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.
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).
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.
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.
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.
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.
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.
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 (Mavranezouli). 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 ( 2020Greenwald, 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.
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).
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.
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.
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).