Correspondence should be addressed to the author c/o:
Traumatology Institute
2104-C University Center
Florida State University
Tallahassee, FL 32306
Email: jeg9860@garnet.acns.fsu.edu
(For more information about Time Limited Trauma Therapy, please visit Dr. Tinnnin's Trauma Recovery Institute Website at http://access.mountain.net/~trauma).
Pierre Janet, over 100 years ago in Paris, had begun to record observations, establish hypotheses and develop effective treatments of traumatic memories, which he viewed as "the nucleus of later psychopathology" (van der Kolk & van der Hart, 1991, p. 425). While much of this valuable writing was discarded for many years, recently clinicians, theorists and researchers have resuscitated these important writings and treatments (van der Hart & Horst, 1989; van der Hart et al, 1990). Building upon these principles, Time-Limited Trauma Therapy was born. Of this Tinnin (1997) writes: "We have researched and developed a treatment program that applies modern knowledge to the dissociative model formulated by Pierre Janet over 100 years ago."
A treatment manual was published in 1994 and since that time hundreds
of patients with posttraumatic stress and dissociative disorders have been
successfully treated, in the U.S. and abroad, by many different therapists
using this model. The procedure uses a combination of relaxation
induction, visualization, voluntary dissociation, narration, art therapy,
focal psychotherapy, video-technology and integration to process traumatic
memories with minimal abreaction and painful re-experiencing. Dr.
Tinnin has developed a videotape detailing the procedures of this protocol
and it, along with the treatment manual, may be obtained by contacting
him at the address below.
Within moments the police arrived at the scene and Jennifer and
her son were reunited. The assailant was apprehended within an hour
of the event. Her son was unharmed. Jennifer was transported
to the hospital where she was treated and released for the laceration of
her hand.
A. History of Trauma: Type I traumatic experience of being attacked in her home by an armed assailant during which she responded with horror and terror.
B. Intrusive Symptoms: Recurrent images and thought of the event, nightmares, dissociative flashbacks (hypnopompic), emotional reenactment, psychological and physiological distress with reminders of the trauma.
C. Avoidant Symptoms: Efforts to avoid thinking about the trauma, diminished interest in participating in significant activities, inability to recall specific aspects of the traumatic event (psychogenic amnesia), restricted range of affect, alexithymia (moderate).
D. Arousal Symptoms: Insomnia/sleep disturbances, outbursts of anger and aggression, difficulty concentrating, hypervigiliance, exaggerated startle response, marked increase in anxiety since attack.
E. Depressive Symptoms: Alternately depressed and irritable mood every day, anergia, anhedonia, inappropriate guilt, feelings of worthlessness, fluctuations in appetite and sexual desire.
F. Dissociative Symptoms: Psychogenic amnesia (for events of the trauma and recent events), infrequent hearing of "voices" (20% of the time on DES)
G. Other Symptoms: Victim mythology, loss of subjective sense of safety, relationship dysfunction, difficulty with parental responsibilities, self-critical cognitive style.
Trauma Work: Time Limited Trauma Therapy (Tinnin, 1994, 1995, 1997) - Verbal Anamnesis (1-2 Sessions); Recursive Anamnesis (1-2 sessions), Non-verbal Anamnesis (1 session), if necessary.
Video-Dialogue: To resolve traumatic dissociation, traumagenic cognitive distortions, inappropriate guilt and traumatic grief (2-4 sessions)
Family Empowerment Therapy: To resolve intra-familial posttraumatic issues (1 - 2 sessions)
Repeat testing at 1 month, 3 months and 6 months
Jennifer describes several scenarios during which she feels overwhelmed and de-skilled due to the intrusive remembrance of the traumatic event. She especially has difficulty feeling sufficiently safe to allow herself to go to sleep at nights, while Mark is working.
Jennifer’s belief that she is going to be attacked again and is
not currently safe is challenged by the therapist in the following transcript:
Next, she participates in Cognitive-Behavioral Techniques (Meichenbaum, 1994) designed to help her reduce her arousal. She utilizes deep diaphragmatic breathing and positive self-talk to lower her arousal. She is taught sensory "grounding" during which she utilizes senses of sight, hearing, touch and smell to help her re-connect to the physical reality of the present and moving her away from the intrusive imagery and autonomic arousal associated with the traumatic event. She responds favorably to learning these techniques and states a sense of empowerment to navigate though difficult periods of anxiety and intrusions.
This session concluded with Jennifer completing the following assessment instruments:
Jennifer participates in the Time-Limited Trauma Therapy protocol of Verbal Anamnesis (Tinnin, 1994, 1995, 1997). She is provided with a relaxation induction during which she utilizes imagery to create a voluntary dissociation to access and process the events of the traumatic experience. Utilizing this "observer mode"(Tinnin, 1994) perspective, Jennifer narrates the traumatic experience in great detail with minimal re-experiencing of the affective/sensory component of the memory. Care is taken to assure that she has a chronological narrative of all events associated with the trauma, especially during period of altered consciousness ("when Jennifer’s eyes were cloudy and glazed…like a deer in the headlights"). She also identifies an point of safety which signifies the end of the traumatic event. She is then challenged to utilize the "observer mode" to obtain fragments of the memory for which she was previously amnestic. She is able to "see" and narrate the experience of her hand being incidentally cut in the altercation with the assailant and the location of the rifle for which she had no memory prior to this procedure. Finally, the therapist, using Jennifer’s language, narrates the story asking her to fill in any gaps or distortions in the narrative. She is video-taped during this procedure. She completes the narrative of the traumatic event and is restored to waking consciousness.
She reports that the procedure was challenging but manageable.
She agrees to return in two (2) days to complete the Recursive Review of
her video-taped narrative.
Jennifer reports that she has had no nightmares since the previous session. This is the first two nights since the event that she has had no nightmares. She further reports that she has had no flashbacks and/or intrusive thoughts associated with the traumatic event.
She and her son are then instructed in relaxation techniques of breathing and progressive muscle relaxation to prepare them for the watching of the video tape of the previous Verbal Anamnesis. She watches the video-tape of herself narrating the story of her attack and experiences strong but manageable affect throughout the viewing. Her son also watches intently. They both agree that this was a horrible experience and that they are lucky to be alive. Her son, Robert, states that watching the tape was helpful to him in piecing all the events together and "getting it out in the open." (Note: Robert is offered individual psychotherapy several times throughout his mother’s treatment to which he declines each time).
She agrees to watch the video two times over the next two weeks.
There is a two week break between sessions.
Jennifer identifies the following "symptoms of healing" in her life since beginning treatment:
Jennifer participates in video-dialogue during which she is challenged to identify the part of herself which she states "I left back there [in the traumatic memory]" and allow this "part" to have a voice. Jennifer begins to speak into the camera and gives this "part" of herself a "voice" and expresses her sadness about the horror and terror she experienced during the attack. The video-tape is then played back and she is asked to view it and respond from the perspective of her "present-day self". Jennifer provides herself with soothing and comforting words and begins to cry. She continues this process of expression of grief while, at once, providing her own soothing, via the video-dialogue.
She completes this procedure stating that she feels "whole".
She denies any symptoms of posttraumatic stress disorder.
She requests one final session with her entire family to resolve
intra-familial difficulties resultant from the posttraumatic stress and
then will terminate trauma therapy. She will continue with supportive
and relationship counseling.
Jennifer has recently enrolled in a Master’s Degree Program and reports
that she continues to thrive and be free from posttraumatic symptoms.
It is more than one year after the traumatic event and six (6) months after
termination of treatment.
The utilization of Time-Limited Trauma Therapy which allowed Jennifer to access, narrate and record the memory of the traumatic event with minimal affect and pain seems to have been the active component to this treatment trajectory. It is isolated both by objective measure and by subjective report as the mechanism which allowed the client to resolve her posttraumatic symptoms.
This procedure facilitates the access to and integration of fragments of the traumatic memory which may have been encoded while in altered states of consciousness during the traumatic event and therefore stored in alternative and difficult to retrieve memory systems. It was successful in retrieving previously dissociated contents of the traumatic memory.
Recent theorist in traumatology hypothesize that transferring/ integrating this "implicit memory" of the traumatic events into an declarative, explicit or narrative memory may be the active ingredient in the resolution of the intrusive symptoms of posttraumatic stress (Tinnin, 1990; van der Kolk, 1996). Time-Limited Trauma Therapy was designed around this theoretical assumption and provides a vehicle for the clinician to assist the client in retrieving and narrating this vital information.
The Video-dialogue technique was also instrumental in assisting her
with the integration of the painful affect and cognitive polarities resultant
from the trauma. This process was less of an abreaction and more
of an integration of the residual affect remaining from the event. She
seemed to experience this titrated dosing of integration as empowering
rather than destabilizing.
It is important to note that the treatment trajectory utilized in treating
this client is an abbreviated version of Time-Limited Trauma Therapy because
she had such rapid amelioration of intrusive and arousal symptoms.
It is recommended that each client participate in two (2) Verbal Anemnesis
and one non-verbal (graphic) narrative and at least two (2) Recursive Reviews.
It is also recommended that clients complete four (4) Video-Dialogue sessions
and then Focal Psychotherapy as necessary to resolve and residual symptoms.
This case, utilizing Time-Limited Trauma Therapy, enjoys excellent results for the client and her family. It is, however, important to discuss some of the limitations of this case and Time-Limited Trauma Therapy here. The client was highly motivated for therapy and exhibited a genuine willingness to engage in this quasi-experimental treatment procedure. She also had excellent verbal skills, adequate-to-excellent supports, a successful history of previous psychotherapy and a single discreet traumatic event. All of these factors combine to create an expectancy for a good treatment prognosis which may not be present for clients without one or more of these assets.
Furthermore, this is a case study and the results are not able to be
easily generalized. It is quite possible that some extraneous factor,
such as family support, motivation for treatment and/or timeliness of treatment
skewed the results in a positive slant. However, I and other therapists
using Time-Limited Trauma Therapy, have seen many clients from very different
backgrounds with divergent trauma histories enjoy the same excellent results.
While Time-Limited Trauma Therapy is a relatively new procedure and
does not have published clinical results, hundreds of clients with posttraumatic
stress disorder and dissociative disorders have been successfully treated
at West Virginia University’s Chestnut Ridge Hospital’s Psychotraumatology
Intensive Outpatient Treatment Program and by many private pratictioners
trained with the protocol in the U.S. and abroad. Plans are currently
underway for the first series of systematic clinical demonstration studies
at Florida State University’s Psychosocial Stress Laboratory and Traumatology
Institute.
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