TIRA

Traumatic Incident Reduction Association

Research on TIR and Related Technique

The views and opinions expressed in these articles and interviews are those of the individuals speaking, and do not necessarily represent those of Applied Metapsychology International or the TIR Association.

Volume VI, Issue 4, Article 1 (December, 2000)
Traumatology


A Review of Alternative Approaches to the Treatment of Post Traumatic Sequelae

Anne M. Dietrich, Ph.D. cand. - University of British Columbia, Anna B. Barranowskky, Ph.D. - Private Practive, Toronto (Canada), Mona Devich-Navarro - University of Southern California, J. Eric Gentry, Ph.D. cand. - Florida State University, Chrys J. Harris, Ph.D. - Private Practice, Boone, North Carolina (USA), Charles R. Figley, Ph.D - Florida State University
Abstract

Approaches to the treatment of posttraumatic sequelae are reviewed in terms of criteria for evaluating inferential validity with case studies, and where applicable, effect sizes are provided where there are data from group comparisons. The approaches covered in this paper include the Trauma Recovery Institute (TRI) Method, Traumatic Incident Reduction (TIR), Visual/Kinesthetic Disassociation (V/KD), and Thought Field Therapy (TFT). Internal validity of case studies on the TRI Method and V/KD appear controlled for, whereas reports on TFT do not meet internal validity criteria. Effect sizes are reported on one study that compared TIR to waitlist control and Direct Therapeutic Exposure (DTE), suggesting that TIR is superior to waitlist control, and shows more modest gains over DTE. The available evidence suggests TIR, the TRI Method, and V/KD are effective treatments for posttraumatic sequelae.

Key Words: PTSD; Alternative Treatments; Case Study Evaluation; Mechanisms of change.


A Review of Alternative Approaches to the Treatment of Pos Traumatic Sequelae

Although there is evidence for the efficacy of various treatment approaches for simple posttraumatic stress disorder (PTSD) (Foa, Keane and Friedman, 2000), there is some proportion of individuals in the field with PTSD who may deteriorate following these interventions (e.g., see Kilpatrick & Best, 1984; Litz, Blake, Gerardi, & Keane, 1990; Pitman, et al, 1991; Pitman, et al, 1996; Scott & Stradling, 1997; Scurfield, Wong, & Zeerocah, 1992; Solomon, Bleich, Shoham, Nardi, & Kotler, 1992; Watson, Tuorila, Detra, Gearhart, & Wiclkiewicz, 1995).

In this paper we review four approaches that are viewed by their originators as alternatives to mainstream treatments for PTSD. Rapid reductions in symptomatology have been reported following the implementation of these alternative approaches; however, the available data on their relative degree of effectiveness consist largely of case studies, with a concomitant absence of controlled studies on efficacy.

The four treatments we have included are, in alphabetical order, Thought Field Therapy (TFT) (Callahan & Callahan, 1996), the Trauma Recovery Institute (TRI) Method (formerly called Time-Limited Trauma Therapy (Tinnin, 1994a), Traumatic Incident Reduction (TIR) (Gerbode, 1995), and Visual/Kinesthetic Disassociation (V/KD) (Bandler & Grinder, 1979). Eye Movement Desensitization and Reprocessing (EMDR) is not included in the paper due to length considerations and because there are reviews of controlled studies on EMDR reported elsewhere (e.g., see Chemtob, Tolin, Pitman, & van der Kolk, 2000; Maxfield, 1999).

The purpose of this paper is to provide readers with a) information on the existence of these nontraditional approaches; b) a review of the degree and type of data available on the effectiveness of these approaches, where applicable; c) an evaluation of case study data based on criteria for drawing valid inferences from case studies as set forth by Kazdin (1998); d) hypotheses regarding possible mechanisms of action; and e) recommendations for possible further study.

Overview of Alternative Treatments
Thought Field Therapy

Thought Field Therapy (TFT) (Callahan, 1996) attempts to integrate the eastern philosophy of acupuncture with more contemporary theories of cognitive processing. The treatment is gaining a modicum of support among clinicians and severe criticism from researchers. This review will assist clinicians in examining the assertions of its creator, Roger Callahan, a bit further.

TFT targets two areas: 1) the client's negative beliefs/emotions and 2) the physical imbalances in the body's "bioenergy control system"(p. 131), which Callahan (1996) calls "perturbations" (p.130). A perturbation is similar to the increased arousal or agitation symptoms frequently reported with Post Traumatic Stress Disorder (PTSD). These disturbances are encoded in the body's energetic system, and ultimately stimulate the negative beliefs/emotions of the "thought field" (p. 130). A "thought field" refers to the various cognitive and memory processes involved in the maintenance of emotional distress.

Based on the meridian system of acupressure, Callahan developed several algorithms that target these perturbations. The algorithms are comprised of pressure points that are tapped on the body during the treatment. Removal of the perturbations eliminates corresponding pathology. According to Callahan (1996), TFT targets PTSD, panic, phobia, all anxiety disorders, sexual problems, depression, addictive behaviors, and heart rate problems.

Data Summary. To date no treatment outcome research has been conducted. Callahan's treatment assertions are not based on controlled and randomized studies and his writings have not appeared in peer-review publications, other than TRAUMATOLOGYe . The absence of waitlist or placebo controls limits a comprehensive examination and validation of the treatment. Reports of TFTs efficacy tend to be based on anecdotal evidence gained by clinician reports. Information on the treatment is obtained primarily through the web or special publications distributed by Callahan.

Hooke (1998) conducted a review of several unpublished studies frequently cited by Callahan (1987; Carbonell & Figley, 1995; Leonoff, 1995; Wade, 1990; Wylie, 1996). He found the results uninterpretable due to several methodological limitations such as "no control groups, nonrepresentative sampling, and demand characteristics of a public radio broadcast (p. 4)." However, findings from a study by Carbonell and Figley (1995) were supportive even though the generalizability of the results is limited due to the absence of a control group. This study found that the rate of change in distress levels was faster than those recorded for other exposure-based treatments. In addition, an unpublished controlled study by Carbonell (1996) does deserve some merit. The design of the study had the experimental group receive a legitimate TFT algorithm and the control group was given a sham algorithm consisting of arbitrary points. Both groups showed reductions in distress levels, however the experimental group reported significantly greater reductions in distress. Unfortunately, effect sizes were not reported and therefore these results must be viewed cautiously.

Trauma Recovery Institute (TRI) Method

The Trauma Recovery Institute Method (TRI, formerly known as Time-Limited Trauma Therapy) (Tinnin, 1994a, 1994b) is a neo-Janetian protocol developed by Louis Tinnin, M.D. in 1991. The procedure uses a combination of hypnosis, voluntary dissociation, narration, art therapy, focal psychotherapy, video-therapy, and integrative techniques, with the goal of processing traumatic memories with minimal abreaction or painful re-experiencing.

The three phases of treatment of the TRI Method model are: (1) stabilization (including management of the fear of confronting traumatic memories) (2) "trauma work" or memory processing, and (3) integration of trauma-related affect, cognitions, and patterns of behavior. The first phase of the TRI Method focuses on providing the patient with the minimum safety and stability necessary to transition to the next phase of resolving intrusive symptoms, which is facilitated through memory processing.

The resolution of intrusive symptoms is the primary goal of the TRI Method. The theory, based on the work of Pierre Janet, holds that by completing a narrative of the traumatic memory, including all previously dissociated memory fragments, the intrusive symptoms abate and the memory becomes relegated to the past, where it no longer encroaches on present functioning. To achieve this resolution, the TRI Method utilizes a protocol that creates a detached "observer mode" to complete the narration of the micro-events of the traumatic experience. These micro-events are processed into a chronological narrative using both verbal (anamnesis) and nonverbal (graphic narrative) techniques (Tinnin, 1994a).

The final phase of treatment, Video dialogue, addresses "victim mythology" (Tinnin, 1995) and other posttraumatic symptomology through diverse applications of videotherapy and traditional treatment methods. Video-dialogue involves the use of video technology to allow the patients to access and integrate emotional and cognitive states that were dissociated as a result of the traumatic experience(s) (Holmes & Tinnin, 1995).

Clinical observations suggest that for clients with simple PTSD, effective treatment can usually be completed in 8 - 20 sessions. For clients with complex PTSD, dissociative disorders and/or co-morbid disorders treatment will take longer. Although clients are free to terminate therapy at any time, the treatment contract is fulfilled when clients report that their PTSD and dissociative symptoms have diminished to a satisfactory level.

Data Summary. To date, there has been one peer-reviewed published study using the TRI Method (Gentry, 1998). This is a case study of a woman who was the victim of a violent crime, developed PTSD and was treated with the TRI Method in eight sessions. The client was administered the Clinician-Administered PTSD Scale (CAPS) (Blake et al, 1990), the Impact of Event Scale (IES) (Horowitz, Wilner, & Alvarez, 1979), the Symptom Checklist-45 (Alvir, Schooler, Borenstein, Woerner, & Kane, 1988), the Trauma Recovery Scale (TRS) (Gentry, 1999) and the Toronto Alexithymia Scale (TAS) (Taylor, et al, 1988) at baseline and at the end of the 8 sessions. Her scores on all measures showed substantial improvement, as shown in table 1.

Table 1. Raw score changes from baseline to post treatment for single-event trauma victim on various measures
MEASURE BASELINE POST-TREATMENT
CAPS 74 24
IES 49 15
SCL-45 103 51
TAS 73 45
DES 9 5
TRS 4.37 97
DTRS 13 1

A recent preliminary analysis was conducted by the first author on some unpublished data collected by Tinnin on 22 treatment-seeking civilians diagnosed with PTSD as per diagnostic interview. Of 22 patients who were treated with the TRI Method and who completed the Impact of Event Scale-Revised (Weiss & Marmar, 1995) at baseline and post-treatment, twelve experienced single-event or multiple single-event traumas only (Type I traumas); six experienced prolonged (type II) trauma only; and four experienced mixed traumas (both Type I and Type II). IES-R scores decreased after treatment for all cases except one, whose score rose by one point following treatment. The mean decrease in raw IES-R scores for the remaining 21 patients was 20.8 points.

Paired samples t-tests show significant reductions on mean IES-R scores from baseline (M = 44.25, SD = 15.5) to one-week post-treatment (M = 27.6, SD = 18.6) for the 22 individuals (t = 6.37, p. = .000, two-tailed). Follow-up data were also collected at three-month post-treatment and at six month post-treatment. Paired-samples t-tests show that mean IES-R scores were not significantly different between one-week post-treatment and three-month follow-up, or between one-week post-treatment and six-month follow-up, indicating maintenance of treatment gains for at least six months following termination of treatment. It should be noted that data were not available at follow-up for all participants. Effect sizes were not calculated given the unreliability and over-estimation of effect size estimates with change scores and repeated measures data (Ray & Shadish, 1996).

Traumatic Incident Reduction (TIR)

There are two formats of Traumatic Incident Reduction, Basic TIR and Thematic TIR. Basic TIR is used to process a specific traumatic incident, whereas thematic TIR is used to process problematic themes related to the trauma, including specific feelings, emotions, sensations, attitudes, or pain (French & Harris, 1998).

TIR involves having clients talk through the incident repeatedly, thereby requiring that they engage the traumatic memories. It is anticipated that changes in affect will occur throughout the repetitions with both TIR and other forms of imaginal exposure. TIR is highly client-centered in its' approach, where the role of the therapist is largely to bear witness as the clients process their traumas. Alterations in both affect and traumatic content are frequently observed with this procedure throughout the session.

In basic Traumatic Incident Reduction, the session begins by having clients identify a specific, single, traumatic event, while ensuring that the clients do not target a series of incidents over time. The identification of a single incident is easier to obtain and retain in working memory than a series of incidents. Once a specific traumatic event is identified, the client is directed to articulate the specifics of the event, including the time and place it occurred, its' duration, and so forth. Locating the event in the past, at a specific place and time, assists in helping clients identify a clear starting point for the procedure.

The second step involves instructing clients to focus on the starting point of the incident in their mind's eye, by having them "rewind" -like a videotape- the incident to its' starting point. Clients may close their eyes as they envision the trauma or keep their eyes open, as is their preference. Next, clients focus on what they are aware of initially at the identified start of the incident. This step is only used when they are focusing on a specific incident for the first time in TIR. Clients are then instructed to run through the incident silently to the end. Following this, they are asked to describe to the therapist what happened. Once they have recounted the event to the therapist, they are instructed to return to the starting point, run it silently, and describe (aloud) the incident. These three steps are repeated until clients reach an end point. An end point is defined as that point in the processing of the traumatic event where there is insight regarding the event, the temporal reference shifts from the past to the present, there is an improvement in affect (e.g., tears, anger, fear, etc., is replaced with relief, laughter, smiling, and so forth), and the client evidences general relief (compared to the charged affect at the beginning). In other words, the incident has lost its' emotional charge.

Data Summary. Bisbey (1995) studied 57 participants diagnosed with PTSD, who were randomly assigned to one of three separate conditions: Direct Therapeutic Exposure (DTE), which is an exposure treatment that has clients revisit the trauma without strict facilitator directives, TIR, and a control group. Clients in the two treatment groups evidenced significant reductions in trauma symptoms as per the Penn Inventory for Posttraumatic Stress (PENN) (Hammerberg,), the Impact of Event Scale (IES) (Horowitz, et al, 1979), and the Crime-Related PTSD scale (CR-PTSD) (Saunders, Arata, & Kilpatrick, 1990). Effect sizes using Hedge's unbiased g statistic are calculated for the groups and are reported in table 2.

Table 2. Hedge's unbiased g effect sizes for TIR compared to DTE and Controls on the PENN, IES, and the CR-PTSD
MEASURE TIR/DTE TIR/CONTROL
PENN 0.89 2.01
IES 0.95 2.08
CR-PTSD 0.56 1.40

Visual-Kinesthetic Disassociation (V/KD)

Visual-Kinesthetic Disassociation (V/KD) (Bandler & Grinder, 1979) facilitates the attainment of a degree of kinesthetic dissociation as the individuals visually re-experience their trauma (Hossack & Bentall, 1996), enabling them to process the event(s) from a de-centered perspective. The approach has not been researched with persons with complex posttraumatic and dissociative disorders, and should be utilized with care with this clientele in the absence of further study, since it facilitates dissociation. Clinical experience shows that some individuals will re-enact traumas when in highly dissociative states, and may take action that results in harm to themselves and/or others. According to Koziey and McLeod (1987, p. 278), V/KD was initially used by E. Fromm, who described the approach as a means of dissociating the "observing ego" from the "experiencing ego." Bandler extended Fromm's usage from a 2-point position of displacement (i.e., the observing ego watching the experiencing ego) to a 3-point displacement (i.e., a "higher order" observing ego watching the observing ego watching the experiencing ego; Koziey & McLeod, 1987).

Participants are asked to imagine observing themselves (e.g., from the vantage point of a projection booth in a movie theatre) watching themselves (sitting in a theatre seat) re-live their traumatic experience as though in a moving picture (up on the "screen"), while they re-process the event. As they envision their traumatic experience from the 3-point displacement, they are effectively disconnected from their somatic, spatiotemporal, experiencing ego sensations. They are instructed to metaphorically modulate affective intensity as they proceed through the procedure, through imagery such as "volume control," "colour options" (e.g., making the picture black and white to decrease affect intensity; making the picture colorful to increase affect intensity (Konefal, Duncan, & Reese, 1992), and so forth.

Data Summary. Published data on the V/KD technique is limited to 3 small studies. Koziey and McLeod (1987) utilized V/KD in the treatment of 2 female university students who had been raped. Posttraumatic symptoms were assessed both pre- and post-treatment with the Veronen-Kilpatrick Modified Fear Survey (Veronen & Kilpatrick, 1980) and other indices. Both women showed reductions of at least one standard deviation on several scales of the various instruments; however, no specifics were reported.

Muss (1991) conducted an uncontrolled study with a sample of 19 British police officers who met DSM-III criteria for PTSD and who were treated with V/KD. All participants reported a decrease in intrusive imagery and a return to normal functioning at one-week follow-up.

Hossack and Bentall (1996) conducted a multiple baseline design study with five males who met DSM-III-R criteria for PTSD following disasters. All five men reported vivid intrusive imagery of death and dying at the initiation of the treatments. Four of the five men showed clear improvements in symptoms and functioning following the procedure.

The V/KD technique increases kinesthetic detachment, which might result in increasing dissociation with susceptible individuals. Although not all persons who have been diagnosed with PTSD evidence pathological levels of dissociation (e.g., Putnam, et al, 1996), using the V/KD technique with individuals who are highly dissociative should be used with caution.

Evaluation and Critique
Case Studies

Kazdin (1998) has described several criteria for evaluating the dimensions of case studies in terms of drawing valid inferences. The problem of threats to internal validity is the main reason for the unpopularity of case study research - in the absence of controlled, randomized studies, it is difficult to ascertain whether any observed effects are due to the therapeutic intervention or to extraneous variables. Kazdin holds, however, that when case studies meet specific criteria, they can offer information that approximates the information obtained from experimental research.

Criteria by which to evaluate case studies in terms of their inferential validity include characteristics of the case, which provide information to help rule out major threats to internal validity. Characteristics of the case include the type of data obtained; how often measures are taken; stability (e.g., acute versus chronic symptoms and course of the disorder); whether observed effects are immediate and/or marked; and the use of multiple and heterogenous cases. Threats to internal validity include historical and maturation effects, testing (i.e., repeated exposure to assessment procedures), instrumentation (changes in the scoring procedures or criteria over time), and statistical regression to the mean. A summary of the degree to which the case data reported on three of these alternative approaches meet Kazdin's criteria can be seen in Table 3.

Table 3. Internal Valdity Criteria for TRI, V/KD, and TFT
TRI Method V/KD TFT
Characteristics of Cases
Objective Data + + -
Continuous Assessment + + -
Stability of Problem ? ? -
Immediate and Marked Effects + + +
Multiple Cases + + ?
Major Threats to Internal Validity
History + + -
Maturation + + -
Testing + + -
Instrumentation + + -
Statistical Regression + + -

Note + indicates the threats to internal validity appear controlled, - indicates that the threat has not been controlled, and ? indicates the threat may remain uncontrolled (Kazdin, 1998, p. 411).

Based on the case data summaries of the approaches, both the TRI Method and one study on V/KD (Hossack and Bentall) appear to have major threats to internal validity controlled for. Data on these two approaches include the use of objective assessments (cf Muss), continuous assessments over time (cf Koziey & McLeod; Muss), assessment of PTSD (cf Koziey & McLeod), immediate effects, and the use of multiple cases. To assess for history and maturation criteria, the use of multiple, heterogenous cases and observations of marked and immediate effects provide some evidence that the observed effects are not due to particulars of the case. The patients who were treated with the TRI Method experienced a variety of traumas, including single event, multiple event, and continuous traumas over time. As such, the history and maturation criteria appear controlled for.

The course of PTSD is highly variable, and depends on many factors, including the intensity, duration, and number of traumatic events, the type of trauma, contextual factors, and predispositions (McFarlane & Yehuda, 1996). Shalev et al (1996) note that PTSD is chronic in about 15% to 25% of cases. It is unclear whether the stability criterion is met for V/KD and the TRI Method, in that information on PTSD chronicity of the cases was not reported in any of the studies. The multiple assessments by Tinnin on the TRI Method and by Hossack and Bentall for V/KD suggest that both testing and statistical regression are controlled for; similarly, instrumentation is controlled for in that the scoring procedures and criteria were the same at pretest and posttest assessments.

One uncontrolled, small-n study on TFT reported an immediate reduction in SUD levels following the intervention (Carbonell & Figley, 1995); however, the absence of continuous assessments over time and objective measures prevents conclusions regarding treatment effectiveness. Similarly with TFT, no PTSD assessments have been reported, and so there is no evidence that TFT is effective for the treatment of PTSD. Given the absence of diagnostic assessment data for TFT, stability of the reported problem cannot be commented on. The absence of continuous assessment for TFT results in the absence of control for the testing and statistical regression criteria. Major threats to internal validity are not controlled for with TFT.

Table 3 highlights the limitations with this treatment. The majority of Kazdin's criteria were not controlled for and the only documented strengths were the immediate and marked effects observed in the Carbonell and Figley (1996) study. Callahan's assertions are based solely on the subjective reporting by clinicians and no detailed case material is available for review. Therefore, further documentation of case studies is needed.

Even though the Carbonell et al. study is not a detailed review of case material, it does attempt to document various outcomes of TFT with the use of SUDs ratings. Despite the reductions reported in SUDs levels, the lack of objective measures does place some constraints on the interpretation of SUDs ratings. Unfortunately, to date, case studies referred to in Callahan's writings do not provide sufficient controls for threats to internal validity, including objective measures, and therefore clinicians are unable to draw firm conclusions.

Group Comparison of TIR

The results from Bisbey's randomized, controlled study provide preliminary evidence for the efficacy of TIR. Effect sizes for TIR show that it results in considerable improvement over waitlist control, and modest improvement over DTE. Further studies are needed to determine whether these effects are robust.

Postulated Mechanisms of Change

In this section, we postulate on various mechanisms that could account for the observed changes that have been reported with some of these approaches. These possible mechanisms include a combination of exposure, elicitation of a parasympathic response in the manner of reciprocal inhibition, and facilitation of affect modulation. It is also surmised that these are likely not sufficient for complete recovery from PTSD, and in particular, Complex PTSD.

Exposure

In accord with a review by Shalev et al (1996) (see also van der Kolk, McFarlane, & van der Hart, 1996), although not sufficient per se as a cure for PTSD, exposure is one of the main active ingredients in treatments for posttraumatic symptoms, particularly for intrusions. It has been long recognized (Wolpe, 1958) that a major element in cognitive-behavioral treatment approaches is that clients are assisted in gathering sufficient data about the conditioned stimulus to reduce its power in evoking conditioned reactions. Of the approaches covered in this paper, TIR is the best example of how exposure can be guided by clients, facilitate insight, and can facilitate tracking of shifts in trauma-based cognitions.

V/KD allows clients to experience exposure through guided visualization and kinesthetic disconnection from the client's simple (Type I) trauma in "fast-forward" and "rewind." The disconnection and rapid replaying of the trauma may assist clients in better tolerating distress from the exposure, than might occur without the disconnection and rapid replaying. The TRI method includes video exposure to the re-experiencing of the trauma, in combination with other techniques to minimize abreactive re-experiencing. TFT, although not a treatment for PTSD, uses exposure at select moments when the SUD rating is taken. As noted by van der Kolk, et al (1996), eliciting trauma-related affect, while also introducing information that is discrepant from the original trauma (e.g., see Foa, Steketee, & Rothbaum, 1989), is necessary for effective re-conditioning. In this regard, exposure may facilitate the evocation of a parasympathic nervous system response.

Parasympathetic Reflex and Reciprocal Inhibition

The sympathetic nervous system (SNS) enables individuals to respond appropriately to danger. With traumatized persons, the SNS is activated in response to trauma-related cues, and stimuli that would otherwise be innocuous may elicit a conditioned fear reaction. Some of the approaches reviewed here could function through the elicitation of a parasympathetic nervous system (PNS) reflex to counteract the trauma-induced sympathetic activation. This "relaxation factor" had been dismissed long ago as a critical element in cognitive and behavioral therapies, with the view that exposure was sufficient for desensitization and that relaxation actually hindered the process. Recent evidence, however, suggests this may not be warranted. Relaxation is a component in many major treatments of anxiety-related disorders. In a treatment approach reported recently in the JAMA (Barlow, Gorman, Shear & Woods, 2000), relaxation skills and efforts to invoke humor were both utilized in a cognitive behavioral desensitization protocol.

The reciprocal inhibition (RI) reflex is premised on the view that, as the PNS counteracts the SNS response, re-learning (i.e., counter-conditioning) takes place. The body learns to replace the conditioned fear response with one that is relaxation-induced. The observation reported by Figley and Carbonell (1995) that tapping with the TFT approach reduces in-session SUD levels suggests that the tapping may elicit PNS activity in response to hyperarousal, which had been conditioned to the trauma stimulus. This hypothesis has not been tested. V/KD visualization provides clients with disconfirming evidence that somatic distress is a necessary consequent whenever they focus on the traumatic event. That is, the somatic disconnection constitutes new information discrepant from the original trauma, which, as noted above, is necessary for effective de-conditioning. When treatment is effective, the distress is attenuated and may be eliminated while new information about the conditions under which the client was traumatized is reviewed, examined, and analyzed. Clinical observations suggest the RI reflex is very fast and results in powerful affective shifts. This is frequently reported among clients treated with EMDR (Lipke, 1999).

Affect modulation

It is hypothesized that these techniques have components that offer some protection from the overwhelming affect that may accompany exposure with some clients (Briere, 1997; see Shalev et al, 1996 for a review).

TIR is highly client-directed. Clients have control over the content, pacing, and degree of traumatic memory processing during sessions, and thereby have some control over the amount of affective arousal they experience. The presence of the therapist acts to provide support and encouragement, while also bearing witness in a non-judgmental manner. Attachment to the therapist can assist clients in modulating affective arousal, and the provision of safety by way of the therapeutic alliance may constitute discrepant information from the original, feared traumatic event to increase the effectiveness of desensitization (van der Kolk, et al, 1996).

The TRI method and V/KD both utilize guided imagery to facilitate an "observer mode." Such disconnection from direct re-experiencing may help with the modulation of affective arousal during processing of the trauma. According to van der Kolk, et al (1996), effective treatment requires exposure without total re-experiencing of the trauma; with too much arousal, new information cannot be assimilated. High arousal may also increase avoidance, thereby precluding desensitization.

The tapping with TFT provides physical, rhythmic, stimulation that may have a calming and soothing effect on agitated clients during the stabilization phase of treatment, and when processing traumatic memories. In this sense, the reciprocal inhibitory relaxation response may assist the PNS in reducing the hyper-reactivity of the SNS. The tapping also focuses clients on the here-and-now, and may function to keep clients grounded.

Summary

The results of this review suggest that the Trauma Recovery Institute Method, Traumatic Incident Reduction, and Visual/Kinesthetic Disassociation are effective in the reduction of posttraumatic symptoms. The available case study data on the TRI Method and V/KD provide evidence that most internal validity criteria have been met, and that the treatment intervention per se results in improvement. The one controlled study on TIR suggests that it is more effective than no treatment in treating PTSD, and shows some improvement over DTE. This review does not support Callahan's assertions that Thought Field Therapy is an effective treatment for PTSD; however, the data by Carbonell and Figley (1995) suggest that TFT may function as a rapid self-soothing technique for attenuating distress.

As noted by van der Kolk, McFarlane, and van der Hart (1996), results from the Koach project (Solomon, et al, 1992) show that impressions of treatment success are not necessarily borne out by objective data. Data from the field of cognitive psychology provide further evidence for cognitive processing biases, such as the availability heuristic. These findings emphasize that clinical impressions per se need to be supported with objective indices. In the Koach project, although clinicians and clients felt that treatment was successful, the objective data showed that treated veterans had both short-term and long-term negative effects. Should empirical research support the hypothesis that exposure, reciprocal inhibition, and arousal modulation are necessary, if not sufficient, components in effective reduction of posttraumatic symptoms, clinicians may want to consider devising treatment approaches that incorporate all three components.

Establishing the validity of therapeutic techniques is a relatively recent and clearly timely pursuit (Figley, Carbonell, Boscarino, & Chang, 1999). This trend enhances clinician ability to select the most appropriate approaches in the treatment of mental health disturbances. It enables research to inform clinical practice and encourages informed decision making for both client and practitioner. Validating treatment approaches means committing to ongoing research and a dedication to providing the best services possible.

Each of the therapeutic approaches discussed in this paper is relatively new. In order to determine the efficacy of these approaches, ongoing research adherence to Task Force (American Psychological Association, Division 12 Task Force, 1995) guidelines for "well-established" treatment is recommended. Specifically, rigorous studies need to be conducted and replicated using comparison groups to demonstrate that the identified treatment is equivalent to another "well-established" treatment or superior to medication, psychological placebo or other treatment. Scientist-practitioners are encouraged to take an active role in this line of enquiry and to conduct research with combined components, using good experimental designs and standardized approaches.

An example is the study by Barlow and colleagues (Barlow, et al, 2000) who compared CBT with a promising drug compared to each alone in treating severe social phobia. It was demonstrated the CBT was superior to drugs, but together they had both short and long-term gains. This is also consistent with suggestions by Shalev et al (1996) who note that there is no one treatment that results in complete cure of chronic PTSD, and that effective treatments may require combinations of different approaches. van der Kolk, McFarlane and van der Hart (1996), further note that no research has examined treatment effectiveness for both PTSD and its' associated features.

The most important point to consider is the impact that these approaches may have on clinical work and the potential for a reduction in the length of suffering endured by trauma survivors. If it is found that the approaches presented in this article are efficacious based on rigorous research studies, they have the potential to enhance the manner in which PTSD is treated as well as the long-term prognosis for clients. It remains our responsibility to empirically validate alternative approaches that can withstand careful scrutiny and to discard or revise those that fail to maintain standards. In so doing, we become well-informed and able to choose the best for our clients.

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* Note: In alphabetical order: Anna Baranowsky co-wrote the Summary, Mona Devich Navarro reviewed and evaluated TFT, Eric Gentry reviewed the TRI Method approach, and Chrys Harris reviewed TIR. Charles Figley co-authored mechanisms of change and summary sections, and provided executive supervision of the paper. First author coordinated the paper, wrote the introduction, V/KD, and evaluation sections (with the exception of TFT), and co-wrote the mechanisms of change and summary.


Volume VI, Issue 4, Article 1 (December, 2000)
Traumatology

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