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Summary

Our treatment model and training programs are based on the state of the trauma treatment field, featuring an overall approach to trauma treatment as well as a series of specific empirically-supported interventions. Because trauma and loss cause or contribute to such a wide range of mental health, behavioral, and health problems (Anda et al, 2006; Fairbank, Putnam, & Harris, 2007; van der Kolk, 2007), trauma-informed treatment is widely applicable, and is arguably the ideal trans-diagnostic treatment approach (Greenwald, 2013c). The phase model is recognized as the standard of care (Foa, Keane, & Friedman, 2009; ISSTD, 2011). Our phase model approach includes a series of specific interventions (e.g., motivational interviewing, cognitive-behavioral skills training, parent training, attachment work, trauma resolution, relapse prevention), each with their own extensive empirical support. Our model also incorporates and in many ways emphasizes the “non-specific factors” found to contribute to positive outcomes (Duncan, Miller, Wampold, & Hubble, 2010), as well as memory reconsolidation and the specific factor found to lead to rapid, dramatic, and lasting improvement (Ecker, Ticic, & Hulley, 2012). Our intensive therapy model facilitates rapid and efficient treatment.

The Fairy Tale Model of trauma-informed treatment is now recognized as an evidence-based treatment by the California Evidence-Based Clearinghouse, based on the empirical support for the interventions (taught in our programs) as a package. For example, Becker, Greenwald, & Mitchell (2011), using this approach in an impoverished multi-cultural neighborhood in San Diego, achieved an 87% rate of retention of families in treatment, and consistently good outcomes for the child(ren) who completed treatment. Farkas et al (2010) used the individual portion of the treatment approach in a controlled study of youth in care (in foster and residential placements) in Quebec, and compared to the standard care control group found substantially superior outcomes. Introducing this training in one youth residential facility reduced incident rates by 50% or greater on every unit, with greater reductions on the most serious types of incidents (Greenwald, 2003).

In another youth residential facility, when this training was provided to clinical and direct care staff, treatment time was reduced by 39% while rate of positive outcomes doubled, compared to the previous year (Greenwald, Siradas et al, 2012).

Finally, the training programs have been found to improve participant competence and sense of work-related satisfaction (Greenwald, Stamm et al, 2003). One particular module of the program has been shown to reduce worker reactivity and improve both attitudes and behaviors towards challenging clients (Greenwald, Maguin et al, 2008).

Non-Specific Factors

Therapeutic Alliance

The centrality of common factors to therapy’s effectiveness has become ever more widely recognized and embraced, as evidenced by the republication of the best-selling Heart & Soul of Change (Duncan, Miller, Wampold, & Hubble, 2010). This recent synthesis of the common factors research emphasized the integration and inextricability of the various factors. That is, you can’t just add more empathy or therapeutic alliance to an otherwise non-viable treatment approach and suddenly have a viable treatment. Rather, the common factors are necessarily grounded in a coherent and credible treatment model – itself a common factor – that is embraced by therapist and client. Such a treatment model serves as the foundation for the explanation of the problem, the plans for rectifying the problem, and the hope for successful change. These constitute much of the basis for the therapeutic alliance, the most important predictor of treatment success (Norcross, 2010). Our phase model of trauma-informed treatment is highly credible for addressing a wide range of presenting problems, and is readily embraced by therapists as well as clients, so it provides an excellent foundation for the therapeutic alliance.

Shared Perspective and Plan

Among the common factors that predict positive outcome across treatment approaches are presenting a convincing rationale for treatment activities (Messer & Wampold, 2002) and coming to agreement on treatment goals and tasks (Horvath & Greenberg, 1994). Although these are complex and difficult interventions to implement (Mallinckrodt & Nelson, 1991), the scripted interventions for case formulation and treatment contracting facilitate the process even for less experienced therapists.

Client Agency

When the client is an active participant in the treatment, outcomes are better (Bohart & Tallman, 2010). This treatment approach is based on an empowerment/strength-based model, uses a collaborative approach to develop the client’s goals, motivation, and initiative, thus maximizing each client’s potential to succeed.

Regular Feedback

Every-session feedback, especially focused (at the beginning of the session) on the client’s symptoms and (at the end of the session) the client’s perceptions of the therapy alliance, have been found to dramatically improve the consistency of positive treatment outcome (Lambert, 2010), primarily by catching problems so that the therapist can address these in a timely manner. This treatment approach includes beginning- and end-of-session structured check-ins to accomplish this.

Empathy, Warmth, Positive Regard

Empathy, warmth, and positive regard, also among the common factors leading to positive outcomes (see Norcross, 2010), are generally considered to be therapist qualities rather than treatment characteristics. Even so, this treatment approach is likely to guide the therapist towards experiencing and conveying these qualities. For example:

The first interview is focused on getting to know the positive qualities of the client, not the problems.
The scripted trauma history is conducted in a way that conveys caring, both by the fact of asking about what happened to the client, and the careful way of containing this interview to help the client from becoming overly upset.
The motivational interviewing approach frames the treatment as the client’s initiative to work towards his own positive goals (even for mandated clients).
The case formulation begins with a description of the client’s strengths and resources, followed by a non-pathologizing trauma-informed explanation of the presenting problem. This presents the therapist’s positive view of the client.
The explicit message in the case formulation and the treatment plan – typically accomplished in a single session – is that the therapist believes the client has what it takes to solve the problem.

A series of studies consistently found that therapists completing the Meaning of Behaviors form (the core of the case formulation) focused on their most challenging client led to the therapist feeling less reactive towards that client, more caring and empathic towards that client, and more comfortable and confident in their professional role with that client (Greenwald, Maguin et al, 2008). Adding the trauma-informed case consultation exercise enhanced the effect.

Research has consistently found that effective therapists tend to behave more like other effective therapists (regardless of treatment orientation) than like ineffective therapists who share their treatment orientation (Beutler, Crago, & Arizmendi, 1986; Lafferty, Beutler, & Crago,1989). Thus the therapist’s endorsement of a given treatment approach is not a very good predictor of the therapist’s behavior. However, because the present treatment approach includes structured and sometimes even scripted interventions for many steps in the treatment, it may be uniquely and reliably facilitative of the common factors that contribute to positive outcomes.

Memory Reconsolidation and the Specific Factor

The book, Unlocking the Emotional Brain (Ecker, Ticic, & Hulley, 2012), explains the recent brain research that definitively maps the deep structure of healing via memory reconsolidation. The authors describe most presenting problems as being driven by schemas or mental models that are locked in the brain as a result of traumatic events (my term, used broadly to include any upsetting events that have not been fully processed or integrated). They characterize most therapy approaches as counteractive in that the focus is to manage or over-ride the mental model, emotional reactivity, and associated symptoms. Such approaches tend to be incremental and subject to relapse because the underlying mental model and emotional reactivity remain. Instead, they recommend a transformative approach – using the brain’s ability to reconsolidate memory – to permanently modify the underlying mental model and eliminate the emotional reactivity.

The primary criticism of the common factors research is that it has relied on statistical analysis of randomized clinical trials. This means that outliers – for example, individual cases in which dramatic and lasting improvement occurred – have been rendered invisible in the group average, rather than specifically studied. On the other hand, process research focusing on individual cases has identified a specific factor that typically quickly leads to large and durable changes: guiding clients to face and process previously avoided emotional experiences (see Ecker, Ticic, & Hully, 2012).

Guiding the client to face, process, and resolve a trauma memory is arguably the most profound and impactful example of such a treatment activity. Furthermore, transformative trauma resolution procedures, such those taught in our programs, can effect memory reconsolidation at the source of the associated symptom-generating mental model.

This does not mean that the common factors are not important; indeed, these specific treatment activities are unlikely to occur without a treatment approach incorporating the common factors. It is probably most useful to conceptualize the common factors as the necessary foundation for the specific healing activities to be implemented.

Component Interventions

Motivational Interviewing

Motivational interviewing (MI) is a directive counseling approach – involving both style and specific procedures – designed to elicit motivation and action for positive behavioral change (Miller & Rollnick, 2002). It explicitly avoids the authoritarian, confrontive approach which has been shown to increase client resistance (Patterson & Forgatch, 1985). Intervention components include: (1) individual assessment and feedback focusing on the discrepancy between behaviors and goals; (2) emphasizing the individual’s free choice and responsibility for his or her own behavior; (3) providing advice to make a positive change; (4) offering a menu of ways to accomplish the change; (5) attitude of empathy and acceptance of the client’s perspective; and (6) interventions to enhance self-efficacy, reinforcing self-confidence and optimism regarding goal achievement (Miller & Rollnick). MI has an impressive track record of leading to improved treatment compliance as well as positive behavioral changes (Hettema, Steele,& Miller, 2005). However, as a stand-alone intervention, treatment effects do not endure (Miller, 2005); therefore it is essential to capitalize on the client’s motivation with further interventions to effect lasting change.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) refers to an array of structured intervention strategies designed to provide corrective experiences, develop more constructive ways of thinking and behaving, and enhance specific self-management skills (Nathan & Gorman, 2007). Seeking Safety, a structured package of trauma-sensitive CBT interventions, has been found effective in treatment of substance abusers with PTSD (Najavits, 2002). In a controlled anger treatment study in an adult PTSD population, highly volatile veterans’ participation in anger management therapy led to increased self-control as well as reduction of apparently unrelated trauma symptoms (intrusive thoughts and images), whereas standard trauma treatment did neither (Chemtob, Novaco, Hamada, & Gross, 1997). Anger treatment completers maintained their post-treatment gains at 18 month follow-up. These findings were consistent with another study, in which a multi-component treatment for combat-related PTSD found incremental effects for both the exposure and the anger management components (Frueh, Turner, Beidel, Mirabella, & Jones, 1996).

Why should self-management training lead to reduced post-traumatic symptoms? Perhaps because when problem behaviors are reduced, the environment responds by becoming less hostile and more supportive. When the environment is experienced as being safer, survival mode can be relaxed and the trauma is less pressing, more part of the past.

Parent Training

Parent training has been shown to be quite effective in reducing the problem behaviors of children and (to some extent) adolescents (Kazdin, 2005), and is included in some of our programs.

Attachment Work

The focus on attachment-related issues has become more mainstream in the psychotherapy field, especially among those therapists working within a trauma orientation. The goal is to assist certain clients in achieving secure attachment status, which occurs naturally during early childhood for much of the population. People with secure attachment status tend to be more resilient in the face of potentially traumatic stressors (Muller, Sicoli, & Lemieux, 2000), which is not surprising because secure attachment comes with a repertoire of coping skills, as well as a likelihood of having healthier relationships and thus better social support. Furthermore, those with less than secure attachment status tend to be less responsive to trauma treatment (Muller & Rosenkranz, 2009; Stalker, Gebotys, & Harper, 2005). Brief interventions directly targeting the client’s attachment status, such as the one we teach, have not yet been formally tested.

Trauma Resolution

A recent meta-analysis found that eye movement desensitization & reprocessing (EMDR) is more cost-effective (that is, more efficient) than the other well-established research-supported trauma treatments (Mavranezouli2020). It may also be more effective in certain ways (Ho & Lee, 2012). EMDR is also well tolerated by children and others with limited affect tolerance. Thus it is currently the trauma treatment of choice. However, it is complex and resource-intensive to learn (Greenwald, 2006).

The counting method matched EMDR for efficiency and effectiveness, in the only comparison study to date (Johnson & Lubin, 2006). Progressive Counting (PC; Greenwald, 2013c) is based on the counting method with modifications for improved efficiency and client acceptability. Data from a large open trial was promising (Greenwald & Schmitt, 2010). In direct comparisons, PC was found to be about as effective as EMDR (Greenwald & Camden, 2022; Greenwald, McClintock, & Bailey, 2013; Greenwald, McClintock, Jarecki, & Monaco, 2015) while being less difficult for clients, and possibly more efficient (Greenwald, McClintock, Jarecki, & Monaco, 2015). PC is also far simpler to master.

The Flash technique is a newer method that is relatively non-distressing and quick, and preliminary research is promising.

Most of our training programs feature EMDR, PC, and/or Flash, and we use these methods in our treatment as well.

Relapse Prevention and Harm Reduction

Once trauma resolution work has been completed, this model focuses on guiding the client to anticipate future challenges. Cognitive-behavioral relapse prevention and harm reduction interventions (Marlatt & Gordon, 1985) focus on strategies for avoiding anticipated problematic situations and stressors, coping with those situations that cannot be avoided, and coping with anticipated relapse to prevent further deterioration. This approach has been used with some success in treating a range of addictions (Marlatt & Donovan, 2005) as well as with sex offenders (Dowden, Antonowicz, & Andrews, 2003), although when used as a stand-alone intervention, its limitations have also been noted (Polaschek, 2003). It has not yet been widely applied to other types of treatment. In one study, this approach was used, in combination with other skills training, with adults arrested for driving while disqualified (often as a consequence of a drunk driving conviction). Compared to a matched control group, this treatment reduced incidence of driving while disqualified; other criminal offending was reduced as well (Bakker, Hudson, & Ward, 2000).

The Fairy Tale Model -- The Treatment Approach as a Package

The Fairy Tale Model of trauma-informed treatment is now recognized as an evidence-based treatment by the California Evidence-Based Clearinghouse, based on the empirical support for the interventions (taught in our programs) as a package. Here are the studies of the fairy tale model. Becker, J., Greenwald, R., & Mitchell, C. (2011). Trauma-informed treatment for disenfranchised urban children and youth: An open trial. Child & Adolescent Social Work Journal, 28, 257-272. Abstract: Community outreach and focus groups were conducted in an impoverished multi-cultural urban neighborhood to develop a local, culturally-sensitive and community-responsive adaptation of Greenwald’s (2005) phase model of trauma-informed treatment. Fifty-nine children with a wide range of presenting problems were referred for treatment. Outcomes included 87% retention rate of participants treated to successful termination, as well as clinically significant reduction of post-traumatic stress symptoms. This project demonstrates that hard-to-reach disenfranchised urban children can benefit from trauma-informed treatment when it is appropriately adapted and presented. Farkas, L., Cyr, M., Lebeau, T., & Lemay, J. (2010). Effectiveness of MASTR/EMDR therapy for traumatized adolescents with conduct problems. Journal of Child & Adolescent Trauma, 3, 125-142.

Abstract: This study examined MASTR/EMDR, a trauma-focused treatment for traumatized youth taken in charge by youth protective services. Participants were 40 adolescents who were exhibiting conduct problems and internalizing and externalizing behaviors and who had been exposed to maltreatment. Participants were randomly assigned to MASTR/EMDR treatment or to a routine care condition. Self-report questionnaires and semistructured interviews were administered to participants and one of their parents/caregivers at three points in time: pretreatment, post treatment (12 weeks), and follow-up (12 weeks). Repeated measures analyses of covariance showed that participants in the experimental group had significant improvements in their trauma symptoms and behavioral problems compared with the control group at the posttreatment evaluation. These effects were maintained at a 3-month follow-up. Results support the effectiveness of MASTR/EMDR.

Greenwald, R. (2003, Spring). The power of a trauma-informed treatment approach. Children’s Group Therapy Association Newsletter, 24(1), 1, 8-9.

Summary: Trauma-informed treatment was introduced in a youth residential facility that had been experiencing significant problems with resident violence and other serious problem behaviors. Training in trauma-informed treatment was provided to therapists, direct care staff, and supervisors. By two months post-training, the incident count was down by 50% or greater in every incident category, on all 5 residential units, as compared to any of the prior 6 months. In the most serious incident category, physical assault, the reduction was much greater. This change was maintained for the 6 months it was tracked.

Greenwald, R., Siradas, L., Schmitt, T. A., Reslan, S., Sande, B., & Fierle, J. (2012). Implementing trauma-informed treatment for youth in a residential facility: First-year outcomes. Residential Treatment for Children & Youth, 29, 1-13.

Abstract: Training in the Fairy Tale model of trauma-informed treatment was provided to clinical and direct care staff working with 53 youth in a residential treatment facility. Compared to the year prior to training, in the year of the training the average improvement in presenting problems was increased by 34%, time to discharge was reduced by 39%, and rate of discharge to lower level of care was doubled. The inclusion of numerous interventions, along with limitations in implementation and evaluation, make it difficult to precisely identify the cause(s) of the improvement.

Additional Fairy Tale Model studies are cited in the Intensive section, below.

Intensive Therapy Format

In recognition that memory reconsolidation does not require a slow, incremental approach (Ecker, Ticic, & Hully, 2012), we, and a growing number of trauma-oriented therapists, now offer therapy in an intensive format typically involving many hours per day on consecutive days. Advantages of intensive therapy include treatment efficiency, rapidity of results, reduced risk of treatment-related destabilization, reduced risk of treatment disruption, and reduced total treatment cost (Greenwald, Camden et al, 2020).

A large, well-designed randomized study found that an intensive 1-week course of evidence-based PTSD therapy had the same outcome as delivery of the same treatment over several months; except that the results were achieved much more quickly in the intensive format (Ehlers et al, 2014). Equivalent outcomes were also found for a non-randomized comparison of intensive to weekly EMDR for veterans with PTSD (Hurley, 2018). A study of intensive trauma-focused therapy featuring both EMDR and prolonged exposure had good outcomes (Van Woudenberg et al, 2018).

Our own studies of intensive EMDR and PC, using the fairy tale model, have yielded excellent outcomes, consistent with the best of reported outcomes for EMDR when provided in the conventional manner (Greenwald et al, 2020; Greenwald & Camden, 2022).

References

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