Sponsored by The
Rhode Island Foundation
In
Collaboration with Rhode Islanders Sponsoring Education
T.R.U.
Treatment Provider
Project
Director
Report Submitted August,
2000
As
Director of the Trauma Relief Unlimited (T.R.U.) Pilot Project, I am pleased to
acknowledge the many people who made this project possible. First and foremost, I am deeply indebted to
my wife, Joan McLaughlin, Director of Marketing and Training for the T.R.U.
Program, for her unwavering support, valuable suggestions and constant faith in
me and the T.R.U. method.
I am grateful to Dr. Ronald Gallo,
President of the Rhode Island Foundation, and his staff, for funding this
project. Dr. Gallo immediately recognized
the “ breakthrough” potential of the T.R.U. method.
Many thanks to Dr. Kevin Vigilante,
Co-Founder of Rhode Islanders Sponsoring Education (R.I.S.E.), for offering the
R.I.S.E. Program as a venue for the project.
Dr. Vigilante’s agreeing to guide and “mentor” me throughout the project
was always helpful, if not critical, to the project’s development and
completion.
Particular thanks to Kristen
Heffenreffer-Moran, Executive Director of R.I.S.E., for approving the project
and offering administrative leadership and assistance throughout the project.
The help of Anna Morales, M.S.W.,
Administrator at R.I.S.E. was invaluable, particularly during the
implementation stages of the project.
Her skills in coordinating the various involved parties including
R.I.S.E. students, their parents, school administrators, teachers and others
was greatly appreciated.
Many thanks to the four
participating school administrators and their assistants. At times, I was amazed at how smoothly the
project went. Without their help, the
going would have been much more difficult, if not impossible.
I am grateful for all the parents,
students and teachers who gave their time and attention to the project, often
“beyond the call of duty”. Their
participation in filling out questionnaires and giving attention to differences
in student performance was valuable in giving validity and perspective to the
project.
Speaking of validity and
reliability, many thanks to Dr. Christopher Willis for providing the necessary
scientific perspective. Dr. Willis was
particularly helpful with data tabulation and analysis at the conclusion of the
project.
Many thanks to Dr. Vicki Moss, Dr.
Tom Guilmette, Dr. Raymond Kilduff, Ms. Rebecca Silver and the folks at Western
Psychological Services for their help in choosing an appropriate test for the
project.
Finally, I am very grateful to the
ten R.I.S.E. students who participated in this study. Ultimately, without their willingness and
cooperation, this project would not have been possible.
Robert M. Cicione, L.I.C.S.W.
The
Trauma Relief Unlimited Pilot Project was truly a collaborative venture between
The Trauma Relief Unlimited (T.R.U.) Program, Rhode Islanders Sponsoring Education
(R.I.S.E.), and The Rhode Island Foundation.
T.R.U. provided the treatment methodology, application and overall
design of the project. R.I.S.E. and its
associated schools provided the venue, support personnel, students and
coordination of the various aspects of the project. The Rhode Island Foundation provided the
funding.
The
project commenced in February 2000 when the Rhode Island Foundation approved a
$5,000 grant. During the next two
months, T.R.U. and R.I.S.E. worked together to design and organize the
project. Project participants were
selected; the support and participation of parents/guardians and school
authorities was solicited, and treatment schedules at four participating
R.I.S.E. network schools were established.
Also, appropriate tools to measure change in student attitude, behavior
and performance were selected. A “before
and after” format was chosen to demonstrate the power and effectiveness of the
T.R.U. method.
The
treatment phase began in May. Ten
R.I.S.E. students took the Trauma Symptom Checklist for Children-Alternative
Version (TSCC-A) a nationally recognized, standardized test for PTSD in
children. This “before test” established
a clinical baseline for treatment. Three
other cross-checking tools were also instituted before treatment. A Parent Questionnaire that consisted of ten
questions about their child’s behavior was administered to parents of
participating students. A second questionnaire
was given to teachers to record changes in student behavior. Finally, a weekly inventory by the therapist
was administered to each student monitoring changes in common symptoms of PTSD
including flashbacks, nightmares, anxiety attacks, violent episodes and
depression. Each student was
subsequently treated in three successive weekly sessions with the T.R.U.
method. Two weeks following the last
treatment session the student took the “after test”, i.e. a second TSCC-A
test. Scores on the “before test” and
“after test” were subsequently tabulated, compared and analyzed. A second post test, approximately three
months after the treatment, is planned.
This post test would add a longitudinal perspective to the project.
The
Trauma Relief Unlimited method took nearly twenty years to develop. The first fifteen years, I used a variety of
art related exercises on myself as a form of my own self-therapy. At a very early stage, I recognized the
psychological value of art to bolster the human spirit and to cleanse those
residuals from the self that tended to sap that spirit. In effect, I observed that art was an
incredibly powerful process for ridding oneself of excess anxiety and for
raising one’s spirits. In short, the
incredible renewal, rejuvenation and revitalization power of art was recognized
and acknowledged.
Approximately
seven years ago, a professionally traumatic episode changed the course of my
career. I had been treating abuse
survivors for years using traditional left-brain, talk therapies. In this instance, it took nearly two years
for this particular patient to access and to share one of the most disturbing
and ghastly episodes of physical/sexual abuse I had heard before or since. Within twenty-four hours of that disclosure,
this person made a serious suicide attempt resulting in hospitalization. I can recall sitting in the psychiatric
hospital reflecting on this episode. I
knew then there had to be a better way.
The
convergence of the recognition of the revitalization power of art and the need
to find a more effective way to treat trauma survivors resulted in the birth of
the T.R.U. method. Six years ago, I
began using what I knew about art to treat others. I began developing a right-brain, non-verbal
protocol to treat patients. After many
changes and refinements, the T.R.U. method was developed into what it is
today. (Note attached T.R.U. brochure
and Description of Treatment). In
effect, the T.R.U. method is a streamlined version of traditional Art Therapy. Whereas Art Therapy takes several months to
get results, T.R.U. takes one to six weeks.
In the case of a one-episode trauma consistent and reliable results
occur in one 45-minute application.
Unlike traditional Art Therapy that has historically been used almost
exclusively with children under 12 years old, the T.R.U. method is user friendly
for all ages. In short, the T.R.U.
method represents a major breakthrough in treating trauma survivors surpassing
in effectiveness both traditional Art Therapy and more commonly used
left-brain, talk therapies.
From the experience of the very first
T.R.U. treated patient, I knew the power and effectiveness of this new
methodology. A one-episode molestation
survivor was able to unload nearly fifty years of weekly flashbacks and
nightmares with three applications of the treatment. Today with refinements to the process,
symptom extinction would likely occur in this case with one application of
T.R.U. After treating hundreds of
similar patients during the past six years, the results are convincing.
However,
in this empirically/scientifically based culture of ours, there is a need to
produce more than one’s own personal experiences or even one’s professional
observations. In January of this year, I
began looking for a sponsor for a pilot project that would produce the first
empirical evidence of the power and effectiveness of T.R.U.
The Rhode Islanders Sponsoring
Education (R.I.S.E.) Program provided a valuable venue for observing the
effects of the T.R.U. method. R.I.S.E. is
a network of 23 schools providing education to approximately 110 students. All students are from “high risk”, inner city
environments. All had experienced at
least one trauma through the incarceration of at least one parent, usually
mother. Of the ten participating
students, most had experienced this separation trauma before the age of eight.
The
first design objective was to treat a significant number of actual trauma
survivors from the general population of 110 R.I.S.E. students. A significant sample of ten students was
ultimately selected from the general population. All ten students participating had
experienced other traumatic episodes in addition to the separation trauma of
incarceration noted above. All ten had
experienced at least one episode of physical abuse, sexual abuse, rape, or the
death of a close family member. Thus,
the first objective of selecting actual trauma survivors for this pilot was
achieved.
A second
objective was to provide a sufficient number of applications of the T.R.U.
method to provide necessary scientific data of observable change. Three such T.R.U. treatment applications were
provided by Robert M. Cicione, L.I.C.S.W.
This series of three weekly treatment sessions was preceded by a
Psycho-Social Evaluation of each student.
This was a fairly standard Psycho-Social Evaluation commonly used for
initial intake in the psychotherapy field.
It served to summarize the psychosocial experience of each student and
to provide an overview for the therapist.
A particular emphasis was placed on significant trauma experiences
reported by each student. In all cases,
at least three major trauma episodes were identified for treatment. In some instances, more than three were
reported. In this instance, the
therapist, with student input, chose those three most significant for
treatment. Usually, the most severe were
treated. One student for instance, had been raped three times in addition to
multiple episodes of physical abuse and the aforementioned incarceration
separation trauma. Because the sexual
episodes were most likely to cause the most psychological damage, they were
given priority for treatment.
The
Psycho-Social Evaluation also provided a baseline for therapist observations of
change in common trauma symptoms. Accordingly,
the therapist noted on a weekly basis the number of
common trauma symptoms including
flashbacks, nightmares, anxiety attacks, violent episodes and depression. In the later case, a five-point scale of
depression was used to note changes in suicidal material and in vegetative
signs. (Note the graph and data sheets
of therapist observations of symptom changes attached here: Graph 1 and Graph 2).
The third objective of the pilot design was to
provide more than one series of observations of change in student
behavior. In actuality, four series of
data were tracked adding to scientific validity and reliability. In addition to those observations of the
therapist noted above, there were three others.
A second series of data came from the standardized test, the
TSCC-A. Note the “before and after” data
graph attached and the report
of the Psychometrist attached. Both
the tool itself and Dr. Willis’ interpretation of results are valuable measures
of the power and effectiveness of the T.R.U. method. A third data stream was produced by a
questionnaire given to parents. (Note attached graph that
indicates parent observations of change).
Finally, a fourth collection of data came from the teacher reports. An attempt was made to get quantitative
teacher evaluations of the student behavior change. Because of some teacher confusion in
interpreting the form and in inconsistencies of reporting, quantitative data
from teachers is not reported. However,
in more than one-half of all the cases, positive comments were noted by
teachers about changes in student behavior.
This was quite significant in itself since one would expect academic
changes to have many roots in addition to previous trauma experiences. Moreover, positive teacher responses were
remarkable since the study occurred at the end of the school year. Although not an educator, I wonder if there
isn’t a momentum – positive or negative – as the school year moves on.
From
a design perspective, it is important to note that multiple observation and
data collection streams add to scientific validity and reliability. Important for our purposes, all four data
collections support the direction, if not the degree, of positive changes. In short, the therapist, the parents, the
teachers, and the standardized testing device all point to the power and
effectiveness of the T.R.U. method.
This Trauma Relief Unlimited (T.R.U.)
Pilot Project presents scientific data to support the breakthrough impact of
this new and innovative methodology. The
data speaks for itself. The data
warrants a more formal, more extensive, research project that would erase any
lingering doubts about the power and effectiveness of T.R.U. Perhaps a study with a larger sample, or one
with a control group, would add to scientific validity and reliability.
From
a human standpoint, a more formal study, greater in scope, might also afford
the opportunity to treat more people in need.
Perhaps all abuse survivors in the R.I.S.E. Program, for instance, could
be treated under an expanded format.
Perhaps, other programs serving other populations of trauma survivors
could be considered.
From
a need standpoint, with the growing concern about violence, especially in
schools, there seems to be little doubt about the potential of the T.R.U.
Program to meet the challenge of safety.
And this is but one possible application. Concerns about the growing incidence of
domestic violence would seem to offer another obvious application. The violence reduction and elimination data
of the project would seem to overwhelmingly support T.R.U. effectiveness in
violence prevention and elimination. The
possible applications in this connection would seem to be virtually unlimited.
From
an economic perspective, T.R.U. offers a great opportunity to address problems
of violence and abuse with “cost effectiveness”. The brief intervention nature of the
methodology could save both economic and human resources to address a variety
of problems. The fact that T.R.U. is
transferable suggests that others could be trained in a relatively short period
of time. Moreover, comparisons to other
methods seem to suggest that the method itself is “easier on the therapist”
than other thought intensive methods.
The fact that symptoms, once eradicated do not recur, suggests the
mounting tide of abuse and violence could be abated. More importantly, “the cycle of abuse”, often
generational, could be broken.
There
is a willingness to pursue any and all objections to T.R.U., including doing a
more formal research project. At some
point, however, this method needs the support of all interested community
members to meet even a fraction of some of the problems facing us as a
society. Once again, the pioneering
support of the Rhode Island Foundation has been greatly valued and appreciated.
Compiled and written by Dr. Christopher S. Willis, Ph.D. with assistance from Robert M. Cicione, LICSW, the treating clinician and data collector.
This pilot project examines the
effectiveness of the T.R.U. method in reducing the psychological symptoms
commonly associated with post-traumatic stress disorder in children;
specifically anger, anxiety, depression, dissociation, and post-traumatic
stress. It is hypothesized that the
T.R.U. method will reduce the frequency of these symptoms.
METHOD
Measures
Each
subject completed the Trauma Symptom
Checklist for Children-Alternate Version (TSCC-A) as a pre-treatment and
post-treatment measure. The TSCC-A is a
self-report measure of post-traumatic distress and related psychological
symptomatology. Forty-four items yield
five clinical scales (anger, anxiety, depression, dissociation, and
post-traumatic stress) and two validity scales (under-response and hyper-response). Reliability analysis of the TSCC-A scales in
the normative sample (N=3008) demonstrated high internal consistency (alphas
range from .82 to .89). Convergent,
discriminant, and construct validity data are provided in the TSCC Professional
Manual (Briere, 1996).
A clinical interview was conducted as part of an initial intake
evaluation and prior to each treatment session.
Subjects responded to regular therapist inquiries regarding the
frequency of violence, angry outbursts, nightmares, flashbacks, and anxiety
attacks. Subjects also indicated a level
of depression (1-5) at each session.
Frequencies were reported in terms of the number of times per week they
experienced the particular category.
The mothers of nine subjects
responded to a parent questionnaire as
a pre- and post-treatment measure.
Mothers indicated the frequency (1=Never to 4=Almost Always) with which
they observed their children engaged in ten types of behavior/feelings (e.g.,
“I observe my child getting into fights”).
Teachers of the subjects were also
asked to respond to a pre- post-treatment Student
Status Report. Confusion with the
form resulted in inconsistent quantitative data, however, qualitative data are
reported.
Participants
Eight males and two females, ranging
in age from 8 to 14, were selected from nominations made by the administrative
director of Rhode Islanders Sponsoring Education (RISE). All subjects attended a non-public inner-city
school. Seven were African-American, two
were Hispanic, and one was Caucasian.
All had a history of one parent being incarcerated at some point in
time.
Procedure
Each subject was met by the T.R.U.
therapist for an evaluation session prior to beginning treatment. Demographic information and pre-treatment
data were collected at that time.
Following the evaluation session, subjects were met by the therapist for
three treatment sessions. The
intervention was time limited because it was felt that three treatment sessions
were sufficient to significantly reduce the frequency of symptoms and provide
relief from post-traumatic distress.
Financial limitations were also a consideration. (An additional session was provided to one
subject who was assaulted during the weeks he was in treatment.) The mean time between the evaluation session
and the collection of post-treatment data was 38.6 days (median = 35). Post-treatment data was collected within two
weeks of the final treatment session.
RESULTS
Prior to treatment, subjects
reported significantly higher frequency of anger (M = 52.5, SD = 10.4)
than they did following the treatment (M = 43.5, SD = 6.8), t
(9) = 3.55, p < .01. Subjects
reported significantly greater pre-treatment depression (M = 54.2, SD
= 11.6) than they did post-treatment (M = 42.4, SD = 5.8), t
(9) = 3.15, p < .05. Pre-treatment
levels of post-traumatic stress were reported at a significantly higher level (M
= 54.0, SD = 9.9) than they were following the treatment protocol (M
= 40.8, SD = 6.0) t (9) = 3.67, p < .01.
The difference between the pre-treatment
levels of anxiety reported on the TSCC (M = 52.4, SD = 10.8) and
the post-treatment levels (M = 42.5, SD = 6.4) approached
statistical significance, t (9) = 2.18 p < .058). (See table 1).
Table 1. Pre – and Post – Treatment Scores
for TSCC Factors
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|
Pre Treatment |
Post Treatment |
|
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|
Variable |
Mean |
SD |
Mean |
SD |
df |
t-value |
Signif. |
|
Anger |
52.5 |
10.4 |
43.5 |
6.9 |
9 |
3.55 |
.006 |
|
Anxiety |
52.4 |
10.8 |
42.5 |
6.4 |
9 |
2.18 |
.058 |
|
Depression |
54.2 |
11.6 |
42.4 |
5.8 |
9 |
3.15 |
.012 |
|
Dissociation |
54.0 |
13.2 |
46.7 |
14.7 |
9 |
1.38 |
.200 |
|
Posttraumatic Stress |
54.0 |
9.9 |
40.8 |
6.0 |
9 |
3.67 |
.005 |
A marked decrease in dissociation from
pre-treatment levels (M = 54.0, SD = 13.2) to post-treatment
levels (M = 46.7, SD = 14.7), was not statistically significant, t
(9) = 1.38, p = .200. However,
one subject indicated a significant increase in dissociation following an
assault that occurred near the end of his treatment.
The total frequency of
post-traumatic symptoms reported also showed a marked decrease over the course
of the treatment. (See figure 2). The total number of symptoms (violence, angry
outbursts, nightmares, flashbacks, and anxiety attacks) reported by the subject
to the therapist dropped from a mean of 8.58 per week (Evaluation Session) to
0.4 per week (Third Treatment Session).
The frequency of observed behaviors
and feelings that the mothers of the subjects reported also decreased as a
result of the treatment. The mean
pre-treatment score for the Parent Questionnaire was 8.22 (N=9). The mean post-treatment score was 3.67. (See figure 3).
The teachers of five subjects noted an
improvement following the treatment.
Comments included; “(EL) shows many fewer incidents of crying and
getting upset…better able to handle conflicts appropriately.” “(TP) is “less argumentative,…improvement in
making up work.” “(AA) has had several days
when he does all assigned work. I have
really noticed a change in a positive direction.” “(SM’s) attendance has improved.”
The teachers of two subjects
reported no positive changes. Three
teachers provided no report of change following the treatment.
DISCUSSION
The findings of this pilot project
indicate that the T.R.U. method effectively reduces psychological symptoms
associated with post-traumatic distress.
Improvement in functioning was noted via self-report measures, clinician
interview, parent report, and teacher report.
Threats to the validity of these
findings include the small sample size (N=10) and the fact that the treatment
protocol was conducted by a single therapist.
Further research with larger samples of clients and additional
therapists is recommended. As the T.R.U.
method purports to impact the non-verbal, right-brain imprinting of the
traumatic experience, a non-verbal measure of effectiveness (e.g.,
Draw-A-Person) should be added to the pre- and post-treatment test battery.
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