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Finding an Evaluation Criterion 
for Trauma's Resolution

About/ Theory/ Measuring for Trauma Resolution describes the ETM method for measuring for trauma's resolution.

Until the time of this (1992) writing, trauma resolution and etiology reversal were described from three points of view. There was the objective (observations of symptom reduction) view that came from the clinician's perspective, the subjective (the client's description of the resolution experience -- self report) view that came from the trauma victim's perspective, and the ETM perspective, which was and still is comprised of a mixture of both the objective and subjective perspectives, but under special criterion and guidelines. This chapter considers the first two methods as their deficiencies contributed to the establishment of the ETM measurement approach.

Objective Perspective (Symptom reduction)

The objective view results from an appraisal of symptoms by someone other that the trauma victim. Van der Kolk (1987, pg. 12-14) explains this approach in his study of resolution; he quotes Horowitz's (1976) description of trauma resolution: "the capacity to recall the trauma at will, while being equally capable of turning one's mind to other matters." In this approach, one that is dependent upon the clinician's observations of behavior, trauma resolution is determined by the ending of certain symptomatology: the inability to recall the trauma at will and without becoming obsessed by the experience while making the recollection.

Other attempts to clarify, understand or define "trauma resolution" through the appraisal of symptoms are provided through van der Kolk's review of studies of kidnapped (Terr, 1983) and rape (Burgess and Holstrom, 1974) victims. In both of these studies trauma victims were observed periodically over a matter of years. The symptoms of the trauma were seen as continuing, inferring that resolution was a protracted and indefinite process with an inconclusive ending.

There are several problems with the symptom focused approach to determining resolution. They are overviewed in the rest of this subsection.

First, in the literature, symptoms are described as coming and going without consistent or predictable patterning. Their non appearance does not mean that the PTS condition does not exist (Bower, 1988). Van der kolk (pg. 14) describes his own studies (1985) of the failure of the focus on certain symptoms to provide a consistent means of measuring or testing for PTSD. Furthermore, he also describes (1987, pg. 14) Laufer's criticisms of the DSM diagnostic criterion for determination of a PTSD,
both intrusive reexperiencing and denial are required for a positive diagnosis. They (quote: Laufer et al., 1985) call for a clearer bidimensional approach in defining PTSD, in which either dimension may dominate, at the exclusion of the other, at different stages.
Thus, based upon the literature's consideration of symptoms, delineation of them is an unreliable method of determining that the PTS condition exists; symptoms may not always be present or apparent, or they may reappear at any time. In our observations of symptoms, however, the symptoms only "come and go" or reappear, as a rule, if the client is using psychoactive substances, drinking alcoholic beverage, simultaneous (between sessions) with the application of the therapy. When the use is ended (and the person uses the structured TRT process as directed), the symptoms disappear and do not come back, at least during the periods in which we have seen or otherwise had contact with the individual (often as long as 2 years as the client may have been engaged in other treatment processes: see Clinical/ Family).

We were careful to observe in the literature whether those conducting their studies accounted for the prospective influence of such drug use as a parallel therapy (medication). None did, except where general comments were made about the undefined levels of reductions of such use in certain situations, which studies, in the main, told us that parallel drug (alcohol) use was occurring while the studies on symptoms were being conducted, but the parallel drug use was not being accounted for: the drug use was not being considered as an interfering, or at least influencing, variable as we consider it to be.

Thus, the symptom reduction measurement method is a reliable evaluative device if used to determine if trauma resolution is occurring or has occurred in the application of TRT, and when no parallel drug (alcohol) therapies are interfering with the process. However, the literature does not support measurement of symptom reduction as a determiner of trauma resolution because the manifestations of PTS symptoms are shown in those studies to be indiscriminate. Moreover, symptom appraisal methods that have attempted to evaluate for a particular therapy's effectiveness in the treatment of PTSD have been shown, with one exception (Solomon, 1992), to be inconclusive; the exception is that flooding is demonstrated to have a consistently positive effect across all kinds of trauma.

A second problem with the symptom approach, and again, one that is also not recognized in the literature, is that a focus on symptoms, survival responses, with the intent to eventually change those symptoms as a condition for recognizing that resolution has occurred, will paradoxically reinforce the very survival defense structure that protects the person from experiencing the damage resulting from the trauma (see chapters 3 and 14 in the text). Therefore, symptom focused approaches that rely on measuring, defining and determining behavior, can themselves become an integral part of the trauma's defense structure, thus removing the primary value of its (symptom focused) approach; assuming our theory is correct, when the method becomes part of the problem, the symptom focused method must lose its claim to objectivity -- objectivity is an illusion.

The third problem with the nosotropic model is that the locus of the responsibility for trauma resolution is assumed by the observers to lie within the ontology of the trauma victim. "Locus of responsibility for the trauma's resolution" means that the trauma's resolution is a function of what the individual does or doesn't do toward resolving the trauma. In this concept of resolution, the victim may resolve the trauma or not.

Moreover, in terms of time and conclusion, the resolution process is indeterminate. We suspect that this attitude about resolution is a consequence of the use of psychotherapy and non structured grief resolution models in the treatment of trauma victims.

The idea spawned by these models is that the Self that is damaged by the trauma and loss will progress, that is, restore the damaged state to non damaged levels, at a pace that is existential in its orientation and to be determined by an undefined actualizing component of the Self. In some instances, there is little to no consideration for the role of interfering variables and the prospects for these variables' adversely influencing the Self's attempts to work out of the trauma's effects.

Consequently, without knowledge of the prospective interfering variables influences and a knowledge of how TRT's structure accelerates, defines, and concludes the resolution process to include preventing interfering variables from influencing that Self's efforts, there is no consideration by the observers that the resolution of psychological trauma can be anything other than a solitary effort and the primary responsibility of the trauma victim. Observations (provided in the literature) of trauma resolution are influenced by these ideologies/ philosophies about and methods for resolving trauma: ideologies, philosophies and methods that are not listed by the scientific approach as influencing criterion for determination of trauma resolution. Conclusions about resolution are unknowingly determined before evaluations are begun.

To make this point clearer through contrast, if measurers of trauma were TRT trained, none would bother measuring trauma resolution in individuals who are attempting to resolve the trauma alone because without special assistance coming from outside of that individual, trauma resolution, etiology reversal, would be considered practically impossible (in cultures where interfering variables occur as a routine matter). If such resolution is going to occur, it will be a function of what those surrounding the trauma victim do or don't do (they do or don't preclude cultural interfering variables from preventing individual resolution efforts) and not a function of the trauma victim's particular personality or activities.

In other words, if psychological trauma etiology is not emphatically identified by those surrounding the trauma victim, and then reversed, rarely will people be able to resolve trauma on their own while living in a culture dominated by trauma coping philosophies and drug use that prevent resolution. The culture will guarantee no resolution occurs (see pages 310-312).

To summarize the use of the objective (symptom focused) perspective in appraising whether trauma resolution has occurred:
  1. The literature does not support symptom reduction measurement as a viable determiner of trauma resolution because symptoms are shown in those studies to come and go.
  2. Symptom reduction measurement can be a viable determiner of trauma resolution in TRT (but under the special criteria described in the last paragraph under this subheading and as considered in the next highlighted summary) because, unlike the evaluative efforts described in the literature, TRT guidelines require consideration of social alcohol use as a parallel and highly likely interfering variable, and that when such use is precluded, and when the TRT structure is appropriately applied, the symptoms do not reappear.
  3. Evaluative processes that focus on the presence of symptoms as the primary measuring device, tend to infer that the goal of the therapy should be to reduce such symptom activity. If symptom reduction is made the primary goal of therapy, such a goal will interfere with the trauma resolution process -- it will become caught up, and eventually controlled by, the paradoxical formation created in response to the damaged existential identity and the incapacitated operational identity. Thus, symptom-focused measurement approaches can lose their objective status because they become, unbeknownst to the researcher or therapist, a participating clinical variable: a part of the systemic psychopathology of psychological trauma.
  4. The objective perspective, as it is represented in the literature, presumes that the initiation of and responsibility for the trauma's resolution is a function of individual ontological makeup, which at least, it may not be, and from the TRT perspective, certainly is not as long as the surrounding system introduces interfering variables, stoicism and drug use.
  5. The objective approach, which relies chiefly on the delineation and categorization of symptoms, is demonstrated as having conflicting variables (as described above and under this subheading), and thus is only reliable under special conditions (described under the heading: "ETM Perspective"). Because of those conflicting variables and special conditions, measurement of symptom reduction cannot be considered as the primary means of determining trauma resolution.

Subjective Perspective (Self-report)

As a rule, self reports, when taken by themselves, are considered anecdotal data; the data is considered unreliable because the information cannot be verified by a third and unbiased party. The evaluator cannot get into the mind of the trauma victim, nor can the data be codified and evaluated within the context of accepted statistical methods; control groups are required.

Moreover, self-reports, when taken from people under the preconception that trauma resolution is a function of individual responsibility and ontological makeup (where systemic interference is not recognized), usually include the subject's (trauma victim's) general descriptions of feeling states, other psychic conditions such as thoughts and attitudes about the traumatic event, and changes (or lack of change) in living experiences; general elicitations of such information are subject to myriad meanings and they are not conclusive. Consequently, the subjective perspective, when limited by preconceptions of trauma resolution and generalizations about psychic conditions, also does not provide an adequate measuring vehicle for trauma resolution.

(Forming the ETM Definition of Trauma Resolution)

Because no logical means existed for determining trauma resolution, and because the structured approach provided us with what we believed was both a clearer definition of trauma and its resolution, Nancy and I developed our own criterion for making that determination. In this perspective, the appraisal of trauma resolution as it occurs within the context of the application of TRT, the measuring device is a combination of subjective and objective methods, but with the application of special criterion that have evolved out of our observations of the trauma resolution therapy process. Trauma resolution per these special criterion involves self-reports and the facilitator's observations.

Self-Report

Numerous self-reports have been taken at the end of the trauma victim's use of the 5 phase structured psychodynamic process. Virtually in every case, those people reported that the trauma had been resolved. To them, "resolved" carried a special meaning; it is described next. Simultaneously, the facilitator has observed the trauma resolution process, even experienced it with the patient. Both, the client and the facilitator/observer, combine to present the following criterion that demonstrates resolution, etiology reversal.
  1. The acute emotional pain and loss resulting from the event is addressed to the extent and degree that the person feels fully "heard" or "finished" with the experience or that the emotional pain is "completely addressed, resolved, and reconciled"; further address, resolution, and reconciliation is unnecessary. In addition, the counselor who has made the journey with that person also experiences a similar sense of completion from that person. The individual also explains that if further address of emotion is necessary, the person would, with confidence, know what to do; the person would know what was required to address any recurring experience. In our facilitation of TRT, such additional needs were rare; we have no recollections of an example of an individual's demonstrating a need to return to, or an interest in returning to, a discussion of the traumatic event for the purpose of addressing emotional pain and loss resulting from that event. Nor have we ever heard of such a requirement by any of the 1000 (at the time of this writing in 1992-93) professionals trained and certified to administer TRT.


    2. and 
  2. The person has an understanding of the following (A - D): ("Understanding" refers to a well grounded intellectual [rational/cognitive] and experiential [empathic, intuitive, emotional, and for some, spiritual] realization.)
When the trauma victim provided a self-report that the trauma had been resolved, that is, the trauma victim described his or her understandings of the trauma and its effects upon the person's life -- the description was provided within the criterion described in "1" and "2: A,B,C and D" from the foregoing, the standard for trauma resolution under the ETM definition had been met. The trauma had been resolved. The etiology created by the event has been reversed.

Facilitator's Observations -- Validation of Resolution

Validation of the trauma victim's self-report that the trauma has been resolved is accompanied by the facilitator's determination through observation of the therapeutic process that:
  1. all contradictions to values, beliefs, images and realities, including both contradictions created by the initial trauma and the survival responses, have been identified.
  2. all losses stemming from those contradictions have been resolved; "resolved" means that they have been identified, experienced, expressed, understood and accepted.
  3. all contradicted values, beliefs, images and realities have been reconstituted.
  4. all grief cycles (described in Part One of the text) related to the individual's passage through the process of identifying the trauma-causing event, its damage to existential identity, survival responses that also damage existential identity, and identification of that specific damage, and reconciling all such damage described herein have been fully negotiated. "Fully" means that no elements of the psychological trauma patterns remain to be addressed.

Observations of TRT Including a 
Comparison to Selected Therapies

The following are general comments about TRT's results, to include a comparison to some predominant approaches used in the treatment of the noted populations. Before making these comments, we list several qualifiers. With that said, over a 7 year period (1979 to 1985), Nancy and I provided, either directly, or indirectly through the supervision of the activities of other professionals, therapeutic services to many people (see ETM's Historical Overview under the Level 4 Development). In addition, at the time of this writing (1992), over 1000 professionals have been certified as ETM counselors. According to the periodic interactions between many of these people and our agents, the professionals trained over the last 9 years have provided TRT to their clients as well. ETM is provided in individual practice and in clinical facility settings where treatment teams are utilized.

Moreover, the TRT short form is routinely applied in crisis management organizations, to include school districts. The rest of this section is based on these experiences, our practice and professional testimonials.

At the time of Nancy's and my direct service endeavors, our focus was on helping people to the best of our abilities, observing the criterion required for a successful outcome, and ensuring those criterion were met (see About/ Development/ Historical). There was no intent to provide qualitative and quantitative test results for the therapeutic community, except as were required under the government and Joint Commission for the Accreditation of Hospital standards; audits of our work were routinely made by licensing authorities (again see ETM's Historical Overview under the Level 4 Development).

In the beginning of TRT's development, that is, between 1980 and 1981, I applied the TRT model to two groups (8 members in one group and 6 in the other) comprised predominantly of battered spouses, women and one man who lived with and/or were beaten by violent alcoholics; Nancy provided in a similar number of groups and to a similar number of and likely affected people some of the models (not TRT) that were in vogue at the time (described in the development section).

TRT was introduced in my group, not as a therapy, but as an ancillary process: an educational means for helping people to organize and manage their understandings of the various trauma's myriad effects (this initial application is described in detail in "Individual TRT" development). Not only were the outcomes of the applications of the new management system extraordinary, shown to have profound therapeutic value, but this value was related by my group members to the members in Nancy's groups. Apparently many of these people knew each other, often through their associations in the Twelve Step programs.

Nancy's group members then asked for the opportunity to use the new educational and management system. Thereafter, Nancy's group members were administered the model to those who wanted to use it; the results were the same as in my group: extraordinary. We then made TRT available to anyone who wanted to use the program.

We have not participated in statistical evaluations of the TRT model's viability because we know that it does reverse etiology and exclusion of controls (people who do not have TRT available to them) from TRT would prevent us from meeting our ethical responsibilities. We did not experiment on trauma victims as such experiments are reflected in the literature (see the bibliography).

Every known response accorded by ETM trained and certified professional's has validated the value of TRT.

Even though we did not and do not engage in experimental projects intended to compare therapeutic processes with TRT, we were repeatedly confronted with the use of other modalities by clients who were participating in parallel treatment processes. We were also apprised of situations where newly training (in TRT) professionals attempted to use the various models (not TRT) underpinning their professional experiences and prior to learning about TRT.

From these experiences (addressing TRT's differences from other therapies) we were able to ascertain enough of an evaluative view to report general observations and express subsequent opinions, that is, make claims about, the therapeutic efficacy, in part relative to the other approaches, of TRT. Such observations, opinions, and claims are presented here with the understanding that validation of them can only occur through applications of the TRT model under ethical guidelines and by people other than ourselves. The use or experience of the model by practitioners independent of us is the best means for substantiation of our experiences and subsequent opinions -- letters and other reference are available under About/ Professional References.

Furthermore, the ETM Professional Training School accords professionals with the opportunity to experience the TRT model's applications first hand in training sessions. We believe that this approach is the most effective, ethical, and responsible means for transferring the knowledge of the TRT and ETM models to others so that they can determine the clinical viability of the models for appropriate clients (see ETM Certification).

When TRT is applied as described in this book and shown in the ETM Professional Training School, the administrator of the model can expect application results to include: From a comparison perspective, ETM administrators are likely to find that: Generally, almost everyone who has completed TRT, and been involved in other therapeutic endeavors, has reported that TRT is the Cadillac (at the time "Cadillac" was intended to mean "the best") of therapy. We have numerous testimonials that support this praise. Although not available for publication, independent audits of client exit evaluations upon exiting treatment (in institutions other than our own) showed TRT to be the most valuable care element of the continuum.

Testing Criterion

TRT will resolve trauma if:

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