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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. |
