Trauma Response Profile
Donald Meichenbaum, Ph.D.
Joseph S. Volpe, Ph.D., F.A.A.E.T.S.
Editor, Trauma Response
Director, Professional Development
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 theAmerican 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
classicCognitive 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 employmetaphors. "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. InA Clinical Handbook/Practical Therapist Manual for Assessing and Treating Adults with Post-Traumatic StressDisorder(referred to as thePTSD Clinical Handbook), I describe a variety of psychotherapeutic techniques to accomplish these objectives.
JSV:On that note, in 1994 you publishedA 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. TheClinical Handbookis 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 thePTSD 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 theClinical Handbookmyself. 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 accomplishin spite ofthe 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 accomplishin spite ofthese traumatic events. The therapist can not only elicit such accounts, but can then ask clients to describe in more detailwhatthey had accomplished andhowthey 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?