What works with childhood trauma survivors?


Barry Duncan responds to the question in italics below:

You said: She says that the research on this population clearly establishes that you must do some type of therapy that is sensory in nature (for example, Theraplay®), not just verbal or cognitive therapy because for so many of these children the abuse occurred early in life, at pre-verbal stages, and so that is how the abuse memories are stored.  I do not have specific research studies to cite at this moment; although I’m sure I could easily get my hands on some.  I’m guessing Scott & Barry as well as the other trainers have been asked this question before and are familiar w/ the research in this area as well to respond.  So, she says that because this is well-established in the literature, the first part of her job is to educate the clients and family on the fact that this is the specific type of treatment that they need.  She does not agree that there would need to be a negotiation with the client & family about what type of therapy would help; because they may not be aware of the research.  She sees that part of her job is to make sure that they understand that this is the type of therapy that the child needs and hopefully they are accepting of that. 

I hear this kind of stuff all the time. “But what you’re saying doesn’t apply to (fill in the blank). This approach (fill in the blank) is vital for this population and is well established in the literature.”

What people tend to confuse here is efficacy and differential efficacy. Efficacy over sham or no treatment or over treatment as usual that is not an equal or fair contest is not the same as efficacy over another therapy approach delivered in a similar fashion by therapists who believe in what they are doing. The dodo verdict rules.  I try to answer the question as respectfully as I can but this is rough terrain when someone really believes an approach is better.  They can almost never cite a study so it’s more of a belief, but I don’t rub their noses in that. No point there especially if I want them to consider what I am saying.  So here is what I would say:

“Sounds like you have really found an approach that resonates with you and is helpful for the folks you work with. I am not familiar with that literature but I respectfully disagree that the approach has demonstrated its superiority over another treatment model.  It may be very well established in the literature, but that brings us to the distinction between efficacy over sham or no treatment and differential efficacy over other approaches…”

The second part of your friend’s comments are far more troubling. No approach should ever trump client values and preferences. If you look at APA’s definition of evidence based practice:

Definition:  Evidence-based practice in psychology is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences (American Psychologist, May 2006).

Implications:

l  Clinical decisions should be made in collaboration with the patient, based on the best clinically relevant evidence, and with consideration for the probable costs, benefits, and available resources and options

l  Psychological services are most effective when responsive to the patient’s specific problems, strengths, personality, sociocultural context, and preferences.

l  The application of research evidence to a given patient always involves probabilistic inferences.  Therefore, ongoing monitoring of patient progress and adjustment of treatment as needed are essential.

 

So the one way or the highway application doesn’t make sense to anyone. The alliance implications are also troubling. What does she do if families don’t accept her prescription? What if they do accept it but don’t benefit?

 

then Dave Elliot chimes in: I really resonate with what Russ and Barry have said.  Just a couple thoughts. 

In my work with trauma survivors there is a great deal of mistrust.  This mistrust is founded not just on the traumatic experiences, but also on betrayals in their efforts to find support and validation.  The Killer D’s come to mind or the “False Memory” fiasco of the mid 1990’s and its lingering impact.  Therapists can be very protective of these clients.  I think we should be careful in questioning the allegiance of therapists with their theory.   Our intention of wanting to bring more information on therapy effectiveness can seem like, ‘you don’t know what you are talking about.  I have the best theory.’   This attitude turns people away.  We have to be careful not to create a ‘Tyranny of Science’.  (Now, don’t get me wrong.  I am a believer that measuring outcomes and following the clients direction in a boon for trauma survivors and those who help them.  Hell, I wrote a computer program that is grounded in the science.  Still, there is a prevailing oppression that uses !
science as its primary tool. )

What works best for me is the positive attitude of folks like on this list.  We need heroes who are steeped in the science and use that wisdom to advocate for client welfare.  I love to see how people bring a respect for therapy balanced with a challenge to improve our ability to help.  I remember Jim Walt said something like, “I think it’s great that you’re doing this, but how do you know it’s working?”  I did a double take.  The words could seem belittling, but Jim said it in his curious respectful way.  I couldn’t help letting the challenge in.  I’m so glad I did because now I challenge myself with that question in every session.

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