A CONVERSATION WITH
DONALD
MEICHENBAUM
Following is a condensation of a conversation between Donald Meichenbaum and Michael F. Hoyt which took place in San Francisco on May 4, 1994, where Meichenbaum was conducting a two-day workshop on "Treating Patients with Post-Traumatic Stress Disorder" for the Institute for Behavioral Healthcare. The full conversation will appear in Constructive Therapies 2, edited by Hoyt and forthcoming from Guilford.
Hoyt: How did you come to think of treating
PTSD as a
narrative constructive endeavor?
Meichenbaum: I became fascinated with how people describe their experience and how their accounts changed over time. When something bad happens to you, when some natural or man-made disaster occurs, when some form of victimization experience occurs to you or to your family, ordinary language and everyday vocabulary seem inadequate to describe your experience and reactions. In their own ways, these "victimized" individuals became "poets," using metaphors to describe their experiences. They conveyed their experiences by using phrases such as, "this is like..."; "I feel like a..."; and so forth. The "victimized" individual may describe herself as a "prisoner of the past," as a "doormat," a "whore," as a "time-bomb ready too explode," and the like. Just imagine the impact on yourself and on others if you go about describing your experiences in such metaphoric terms? As a result of these initial clinical impressions, I undertook the task of analyzing the nature of the metaphors and the narrative accounts that clients offered over the course of their therapeutic sessions. Based upon both clinical analysis and a literature review, I came to appreciate the heuristic value of a constructive narrative perspective.
Hoyt: When someone becomes a victim, has a horrible trauma, how does that affect them? What changes, especially in terms of their world view?
Meichenbaum: That depends on which piece of the puzzle you look at. Clearly there is increasing evidence that something changes physiologically. This is especially true of chronic, prolonged exposure or what are called Type II stressors (e.g., abuse, domestic violence, holocaust victim). Such exposure leads too what are called Disorders of Extreme Stress that affect one's sense of trust in family and beliefs about self and the world. Traumatic events can "shatter" your basic assumptions about the world and can violate and invalidate your core beliefs. Another thing that trauma does is overly sensitize you to trauma-related cues and this hypervigilance feeds into, and is in turn, affected by the ruminations, flashbacks, and avoidance behaviors that characterize PTSD.
Meichenbaum: I think there are functional and adaptive values in such behavior. To become vigilant and to over-respond after exposure to a trauma can be adaptive initially. But, what happens to the people who have difficulty recovering is that they continue to behave in ways that may be no longer "necessary." People get "stuck" using techniques such as dissociation that were at one time effective in order to deal with trauma such as incest, or rape, or combat. It is my task, as a therapist, to help clients understand and appreciate the adaptive value of how they responded. But, I also help them appreciate the "price" of continuing to respond in this fashion, when it is no longer needed. This approach helps clients reframe their reactions as adaptive strengths, rather than as signs of mental illness. We work together to help them not only change their behavior, but also to tell their "stories" differently.
I go beyond understanding, to nurturing the client's discovery process by using Socratic questioning. I encourage clinicians to use strategically their bemusement, their befuddlement; I want them to be collaborators. The goal is to help the client in the initial phase of stress inoculation to better understand what they have been through, how are things now, how would they like them to be, and what can we do, working together, to help them achieve their goals? The educational phase of SIT lays the groundwork whereby the client can come to say, "You know, I'm stuck." A related objective of this initial phase is to help clients move from global metaphorical accounts of their experience and reactions to behaviorally prescriptive descriptions that lead to change and nurture the "sense of hope" to undertake this change.
Hoyt: In essence, I think you're saying that as clinicians, we're trying to help clients reauthor their narratives, rather than undertake the role of correcting their accounts.
Meichenbaum: Correct. The metaphors that describe my therapeutic approach include rescripting, reauthoring, helping clients generate a new narrative, being a coach. I don't just record the clients' accounts; rather I help them alter their personal stories. A second way is to help them engage in "personal experiments" in the present that provide them with "data" that they can take as "evidence" to "unfreeze" the beliefs they hold about themselves and the world. The results of such ongoing experiments that occur both within and outside of the therapeutic setting provide the basis for the client to develop a new narrative. This co-constructive process is one that emerges out of experientially meaningful efforts by the client. In terms of "strengths" and coping efforts, I help people who have post-traumatic stress disorder to appreciate that their intrusive thoughts, hypervigilance, denial, dissociation, dichotomous thinking, moments of rage, each represent coping efforts, and metaphorically reflect the "body's wisdom." For example, intrusive thoughts may reflect ways of making sense of what happened, as attempts to "finish the story," to answer "why questions." Denial may be an attempt to "dose oneself" dealing with limited amounts of stress at a given time, a way to take a "time out." Hypervigilance may be seen as being on continual "sentry duty" when it is no longer needed. In other words, it is not that people get anxious, angry, or depressed per se; those are natural human emotions. Rather, it is what people say to themselves about those conditions that is critical.
The collaborative process of therapy is designed to help the client "say" different things to herself, as well as, to others. A key element of cognitive behavioral interventions is that an effective way of having people to talk to themselves differently is to have them behave differently. Thus, a critical feature of cognitive behavioral interventions, such as stress inoculation training, is to encourage and even challenge clients to perform personal experiments, in vivo so, as I mentioned, they can collect data that will "unfreeze" their beliefs about themselves and about the world. Cognitive behavioral therapy is not just a "talking cure," it is a proactive, enabling form of intervention, that fits an "evidential" theory of behavior change. But such change is not enough. It is critical for clients to take credit for the changes that they have brought about. There is a need for the therapist to ensure that the clients take "data" resulting from "personal experiments" as "evidence," and thus, assume a greater sense of responsibility for the changes that they have brought about. This process of "ownership" is evident in the new narratives that clients relate. I listen careful to the clients' stories. I listen for their spontaneous use of metacognitive self-regulatory verbs as part of their new accounts. Improvement is evident when clients use such verbs as "I noticed...caught myself...interrupted...used my plan...felt I had options...patted myself on the back...became my own coach...anticipated high risk situations...tried my other options." When clients incorporate these expressions into their narratives, then they have become their own therapists, and truly have taken (appropriated) the clinician's "voice" with them.
Meichenbaum: But for meaningful change to occur it has to be "affectively-charged." I am referring to the time-honored concept of "corrective emotional experience." People can readily dismiss, discount, dissuade themselves of the "data." They don't really accept data as "evidence," and it is critical therapeutically to work with clients in order to ensure that they take the "data" they have collected as evidence to unfreeze their beliefs, to get into the nature of the clients' belief system and to nurture an internal dialogue that they would find most adaptive, as compared to being "stuck" in maladaptive patterns of thinking and behaving.
Hoyt: Watching you work, I'm always impressed by how much caring and effort goes into developing a therapeutic alliance and a collaborative relationship with the client. It appears to be the vehicle that carries the rest of your work.
Meichenbaum: I agree. I think the therapeutic relationship is the glue that makes the various therapeutic procedures work. Some of the things that I try to highlight for a clinical audience watching my video tapes is how often I "pluck" and reflect the client's key words, use Socratic questioning, and often over the course of the session, I let the client finish my sentences. You need to encourage clients to tell their stories, at their own pace and to be in charge. But out of the telling of their stories, out of the narrative sharing--and there's a lot of therapeutic value in sharing one's story--new stories emerge that also reveal strengths and resources. Clients' stories are filled with expressions of hopelessness and helplessness. They often convey a tale of having been "victimized" and it is my job, as the therapist, to not only hear their stories and empathize with them, but also to help them appreciate what they have done to survive and to cope with their feelings, namely, help them attend to "the rest of the story." For "the rest of the story" is often the tale of remarkable strengths. Keep in mind that the story of how people cope with stressful events is inherently the story of resilience and courage. Even in the worst scenarios people evidence remarkable strengths. As a therapist, I need clients to attend to that part of their stories. Thus, the "bad things" that happened to people are only one chapter in their life stories.
Hoyt: Often times therapists rush past the painful material, trying to reframe or restructure so quickly that the person doesn't feel heard of validated. Do you think there's also--maybe following from Aristotle--a need for catharsis and abreaction?
Meichenbaum: The questions about differential forms of treatment is complex. How one should proceed therapeutically is dependent upon the target group. If you are treating people who have experienced traumas that are brief, sudden, yet life-threatening, such as automobile accidents, robberies, rape, and sudden disasters, or what have been characterized as Type I stressors. Yes. The data suggest that having clients go through re-experiencing procedures as a means of "coming to terms" with what happened, is therapeutic and beneficial. Indeed, there are a variety of very creative clinical techniques, including direct therapy exposure, guided imagery procedures, graded in vivo procedures, and the like, that are helpful. They fit your Aristotelian catharsis model and provide a means of "index.html"working through" that can prove valuable.
Hoyt: What about people with more prolonged trauma?
Meichenbaum: When, however, you are treating post-traumatic stress disorders that are chronic--and the traumatic events occurred many years ago--the treatment decision to undertake "memory work" of having clients "go back" may not be the most effective treatment strategy. Having clients recount and re-experience traumatic events, even in the area of incest, may not be the most therapeutic approach. Because in the attempt to conduct so-called "memory work," there is the danger that the therapist can inadvertently, unwittingly, and, perhaps, even unknowingly, help clients co-create memories. With such prolonged traumas that have a number of secondary sequelae it is important to address the secondary consequences such as depression, interpersonal distrust, sexual difficulties, addictive behaviors, and the like that may accompany PTSD. The full cognitive-behavioral therapeutic armamentarium needs to be employed to address these signs of co-morbidity. A "here-and-now" therapeutic focus as compared to a "there-and-then" approach, may prove most helpful. But keep in mind that from a constructive narrative perspective, even when clients are doing so-called "memory work," they are not relating, nor "uncovering" history, but rather, they are co-constructing history in a mood-congruent fashion. As Donald Spence observes, it is the "narrative truthfulness," not the "historical truthfulness," of clients' account that needs to be the focus of therapeutic interventions.
Meichenbaum: That question raises the important issue of how important it is to be culturally sensitive in formulating a treatment plan. Let me give you an example. There are "testimony" procedures in treating people who have been victims of torture. These procedures have individuals "go public" with what traumas they have experienced and what retribution should occur. For instance, one group of torture victims for whom this testimony procedure has been used came from Argentina, Chile, and other South American countries. On the other hand, there is another group of victims of torture who come from Southeast Asia-- Cambodia and other countries--who have also received treatment. Therapists such as Mollica and Kinzie have indicated that a somewhat different therapeutic approach, one that is designed to deal with their "here-and-now" problems, their practical employment and living situation, rather than do "memory work" is more effective. The torture victims' cultural orientation suggested that treatment should not encourage clients to go back and relive their victimization experiences, per se. When I am in doubt, I spell out the treatment options and collaborate with the client in formulating, implementing, and evaluating the therapeutic options. This is especially important when the database for alternative treatments is so limited. We are at such a preliminary stage in the area of PTSD treatment that anyone who gets on a soap box and say that, "Memory work interventions are essential," or who claims that, "This is the way to conduct intervention," should be received with a great deal of skepticism and caution; no matter what the therapeutic approach they advocate. I also think, however, that straightforward empiricism is not going to advance the field. We need a theoretical framework to explain therapeutic approaches. One such theoretical framework is that of a constructive narrative perspective.
Hoyt: How would you distinguish the constructive narrative perspective from the other wing of cognitive therapy that sometimes is called "rationalist"?
Meichenbaum: I really take issue with the so-called "rationalist" perspective. It is not that people distort reality, nor make cognitive errors, that contribute to their difficulties. Instead of one reality that is distorted, as some "rationalists" would advocate, I believe that there are multiple potential "realities." Instead, the focus of therapy is to help the client appreciate how he/she has constructed his/her realities, and what is the price of such constructions. Most importantly, what are the alternative constructions?
Hoyt: How does this apply in the case of individuals who have been traumatized or victimized?
Meichenbaum: For instance, consider the client who has been victimized sexually. Envision the clinical impact of this individual characterizing herself as being "damaged goods" or as "soiled property." Such labels, such metaphors, may be culturally reinforced. Whatever the origins and influences, the consequences of such narrative constructions are likely to lead to dysphoric feelings and distressing behavior. In therapy, I would help the client share her story either in individual or group therapy, "validate" her feelings, but at the same time help the client appreciate the price she pays if she goes around telling herself that she is "soiled goods"; that she is "useless." In this way, she can come to also appreciate that she speaks to herself in the same manner that the perpetrator spoke to her. She may inadvertently reproduce the "voice" of the perpetrator, as in the case of the victims of domestic violence. She needs to develop her own voice. One goal of treatment is to no longer let the perpetrator continue to victimize her when he is no longer present. Instead, what is the best revenge?
Hoyt: Living well.
Meichenbaum: To live life well. In therapy, we need to explore with clients operationally what it means to live life well. Moreover, given the cognitive behavioral approach, therapists also consider with clients what are the barriers, the obstacles, the potential reasons why clients may not do anything that they said they are going to do. This, when clients say, "I need to live well," there is a need to help clients translate such general admonitions into behaviorally prescriptive statements such as, "Between now and next time, how will that show up? What will you do differently?" There is also a need to build relapse prevention procedures into the treatment regimen, anticipating "high-risk" situations, as well as ways of handling possible setbacks, so lapses don't escalate into full-blown relapses.
Meichenbaum: I don't know the answer to your question, and I don't think the field knows either, but let me offer a clinical strategy. When the client responds with "I'm soiled property," or "I'm useless," or the words to that effect, it's usually said with a great deal of emotion. What I would do as a therapist is to not only attend to the client's words, but to the affect. So I would say "Soiled property, tell me about that." I would "pluck" the key words and put them back in the client's lap, and encourage her to elaborate. I would also attend to the feelings with which this was said. The feelings might convey a sense of being overwhelmed. or feelings of being depressed, and the like. I want to learn about the circumstances that led to such self-perceptions and accompanying feelings. Next, I "commend" the client for being depressed. After empathetically listening to their distress I might say something like: "Given what you've been through if you were not depressed at times, if you did not feel at times like you were "soiled property," or at times as if you were "useless," then I think I would be really concerned, and conclude that something was seriously wrong." In this fashion, I attempt to validate the client's experience. I am going to go beyond that and even compliment the client for the symptoms of being depressed. For instance, I might say to the client, "What does your being depressed say about what's going on?...Perhaps it conveys that you are in touch with your feelings, that you are reading your situation, that you're responsive to what you have experienced."
Hoyt: The first step is to join with, to validate, to recognize...
Meichenbaum: And also to commend the client because her depression and the resultant withdrawal at one time may have been adaptive. I need to help the client see that when she calls herself "soiled property," that maybe that self-attribution was an impression management stance and her way of trying to control the situation. So even if she says, "you know, I was a zombie with no emotions," I try to have her appreciate that the dissociative responses that she used were adaptive. The critical step in helping her to alter her view of herself is whether I can help her appreciate that what she is continuing to do now, even in "safe" relationships, is no longer her only option. I am helping her move away from a so- called "deficit model" where she continually questions her self-worth and even her sanity. Instead, I want to help her cognitively reframe her experiences. I encourage the client to consider the question: What is the price she is paying for being "stuck"? The answer to this questions is not discussed in the abstract, but rather the client is encourage to experientially feel, in the session, the "costs" of being "stuck." Moreover, if the client is "stuck" I then ask, in my best Columbo-like style: "What, if anything, can you do to change your situation?"
If I have laid the groundwork well by means of:
- "plucking" key metaphorical terms;
- validating the client's experience and the accompanying feelings;
- commending the client for her presenting symptoms;
- helping her cognitively reframe these symptoms as a form of "coping" and as a set of "survival skills";
- examining collaboratively how such survival skills "worked" in the past, but how she continues to do so now, even in situations in which the client is no longer in "danger";
- considering the "devastating impact," the "emotional toll," and the "interpersonal price" of her being "stuck."
Meichenbaum: In fact, I have two cases that come to mind. First, I wish to describe a challenging case of a woman who has experienced a disastrous accident. She was with her fiance; the only man she had fallen in love with after several previous broken relationships. They were returning from a party and decided to take a short-cut and cross some train tracks. They were running along the train track to get to the other side where this woman lived, and a horrendous thing happened. As the train approached, she yelled out to her fiance, "Let's beat it," and she darted in front of the oncoming train safely. Her fiance tripped and did not make it. He was hit by the train and instantly killed. His body was severed.
Hoyt: Oh, my gosh.
Meichenbaum: It was horrendous. In a dissociative state, she picked up his body parts. It was one of the most horrific stories that I have ever heard. She is suffering from PTSD, depression, and suicidal ideation, as she feels responsible and guilty about his death. Her intrusive thoughts are overwhelming.
I have another case of a mother who had a ten-year-old daughter. They were at home alone. In the middle of the night, she woke up thinking that someone had broken into her home. Since she had experienced such a robbery in the past year, she became fearful. In a state of panic, she reached into her night table to grab hold of a recently obtained pistol that her husband had given her. With gun in hand she was running into her daughter's room when her bedroom door slammed open and hit her hand and the gun discharged.
Hoyt: Don't tell me.
Meichenbaum: Yes. It was her daughter. The mother shot her daughter and blew her daughter's brain away.
Hoyt: That is terrible!
Meichenbaum: Michael, what are you going to say or do in therapy with these clients? In each instance, I listen sympathetically to the tale of the horrendous events. And eventually asked the mother, "What did you see in your daughter that made your relationship with her so special? Please share with me the nature of the loss." In fact, I asked the bereaved mother to bring to therapy a picture album of her daughter and to review with me the special qualities of her daughter. The picture album permitted the client to tell the story of her relationship with her daughter in some developmental (time-line) context, and thus not delimit her memories to only the time of the shooting, which she played over and over again, with the accompanying narrative of, "If only"; "Why didn't I tell my husband I didn't want to own a gun?"; "Why my daughter?"; "Tell me it is only a dream"; "How could I have?" and so forth. Moreover, the review of the picture album provided the opportunity to query further what she saw in her daughter; and, in turn, what did her daughter see in her.
Following this exchange, I asked the client, "If your daughter, whom you described as being 'wise beyond her years,' were here now, what advice, if any, might she have to help you get through this difficult period?" Fortunately, with some guidance I was able to help the client generate some suggestions that her daughter might have offered. I then note, "I can now understand why you described your daughter as being 'wise beyond her years.' "She does sound special." Moreover, if the client followed through on her notion to commit suicide in order to "stop the emotional pain," what would happen to the memory of her daughter? Did she feel that she owed her daughter more? Like many victims of traumatic events, this client found a mission in order to cope with her distress. She undertook the task of educating parents about the dangers of keeping guns in their homes. She became an expert on the incidence of accidental homicides and developed a foundation named after her daughter designed to decrease the likelihood that this could happen to other children. She felt that if she could save one other child, then her daughter would not have died in vain. Through her actions, she was writing a new script, fashioning a new more adaptive narrative. In therapy, we also addressed her feelings of guilt.
Meichenbaum: You're right, but there is a greater likelihood that clients will follow through if they come up with the ideas than if you, the therapist, give them the ideas. I use a phrase to caution therapists not to act as "surrogate frontal lobes" for their clients.
Hoyt: [laughter] I like that -- "surrogate frontal lobes" -- it's better to support the client's own construction. What did you do with the client whose fiance died in the train accident?
Meichenbaum: I used a similar therapeutic strategy, but I had to alter it somewhat. As in the case of the grieving mother, I asked the client who lost her fiance to help me appreciate what happened exactly, and more importantly, "To help me understand what you saw in your fiance, Jimmy. What was life like with him? What did you see in him that attracted you to him?...What do you think he saw that attracted him to you?...If Jimmy were here now, what advice, if any, would he have for you in this difficult time?...What do you think would be the best legacy, the best way to remember Jimmy, not only for yourself, but for others who knew him?"
Whereas, this strategy worked with the bereaved mother, it did not work with this client. When I asked her to come up with advice that Jimmy might offer, she drew a blank. The image of Jimmy's grotesque death was so vivid and current that she could not assume any distance psychologically. So instead, I pursued a somewhat different line of questioning. I asked her when else she might have experienced a personal loss. She described the loss of her grandmother whom she loved a great deal. I then asked her what did she see in her grandmother that made the relationship so special?...What do you think your grandmother saw in you?...If your "wise" grandmother were here now what words of support, what advice, if any, do you think your grandmother might have for you? (Interestingly, this grandmother sounded like a good cognitive-behavioral therapist!)...I then conveyed, that "Now, I understand why your grandmother was so special."
From my perspective, the "name of the game" is to use the art of questioning to enable and empower clients to come up with possible coping strategies.
I could have told this client every single thing that the grandmother would have offered, but it would not have been as helpful.
Hoyt: What about the client who did not have the positive experience that they can draw from with the lost object? The person who says, "I've always had low self-esteem, I'm not good, I deserve what I got." It stimulates earlier relationships that were very negative, the family abused them. What would you have done if she had said, "My father told me I'd never be happy"?
Meichenbaum: You are right on target. One of the things she says is that her father called her up and conveyed that she is a "total screw-up," because she went down to the tracks. Not only that, but this guy, Jimmy, wasn't that good anyway, so the accident is a "blessing in disguise." Not very sympathetic, to say the least. In fact, she goes on to report a whole series of troubled parental interactions. During the course of therapy the client came to realize that part of the reason she is so depressed is that she is talking to herself, reproducing the same narrative, that her father said. Part of the reason that she is suicidal and depressed is not only due to this horrendous event, but she is playing the same CD she heard during her entire childhood. For the client who lacks positive developmental experiences the therapist can help the client appreciate that she is reproducing someone else's script, that she is playing their narrative. The challenge or question is whether she can develop a voice of her own to write her own narrative, does she have the courage to do that? It is not enough to have clients produce a new narrative. This new narrative must be tied into behavioral acts that lead to "data," this is taken as "evidence" to alter the client's view of oneself and the world. While I advocate a constructive narrative perspective, it is important to appreciate that I also employ the full clinical array of cognitive-behavioral procedures.
As you know, mental-health workers have their own innumerable metaphors. The bottom line is that people come into therapy with a "story," and you, the therapist, try to help them change their "stories." My own approach is to remain phenomonologically-oriented, using the client's metaphors. It is better to "unpack" the client's metaphor than to impose the therapist's metaphors.
Meichenbaum: I listen very attentively to how clients tell their stories. I especially listen for how clients use transitive verbs. When I hear such verbs being used such as "stuffed" or "noticed," "caught," "put myself down," etc., I "pluck" these from their narrative and reflect it back to them. I explore what she does. And then we consider what is the impact of such behavior. Once we do that, I say, "What could you do about it?" You don't have to be a rocket scientist for the client to then say, "Well, maybe I should not stuff the feelings." They I say, "Not stuff the feelings, that's interesting, what did you have in mind?" Once again I am laying the groundwork where the client is going to co-define the problem and collaboratively generate possible solutions. We are now collaborating in this constructive narrative process. Another example is when clients spontaneously offer an example of some strength, some successful coping effort and I then use this "nugget" (as I perceive it) to ask: "Are you saying that in spite of all that you experienced [give specific examples], you were able to do (to try, to achieve) [give specific examples]? How did you come to the decision that X? How did you manage to do X? ...Where did this courage come from?"
The strategy I employ to help clients "restory" their lives is (1) to solicit from the clients an example of his/her strengths; (2) ask an "in spite of question," and (3) a "how" question. In turn, we can explore how clients can employ these coping skills and take credit for the change they bring about.
This is not just a "repair" process as Schaefer describes. The metaphor of "repair" implies that an individual's narrative is broken, like a tire, and one has to fix it. It conveys that the narrative one is using was "wrong," it was "broken," and needs to be "fixed." This, I try to stay away from the term, "narrative repair," but rather, talk about the "constructive narrative process" that clients are now engaged in. I help clients to become better observers and become their own therapist. As Tomm suggests, I ask the client, "Do you ever find yourself, out there, asking yourself the kind of questions that we ask each other right here in therapy?" I convey to clients that the treatment goal is be become your own therapist, your own coach. In this way, the clients can learn to take the therapist's voice with them and appropriate, own, and internalize the suggested changes. They can now write their own stories. That is what the therapeutic process is all about.
Our research task now is to demonstrate that doing all this makes a difference. The PTSD Manual that I have spent the last two years writing is designed to operationalize these procedures, so that investigators will be able to empirically validate what I have been describing. I thank you for the opportunity to share these ideas.
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