Review and Annotated Commentary of Mary Jo Barrett's video
               -- available here -- [LINK]

I found this review hard to write. the temptation was to "intrude" into it in the form of personal experiences of counselling/therapy. On the other hand, and what I have chosen to do, was to try to incorporate at least some known research, though there's probably some element of personal experience. The question ended up being: "Given my experiences, and my knowledge, how would I feel if I were in receipt of Barrett's style of therapy?. In short, my answer would be: "relieved, that after 50+ years I had finally found someone who knew what they were doing (but quietly resentful that so many so-called "registered mental health care professionals" have not known the basics and caused me so much suffering and wasted life time!)"

From the start Mary Jo Barrett, in her discussion of "five essentials of trauma treatment", highlights the importance of something rarely done in everyday practice -- asking clients to review or "evaluate" the "good things" and the "not so good things" about the therapy they receive. Moreover, it's clear she's listened to what clients have said, and tried to understand their views in the context of their life experiences. Certainly she seems to have considered, and where possible incorporated, practices other therapists regard as essential for safety -- see my page [LINK]. Traditionally, despite such organisations as the New Zealand Psychotherapists Society requiring their members to "contextualize" their assessments, this is rarely done -- there is no requirement (in fact the system is set up against it) for psychiatrists and psychologists, those most involved in providing "diagnoses", to view the patients behaviour in the context in which it occurs. How true "understanding", let alone empathy or compassion, can result from this process beggars the imagination. Clients who have been traumatised have been in situations where they are dependent on someone who has power over them, and this person has abused such power. They have not been in positions where they have known what to expect, except that when they are most vulnerable, they are most at risk. Barrett notes that, as a result, in vulnerable situations, clients have a need for the situation to be "safe" and key to this safety is predictability and a sense of control. Those who have suffered interpersonal trauma as children are not only in this position, but their whole history of abuse by attachment figures, and their capacity for alliance building, predisposes them against trusting, relying on, and disclosing to those in such positions of power -- (Fuertes et als 2008 -LINK], Bennett 2011 [LINK]).

In such a context, Barrett notes that the first requirement is the establishment of a "collaborative" relationship with the client, within this, a need to know "what is happening now?" "why is this happening to me". there is a need for the therapist to constantly check, rather than just "relying" on the client to tell them, that the client has this knowledge and sense of security -- clients after all, coming from a background of being abused as children, sexually, physically, emotionally, of remaining safe through "keeping quiet" -- never being sure what would happen if they spoke up, but fearing they would be made to keep quiet. There is also a need to "move through" therapy at a pace that is dependent on maintaining the client's feelings of security, and trust in the therapist -- trust that can easily be lost for a variety of reasons -- the reasons varying for reasons barrett is not clear about, but which would seem to depend, partly on the type of abuse experienced, but partly also on the particular client's individual circumstances and preferences -- all of which need to be constantly checked by the therapist with the client. Part of these "individual circumstances" would include the acceptability of different types of therapy within particular groups -- but I'll address this later when addressing the "content of therapy" rather than its structure and process.

Barrett's "Stage 1" is necessarily of indeterminate duration. It involves the "creation of a context for change" (she's the director of counselling, after all, at Chicago's "Centre for Contextual Change" -- [LINK]). this stage involves learning what the client wants and doesn't want; what trauma is -- the difference between fight/flight/freeze reactions; and recognition of what's going to make the client feel comfortable. She considers this the most important stage of therapy, and accepts it can take a long time. By the end of the first session, she hopes she has helped the client understand what therapy looks like, what trauma cycles look like, what growth looks like, that it proceeds in stages, and the therapist hopes to undertand what the client's previous experience in therapy has been, what worked, and what didn't , with the client in turn understanding what therapy with her is like in terms of roles and structures. She hopes the client can go home at the end of the first session feeling that they have gotten something out of the session, and hopefully with a joint agreement made for an initial four session commitment, understanding the advantages and disadvantages of therapy (what has to be given up, such as symptoms and old coping habits) and that therapy "makes sense to them". She feels that she doesn't need to "know the details", the narrative of the trauma, till the second stage, just that it's been traumatic.

Following on from Stage 1, with the client understanding the advantages and disadvantages of therapy, comes Stage 2, which involves the challenging of old patterns of coping, and the expanding of new realities. Stage 2 involves the design of the overall program for treatment --- matching the client's needs with different types of therapy -- individual therapy, couples therapy, and so forth. There's a recognition that the client will be at different stages of therapy in different types of treatment, and this is all part of the collaborative process, with the therapist and client collaborating with different therapists handling different types of treatment. Here, in the planning stage for further treatment, the "client's voice is privileged", their experiences, preferences, and opinions being the determining factor for what constitutes the "content" of further therapy.

Stage 2 thus involves the implementation of what's usually considered "treatment", organising methods/models around different symptoms / needs, perhaps with single session trials to see if the client can feel comfortable and hopeful of success with different types of treatment. The client's preferencess may be dependent on what context they wish to operate in, and the "expectations" of this context. Reger et al (2012) have examined this aspect as it applies to the treatment of soldiers experiencinng trauma disorders in response to combat. -- [LINK]

Reger et al note that only a minority of service members with posttraumatic stress disorder (PTSD) access care despite growing availability of evidence-based and innovative treatments. Although preferences for military personnel have not been established, previous research on civilian populations with PTSD suggest treatment preferences for exposure-based treatments over medications. There are also unique stressors in the deployed environment that may impact treatment preferences, such as close living proximity to peers and leaders, and limited access to typical coping strategies. Soldiers deployed to Iraq (n = 174) were provided a written hypothetical scenario about difficulties after combat exposure and were provided descriptions of Prolonged Exposure (PE), virtual reality exposure (VRE), and FDA-approved medications for PTSD. Soldiers completed a Treatment Reactions Scale for each treatment type. Responses were significantly more favorable for both PE and VRE relative to medications (p < .001). Relative to both exposure therapies, soldiers reacted to medications with significantly stronger agreement to scales reflecting embarrassment/shame for seeking a particular form of treatment, negative occupational/career impact, and perceived debasement for seeking the treatment. Relative to PE, soldiers were significantly less willing to recommend medication treatment and had significantly less confidence/belief in the efficacy of medications. In a further study, Mott and colleagues (2012)    [LINK]  examined veterans' perspectives on the effectiveness and tolerability of a 12-week model of group-based exposure therapy (GBET) for PTSD. Analysis of qualitative and quantitative self-report data from 20 combat veterans indicated that participants were highly satisfied with GBET and experienced it as both helpful and acceptable. Eighty-five percent of the sample (n = 16) evidenced reliable reductions in PTSD symptoms from pre- to posttreatment, without experiencing symptom exacerbation over the course of treatment. The observed dropout rate was low (5%, n = 1), and treatment completers reported that commitment to the group was instrumental in their decision to remain in treatment. Veterans described that hearing other group members' in-session imaginal exposures had a normalizing effect, and they indicated that feedback from fellow veterans on their own imaginal exposures was the most helpful aspect of GBET. (These findings can help inform provider education of treatment options and demonstrate the importance of considering patient reactions to a treatment plan, as preferences may impact adherence.

In Barrett's model, both therapist and client, with the client now more insightful of their patterns of coping and growth, agree that they're ready for Stage 3 when the client begins being able to be more responsible for their own treatment, reporting on what new things they've been doing to cope, feeling a sense of active agency, and taking responsibility for selecting and engaging in different therapy resources, such as family therapy, group therapy and whatever else they feel they need -- broadening the client's skills beyond the therapist to a broader social supportive circle. When progress is made in these areas in achieving the client's goals, a joint decision is made about what is to be done when they need the therapists's assistance again -- a form of relapse prevention planning, planning for termination, and tailoring off of involvement in therapy. The client feels a valuing of the therapist, mirroring the therapist's valuing of the client as an active, responsible, independent agent, with a sense of empowerment and a meaningful vision of the future. The vision is part of a world view, where they have suffered but they have changed now for the better, with a broader social circle; the view that the more things can be like this, the greater the chances will be better in the future. Stage 4 thus involves the creation of workable realities in the future, in a concrete defined way not just a style of "positive thinking".

Barrett says her style of therapy requires the therapist to be deeply attuned to their own process, maintaining their sense of energy, their own health. In my view, the concept of "energy" can be extended to resilience and thus the core elements of treatment can also be considered as Relationship, Responsibility, and Resilience, with therapy questions focusing throughout on matters of what and how, not why -- a concept reinforced by Don Meichenbaum in his video -- [LINK]. There is throughout a recognition that trust is fragile, that clients can become angry if their trust is violated -- if, for example, the therapist acts without the client's understanding and being able to predict what's happening in therapy, and that if anger and distrust arise as a result, the client may well drop out -- this is the therapist's responsibility.

>Effective trauma therapy can thus be considered to have five essential elements:

1. a recognition and acceptance, by the therapist and the client that "You have suffered, but things can change for the better"
2. Skills building -- such skills might include:
• mindfulness skills -- making room to pause and make choices
• communication skills
• parenting skills
• cognitive behavioural skills
• an acknowledgement that coping required skills (even some "symptoms") which can still be used
• integration skills -- integrating cognitive, spiritual, and bodily (sensorimotor, sensing and soothing type) functions
3. a strength orientation -- an understanding of how symptoms have worked in the past as coping skills -- and thus therapy involves a loss, of symptoms, but has benefits as well
4. the recognition by the client that during therapy "I felt safe" -- as the therapy was well structured and explained to the client whenever requested by the client, with the therapist regularly checking on the client's understanding and acceptance of therapy processes; and as a result, therapy was predictable, had known boundaries, goals, structure -- this feeling of safety is essential for change to occur, The therapist needs to say "You tell me how to act", and act in a collaborative, elaborative way.
5. therapy must involve the creation of "workable realities" -- requiring the therapist to know at all times what they're doing; the client is confident that the therapy is evidence-based; and involves the creation of a workable future, in a concrete, defined way, and not just positive thinking