PC 10th Anniversary

Like most people, I never set out to develop a new trauma treatment. It happened more or less by accident. I had long regarded eye movement desensitization and reprocessing (EMDR; Shapiro, 2001) as the trauma treatment of choice, because it is so effective, as well as being better tolerated and more efficient than the other leading brands (Greenwald et al, 2017). The problem with EMDR is that it’s a complex treatment that takes a lot of time, practice, and supervision to master, making it troublesome to teach and prohibitively resource-intensive to learn (Greenwald, 2006).

I first came across the counting method (CM) in a paper published many years ago (Ochberg, 1996). The therapist directed the client to visualize the story of the trauma memory as if watching a movie of it in the mind, while the therapist counted aloud from 1 to 100, with the movie beginning at “1″ and ending at “100″. I read the paper, said to myself, “That’s stupid!” and promptly forgot about it.

Fast forward about a decade. I came upon a paper in which CM was compared to EMDR and to prolonged exposure (Johnson & Lubin, 2006). This well-designed study had lots of bells and whistles: random assignment, efforts to ensure that the treatments were done properly, blind independent evaluators, etc. As expected, everyone got better from their PTSD, and those receiving EMDR got better in about 2/3 of the time it took those receiving prolonged exposure. The surprise was that those receiving CM got better just as quickly as those receiving EMDR.

This outcome gave me quite a start. As an experienced EMDR instructor I was all too familiar with the difficulties in getting my trainees to actually become competent in EMDR. Was it possible that this simple and “stupid” technique of counting during client visualization of the memory could be just as efficient and effective as EMDR? If so, it would greatly simplify my efforts to train therapists in trauma treatment.

So I asked David Johnson (the study’s lead author) if I could attend a CM training. “Sorry,” he e-mailed back, “We don’t have any trainings scheduled at present.” Then I asked for a copy of the treatment manual. “Sorry,” he e-mailed back, “It’s under revision right now. I’ll be glad to send you a copy when it’s finished.”

While awaiting the treatment manual, CM was on my mind when, in the summer of 2007, I was giving a 5-day training in child trauma treatment for a group of therapists in a children’s hospital in northern Israel. On the 4th day, when I would have normally taught a child-adapted version of prolonged exposure (see Greenwald, 2005), I asked the group, “Do you mind if I teach you something I’ve never tried before?” They all said, “Sure!” It was, after all, the 4th day, and we were comfortable with each other by then. I said, “OK, but I’m not going to teach it to you the right way. I’m going to teach it the way I would modify it to use with children.” I would not want to start a child on a movie to a count of 100; that seems like too much at once and could be overwhelming. Thus instead of guiding the client to visualize a movie going to a count of 100, we started with a count of only 10, and the next time 20, next time 30, etc.

The participants practiced the technique on each other, and it proved to be quite a hit. The following week I tried it again with another Israeli group, and again the response was very positive. Upon consideration I realized that visualizing the movie of the memory during therapist counting incorporates many of the same features as EMDR (Greenwald, 2012), including:

• client option for privacy regarding details of the memory
• client working at speed of thought, not slowed down by the talking (or writing, drawing, etc.) required in most other trauma resolution methods
• dual focus of concentrating on the memory and a distractor at the same time; this seems to create an observer or distancing effect that minimizes overwhelm and facilitates healing

Finally I received the revised CM manual (Johnson, Lubin, & Ochberg, 2007) and discovered that I had bungled the whole thing. That is, I had substantially misunderstood the CM procedure, and had inadvertently changed it more than I had realized. I had thought that CM was all about the movies, but no. In CM, I learned from the manual, the movie is only done once, near the beginning of the session. The remainder of the session is devoted to review, the procedure for discussing the contents of the movie. It seemed to me that the many advantages of the movie portion of CM – the privacy option, working at thought speed, and dual focus – were lost during the talk portion of the session, which would be a grueling ordeal for many clients.

In the EMDR community we have a joke about psychoanalysts who learn EMDR: “The analyst does an EMDR session, the client has a major breakthrough, and for the next six months, they talk about that session.” This is how I came to view CM: Someone came up with a brilliant intervention, and spent the rest of the session talking about it. Even so, adding that 100-second movie to a session otherwise devoted to “talking about it” had increased treatment efficiency by 50%, compared to only talking about it, as done in prolonged exposure (Johnson & Lubin, 2006).

This is when I started losing sleep. “How efficient would the treatment be,” I wondered, “with lots of movies and not so much talking?” Thus progressive counting (PC) was born. A spinoff of CM, PC is designed not only for enhanced treatment efficiency, but also to be better tolerated by clients (including children) who may have difficulty working through trauma memories due to limited tolerance of negative affect. And as an added benefit, it’s easier to master than EMDR – on a par with other exposure methods – making therapist training less resource-intensive.

Fast forward again, PC is now 10 years old, and well on the road to realizing its promise. It seems to work well with children (Greenwald, 2008a, 2014) as well as adults (Greenwald, 2008b; Greenwald & Schmitt, 2010; Jarecki & Greenwald, 2016). In the two published comparisons to EMDR, PC has come out about as effective (Greenwald, McClintock, & Bailey, 2013; Greenwald, McClintock, Jarecki, & Monaco, 2015), less difficult for clients, and more efficient (Greenwald, McClintock, Jarecki, & Monaco, 2015). We’ve got a PC book, PC training programs, and PC certification.

Even so, we’ve been holding off on widespread dissemination pending publication of a high quality randomized study comparing PC to another leading trauma treatment. Without giving anything away, the good news is that this study is nearly complete. Perhaps by PC’s 15th anniversary, PC will also be considered a well-established trauma treatment of choice, like EMDR is today.

References

Greenwald, R. (2005). Child trauma handbook: A guide for helping trauma-exposed children and adolescents. New York: Haworth.

Greenwald, R. (2006). The peanut butter and jelly problem: In search of a better EMDR training model. EMDR Practitioner.

Greenwald, R. (2008a). Progressive Counting: A new trauma resolution method. Journal of Child & Adolescent Trauma, 1, 249-262.

Greenwald, R. (2008b). Progressive counting for trauma resolution: Three case studies.   Traumatology, 14, 83-92.

Greenwald, R. (2012). Progressive Counting: Asking recipients what makes it work. Traumatology, 18 (3), 59-63.

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

Greenwald, R. (2014). Intensive child therapy to prevent further abuse victimization: A case study. Journal of Child Custody, 11, 325-334.

Greenwald, R., McClintock, S. D., & Bailey, T. D. (2013). A controlled comparison of eye movement desensitization & reprocessing and progressive counting. Journal of Aggression, Maltreatment, & Trauma, 22, 981-996.

Greenwald, R., McClintock, S. D., Hall, S. L., Verbeck, E. G., Lamphear, M. L., Seibel, S., Doss, J., Halvorsen, L., & Gray, A. K. (2017). A meta-analytic comparison of EMDR to other trauma treatments: Effectiveness, efficiency, and acceptability to clients. Manuscript in preparation.

Greenwald, R., McClintock, S. D., Jarecki, K., & Monaco, A. (2015). A comparison of eye movement desensitization & reprocessing and progressive counting among therapists in training. Traumatology, 21, 1-6.

Greenwald, R., & Schmitt, T. A. (2010). Progressive Counting: Multi-site group and individual treatment open trials. Psychological Trauma: Theory, Research, Practice, and Policy, 2, 239-242.

Jarecki, K., & Greenwald, R. (2016). Progressive counting with therapy clients with PTSD: Three cases. Counselling and Psychotherapy Research, 16, 1-8.

Johnson, D. R., Lubin, H., & Ochberg, F. (2007). The counting method manual, revised 1/1/07. Author.

Johnson, D. R., & Lubin, H. (2006). The counting method: Applying the rule of parsimony to the treatment of posttraumatic stress disorder. Traumatology, 12, 83-99.

Ochberg, F. (1996). The Counting Method. Journal of Traumatic Stress, 9, 887-894.

Shapiro, F., (2001). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2nd ed.). New York: Guilford Press.

Note: This post includes excerpts from: Greenwald, R. (2011). Progressive counting: A simple, efficient, well-tolerated trauma treatment. Counseling Children & Young People Journal, June, 7-9.