| Thousands
of individuals from around the world including
patients, professionals, and organizations have
benefitted from the work of Donald Meichenbaum,
Ph.D. Dr. Meichenbaum is Professor of Psychology
at the University of Waterloo in Ontario, Canada
and a member of The American Academy of Experts
in Traumatic Stress. He was the innovator of Cognitive
Behavior Modification (CBM) and at the forefront
of the "Cognitive Revolution" in the
field of psychology in the 1970s and 1980s. He
was voted one of the ten most influential psychotherapists
of the century by North American clinicians in
a survey reported in the American Psychologist,
the official publication of the American Psychological
Association. Dr. Meichenbaum is Editor of the
Plenum Press series on stress and coping and serves
on the editorial board of a dozen journals. He
has authored and coauthored numerous publications
including the classic Cognitive Behavior Modification:
An Integrative Approach (1977), Stress
Reduction and Prevention (1983), Pain and
Behavioral Medicine: A Cognitive-Behavioral Approach
(1983), Stress Inoculation Training (1985),
Facilitating Treatment Adherence: A Practitioner's
Guidebook (1987), and more recently, A
Clinical Handbook/Practical Therapist Manual For
Assessing and Treating Adults with Post-Traumatic
Stress Disorder (PTSD) (1994).
JSV: I
know that you keep quite busy as a clinician,
lecturer, consultant, researcher, and author.
Can you tell me about the various roles and/or
positions that you currently hold?
DM: I am a Professor
at the University of Waterloo who has recently
retired. I am maintaining a full lab, as well
as being a clinical consultant. I consult at a
number of child, adolescent and adult programs,
inpatient and outpatient, where a sizable percentage
of the clientele have a history of victimization.
I am also the Editor of a series for Plenum Press
on stress and coping. And, perhaps, most exciting,
I recently became involved as the Director of
an Institute in Miami, Florida called "The
Melissa Institute." Melissa was a young lady
who was brutally murdered in St. Louis and her
family has recently established an Institute in
her name designed to explore issues on the prevention
of violence and the treatment of victims of violence.
The intent of the Institute is to bridge the gap
between research findings and practical applications.
The Institute is starting to take on more and
more of a central role in my functioning. It ties
directly into my work with victimized individuals.
JSV: When
did you retire from the University?
DM: Just this
last July
JSV: Well,
congratulations!
DM: That's not
the way my mother put it! My mother, who is 81-years
old, works full-time in New York City. When I
told her that I was retired, a perplexed look
came upon her face. She said, "you're retired
and I am working full-time. What am I going to
tell my friends?" (laughs).
JSV: With
so many exciting changes taking place in the area
of traumatic stress (e.g., neurobiological findings,
etc.), what things do you believe are in need
of greater investigation?
DM: That is really
a big question and I think the answer to it depends
on which specific population one is looking at.
I don't think that there are robust questions
that cut across all populations. In general, at
the level of adult, we need to examine the interrelationship
between various spheres of behavior. That is,
neurobiological, psychosocial, cognitive, and
cultural. My own area of interest, as we will
get into in a moment, is trying to better understand
the cognitive arena. Once we have developed a
metric for each of these areas, then we can start
to look at the interdependence of these factors
across domains. A second major area that needs
to be explored that has not been looked at adequately,
involves the fact that three-quarters of the population
in North America is going to experience a Criterion
A event some time in their life (From the
DSM-IV this relates to an event that a person
experiences or witnesses that involves actual
or threatened death or serious injury or threat
to the physical integrity of self or others rendering
the individual feeling helpless or fearful).
Yet, on average, only about 25% of people develop
posttraumatic stress disorder (PTSD). An interesting
and challenging question is what distinguishes
those individuals who go on to develop PTSD from
those who do not. I think that explicating those
differences can be valuable in guiding both assessment
and treatment. The third and final area involves
the role of cultural factors in influencing the
nature of traumatic responses and the ways in
which these are expressed. As an Editor of the
Plenum series, we have recently published a series
of books on the cross-cultural and intergenerational
features of traumatic stress. I think this latter
area has also been overlooked.
JSV: I
know that you have been a major proponent of the
constructive narrative approach for the treatment
of trauma survivors. Can you please describe the
constructive narrative perspective and how it
is utilized with your patients?
DM: There are
now a number of investigators from different perspectives
who have been very sensitive and innovative in
exploring the nature of the stories that individuals
tell about their trauma. Those stories change
over the course of time. The meaning that a traumatic
event has for individuals is critical. This is
not novel. A number of people have highlighted
the role of appraisal processes and the role of
the stories that people tell over the course of
time. I have become particularly interested in
how these stories change in my patients. I spend
a good deal of time supervising clinicians - psychiatrists,
psychologists, social workers- and we have audio
taped and videotaped therapy sessions. We have
noted that both symptom reduction and behavioral
changes covary with the changing nature of the
accounts that clients offer over the course of
therapy. A sense of personal agency often emerges.
Clients, over the course of therapy as they improve,
often shift the focus of their accounts. They
now move from viewing themselves as victims to
becoming survivors if not - thrivers. As they
do so they offer interesting accounts of how they
can now often have many of the same kind of thoughts,
feelings, intrusive ideation, etc. but this doesn't
seem to bother them as much. They do not feel
"stuck." There is a certain shift in
the nature of their narrative. We have become
very interested in tracking these changes. The
challenge for us, at a research level, is whether
these narrative changes are epiphenomena that
follow behavioral changes and physiological changes
or whether these narrative changes play an instrumental
role in facilitating change. There are a number
of investigators who have studied victims of natural
disasters ( Harvey), rape victims (Foa et al.),
AIDS victims (Folkman and Stein), child sexual
abuse victims (Janoff-Bulman and Silver), each
of whom have highlighted the role of narrative
changes. The challenge for the field is that,
at this time, we don't know how best to analyze
and code these narrative accounts. The constructive
narrative approach is a set of clinical observations
in search of a methodology and a theory. Let me
conclude by saying that when bad things happen
to people, the way they tell others, as well as
tell themselves "stories" about the
trauma, can influence their abilities to cope.
Also note, that how people cope can influence
the "stories" they tell. But often traumatized
individuals struggle to put into words, or into
some other form of expression, the impact of the
trauma. In their attempt to convey their distress
they often employ metaphors. "I am
a walking time bomb." "I am a victim
of the past." "This event opened up
a can of worms." "I am spoiled goods."
"I feel like I am on sentry duty all of the
time." Thus, in their own way, they become
poets. But these metaphors become more than figments
of speech. I believe they become ways in which
individuals come to construe and construct "reality."
One can view therapy as a way to elicit clients'
stories and to help them change their narratives.
In A Clinical Handbook/Practical Therapist
Manual for Assessing and Treating Adults with
Post-Traumatic Stress Disorder
(referred to as the PTSD Clinical
Handbook), I describe a variety of psychotherapeutic
techniques to accomplish these objectives.
JSV: On
that note, in 1994 you published A Clinical
Handbook/Practical Therapist Manual for Assessing
and Treating Adults with Post-Traumatic Stress
Disorder. This compendium of information is
magnificent. In fact, the Administrative Board
of the Academy has recommended this publication
for professionals across disciplines. What motivated
you to develop that project and what were some
of your most memorable moments as you were compiling
it?
DM: I do appreciate
your evaluation and in fact, I have been quite
pleased in how this volume has been received and
reviewed. I have been a consultant for a number
of years and in each setting I am called upon
to give presentations or supervise cases. Given
my obsessive-compulsive academic style and my
commitment to science, I would put together various
handouts on PTSD, depression, anger or addictive
behaviors, etc. People would ask me about assessment
instruments and interventions. In response, I
would put together a rather extensive handout.
The Clinical Handbook is the collection
of these handouts integrated into a format that
hopefully people will find helpful. You asked
about the most anxiety-producing feature of putting
together the PTSD Handbook. In each of
the books that I had written previously, I had
given them to a publisher. In this case, I decided
to publish the Clinical Handbook myself.
This led to some anxiety and I had to convince
my wife that this high risk activity would not
turn out to be a Criterion A event! In fact, it
took an initial outlay of a large set of funds.
In publishing it myself, the proceeds from the
Handbook are now going toward the development
of a research and clinical training institute.
So I now have been able to use the royalties generated
by the Handbook to support graduate students,
innovative research, and expand training materials
that clinicians may be able to use. My dream is
that we will eventually computerize the Handbook
so that clinicians will be able to access this
on a CD-ROM and call up specific clinical problems,
assessment issues, treatment concerns, and even
watch CD-ROM movies of master clinicians demonstrating
each of the core tasks of psychotherapy.
JSV: You
have described how the "art of questioning
is the most critical skill" for clinicians
to develop. Why do you believe this is the case
and how do you apply this skill in treating trauma
survivors?
DM: If you go
back to my comments on the constructive narrative
perspective, then the therapist's "art of
questioning" is critical in eliciting and
changing clients'narratives. It is important to
encourage clients to "tell their stories"
of what they have experienced and the impact on
them, their families and communities. It is also
important that the therapist elicit what Paul
Harvey, the radio commentator, calls the "rest"
of the story. Namely, what has the client been
able to accomplish in spite of the trauma?
A way to facilitate this disclosure is to have
clients use a timeline (or life chart) where they
can indicate when various traumatic events occurred
in their lives. On a second time line, the clients
can indicate what they have been able to accomplish
in spite of these traumatic events. The
therapist can not only elicit such accounts, but
can then ask clients to describe in more detail
what they had accomplished and how
they were able to do this. "How" questions
are especially helpful because they "pull"
for the nature of the strengths that individuals
have and they highlight the instrumental acts
that individuals, couples, groups and communities
have been able to implement to affect change.
Thus, from my point of view, the "art of
questioning" not only serves the function
of assessment, but it sets the direction for change
in the clients' narratives. Finally, it is hopeful
that therapy will result in clients becoming their
own therapists - taking the clinician's "voice"
with them. I will often ask clients if they ever
find themselves out there in the real world, asking
themselves the kinds of questions that we ask
each other right here in therapy? We want clients
to "internalize" the therapist's art
of questioning.
JSV: Although
many people are exposed to traumatic experiences
in their lifetime, most do not develop posttraumatic
stress disorder (PTSD). What factors do you believe
"buffer" a person from developing full-blown
PTSD?
DM: When I give
workshops, I review four classes of factors that
I think distinguish those who develop PTSD from
those who do not. The four general headings have
to do with characteristics of the trauma itself.
There is a good deal of research that highlights
the nature of the objective features of the traumatic
event including its intensity, its durability,
and people's proximity to the event. Another important
aspect of these stimulus characteristics is not
only the objective features but also the subjective
features. There are a number of studies that highlight
that the meaning the event has may play more of
a role than the actual stimulus characteristics.
That is, does the individual feel that by their
actions or lack of actions, that they may have
inadvertently contributed to the traumatic experience?
This can play an important role in determining
who develops PTSD. For example, if the individual
feels blameworthy and guilty about the nature
of their role in the traumatic event, this would
clearly increase the likelihood of people developing
PTSD. So, one whole class of events involves stimulus
characteristics. The second class of events
are response characteristics. We know that
the nature of the response that individuals have
in reaction to the traumatic event is critical
in determining who goes on to develop PTSD. There
are three features that turn out to be important.
One is how the person responded at the time of
the traumatic event. What has notably been characterized
as the acute stress reaction. Does the person
show anxiety, dissociation and the like? This
may play an important role in influencing the
nature of the reactions they encounter and the
support that they may receive.
Another element
that becomes important is the recognition that
the reactions of traumatized individuals change
over the course of time. It is not only important
to recognize that clients have symptoms, but when
they have these symptoms is critical. For example,
a common referral problem is intrusive ideation.
Research by Baum and others indicates that if
intrusive ideation occurs down the road, well
after the event, it increases the likelihood of
PTSD. Also, is there comorbidity? That is when
the individual not only experiences what is considered
classical PTSD, but what is known as complex PTSD.
Are there comorbid responses such as anxiety,
depression, suicidal ideation, and what is often
overlooked, anger responses? Also, as I noted,
are there guilt reactions? This clearly complicates
the nature of the situation and increases the
likelihood of developing PTSD.
Two other factors
play an important role in determining who develops
PTSD. There is a good deal of research to implicate
the role of premorbid features; that is the nature
of prior exposure to victimization increases the
risk of developing PTSD. Whether one looks at
the research on combat, or on being a victim of
crime, or many other traumatic events, you find
that prior exposure both for the individual and
their family or community, can put individuals
at high risk. There are a number of other premorbid
features in terms of socialization patterns and
the like that may also predispose individuals
to develop PTSD. For example, intergenerational
victimization becomes important. Some recent findings
highlight that when children are victimized, if
their parents have had a history of victimization,
it increases the likelihood of the children developing
PTSD. The last and perhaps the most overlooked
factor is the nature of the recovery environment.
It is not only what the person experienced and
how they reacted both at the time or down the
road, or whether this was the first time that
they were traumatized or not. We must also consider
the nature of the recovery environment - it can
become critical. All we have to do is compare
the reactions and welcome that Vietnam vets received
versus those vets who came home from Operation
Desert Storm. There is a clear need to explore
the role that social support, community work and
the like play. Another aspect that I think is
overlooked, is the role that religion plays in
helping people cope with stress. I had spent some
time in Oklahoma City and saw the role that the
church played there. Moreover, in recognizing
that the major way that people try to cope with
trauma is by means of prayer or some kind of religious
ritual, I believe this highlights the need for
us to expand what constitutes the recovery environment.
JSV: As
you are aware, investigation of the effects of
traumatic stress in children is in its infancy.
What issues do you think are in need of greatest
attention in this area?
DM: This is a
big issue for me because I spend a good deal of
time consulting at residential programs with children
who have been victimized. The Melissa Institute
is designed to identify high risk children and
their families and communities and to develop
prevention programs. So there is a good deal that
I could say about this. I think that the major
issue for me involves the changing scenario of
urban settings in the United States where unemployment
and violence, family dysfunction, poverty, racism,
and the like, are so rampant. The epidemiological
data highlights the widespread victimization of
children. I don't think that we have fully appreciated
the nature and impact of just how widespread traumatic
stress is for children. Also, there is an increasing
need to focus research on what constitutes resilience
factors for these children. I think that explicating
and building upon these resilience factors in
terms of preventative programs would be most important.
JSV: We
are learning more and more about the effects of
secondary traumatic stress such that caregivers
themselves become traumatized and/or overwhelmed
through their efforts to assist others. What advice
do you have for those who treat trauma survivors?
DM: Let me enumerate
them in point form. These are described in more
detail in the Handbook. If in fact clinicians
have the chance, they should not limit their practice
just to trauma survivors. Given the challenge
of this population and their often unresponsiveness
to various forms of treatment and the harrowing
tales that they have to tell, it would be helpful
to include the more traditionally "neurotic"
types of cases that are more treatment responsive
in terms of anxiety, marital distress and the
like. This is often not a possibility for trauma
therapists but if it is, I would encourage clinicians
to pursue it. Secondly, I think that therapists/clinicians
could benefit from debriefing. That is, having
the opportunity to share the impact of their trauma
work. One of the things that we know from the
research is that people who have had an opportunity
to tell their story to significant others do better
in the long run than those people who do not share
their stories. That clearly is an emerging finding
in the area of working with victims. Individual
therapists can develop coping techniques both
within sessions and between sessions and in spheres
outside of therapy. This can renew their faith
which can become challenged when dealing with
trauma clients and horrific tales of evil. In
the same way that we know trauma can affect the
belief system and outlook of clients, I suspect
it can have a similar impact on therapists.
JSV: What
do you perceive as the most important factors
for clinicians/professionals, including non-mental
health personnel, to consider when intervening
on behalf of a survivor of a traumatic event?
DM: I think that
the task of the health care provider changes in
terms of when they intervene. If it is soon thereafter,
then there are a number of emergency requirements.
Moreover, the signature of the event becomes important
as to how one would intervene. At first, it is
important to make sure that people have information
and that they are safe. The clinician or health
care provider may act as a support agent and make
sure that survivors are protected from the media
and well-wishers who could make things worse.
There is an immediate crisis that needs to be
addressed. Then there is a second phase that has
to do with education about the impact of the trauma.
Education about PTSD and discussion about adaptive
and maladaptive coping responses, while normalizing
and validating the nature of people's reactions
become important. As one proceeds, especially
if the impact of the trauma occurs over a prolonged
period of time, a major concern is that health
care providers often leave the scene too soon
(i.e., see the research by Pennybaker). There
are also concerns about potential secondary victimization
and later on, anniversary effects. This is especially
the case if the victimization experience is of
intentional human design as compared to a natural
cause. There is often an increased likelihood
of anger that has to be addressed. How does one
make sure there are no comorbid reactions such
as addictive behaviors, depression, anxiety attacks
and the like? It is important that mental health
personnel recognize that people don't heal easily.
You don't cure PTSD. You don't stop the memories.
In fact there is some research that suggests that
the more you intentionally try to stop traumatic
memories, the greater likelihood that they are
going to increase in terms of their intrusiveness.
Therefore, the question is how do you help individuals
transform memories? How do you help people find
meaning in such events? How do you help them transform
their pain into a "mission?" This is
all subsumed under the constructive narrative
perspective. If one sees the task of the health
care provider in this broader view, then what
you do right at that time of the event is only
one small parcel of the total intervention.
JSV: As
you are aware, The American Academy of Experts
in Traumatic Stress is a multidisciplinary organization
with more than one hundred professions represented.
The Academy recognizes that traumatic events are
an unfortunate part of the human experience that
professionals and workers from many fields work
with on a regular basis. What do you see as the
major advantage of an organization such as the
Academy that is dedicated to increasing awareness
and ultimately, improving the treatment for survivors
of such events across such an eclectic group?
DM: Well, I think
that providing an umbrella organization that will
facilitate dialogue as you do both in your journal
and in other events is a valuable service. What
the physician, the emergency worker, and the psychotherapist
have in common and how interventions can be coordinated
across disciplines is a valuable service. Such
a dialogue should result in better treatments
for survivors and for those who provide such services.
©1998
by The American Academy of Experts in Traumatic
Stress, Inc. |
