Evidence-Based Practices in Trauma Treatment: What is the Evidence?

Today in the treatment of trauma, emphasis is placed on evidence-based practice (EBP), a term that is often misunderstood. According to the

American Psychological Association Presidential Task Force on Evidence- Based Practice, EBP is defined as “the integration of the best available research with clinical expertise in the context of patient characteristics and preferences” (American Psychological Association, 2006, p. 273). The 1990s and 2000s were dominated by manual-type approaches of cognitive behavioral treatment as the desired treatment protocol for trauma (Johnson, 2009), and many research dollars and studies were devoted to finding the best evidence for their adoption. These treatment protocols are typically 12-16 highly structured sequential sessions designed to address symptoms such as depression, behavior problems, and shame.

One of the most researched of all of these EBPs is trauma-focused cognitive behavioral therapy (TF-CBT). Many research studies appear to prove that TF-CBT is the therapy of choice when dealing with trauma in children (Cohen, Deblinger, & Mannarino, 2004; Deblinger, Mannarino, Cohen, Runyon, & Steer, 2011; Mannarino, Cohen, Deblinger, Runyon, & Steer, 2012). There is no doubt that this approach is successful in the alleviation of some symptoms of PTSD. However, there are some inherent dangers in the assumption of proof of evidence linked to one treatment protocol to the exclusion of others. Commonalities of most trauma-based cognitive behavioral therapy (CBT) protocols include empirically validated interventions such as “psychoeducation, stress management techniques, some variant of exposure (creating a new narrative of the traumatic event) and cognitive processing” (Vickers, 2005, p. 219), but there is disagreement as to which element is the mechanism for change. In fact, in a meta-analysis of 27 component studies where one variable was left out, it was found that the results were the same no matter which variable was left out (Duncan & Miller, 2006a, 2006b; Wampold, 2006).

When weeding through the literature, it becomes apparent many variables make for successful treatment. One could even argue that it is the expressive components of the trauma-based cognitive behavioral models that are the vehicles for change. Within the trend of CBT protocols for trauma, many interventions include art making and writing as part of creating a narrative about the traumatic event. These interventions often rely on those parts of the brain that are expressive and nonverbal. The bottom line is that the healing variable in these approaches has not been isolated.

There are inherent risks in proclaiming one type of treatment as the preferred method, as it has the potential to restrict practices that exist outside the preferred methods (Gilroy, 2006). In the hands of allied professionals (i.e., lawyers, judges) who don’t understand the basis for treatment decisions, it provides enough knowledge to make uninformed decision makers dangerous. For example, in my own experience lawyers used EBP as a rationale to dictate TF-CBT in a case where it was completely inappropriate. The entire treatment team of psychiatrists, social workers, and therapists believed that TF-CBT could be damaging to the child due to the complexity of the presenting problems and fragile attachment issues, but the court system knew the “buzz word” and mandated it anyway.

Proclaiming certain types of therapy as the preferred method propagates a risk that managed care health plans will dictate adherence to certain treatment protocols and restrict access to others (American Psychological Association, 2006), potentially inhibiting clinical freedom in favor of cost-saving measures (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). In fact, some states are already mandating the use of certain mental health treatments for Medicaid reimbursement (American Psychological Association, 2006). Sweden and the United Kingdom fell into a similar trap in the past years. Sweden’s National Board of Health and Welfare poured two billion Swedish crowns into training therapists and providing only CBT treatment in its health care system. When it became increasingly apparent that there was no difference in outcome based on the type of treatment, the program was ended (Miller, 2012). In the United Kingdom, the National Institute for Health and Care Excellence (NICE) recommended only CBT for most nonpsychotic mental disorders. However, when it discovered that CBT was not as effective as it had hoped for all disorders, the NICE funded a research study to determine if art therapy was clinically effective as well. Results indicated that art therapy appears to have statistically positive effects compared to a control group in patients with different clinical profiles (Uttley et al., 2015).

TF-CBT is a great tool for the therapist’s tool chest. It is invaluable in situations where there is a single identifiable trauma. However, even some of the founders of TF-CBT admit that it is difficult, if not impossible, for children with severe trauma to assimilate into a trauma protocol that requires them to provide a narrative when their trauma lacks a discrete event, memories are fragmented, and their attachment issues are complex (Amaya-Jackson & deRosa, 2007).

Therapists should be trained in multimodal approaches, and trauma therapy should be individualized for the situation and the specific child. For the alleviation of PTSD symptoms in a simple trauma, cognitive behavioral approaches combined with art therapy are highly effective.

Carolyn and Alison, 8 and 10 years old, respectively, experienced a single, acute, identifiable trauma. The sisters came to therapy together after a serious car accident. Both girls were exhibiting symptoms of PTSD: extreme worry and anxiety about riding in a car, panic attacks when going over a bridge, crying, nightmares, difficulty riding the school bus, and smelling air bags at moments of panic. In a single-incident trauma, people have no idea the trauma is coming so they do not activate defenses that would cause them to repress or dissociate the trauma (Terr, 1990). The girls remembered vividly the night their van was hit by a drunk driver. For a single-incident trauma such as this, CBT was the preferred option, with two straightforward therapy goals: (1) The girls will be able to talk about the accident without experiencing anxiety, and (2) the girls will be able to ride in a car without experiencing posttraumatic stress symptoms. To achieve the first goal, creating a narrative about the trauma took the form of each girl creating a feelings book about the accident, including pictures that described the feelings before, during, and after the accident. Figure 1.2, the fourth page of Carolyn’s narrative, showed her extensive bleeding from a head injury and her fear that she was going to die. After the girls completed their books, they were instructed to read them with family members and talk about the feelings in each picture. Drawing allowed the girls to engage in raw emotional expression, and reading the book and talking about it brought them to a higher, more cognitive portion of the brain for processing what happened. Parents and grandparents were willing helpers for this part of the therapy. For the second goal, we worked on identifying diversionary activities they could use while riding in the car. Parents assisted them by practicing systematic desensitization to going over bridges, and the girls learned relaxation techniques for when they were feeling anxious and stressed. After significant improvement in PTSD symptoms, therapy was terminated after only four sessions. Though some mild symptoms persisted (less severe anxiety and some sleep problems), their mother and I agreed that we wanted to support the progress both girls had made, rather than continuing to focus on pathological symptoms. I recently spoke to their mother, and she reported that when the girls experienced a much greater trauma when they were in their teens, they drew on some of the coping skills they acquired at this young age.

For more complex traumas, a different approach is necessary. When children are operating in the fight, flight, or freeze mode as their instinctual trauma response (Gantt & Tinnin, 2009), they are not able to take advantage of the higher brain functions necessary in a CBT approach. A far

Carolyn, age 10, drawing of the accident

Figure 1.2. Carolyn, age 10, drawing of the accident

different approach is necessary, one that allows for flexible implementation and for the relational aspects of the therapy to take precedence.

As noted earlier, many trauma-processing protocols use art and expressive means as a significant component of the treatment. Spiegel, Malchiodi, Backos, and Collie (2006) outlined a conceptual rationale for the use of art therapy with veterans with PTSD, noting six characteristics of art making that distinguish it from other forms of therapy: Art induces relaxation, is nonverbal, serves to contain feelings, allows for symbolic expression, externalizes traumatic memories, and provides pleasure, reducing emotional numbness. Studies with traumatized adults show promising results for art therapy’s role in the alleviation of PTSD symptoms (Gantt & Tinnin, 2007; Johnson & Lubin, 2005; Lahad, Farhi, Leykin, & Kaplansky, 2010), including reduction of frequency and intensity of nightmares (Morgan & Johnson, 1995); reduction in anxiety and phobias (Greenwood, 2011); and decrease in anxiety and somatic and depressive symptoms (Rademaker, Vermetten, & Kleber, 2009).

Positive attributes of using art in trauma therapy included helping clients to verbalize (Lev-Wiesel, 1998); enhancing insight, cohesion, and catharsis (Waller, 1992); decreasing stress and depression accompanied by an increase in self-awareness and self-esteem (Howard, 1990); improving general and social self-esteem (Brooke, 1995); improving personality and professional functioning (Rademaker et al., 2009); increasing tolerance for difficult feelings and body sensations (Lobban, 2014); and assisting in meaning making and posttraumatic growth (Artra, 2014).

Fewer studies have been done on art therapy with traumatized children. Eaton, Doherty, and Widrick (2007) reviewed efficacy studies examining art therapy as an effective treatment for traumatized children and found a coherent analysis to be difficult because “art therapy itself is, by its nature, a process of unfolding and discovery” (p. 260) that makes it difficult to force into an empirical study. The use of drawing in therapy was found to encourage verbalization (Lev-Wiesel, 1998; Lev-Wiesel & Liraz, 2007). Carr and Vandiver (2003) found that children exposed to stressful events responded more positively to instructional art projects that allowed for flexibility and creativity, as opposed to nondirective art, which encouraged more chaotic discharges of emotion, or highly directed art, which impeded creativity and free exploration. This was echoed by Orr (2007), who found that semistructured art interventions work well for children following a disaster. Pifalo (2006, 2007) demonstrated how a combination of art therapy and CBT found significant reductions in some PTSD symptoms for sexually abused children, including anger, anxiety, depression, dissociation, sexual concerns, and sexual preoccupation. One study compared a trauma-focused art therapy intervention with a standard arts-and-crafts activity for adolescents with chronic PTSD in an inpatient psychiatric facility. Researchers found that the trauma-focused art therapy intervention had greater reduction in PTSD symptoms than the arts-and-crafts condition (Lyshak-Stelzer, Singer, St. John, & Chemtob, 2007).

As tempting as it might be to declare that expressive arts therapies must now be the treatment of choice, recognize that, in countless studies, the type of therapy makes little difference, accounting for only 5-8% of the variance (Norcross & Lambert, 2006). Over a thousand studies have demonstrated that the therapeutic alliance is seven times more important than the technique used by the therapist, and at least 40% of the success of therapy is accounted for by what the client brings—strengths, struggles, culture, and preferences (Duncan & Miller, 2006a, 2006b).

In the end, the relationship is what matters. In a meta-analysis of hundreds of psychological studies of therapeutic effectiveness, by far the most important factor of successful treatment is the alliance between therapist and client (Norcross & Lambert, 2006).

Raymond taught me that it really is okay not to talk in therapy, and

a little ice cream occasionally doesn’t hurt. I learned long ago that many of the children I work with didn’t celebrate their birthdays. My office was upstairs from an ice cream parlor, and on clients’ birthdays I always made it a point to take them to get an ice cream, conveying the idea that the day was very special. Raymond participated in this ritual during the 4 years that I worked with him. Raymond was 12 when I first met him, and he did not want to be in therapy. His mother died of cancer, and his father, who was physically abusive to her and the two children, was not an option for placement. He was struggling in his foster home with defiant behavior and difficulty bonding. The day of his first session, he came in, sat down, crossed his arms, and said, “I don’t need therapy.” Those were the only words he said for the next 45 minutes. He sat erect at my table and closed his eyes, keeping his arms crossed and sitting straight up, clearly communicating that he was not sleeping. I agreed he might not need therapy and made a few other feeble attempts at engaging him in conversation but ultimately gave up. I sat with him for the entire session, resisting the urge to do paperwork and trying to stay present with him despite the wall he built. At the end of the session,

I invited the foster father in and said, “Raymond wasn’t very talkative today, but that’s okay, he doesn’t have to talk here.” Raymond looked at me for the first time incredulously, as this was not going as he had planned. During the years that followed, Raymond made only two or three pieces of art. We played therapeutic board games, and eventually he talked, but I was never quite sure what he was or was not getting from therapy. He continued to push the boundaries of his foster family, and I referred him to a residential treatment center when he absolutely refused to go to another foster home.

I continued to stay involved with his treatment team, working closely with his primary therapist in the agency. This therapist and I continued the tradition of celebrating his birthday, and as he grew into adolescence we started taking him to lunch rather than out for ice cream. At age 18 he moved from the residential treatment center into a semi-independent living program, where he thrived.

Raymond turned 30 this year and is now a police officer. To this day, every February as his birthday gets closer, his former therapist and I are reminded that it’s time to go out for ice cream. Of course, now he expects dinner.

There can be no doubt: The relationship between therapist and client is what matters. In the simplest of terms, that is what this book is ultimately about.

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