Evaline was raped three times by her father when she was a young teenager and developed severe posttraumatic stress disorder (PTSD). She tried to put the experiences out of her mind and deal with it on her own. She thought that after he was convicted and put in jail that she would feel better, but she didn’t. For years, she suffered from nightmares, flashbacks, difficulty concentrating, and the inability to hold any job that required her to be in an office with men all day. She tried reading self-help books and keeping a journal, but 13 years passed and she was hardly any better.
When Evaline was 26 years old, she ended up in the emergency room two times because she thought she was having heart attacks. The doctors diagnosed her with panic attacks and suggested she see a psychiatrist. Evaline would not go to a psychiatrist because her health insurance did not cover any psychiatric benefits. Instead, she coped by refusing to leave her apartment except to go to work and to the grocery. Two more years passed before she was able to land a job with better health insurance coverage and finally able to start psychotherapy at our clinic.
Her psychotherapist noticed that Evaline was extremely skittish when it came time to talk about her rape experiences, and in general barely expressed any emotion about anything. She was like a black hole; information seemed to go into her brain, but no words or feelings came back out. It seemed to her therapist that it was impossible for Evaline to get better if she wouldn’t communicate more.
Traditional wisdom in psychiatry and psychology has been that the ideal candidate for psychotherapy is young, intelligent, and talkative. A syndrome was even coined in 1964 by professor William Schofield called YAVIS, standing for young, attractive, verbal, intelligent, and successful. Schofield believed that therapists were biased to work harder to help YAVIS patients because therapists believed YAVIS patients would work harder to get better. If this traditional wisdom was true, things looked bleak for Evaline.
The importance of talking seems magnified in the treatment of PTSD because the disorder begins with one or more traumatic events that need to be talked about but patients want to avoid talking about them because the memories are painful and/or embarrassing. It’s a “no pain, no gain” scenario in which folks have to talk about the painful memories to gain the symptom improvement. If you have a cancer tumor, you have to attack the tumor with surgery or chemotherapy. If you have an infection, you have to attack the bacteria with antibiotics. Likewise, the effective therapies for PTSD fall into the general family of exposure-based psychotherapy in which you have to address the memories.
This raises questions about three main things:
Do differences in any of those three things predict who gets better from therapy or how much they get better? Trauma narratives are the single most important therapeutic activity in all of the evidence-based treatments for PTSD, yet there is no agreement on the qualities, valence, or intensity of narratives that help patients get better.
These might seem like stupid questions. The answers at first blush would seem obvious. The obvious answers would be “yes” to more details, “yes” to be more emotional, and “yes” to be more organized. But there are many reasons to question these obvious answers, not the least of which is that human intuition is notoriously wrong and if it seems obvious it probably isn’t. Also, there are reasons to hope that there are no single best answers to these questions because most patients are reluctant to talk about details, not all patients are extroverts or like to share their feelings, and memory can be a tricky thing.
There has been little good research on these questions, but I recently published a study to try to rectify that. I and my colleagues enrolled 47 youths, seven through eighteen years of age in a randomized controlled trial of cognitive behavioral therapy (Scheeringa and Weems, 2014). The 12-session treatment protocol was structured so that all patients were asked to talk about their traumatic memories for six psychotherapy sessions. Over the course of these sessions, the anxiety level was ratcheted up by asking patients to recount eventually the most anxiety-provoking events. Every therapy session was recorded and transcribed.
Expressive, Avoidant, Undemonstrative, and Fabricated Categories
Two raters read every session and found that patients fell into four categories which my colleagues and I called Expressive, Avoidant, Undemonstrative, and Fabricated. The Expressive group included attributes that might be considered something similar to the ideal YAVIS patient, that is, they recounted details about the trauma events, expressed their emotion during the retelling, and increased expressions of details with subsequent retellings. In other words, the Expressive patients appeared to work hard, and they worked harder with each new therapy session. The Expressive group recounted more details about their trauma events compared to the Avoidant, Undemonstrative, and Fabricated groups. The Expressive group also expressed more negative emotion words and more positive emotion words compared to other groups.
The Avoidant group, on the other hand, appeared to actively inhibit expression of details about the events, as they recounted fewer details about their trauma events compared to the other groups.
The Undemonstrative group was the most guarded about expressing emotions during the retellings. They could relate details about what happened to them in the past, but they would not attach any negative or positive feelings to their stories.
The Fabricated group seemed to believe that some things happened that never happened. They told stories of doing things at the time of the traumatic events that we know they did not do, things that they believed happened that we know never happened, or about people being present who were not.
If you want to try to rate yourself based on how you talk, the category descriptions are available for free. Click here and then click on Trauma Recall Narrative Styles definitions.
Does Narrative Style Affect Treatment Outcome?
Okay, that’s interesting, but so what? Does it matter? Based on traditional thinking, we would expect the Expressive group to improve more in therapy than the other three groups because they are more willing to talk and express their feelings. That is, according to traditional wisdom, they worked harder. What did we find? When the Expressive group was compared to the other three groups combined using parental reports of their symptoms, the other three groups improved more than the Expressive group. We found exactly the opposite of the traditional wisdom!
Interestingly, when using child reports, the Expressive group did not differ from the other three groups combined with treatment outcome. This was probably because the youths in the Avoidant and Undemonstrative groups were less willing to admit to their symptoms and they reported fewer pre-treatment PTSD symptoms. With less symptom severity pre-treatment, they had less room for improvement with treatment and therefore appeared to improve less relative to their parents’ reports.
The surprising take-home message for patients is that, contrary to traditional opinion, recounting more detail with more emotional expression is not needed for everyone to get better. All four groups improved with psychotherapy, suggesting that patients dealt effectively with memories in different ways.
If you are avoidant of talking, that’s okay.
If you are not emotional, that’s okay.
If you have some distorted memories, that’s okay.
The lessons learned from this study are for psychotherapy, however, not for everyday life conversation. If you have PTSD, you still must go to psychotherapy and you still must talk about your traumatic memories to some degree.
There is also a big take-home message for psychotherapists from this study. It is well known that many therapists are reluctant to ask patients to talk about their traumatic experiences, fearing that doing so will make them worse (Becker-Blease & Freyd, 2007), which often causes therapists to be less assertive in directing patients to engage in exposure exercises. These findings ought to provide additional confidence that even when patients are avoidant to talk about details or reluctant to discuss their emotions, they can improve with exposure-based psychotherapy. Good therapists just need to be aware of how to personalize treatment approaches to help different patients construct their narratives.
Evaline is not this patient’s real name in order to protect her identity, but her therapy experience was real. With minimal but directive guidance from her therapist, Evaline actually discussed her traumatic events in much detail. She did not ever express much emotion though. She would be classified as the Undemonstrative type of trauma narrative. The severity of her PTSD symptoms decreased by nearly 60 percent.
Becker-Blease KA, Freyd JJ (2007). The ethics of asking about abuse and the harm of Don't Ask, Don't Tell. American Psychologist, 330-332. doi: 10.1037/0003-066X.62.4.330
Scheeringa MS, Weems C (2014). Randomized placebo-controlled D-cycloserine with cognitive behavior therapy for pediatric posttraumatic stress. Journal of Child and Adolescent Psychopharmacology, 24(2), 69-77. doi: 10.1089/cap.2013.0106.