Research Brief
Submitted to Trauma and Loss: Research and Interventions
April 2002
Trauma Relief Unlimited:
An Outcome Study of a New Treatment Method
The purpose of this study was to test the efficacy of a new method for treating psychological trauma called Trauma Relief Unlimited (T.R.U.). The method uses kinesthetic hand movements and nonverbal techniques. Forty adult participants were randomly assigned to an experimental or control group. Each participant received three 45 minute T.R.U. treatment sessions. Participants were pre and post tested with a four month follow-up using Briere’s Trauma Symptoms Inventory and client self report. Study results showed that T.R.U treatments significantly reduced symptoms of post traumatic stress at both post treatment and the four month follow-up period, with no adverse after- treatment effects.
It has been estimated that seven out of 10 Americans have experienced major traumatic events in their lifetimes, with up to 20 percent developing Post Traumatic Stress Disorder as a result (PTSD Alliance, 2000). Several methodologies have emerged to meet the therapeutic need resulting from traumatic events. Therapeutic interventions for trauma historically have been derived from two major theoretical categories: exposure therapy and cognitive therapy. Exposure techniques desensitize the client to the intense emotional reactions to the relived event by bringing that event repeatedly into consciousness (Emery, 1996; McFarlane, 1988; Piers, 1996; Rachman, 1966; Van der Kolk, McFarlane, & Weisaeth 1996). “Re-exposing the trauma victim to his experience has remained a core component of trauma intervention” (Steele & Raider, 2001).
A second historical approach has been cognitive therapy. The basic premise is that thoughts impact emotional states and by changing the thoughts one can alter the disturbing emotions. Theorists in this category include Beck (1976), Marks (1972), and Saigh and Bremner (1999) among others. Thus, “disturbing, anxiety ridden, pathological emotional states are driven by dysfunctional thoughts. Cognitive therapy suggests that by changing the thoughts, the emotional states change….Cognitive therapy is used to provide a rationale for the victims to expose themselves to the pain of their experience. It is also used to reframe their perception of that experience and as a means of stopping dysfunctional thinking” (Steele & Raider, 2001).
More recently, two other trauma relief methods have gained recognition. Drawing, or Art Therapy, has been used largely with children, although, more recently with adult trauma survivors. With children the rationale appears to be that they lack the intellectual apparatus to express themselves and particularly to express the emotions of disturbing events. Thus they would draw out their experiences and the therapist would interpret them. This method seems to be a hybrid exposure and processing method. The exposure occurs through creative expression and the cognitive therapy occurs through interpretation of these drawings. Several authors have attested to the efficacy of this treatment including Beyers (1996), Magwaza et al (1993), Malchiodi (1998, 2001), Pynoos and Eth (l985), and Steele and Raider (2001).
Another model, Eye Movement Desensitization and Reprocessing (EMDR) has recently emerged. This, too, appears to be a hybrid model composed of both exposure and cognitive processing features. “With EMDR we ask the person to think of the traumatic event, and then we stimulate the person’s information-processing system so that the traumatic experience can be appropriately processed, or ‘digested’. As this ‘digestive’ process takes place, insights arise, the verbal associations are made, whatever is useful is learned and the appropriate emotions take over” (Shapiro, 1997). All of the above methods have had varying degrees of effectiveness and have undergone various amounts of scientific testing.
The Trauma Relief Unlimited (T.R.U.) method was developed from Robert M. Cicione’s more than 20 years of experience as a psychotherapist and visual artist. Cicione was distressed at the amount of time needed to achieve results from the above methods and concerned with the painful negative side effects clients could experience from reliving the event. Wanting to integrate the revitalizing power of art to bolster the human spirit, Cicione began developing the T.R.U. method seven years ago. T.R.U. was derived from and shares common features of traditional art or drawing therapy, and it integrates other elements of the aforementioned methodologies. Informal data collection from Cicione’s private practice produced some of the first evidence of T.R.U.’s effectiveness. Clients reported that PTSD symptoms were greatly reduced or eliminated with one to six T.R.U. treatments. Over 700 clients were treated with no or very slight, short term negative after effects such as mild fatigue or confusion. The T.R.U. treatment protocol produces results unrelated to age, gender, ethnicity or other demographic factors.
In order to scientifically test the efficacy of the T.R.U. method, a T.R.U. Pilot Project was developed and completed in September 2000. The pilot test used a pre-post treatment design with 10 trauma surviving children between 8 and 14 years of age. These multiple-episode survivors received three, forty-five minute T.R.U. treatments and were pre and post tested using Briere’s (1996) Trauma Symptoms Checklist for Children-Alternative Version (TSCC-A) and a Symptoms Tracking Form (STF) developed by Cicione (2000). Trauma symptom scores were significantly lower (p<.01) at post test on three of the five scales (anger, depression, and post-traumatic stress.) More importantly,’ TSCC-A scores continued to decline without further T.R.U. intervention to the point that all scores were significantly lower (p<.05) at the four month follow-up in comparison to the pre-test levels.
The STF collected frequency of client reported symptoms on a weekly basis. The median score before treatment was 8.6 trauma symptoms per week and 0.4 trauma symptoms after three T.R.U. treatments. Four month follow-up testing indicated all clients retained treatment gains.
This research brief reports the results of the next phase of T.R.U. effectiveness testing. The goals of this research study were three fold: (1) use an experimental and control group design with a larger sample; (2) test the efficacy of T.R.U. with adults using a standardized trauma symptom instrument; and (3) test the replicability of the method through the use of an independent therapist. It was hypothesized that T.R.U. would significantly reduce the symptoms of trauma in those treated and that these results would remain stable over time, regardless of who administered the treatment.
Intervention
The T.R.U. treatment protocol consists of a series of kinetic exercises designed to activate the right hemisphere of the brain. The client is guided through a series of hand movements, using a 12”x 18” drawing pad and several multicolored markers. Unlike traditional art or drawing therapy, the client is discouraged from drawing pictures. This is seen as a distraction from ongoing, more therapeutically significant processes. Cicione’s clinical experience indicates that adults experience performance anxiety when asked to draw. Therefore, drawing pictures is not part of the T.R.U. protocol. The process is designed as a non-verbal one. In fact, verbal expression during treatment is discouraged, since it has been found to lead to distraction from, and avoidance of, more significant ongoing, internal therapeutic processes. This non-verbal aspect of the treatment spares the client the need to verbally express disturbing emotional material sometimes leading to anxiety, emotional upset, flashbacks, vomiting or other regressive effects of other trauma treatments.
Unlike EMDR, there is no regression to “child self” experiences or distinctions made between adult and child self that may lead to further fragmentation. Also, unlike EMDR there is no left brain, internal processing like “interlooping or interweaving” (Parnell, 1997). Thus, T.R.U. is a very safe method with no reported cases of regression requiring emergency intervention, medication or hospitalization in over 2100 treatment sessions. The T.R.U. client is simply guided through a series of 12 to 15 “exercises” in a forty-five minute clinical protocol. Once complete, the symptoms are eliminated. In the current study each participant received a 45 minute individual treatment session once a week for three weeks. The delayed treatment group started treatment one month after the first group began treatment.
Participants
Participants were recruited through newspaper advertisements and professional referrals. To be eligible, they had to have experienced at least three episodes of trauma with symptoms of post traumatic stress, had no diagnosis of a major mental disorder or substance abuse, and be at least 18 years of age. Out of 61 applicants, 40 were selected into the study and randomly assigned to an experimental group for immediate treatment or a one month delayed treatment control group. Of these recruits, two in fact had bipolar disorder and substance abuse was suspected in two others. Due to scheduling conflicts, 25 participants entered the immediate treatment group. Of the 15 in the delayed treatment group, three dropped out before receiving treatment, leaving a final N of 37 for analysis. The average age was 44, with a range of 21 to 64. Of the 37 participants, 32 were women, 35 were white and three were black.
Instruments
Data collection instruments included the Trauma Symptoms Inventory (TSI) developed by Briere (1996) and a Symptoms Tracking Form (STF) developed by Cicione (2000). The TSI is a standardized 100 item self report questionnaire that measures post traumatic stress and related psychological symptomatology. It yields 10 clinical scales and three validity scales. A standard T-score is calculated for each scale which can be compared to the T scores of the participants in the standardization sample. T-scores have a mean of 50 and standard deviation of 10, with a score of 65 used as a clinically significant cut-off score.
The Symptom Tracking Form is a clinician interview form developed to measure the weekly frequency of specific post traumatic stress symptoms such as violent episodes, angry outbursts, nightmares, flashbacks, anxiety symptoms and crying episodes. Clinicians also rated the participants’ level of depression on a six point scale with 0 being no depression and 5 being a high level.
Data
collection
Both the experimental and control groups were pre-tested in the same time period with the Traumatic Symptoms Inventory and Symptom Tracking Form. The experimental group then received three treatment sessions one week apart. The post test administration of the TSI and STF occurred two weeks after the last counseling session and again four months later. The control group was pre tested again at the beginning of their delayed first treatment session. This score was the one used for comparison with post test results. In order to test for experimenter bias, two therapists conducted the interventions: the founder and a clinician with 10 years of professional experience, but not in the field of trauma. The second therapist received eight 45 minute pre-study training sessions with the founder.
Analytic
procedures
T-Tests were used to compare the mean scores between the experimental and control groups at baseline and between the two therapists’ results. T-Tests were also used to compare pre and post test scores, post test and follow-up scores, and pretest-follow-up scores on both the TSI and the STF.
As Table 1 indicates, a significant reduction (p<.01) occurred in the clinical symptoms on all ten of the TSI clinical scales, confirming the H1 hypothesis that T.R.U. would significantly reduce traumatic symptoms. Participants’ scores were in the clinically significant range on four of the ten scales (anxious arousal, depression, intrusive experiences and dissociation), but all scores were within normal range at post-test and at follow-up. Scores remained remarkably stable at the four month follow-up, with all remaining significantly reduced from their pre-test level. No significant differences occurred in the scores of the experimental and control groups at baseline or between the baseline and first pre-treatment scores of the control group on either the TSI or the STF.
Table 1. Pre and Post Treatment Scores for TSI
Clinical Symptoms
|
TSI Scale |
Pre-Treatment T-score Mean |
s.d. |
Post-Treatment T-score Mean |
s.d. |
t value** |
Follow-up T-score Mean |
s.d. |
t value** |
|
Anxious Arousal |
66.56 |
9.25 |
49.58 |
8.92 |
7.93 |
48.34 |
10.82 |
7.48 |
|
Depression |
65.25 |
9.76 |
50.61 |
10.19 |
6.22 |
49.69 |
10.43 |
6.36 |
|
Anger/Irritability |
59.53 |
9.89 |
47.50 |
8.98 |
5.40 |
47.41 |
8.80 |
5.31 |
|
Intrusive Experiences |
66.69 |
11.22 |
50.97 |
12.23 |
5.68 |
50.94 |
10.35 |
5.99 |
|
Defensive Avoidance |
63.33 |
10.21 |
50.14 |
9.11 |
5.79 |
49.38 |
9.29 |
5.87 |
|
Dissociation |
65.56 |
10.51 |
50.56 |
10.39 |
6.09 |
49.19 |
7.61 |
7.27 |
|
Sexual Concerns |
59.61 |
13.13 |
49.19 |
8.50 |
3.40 |
47.97 |
8.94 |
4.31 |
|
Dysfunctional Sexual Behavior |
56.44 |
14.89 |
47.67 |
5.42 |
3.32 |
47.72 |
7.40 |
3.11 |
|
Impaired Self-Reference |
63.86 |
9.26 |
50.47 |
8.47 |
6.40 |
49.16 |
8.58 |
6.77 |
|
Tension Reduction Behavior |
57.53 |
12.42 |
47.83 |
6.53 |
4.14 |
47.62 |
7.16 |
4.08 |
N = 37 **p< .01 for all values at post treatment and follow-up
Results from the Symptoms Tracking Form indicate scores decreased on all measures (see Table 2). Significant decreases (p<.01) occurred on three of the seven symptom ratings (flashbacks, anxiety, and depression) at both post-test and follow-up, with the mean number of symptoms consistently decreasing on all measures between post treatment and follow-up.
Table 2. Pre
and Post Treatment Scores for Self-Reported Symptoms
|
Symptom |
Pre-Treatment Mean |
s.d. |
Post-Treatment Mean |
s.d. |
t Value |
Follow-up Mean |
s.d. |
t Value |
|
Violence |
.32 |
1.19 |
0 |
|
1.63 |
0 |
|
1.63 |
|
Anger |
0 |
|
0 |
|
- |
0 |
|
- |
|
Nightmares |
1.55 |
1.91 |
.74 |
1.59 |
1.97 |
.69 |
1.79 |
1.92 |
|
Flashbacks |
10.69 |
19.14 |
.70 |
2.38 |
3.15** |
.44 |
2.47 |
3.22** |
|
Anxiety |
4.81 |
6.89 |
1.14 |
3.57 |
2.88** |
.45 |
1.36 |
3.76** |
|
Crying |
2.73 |
8.17 |
.78 |
1.49 |
1.42 |
.28 |
.68 |
1.81 |
|
Depression |
3.30 |
1.43 |
1.32 |
1.43 |
5.92** |
.91 |
1.20 |
7.45** |
N=37 ** p< .01
In the comparison of clinician interventions, the T.R.U. founder treated 15 clients and the second therapist 10 clients in the experimental group. The T.R.U. founder subsequently provided treatment to all the clients in the control group. The numbers were too small to reliably analyze the results of the TSI scores. Higher levels of self-reported symptoms of flashbacks, crying and depression were reported to clinician 2, a woman, than clinician 1, a man. At post test the frequency of symptoms were near zero for both therapists.
The Trauma Relief Unlimited brief intervention method shows promising results that demonstrate stability over time and preliminarily across therapists. It is a cost effective method that can be easily taught to other trained professionals who have little experience counseling trauma survivors. It has few if any negative side effects. It works with both children and adults, apparently without regard to the severity of the symptoms expressed. Even the two participants with diagnoses of bipolar disorder who were allowed into the study demonstrated greatly reduced symptomatology. Biochemical understanding of brain functioning is not sufficiently developed to explain why the method works. All we know is that empirically, the T.R.U. method works. Future articles and research will address in greater detail the similarities and differences of the T.R.U. method to current psychological theory and practice (Cicione, in process). Ongoing brain research may also better explain the dynamics by which it works.
Recommendations for future research on T.R.U. are as follows. Replicate the current study. Increase sample size, particularly when using more than one therapist to administer the method. Increase the diversity of the sample demographically and diagnostically for various mental and physical disorders. Utilize instruments that measure the neurobiological impact of trauma and are sensitive to changes over time. Extend the follow-up period to at least two years post test with quarterly or triennial data collection. Compare the effectiveness of T.R.U. to other trauma intervention methods. Such research will provide us with a better scientific understanding of the capabilities of the T.R.U. method and its long term effectiveness. Our ultimate goal is to provide proven research based interventions to trauma survivors.
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