Cry Only Once: Designing Better Trauma Therapy Training

I have a lot of beefs (beeves? plenty beef?) with extant trauma training practices, so I might be offending a lot of prominent people here. Hopefully to good purpose. However, I will not be calling out trauma treatment training approaches by name, other than EMDR, which I can critique more freely as that is my own professional “family”.

My training institute recently conducted a needs assessment by surveying clinical directors of mental health agencies in Western Massachusetts. We found that about one out of four agency therapists have been trained in a research-supported trauma treatment method. That’s good, right? But most of those trauma-trained therapists were not routinely providing trauma treatment to their clients. This despite the respondents’ belief that trauma or loss was an important component of most or all of their agency’s clients’ presenting problems.

For all the trauma therapy training that has been done by now, why aren’t more trauma-trained therapists actually providing trauma therapy? In my opinion: because of a variety of deficiencies in what and how we train. Here I’ll identify what I see as the key problems, as well as the solutions I’ve come up with in my own training programs. I don’t claim to have original or “best” solutions; the point is that trauma trainers should make a good effort to address each issue.

Glamour and economy at the expense of foundation. Most trauma therapy training focuses on the trauma resolution method, to the neglect of the remaining aspects of the trauma-informed therapy approach. I get that the trauma resolution method is the draw, the glamourous feature that brings customers to the trainings. You’ll fill a much bigger room by advertising “EMDR” as opposed to “Trauma Training.” But once the participants are in the room, we have an obligation to teach them the whole deal and not just the sexy part. Trauma resolution is a late-stage intervention within a trauma-informed treatment approach, and much has to be done first, so that the client is sufficiently motivated, stable, and strong to tolerate the trauma work (Greenwald, 2013). For this reason, the phase model is the standard of care for trauma therapy (Foa, Keene, & Friedman, 2009; International Society for the Study of Trauma & Dissociation, 2005).

What happens when you only (or primarily) teach the trauma resolution method, to the majority of participants who are not already trauma therapists? Anecdotally speaking here:

• Trainees of a prominent trauma treatment method commonly talk about the difficulty of finding clients who are “appropriate” for it and who meet screening criteria. In other words, the therapists were not trained in how to prepare clients for trauma resolution work; only to determine whether a given client has somehow independently become capable of doing it.

• In EMDR training, at least lip service is given to the entire trauma-informed treatment approach. But mentioning the importance of the preliminaries is not enough, and most EMDR training has fallen short on actually teaching how to do this (Greenwald, 2006).

The result is that many of those trained in trauma treatment end up using it infrequently, because they don’t know how to prepare their clients for trauma work.

Much trauma therapy training is inadequate in other ways as well. For example:

• A text book may be recommended and important, yet not provided. So some participants will not have the book.

• Follow-up supervision/consultation is virtually always recommended as essential to mastery of what has been learned. This is even more important when the training itself has fallen short in important ways (such as how to prepare clients for trauma work). Yet it is often not included as part of the training package.

Premature Dissemination. Some evidence-based trauma treatments were developed primarily in laboratory studies with broad exclusion criteria, and have not translated well to field practice settings. Anecdotally, I have seen this frequently with a leading child trauma treatment: representatives of numerous agencies have told me that all their therapists have been trained; and the treatment is marketed as the agency’s primary treatment model. Yet only a tiny fraction of the agency’s clients are getting through the trauma resolution work.

Again, I believe that we’ve solved this problem as well. Our evidence-based trauma-informed treatment approach was developed in the field, with challenging multi-problem clients, so it works in the field. If some other treatment was not developed in the field, it should be field-tested – and modified as needed – prior to dissemination.

Inadequate or Dicey Trauma Practice Sessions. Someone showing up at a training does not mean that they are going to buy in and transform their practice accordingly. To the contrary, people tend to be most comfortable with what they are already doing; and the prospect of trying trauma resolution work with clients tends to engender even more discomfort than the prospect of trying most other interventions. So if participants only have limited experience with the trauma resolution method during the training – or worse yet, if one or more of those experiences are not positive – the trainee is unlikely to use the method with clients. Yet it’s common for participants to have less-than-positive experiences in their trauma resolution practice sessions.

We address this by teaching a “target order” strategy for which memories to treat, or target, in which order, to maximize the likelihood that therapy clients will be successful (Greenwald, 2013; Greenwald, McClintock, Bailey, & Seubert, 2014). Then when it’s time for trainees to practice the trauma work with each other, we insist that they follow the strategy, and we supervise this closely. Our trainees consistently have positive experiences, which fuel their excitement and confidence. We also provide enough time for trainees to have several client experiences, often allowing for an entire piece of therapy work to be completed. This personal experience of benefit further solidifies their determination to practice with their clients and get good at doing trauma therapy.

Fuzzy Practice Sessions. Some evidence-based child trauma treatments are being disseminated with training programs that are a bit too theoretical and fuzzy, and trainees may never figure out how to properly replicate or implement the treatment. Anecdotally, representatives of several agencies have told me that they appreciated their training in another prominent child trauma treatment and learned a lot of theory, but that their therapists still don’t know what to actually do, how to implement it.

The literature on experiential education is mixed. In sum: you only learn from experience if you learn from it. Merely having people “practice” during a workshop does not ensure that they are learning what you are hoping to teach. For the experiential education approach to achieve its potential, the experience must be carefully framed and structured to facilitate the desired learning (Kirschner, Sweller, & Clark, 2006).

Our training programs achieve this by having participants practice manualized, scripted interventions. I will note, however, that manualizing a treatment may not be sufficient if the manual is inadequate. The manual must provide sufficiently detailed guidance that the participants can readily replicate the treatment. We do this with detailed scripts, as well as a problem-solving rubric. Participants appreciate the detailed guidance; indeed, that’s what they come for.

Value for Investment

There is considerable knowledge on how to deliver effective training, and we should use it. Let’s tell trainees what to do. Let’s teach them how to do it. Let’s provide sufficient quality and quantity of training, materials, and follow-up support that they have their best chance of getting good at it.

Perhaps a couple of decades ago, the present training inadequacies could be attributed to our inexperience as a community of trauma experts. By now, though, we have a pretty good idea of what it takes to train therapists properly. So why don’t we do it? Because it costs so much. It costs more to provide every participant with the book. It costs more to teach not only trauma resolution, but the entire trauma-informed treatment approach. It costs more to provide the follow-up supervision.

I know, because we provide all these essential components of trauma training, and we’ve lost a fair bit of business on that account. For example, I’ve turned down many agency requests for “Part 1 only” or large-group trauma training, because we only provide the full training package, and in small enough groups that the practice sessions can be properly supervised. Yet many agencies chose some briefer, cheaper training that other outfits were willing to provide. Spent half, and got nothing, when their therapists ended up not using the trauma treatment they had supposedly learned.

This brings to mind an advertisement I saw some years ago, for an expensive product that was high quality and durable: “Pay more now. Cry only once.”

References

Foa, E. B., Keane, T. M., & Friedman, M. J. (Eds.) (2009). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (2nd ed.). New York: Guilford.

Greenwald, R. (2006). The peanut butter and jelly problem: In search of a better EMDR training model. EMDR Practitioner. Available Internet: http://www.ticti.org/publications/pbj

Greenwald, R. (2013). Progressive Counting within a phase model of trauma-informed treatment. NY: Routledge.

Greenwald, R., McClintock, S. D., Bailey, T. D., & Seubert, A. (2014). Treating early trauma memories reduces the distress of later related memories. Manuscript submitted for publication.

Kirschner, P. A., Sweller, J., & Clark, R. E. (2006). Why minimal guidance during instruction does not work: An analysis of the failure of constructivist, discovery, problem-based, experiential, and inquiry-based teaching. Educational Psychologist, 41, 75-86.

International Society for the Study of Dissociation. (2005). [Chu, J.A., Loewenstein, R., Dell, P.F., Barach, P.M., Somer, E., Kluft, R.P., Gelinas, D.J., Van der Hart, O., Dalenberg, C.J., Nijenhuis, E.R.S., Bowman, E.S., Boon, S., Goodwin, J., Jacobson, M., Ross, C.A., Sar, V, Fine, C.G., Frankel, A.S., Coons, P.M., Courtois, C.A., Gold, S.N., & Howell, E.]. Guidelines for treating Dissociative Identity Disorder in adults. Journal of Trauma & Dissociation, 6, 69-149.