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Emotion-focused therapy workshop series (third post): narrative therapy and trauma processing

"Those who do not have the power over the story that dominates their lives - the power to retell it, reexperience it, deconstruct it, joke about it, and change it as times change - truly are powerless because they cannot think new thoughts"   Salman Rushdie 

Yesterday was the third day of the seven seminar "Emotion-focused psychotherapy: Level 2 workshop series" that I'm attending at the University of Strathclyde.  I wrote about the second workshop last autumn in the posts "Emotion-focused therapy workshop series (first post): excitement and why am I doing this?" and "EFT workshop series (second post): client processes and therapist-client conflict".  So how was yesterday's workshop for me?  Irreverently that question reminds me of the joke "The love making was so good that even the neighbours stopped for a cigarette". 

It was a good day.  Pretty jam-packed.  In the morning we covered narrative therapy, trauma and their confluence in EFT.  It's topical territory.  Les Greenberg & Lynne Angus's book "Working with narrative in emotion-focused therapy: changing stories, healing lives" came out just last year.  The book description comments "In psychotherapy, as in life, all significant emotions are embedded in important stories, and all significant stories revolve around important emotional themes. Yet, despite the interaction between emotion and narrative processes, emotion-focused therapy (EFT) and narrative-informed therapies have evolved as separate clinical approaches. In this book, Lynne Angus and Leslie Greenberg address this gap and present a groundbreaking, empirically based model that integrates working with narrative and emotion processes in EFT. According to Angus and Greenberg's narrative-informed approach to EFT, all successful psychotherapy entails the articulation, revision, and deconstruction of clients' maladaptive life stories in favor of more life-enhancing alternatives ... Engaging, in-depth case studies ... illustrate how the model can be applied to treatment of depression and emotional trauma."  Mm ... I like the comment "successful psychotherapy entails the articulation, revision, and deconstruction of clients' maladaptive life stories in favor of more life-enhancing alternatives".  I'm less convinced by their use of the description "empirically based model" I would have thought that implied a bedrock of outcome research, that hasn't happened so far and may never do so.  Having said that, there is encouraging emerging work that is relevant - for example last year's paper by Vromans & Schweitzer "Narrative therapy for adults with major depressive disorder: improved symptom and interpersonal outcomes".

And the more I think about it, the more seriously I am attracted to this territory.  I'm a huge fan of our attempts to use evidence-based approaches when we try to help our clients.  Compassion calls out for us to be as effective as we can be in relieving suffering and good science helps us distinguish what's genuinely useful from what's hogwash.  There can easily be problems though with this evidence-based medicine (EBM) approach.  Like Mulla Nasruddin and his lost keys, we can look very thoroughly but in the wrong place - see for example November's post "Psychotherapists & counsellors who don't monitor their outcomes are at risk of being both incompetent & potentially dangerous".  There's a real surge in energy for narrative-based approaches as a way to humanise, balance and increase the helpfulness of EBM.  There are many recent papers highlighting this hope - examples include "The marriage of evidence and narrative: scientific nurturance within clinical practice", "Narrative and psychiatry" and "Narrative vs evidence-based medicine--and, not or"A whole issue of the journal "Psychotherapy Research" last year explored a variety of relevant narrative-based approaches, and last month's British Journal of Psychiatry featured a major review article "Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis".  Its abstract reads "Background: No systematic review and narrative synthesis on personal recovery in mental illness has been undertaken. Aims: To synthesise published descriptions and models of personal recovery into an empirically based conceptual framework.  Method: Systematic review and modified narrative synthesis.  Results: Out of 5208 papers that were identified and 366 that were reviewed, a total of 97 papers were included in this review. The emergent conceptual framework consists of: (a) 13 characteristics of the recovery journey; (b) five recovery processes comprising: connectedness; hope and optimism about the future; identity; meaning in life; and empowerment (giving the acronym CHIME); and (c) recovery stage descriptions which mapped onto the transtheoretical model of change ... Conclusions: The conceptual framework is a theoretically defensible and robust synthesis of people's experiences of recovery in mental illness. This provides an empirical basis for future recovery-oriented research and practice."  Narrative approaches are very much flourishing!

What about trauma?  One might think that the NICE guidelines' advocacy of trauma-focused cognitive therapy and eye movement desensitisation as the recommended evidence-based approaches for posttraumatic stress disorder has somewhat closed this debate.  NICE are certainly clear in their statement "where symptoms have been present for more than 3 months after a trauma, offer trauma-focused psychological treatment (trauma-focused CBT or EMDR) to all patients".  I do think though that Wampold et al's major paper "Determining what works in the treatment of PTSD" has opened up the debate over what types of treatment we should be using for trauma-related problems.  And as Arntz & colleagues have shown, clinically relevant trauma extends way beyond the relatively narrow confines of classical PTSD - see "Symptoms of post-traumatic stress disorder after non-traumatic events: evidence from an open population study".  It's no longer controversial to argue as I have done in the presentation "Traumatic memories" that "1.) Trauma memories are very common in depression and anxiety as well as in PTSD.  2.) Disorder onset, severity and persistence seem contributed to by memories and ‘images'.  3.) Lessons from PTSD treatment may well improve treatment of depression and anxiety".  Last year's excellent book "Oxford guide to imagery in cognitive therapy" co-authored by my friend & colleague James Bennett-Levy, provides a fine state-of-the-art clinical overview of this territory. 

Riches indeed!  Narrative approaches, trauma and emotion-focused therapy all covered in a morning.  Gosh our course facilitator, Robert Elliott, likes crunching on big mouthfuls of material.  And he delineated a useful structure for working with a narrative-based EFT approach to trauma symptoms and off we went in small groups to try it out.  Good, and in the afternoon we went on to begin looking at therapeutic "chair work" and it struck me that - with conflicting & updating "meanings" being so central to trauma work - maybe chair dialogues between different meaning standpoints might also sometimes be useful when working with trauma, a potential bridge between our morning and afternoon sessions.  Tomorrow I'll write about the "two chair work" second half of this day seminar in the post "The importance of working on 'hot cognitions' and feelings"

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