of secondary seuelae it is important to address the secondary conseuences such as depression, interpersonaldistrust, se)ual difficulties, addictive behaviors, and the like that may accompany %$SD. $he full cognitive"behavioral therapeutic armamentarium needs to be employed to address these signs of co"morbidity. 0 #here"and"now# therapeutic focus as compared to a #there"and"then# approach, may prove most helpful. 'ut keep inmind that from a constructive narrative perspective, even when clients are doing so"called #memory work,# they

are not relating, nor #uncovering# history, but rather, they are co"constructing history in a mood"congruentfashion. 0s Donald Spence observes, it is the #narrative truthfulness,# not the #historical truthfulness,# ofclients5 account that needs to be the focus of therapeutic interventions.

Hoyt:-ou have worked c!inica!!y with many diverse groups and you have taught and given workshopsinternationa!!y& How do these guide!ines vary across these diverse settings?

Meichenbaum:$hat uestion raises the important issue of how important it is to be culturally sensitive in

formulating a treatment plan. ;et me give you an e)ample. $here are #testimony# procedures in treating peoplewho have been victims of torture. $hese procedures have individuals #go public# with what traumas they have

e)perienced and what retribution should occur. For instance, one group of torture victims for whom thistestimony procedure has been used came from 0rgentina, 1hile, and other South 0merican countries.


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anticipating #high"risk# situations, as well as ways of handling possible setbacks, so lapses don5t escalate intofull"blown relapses.

?Meichenbaum 'iosketch? 'ehavior


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Meichenbaum:&t was horrendous. &n a dissociative state, she picked up his body parts. &t was one of themost horrific stories that & have ever heard. She is suffering from %$SD, depression, and suicidal ideation,as she feels responsible and guilty about his death. Her intrusive thoughts are overwhelming.& have another case of a mother who had a ten"year"old daughter. $hey were at home alone. &n the middleof the night, she woke up thinking that someone had broken into her home. Since she had e)perienced such

a robbery in the past year, she became fearful. &n a state of panic, she reached into her night table to grab

hold of a recently obtained pistol that her husband had given her. *ith gun in hand she was running into herdaughter5s room when her bedroom door slammed open and hit her hand and the gun discharged.Hoyt:Don%t te!! me&

Meichenbaum:6es. &t was her daughter. $he mother shot her daughter and blew her daughter5s brain away.

Hoyt:That is terrib!e0

Meichenbaum:Michael, what are you going to say or do in therapy with these clients/ &n each instance, &listen sympathetically to the tale of the horrendous events. 0nd eventually asked the mother, #*hat did yousee in your daughter that made your relationship with her so special/ %lease share with me the nature of theloss.# &n fact, & asked the bereaved mother to bring to therapy a picture album of her daughter and to reviewwith me the special ualities of her daughter. $he picture album permitted the client to tell the story of herrelationship with her daughter in some developmental 2time"line3 conte)t, and thus not delimit her

memories to only the time of the shooting, which she played over and over again, with the accompanyingnarrative of, #&f only#- #*hy didn5t & tell my husband & didn5t want to own a gun/#- #*hy my daughter/#-

#$ell me it is only a dream#- #How could & have/# and so forth. Moreover, the review of the picture albumprovided the opportunity to uery further what she saw in her daughter- and, in turn, what did her daughtersee in her.Following this e)change, & asked the client, #&f your daughter, whom you described as being 5wise beyond

her years,5 were here now, what advice, if any, might she have to help you get through this difficult period/#Fortunately, with some guidance & was able to help the client generate some suggestions that her daughtermight have offered. & then note, #& can now understand why you described your daughter as being 5wisebeyond her years.5 #She does sound special.# Moreover, if the client followed through on her notion tocommit suicide in order to #stop the emotional pain,# what would happen to the memory of her daughter/Did she feel that she owed her daughter more/ ;ike many victims of traumatic events, this client found a

mission in order to cope with her distress. She undertook the task of educating parents about the dangers ofkeeping guns in their homes. She became an e)pert on the incidence of accidental homicides and developeda foundation named after her daughter designed to decrease the likelihood that this could happen to other

children. She felt that if she could save one other child, then her daughter would not have died in vain.$hrough her actions, she was writing a new script, fashioning a new more adaptive narrative. &n therapy, wealso addressed her feelings of guilt.

Hoyt:" can see what you mean by arranging the conditions whereby c!ients come up with suggestionsthemse!ves a!though you cou!d have offered a!! of the advice that the daughter might have offered&

Meichenbaum:6ou5re right, but there is a greater likelihood that clients will follow through if they comeup with the ideas than if you, the therapist, give them the ideas. & use a phrase to caution therapists not toact as #surrogate frontal lobes# for their clients.

Hoyt:1!aughter " !ike that ++ $surrogate fronta! !obes$ ++ it%s better to support the c!ient%s own

construction& What did you do with the c!ient whose fiance died in the train accident? Meichenbaum:& used a similar therapeutic strategy, but & had to alter it somewhat. 0s in the case of thegrieving mother, & asked the client who lost her fiance to help me appreciate what happened e)actly, andmore importantly, #$o help me understand what you saw in your fiance, immy. *hat was life like with

him/ *hat did you see in him that attracted you to him/...*hat do you think he saw that attracted him toyou/...&f immy were here now, what advice, if any, would he have for you in this difficult time/...*hat do

you think would be the best legacy, the best way to remember immy, not only for yourself, but for otherswho knew him/#*hereas, this strategy worked with the bereaved mother, it did notwork with this client. *hen & asked herto come up with advice that immy might offer, she drew a blank. $he image of immy5s grotesue deathwas so vivid and current that she could not assume any distance psychologically. So instead, & pursued asomewhat different line of uestioning. & asked her when else she might have e)perienced a personal loss.

She described the loss of her grandmother whom she loved a great deal. & then asked her what did she seein her grandmother that made the relationship so special/...*hat do you think your grandmother saw inyou/...&f your #wise# grandmother were here now what words of support, what advice, if any, do you thinkyour grandmother might have for you/ 2&nterestingly, this grandmother sounded like a good cognitive"behavioral therapist3...& then conveyed, that #@ow, & understand why your grandmother was so special.#

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From my perspective, the #name of the game# is to use the art of uestioning to enable and empower clientsto come up with possible coping strategies.& could have told this client every single thing that the grandmother would have offered, but it would nothave been as helpful.

Hoyt:What about the c!ient who did not have the positive e(perience that they can draw from with the !ost

ob'ect? The person who says $"%ve a!ways had !ow se!f+esteem "%m not good " deserve what " got&$ "t

stimu!ates ear!ier re!ationships that were very negative the fami!y abused them& What wou!d you havedone if she had said $3y father to!d me "%d never be happy$? Meichenbaum:6ou are right on target.

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