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Psychotherapy Research

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Changes in the trauma narratives of youth

receiving trauma-focused cognitive behavioral
therapy in relation to posttraumatic stress

Marie Knutsen & Tine K. Jensen

To cite this article: Marie Knutsen & Tine K. Jensen (2017): Changes in the trauma narratives
of youth receiving trauma-focused cognitive behavioral therapy in relation to posttraumatic stress
symptoms, Psychotherapy Research, DOI: 10.1080/10503307.2017.1303208

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Published online: 04 Apr 2017.

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Download by: [Society for Psychotherapy Research ] Date: 06 July 2017, At: 05:10
Psychotherapy Research, 2017


Changes in the trauma narratives of youth receiving trauma-focused

cognitive behavioral therapy in relation to posttraumatic stress


1 2
Department of Psychology, University of Oslo, Oslo, Norway & Norwegian Centre for Violence and Traumatic Stress
Studies, Oslo, Norway
(Received 7 June 2016; revised 20 February 2017; accepted 26 February 2017)

Objective: To understand the meaning of trauma narration, we examined changes in the trauma narratives of youth receiving
trauma-focused cognitive behavioral therapy (TF-CBT) and explored the relationship between changes in narratives and in
posttraumatic stress. Method: The sample consisted of 12 non-responders and 12 maximum-responders to treatment (M =
14.3, SD = 2.35, range = 1017; 75% girls). The youth were assessed with the Clinical-Administered PTSD-Scale for
Children and Adolescents both pre- and post-treatment. Their first and last narratives were coded according to a
standardized coding manual. Results: For the group as a whole there was an increase in organized thoughts and reports
of internal events (e.g., descriptions of thoughts and feelings), while narrative fragmentation decreased. There were no
significant narrative changes in external events (e.g., descriptions of actions and dialogues). Max-responders differed
significantly from non-responders in developing more organized thoughts. We did not find a significant relationship
between changes in narratives and changes in posttraumatic stress symptoms (PTSS). Conclusions: Youth receiving TF-
CBT develop narratives that contain more organized thoughts and a greater internal focus, which are both thought to be
helpful for traumatized youth. However, more coherent and organized trauma narratives were not related to reductions in

Keywords: trauma; narratives; narrative organization; trauma-focused cognitive behavioral therapy; PTSS

Clinical or methodological significance of this article: This study suggests that trauma-focused cognitive behavioral
therapy contributes to more organized and coherent trauma narratives for traumatized youth. Although, this may be impor-
tant and contribute to meaning making, therapist should be aware that this may not be sufficient in reducing posttraumatic
stress symptoms in youth.

Constructing a trauma narrative may serve several
It is assumed that the ability to construct a coherent important functions. First, the ability to construct a
narrative is important for coping after trauma coherent narrative is important for being able to com-
(Fivush, 1998; Mundorf & Paivio, 2011; Pennebaker municate ones experiences to others and create
& Seagal, 1999; Salmond et al., 2011; Tuval- meaning to the event(s) (Deblinger et al., 2011;
Mashiach et al., 2004). Therefore most rec- Fivush, 1998; Harber, Pennebaker, & Christianson,
ommended trauma treatment models for both chil- 1992; Mundorf & Paivio, 2011; Nelson, 2003).
dren and adults focus on the construction of a Second, traumanarrative work can contribute to the
trauma narrative (Cohen, Mannarino, & Deblinger, processing of the trauma and to integrate the
2006; Foa, Hembree, & Rothbaum, 2007; Neuner trauma memory with other autobiographical mem-
et al., 2008; Schauer, 2011; Smith, Perrin, Yule, & ories (Ehlers & Clark, 2000; Foa & Riggs, 1993;
Clark, 2010). Salmond et al., 2011). Third, narrating the trauma

Correspondence concerning this article should be addressed to Marie Knutsen Department of Psychology, University of Oslo, Postbox 1094,
Blindern, 0317 Oslo, Norway. Email:

2017 Society for Psychotherapy Research

2 M. Knutsen and T. K. Jensen

experience in the context of therapy is a form of appraisals of the trauma and/or its sequelae play in
exposure that can aid in reducing trauma-related generating various feelings such as a persistent
negative emotions in response to trauma reminders sense of threat, guilt, and shame, as well as feeling
through the integration of corrective and new infor- weak, crazy, or damaged. These feelings often lead
mation into the fear structure in memory (Cohen & to a range of coping strategies that may be maladap-
Mannarino, 2008; Foa & Kozak, 1986; Foa & tive and unhelpful (Bryant, Salmon, Sinclair, &
McLean, 2016; Foa, Molnar, & Cashman, 1995). Davidson, 2007; Ehlers et al., 2003; Meiser-
And lastly, trauma narration can help identify and Stedman et al., 2007; Stallard & Smith, 2007).
challenge unhelpful cognitions (Ehlers & Clark, Together these mechanisms can explain why
2000; Smith et al., 2010). In these ways constructing trauma narratives often are disorganized and frag-
coherent trauma narrative involves exposure to, and mented among those with PTSD (Brewin et al.,
emotional processing of, the traumatic event which 1996; Ehlers & Clark, 2000). According to cognitive
can contribute to meaning making and to reduce theories of PTSD, the trauma narrative work can set
trauma-related symptoms such as posttraumatic the scene for improving narrative organization and
stress. However, our understanding of how trauma cohesion, identifying and modifying misappraisals
narratives change during therapy and whether these and maladaptive cognitions, and cause habituation
changes are related to symptom reduction is not to negative emotions through the construction of
clear and research is scarce (Deblinger et al., 2011; new meaning (Brewin et al., 1996; Clark & Ehlers,
Dorsey et al., 2016; Salloum & Overstreet, 2012). 2004; Ehlers & Clark, 2000; Foa & Kozak, 1986).
Therefore the aim of this study was to examine Several studies have found that type and quality of
changes in the trauma narratives for youth receiving cognitive processing after a traumatic event may have
TF-CBT, and further to investigate whether there significant effects on narration, which, in turn, is
was a relationship between narrative changes and related to mental health and PTSS (Alvarez-Conrad,
posttraumatic stress symptoms (PTSS) by comparing Zoellner, & Foa, 2001; Foa et al., 1995; Harvey &
one group of youth that reported having a significant Bryant, 1999). For instance, studies of traumatized
reduction in PTSS with a group of youth who did not adults show that individuals with PTSD have more
report reductions in PTSS during treatment. fragmented and disorganized narratives than those
Although there is a need to pay attention to the without PTSD (Halligan, Michael, Clark, & Ehlers,
developmental phases children undergo and how 2003; Harvey & Bryant, 1999; Jones, Harvey, &
traumatic stress can disturb development, several Brewin, 2007). However, other scholars have criti-
scholars have argued that cognitive models of post- cized this assumption and claim that the relationship
traumatic stress disorder (PTSD) for adults can be between narratives of traumatic memories and
adopted as a framework to explain and understand PTSD lacks empirical support (Gray & Lombardo,
the development of PTSD in children and youth 2001; Rmisch, Leban, Habermas, & Dll-Hentsch-
(Ehlers, Mayou, & Bryant, 2003; Meiser-Stedman, ker, 2014; Rubin, 2011; Young, 2000).
2002; Meiser-Stedman, Dalgleish, Smith, Yule, & Only a few studies have investigated the relationship
Glucksman, 2007: Salmond et al., 2011). According between characteristics of the trauma narratives and
to cognitive models of PTSD, negative appraisals of posttraumatic stress reactions in youth (Filkukova,
the trauma and/or its sequelae together with a dis- Jensen, Hafstad, Minde, & Dyb, 2016; Kenardy
turbance of autobiographical memory play an impor- et al., 2007; McKinnon, Brewer, Meiser-Stedman, &
tant role in the development and maintenance of Nixon, 2017; OKearney, Speyer, & Kenardy, 2007;
PTSS (Brewin, Dalgleish, & Joseph, 1996; Ehlers & Salmond et al., 2011). Kenardy et al. (2007) con-
Clark, 2000; Foa & Rothbaum, 2001). In Ehlers ducted a study where they examined the trauma narra-
and Clarks model (2000), traumatic memories are tives of physically injured children. The findings
thought to be poorly elaborated and contextualized showed that temporal disorganization was related to
and are not adequately integrated with other autobio- PTSS (Kenardy et al., 2007). Another study by
graphical memories. Disturbance in the memory pro- OKearney et al. (2007) explored the association
cessing of the trauma can explain the intrusive and between children`s memory of a traumatic event
involuntary characteristic of trauma memories (i.e., an accident requiring hospitalization) and sever-
where vivid sensory, emotional, and perceptual ity of different sub-clusters of PTSD. A coding
impressions dominate the memories. This is in line scheme was developed to assess childrens trauma
with several reviews showing that trauma narratives memory report through measures of narrative struc-
are characterized by sensory, emotional, and percep- ture and organization. The results identified a signifi-
tual details (Crespo & Fernndez-Lansac, 2016; cant relationship between level of lexical structure
OKearney & Perrott, 2006). The other central and cohesion, and their self-report of intrusive symp-
aspect of Ehlers and Clarks model is the role toms 47 weeks after the traumatic event. The
Psychotherapy Research 3

authors argue that the findings demonstrate the impor- Salmond et al., 2011 study), variations in research
tance of developing a cohesive and conceptual designs and the use of different coding schemes.
memory of the traumatic event in order to reduce These concerns are not limited to the child trauma
trauma-related distress. A recent prospective study field, but are also main concerns in the adult trauma
by McKinnon et al. (2017) examined whether percep- literature (OKearney & Perrott, 2006).
tions of trauma memory quality would predict PTSS To the best of our knowledge, no youth studies and
over and above trauma narrative characteristics. The only three adult studies have examined how trauma
study used the same coding scheme developed by narratives change during therapy and how these
OKearney et al. (2007) to analyze the trauma narra- changes could be related to changes in PTSS. Foa
tives in a sample of injured children, acutely and at 3 et al. (1995) examined the cohesiveness of adult
months after experiencing a potentially traumatic patients trauma narratives and the process of narra-
event. To measure the perception of trauma memory tive organization by analyzing transcriptions of the
quality, McKinnon et al. (2017) used a self-report narratives of 14 female sexual assault victims. Their
questionnaire which is thought to measure the findings supported their predictions that exposure
sensory, fragmented, and disorganized aspects of a treatment, which focuses on reducing trauma-
memory of a traumatic event (Trauma Memory related anxiety through the trauma narrative work,
Quality Questionnaire (TMQQ): Meiser-Stedman can enhance narrative organization. Further, they
et al., 2007). The findings indicate that self-reported found that narrative length and reports of internal
trauma memory characteristics could better explain events in the narratives, such as descriptions of
the variance in PTSS than trauma narrative character- thoughts and feelings the patients experienced
istics. This finding is inconsistent with the results from during the traumatizing event, increased during
a previous child study also measuring both narrative therapy. Organized thoughts, that is, thoughts that
features (coded according to the Foa et al., 1995 reflect reasoning, planning and attempts to organize
manual) and perception of trauma memory quality the trauma memory, also significantly increased
(measured by TMQQ) in order to examine the from the first session to the last session. External
relationship between trauma memory and PTSS events, which are defined as utterances about
(Salmond et al., 2011). Salmond et al. (2011) found actions that occurred during the event or verbaliza-
that children and youth with acute stress disorder pro- tion or dialogues in the narrative, decreased during
duced trauma narratives with greater disorganization treatment, although this decrease was not significant.
compared to narratives of non-traumatic unpleasant The authors did not find significant decreases in
events and compared to the narratives of non- utterances indicating fragmentation during therapy,
trauma-exposed controls. The results also showed although symptom improvement was related to
that narrative disorganization, together with the reduced fragmentation. Based on the results, the
childs cognitive appraisals of the trauma, predicted authors suggest that treatment recovery is related to
post-trauma symptom severity. Contrary to the increased narrative coherence (Foa et al., 1995). A
finding of McKinnon et al. (2017), self-reported study by van Minnen, Wessel, Dijkstra, and Roelofs
trauma memory characteristic did not explain (2002) replicated and extended Foa et al.s study by
symptom severity over and above narrative features. examining two groups of patients with different treat-
According to the authors, their findings provide evi- ment outcomes. The study revealed that all partici-
dence that narrative disorganization is specifically pants (n = 20) showed increased reporting of
related to trauma memory in youth (Salmond et al., internal events, and decreased reporting of external
2011). Lastly, one study examined the relationship events and disorganized thoughts independent of
between narrative structure and PTSS in a group of improvement. Neither of the groups exhibited a
youth who survived a terror attack using the coding decrease in fragmentation. These results are in line
manual developed by Foa et al. (1995). In this study with the findings of Foa et al. (1995). The only sig-
the authors found that survivors with high levels of nificant differences between the groups involved dis-
PTSS described more external events and fewer organized thoughts. The improvers (n = 8) exhibited
internal events in their narratives compared with survi- a significantly greater reduction in disorganized
vors with low levels of symptoms, and that narratives thoughts in their narratives from pre- to post-treat-
containing more descriptions of dialogue and fewer ment than non-improvers. The results raise uncer-
organized thoughts were related to higher levels of tainty regarding the assumption that changes in
PTSS. The groups did however not differ in levels of trauma narratives are related to more adequate pro-
narrative fragmentation or in length of the narratives cessing of the traumatic event, and the authors ques-
(Filkukova et al., 2016). Conclusions based on these tion whether these observable changes in narratives
existing studies are limited due to the lack of within- may be due to the beneficial treatment effect of
subjects control narratives (with the exception of repeatedly telling the same story rather than a
4 M. Knutsen and T. K. Jensen

reflection of changes in memory representation (van reported having a significant reduction in PTSS
Minnen et al., 2002). A third study, by Mundorf (max-responders) with a group of youth who did
and Paivio (2011), examined the trauma narratives not report reductions in PTSS during treatment
before and after emotion-focused therapy for PTSD (non-responders). Although there are mixed findings
in patients exposed to childhood abuse. The results in the literature, our hypothesis is that more orga-
showed that during therapy there were significant nized and coherent narratives will be related to
increases in positive words, temporal orientation, reductions in PTSS given the centrality of trauma
and exploration of subjective internal experiences. narrative work in TF-CBT.
However, inconsistent with the findings of Foa
et al. (1995) and van Minnen et al. (2002), degree
of coherence in the narratives did not change signifi- Method
cantly from pre- to post-treatment. There was a sig-
nificant association between increased temporal Procedures
orientation and post-treatment outcome. Based on This study uses data from a randomized effectiveness
the results, the authors argue that processing the trau- study that compared TF-CBT with therapy as usual
matic experience contributes to improvement in nar- (TAU) for traumatized youth in child and adolescent
rative quality which in turn is associated with better community mental health clinics (Jensen et al.,
outcomes. It should be noted, that Mundorf and 2014). The study is approved by the Regional Com-
Paivio (2011) did not use the coding manual devel- mittee for Medical and Health Research Ethics. The
oped by Foa et al. (1995) which may challenge the sample included youth ranging in age from 10 to 18
comparison of results across the three studies. years. The youth were referred to treatment by
As shown, the existing studies on changes in narra- Child Welfare Services or by their primary physician:
tives and their association to PTSS in adults is limited hence, standard referral procedures were followed.
and to some degree inconclusive. Studies examining The inclusion criteria were as follows: the youth
narrative changes in youth therapy are non-existent. had experienced at least one traumatic event
More knowledge about changes in youths trauma meeting the A criterion of a PTSD diagnosis
narratives are needed to increase our understanding defined in the Diagnostic and statistical manual of
about how therapy can contribute to the processing mental disorders (4th ed.; DSM-IV; American Psy-
of a traumatic event and how these processes are chiatric Association, 1994), and suffered from clini-
related to PTSS. cally significant PTSS. Acute psychosis, suicidal
behavior, mental retardation, and the need of an
interpreter were the exclusion criteria. Participants
Aims of the Study were assessed with the Clinical-Administered
PTSD-Scale for Children and Adolescents (CAPS-
In this paper we analyze changes in narration for CA: Griffin, Uhlmansiek, Resick, & Mechanic,
youth with good and poor treatment response after 2004) before and after treatment by two clinical psy-
receiving trauma-focused behavioral therapy (TF- chologists who were nave to treatment allocation
CBT). The overall aim is to examine changes in the (Jensen et al., 2014).
trauma narratives of youth receiving TF-CBT and
to investigate whether there is a relationship
between changes in narrative organization and
changes in PTSS. Our first hypothesis, based on the-
ories of PTSD and empirical findings, is that the In the present study only youth who received TF-
organization of trauma narratives will increase from CBT were included, as none of the youth in the
pre- to post-treatment and will be evidenced by TAU group created trauma narratives. Because we
more organized thoughts. Moreover, we predict were interested in examining the relationship
that we will find more reports of internal events and between changes in narratives and changes in
fewer reports of external events in post-treatment PTSS, we selected groups of participants with differ-
trauma narratives than in pre-treatment narratives. ent outcomes. Outcome was measured by changes in
Given the inconclusive empirical findings regarding PTSS from pre- to post-treatment. Non-response
changes in narrative fragmentation during therapy, was defined as a reduction of PTSS symptoms <1/2
we do not propose a hypothesis in any particular SD from the pre-treatment mean. This is considered
direction. In order to explore whether changes in as an acceptable criterion for non-response (Wise,
the fragmentation and organization of trauma narra- 2004). Based on this definition, 12 participants
tives during treatment are correlated with changes were classified as non-responders. These participants
in PTSS, we compare one group of youth that were compared with the 12 participants who showed
Psychotherapy Research 5

the most improvement during therapy, labeled max- create a more coherent, organized and meaningful
responders. The final sample consisted of 24 youth narrative of the traumatic experience, all components
(12 non-responders and 12 max-responders) are considered to be important in contributing to
between the ages of 10 and 17 years (M = 14.3, SD treatment effects (see also Cohen, Deblinger, & Man-
= 2.35; 75% girls). Participants had experienced mul- narino, 2016).
tiple traumatic events, and the traumatic event that
they reported to be the worst event is presented in
Table I. Therapists
The TF-CBT therapists (n = 16) were psychologists,
psychiatrists, educational therapists, and social
Treatment workers. The therapists were trained in TF-CBT
All the youth received TF-CBT, a treatment model and were supervised weekly or biweekly by trained
developed by Cohen et al. (2006). TF-CBT is a TF-CBT consultants to ensure treatment adherence.
short-term, trauma-specific treatment consisting of Furthermore, all sessions were audio-recorded and
the following core components: psychoeducation, coded for treatment fidelity by trained TF-CBT
relaxation skills, affect regulation, cognitive coping, therapists using the treatment adherence checklist
working through the trauma narrative, cognitive pro- for TF-CBT (Deblinger, Cohen, Mannarino,
cessing, in vivo mastery of trauma reminders, enhan- Murray, & Epstein, 2008).
cing safety and future development. The intervention
typically consists of 1215 sessions. Parental involve-
ment is viewed as important and the youths non- Measurement
offending parent or caregiver is offered interventions Posttraumatic stress symptoms. The CAPS-
focusing on improving parenting skills in both paral- CA was used to measure the youths PTSS. The
lel and conjoint sessions. Elements from cognitive, CAPS-CA is a semi-structured clinical interview suit-
behavioral, interpersonal, and family therapy prin- able for use with children and adolescents and is
ciples and trauma interventions are integrated into regarded as the gold standard for assessing PTSD
the model. Working through the trauma narrative is symptoms among children aged 8 years and older
emphasized as an important element of TF-CBT. (Griffin et al., 2004; Nader et al., 1996, 2004).
The youth are gradually exposed to the traumatic Assessments are based on the youths scores on a 5-
event(s) throughout the different phases and com- point frequency scale and a 5-point intensity rating
ponents of the treatment leading up to the trauma scale for the past month. The youths answers,
narrative component, when the therapist encourages together with clinical judgment during the interview,
the youth to elaborate on and describe the traumatic serve as the basis for scoring of the items. The CAPS-
event(s) in detail. Typically, three to five sessions are CA has demonstrated good psychometric properties
devoted to working directly with the trauma narra- in several studies (Ohan, Myers, & Collett, 2002).
tive, although the number of sessions deemed necess- In the present study, the total scale showed satisfac-
ary is tailored to each individual`s needs. Although tory internal consistency ( = .90). The DSM-IV-
the creation of a trauma narrative is viewed as a defined tripartite model also showed satisfactory
central part of the treatment to help the youth internal consistency (re-experience: = .87, avoid-
ance: = .77, hyperarousal: = .79).
Table I. Distribution of worst trauma reported.
Narrative coding system. To analyze the narra-
Non-respondersa Max-respondersa
Traumatic experience n (%) n (%)
tives we used the coding manual developed by Foa
et al. (1995) since this manual is widely accepted in
Extra-familial sexual 4 (33.3) 2 (16.7) the literature. The coding aims to explore changes
abuse in narratives from the first to the last session of
Intra-familial sexual 2 (16.7) 1 (8.3)
therapy. First, the narratives were divided into dis-
Peer violence/bullying 3 (25) 3 (25) crete units of text according to the manuals chunking
Exposure to intra- 1 (8.3) 2 (16.7) rules. These units of text are referred to as chunks
familial violence and constitute meaningful parts of the text that
Sudden death/injury of 5 (16.7) 2 (16.7) include only one thought, action or speech utterance.
close person The next step was to code each unit for content by
Other traumatic 0 (0.0) 2 (16.7)
experiences assigning each chunk to one utterance category. Fol-
lowing the manuals instructions, each utterance
N = 12. could only be assigned to 1 of 22 coding categories.
6 M. Knutsen and T. K. Jensen

If an utterance could belong to more than one coding descriptions of action that an individual
category, the most appropriate code was identified by other than the perpetrator or the narrator
referencing a predetermined coding priority list. Fol- takes. Dialogues are chunks reflecting
lowing Foa et al. (1995) and van Minnen et al. direct or indirect verbalization uttered with
(2002), these 22 categories were then reorganized the intent to be heard by another person.
into groups that were considered to belong to the This category consists of five classes, which
same construct. Descriptions of the combined are classified according to the speaker: (a)
groups that we analyzed are presented below. dialogue-perpetrator-threat; (b) dialogue-
perpetrator-non-threat, referring to the per-
(1) Organized thoughts are utterances reflecting petrators verbalizations directed to the
efforts to comprehend the trauma and victim that are not experienced as threaten-
attempts to understand what is happening ing; (c) dialogue-self-perpetrator; (d) dialo-
through, for example, reasoning, planning, gue-self-other, involving the narrators
rationalizing, questioning, or decision verbalizations to a person other than the per-
making. An example of an organized petrator; and (e) dialogue-other.
thought is as follows: then, I realize that he (4) Fragmentation is proposed to measure the
is up to something, () and Im thinking degree of flow in the narrative and consists
that I have to be quiet. of non-functional utterances, referring to
(2) Internal events, reflect thoughts and feelings, chunks that do not add any new information.
and refer to descriptions of internal states. The fragmentation category consists of the
This category is proposed to reflect the following utterances: (a) repetitions; (b)
degree of internal focus in the participants speech fillers, reflecting words or phrases
narratives. Thoughts refer to attempts of that do not carry any meaning in and of
cognitive processing and are subdivided themselves, such as kind of and you
into four classes: (a) organized thoughts; know; and (c) unfinished thoughts.
(b) disorganized thoughts, reflecting con-
fusion and/or disjointed thinking; (c) despe- Two of the codes fall into more than one category.
rate thoughts, involving utterances Organized thoughts can be coded both a separate
reflecting that all coping strategies are una- category and an internal events category. This
vailable; and (d) unfinished thoughts, reflect- choice was based on both theory and empirical find-
ing sentences that are incomplete or single ings indicating the important role that organization is
words relating to ideas. An example of an thought to play in treatment and recovery from
unfinished thought is as follows: and then trauma. Additionally, in line with Foa et al. (1995)
I started to . Feelings capture utter- and van Minnen et al. (2002), unfinished thoughts
ances involving participants expression of can be coded both as an internal events category, and
emotion and are subdivided into three as fragmentation.
classes: (a) positive feelings; (b) negative feel- All therapy sessions were audio-taped. The first
ings; and (c) angry adaptive feelings, concep- narrative was defined as the youths first free story-
tualized as coping emotions such as anger, telling of the traumatic event to the therapist
disgust and outrage. during the trauma narrative component. The story
(3) External events are viewed as an index of the was a free recall elicited by the following open-
degree of external focus in the narratives and ended question posed by the therapist: Today we
refer to overt, observable events. This cat- are going to work on your trauma narrative. Start
egory captures all utterances referring to by telling me what happened. This first free recall
different types of actions and dialogues in of the narrative laid the foundation for further
the narratives. Actions are further divided working with the trauma narrative in subsequent
into the following categories: (a) action-self, session. During the narrative work the therapist
reflecting the narrators own behavior or wrote down the narrative during the session and
actions that the narrator and another person encouraged the child to include thoughts, feelings,
other than the perpetrator jointly take; (b) body sensations, and the worst moment of the trau-
action-perpetrator-threat, involving the per- matic experience into the narrative (Cohen & Man-
petrators actions that frighten or intimidate narino, 2008). After several sessions working with
the victim; (c) action-perpetrator-non-threat; the trauma narrative, the last narrative was defined
(d) action-joint, referring to actions that the as the final narrative that was shared with the thera-
perpetrator and subject take at the same pist. The majority of the youth also shared these final
time; and (e) action-other, involving narratives with their parents in conjoint sessions.
Psychotherapy Research 7

The first and last narratives were transcribed verba- Results

tim resulting in 48 narratives. These 48 narratives
Initial Analyzes
were first coded by hand according to the standar-
dized coding manual developed by Foa et al. There was no significant difference in pre-treatment
(1995). A psychologist with experience in applying PTSS scores between the non-responder and max-
the coding system coded the 48 narratives. The responder group. Furthermore, in line with our
rater was blind to participants outcome scores and classification of the two groups, there were significant
which group the narratives belonged to. To ensure differences in PTSD change scores from pre- to post-
raters reliability, the first author coded a random treatment between the groups, t(22) = 5.55, p = .029.
sample of 10 narratives (20.8% of the total More specifically, participants in the max-responder
sample). Prior to the coding, the two coders met fre- group showed a significant decrease in PTSS
quently to discuss and study the manual, and they during therapy, t(11) = 21.5, p < .001, whereas par-
practiced together using narratives that were not ticipants in the non-responder group did not, t(11)
included in the study to achieve agreement on how = 0.76, p = .465. The majority of the sample was
to divide the narratives into chunks and code the female (75%). The non-responders group had fewer
chunks. Dilemmas arising from different interpret- boys (8%) than the max-responder group (42%),
ations of the manual instructions and a few disagree- and the participants in the non-responder group
ments between the two independent raters were were slightly older (M = 15, SD = 1.81) than those
discussed and resolved in group meetings to in the max-responder group (M = 13.7, SD = 2.71).
ensure reliability. Inter-rater agreements for separ- Due to differences in the number of participants
ate categories ranged from 89.6% to 100%. The nar- who had experienced sexual abuse between the two
ratives were then uploaded in the program NVivo, groups, we used a multinomial logistic regression
where raters labeled the text by the categories analysis to examine whether exposure to sexual
described above. The strength of this program is abuse increased the probability of being a non-
its ability to organize thousands of coding units responder. The result showed that there was not a
and to provide information regarding the percentage significant relationship between sexual abuse
that each category constitutes of the total text. Fol- trauma and outcome group (non-responder versus
lowing Foa et al. (1995), the percentage of utter- max-responder), p = .203. Furthermore, we tested
ances in each category was used in the analyzes whether sexual abuse was related to PTSS level
due to the significant variation in the length of the post-treatment (using CAPS difference scores from
narratives between and within participants. pre-treatment to post-treatment as the dependent
variable), and an independent t-test showed that
there was no significant relationship between sexual
abuse trauma and PTSS, p = .269.
Data Analyzes
To evaluate whether the difference in PTSS
reduction across the non-responder and max-respon-
Changes Between First and Last Narratives
der groups was statistically significant, an indepen-
dent samples t-test on the change scores was The results of the analyzes of the narrative organiz-
performed. Due to differences in narrative length ation and PTSS scores for the two groups pre- and
within and across participants, percentages of utter- post-treatment are summarized in Table II.
ances in the categories of organized thoughts, internal To test our first hypothesis that the narratives
events, external events, and fragmentation were sep- would change during treatment, pre- and post-treat-
arately computed for each participant and session. ment means and standard deviations for the total
The means and standard deviations of each of the sample in each of the combined categories, organized
four combined narrative categories for non-respon- thoughts, internal events, external events, and frag-
ders and max-responders, both pre- and post-treat- mentation, were subjected to paired t-tests. As
ment, were calculated. To examine changes in expected, the results showed that for all participants,
narratives during therapy, the pre- and post-treat- their post-treatment trauma narratives had a signifi-
ment means of each of the combined categories cant increase in organized thoughts, t(23) = 3.66,
were subjected to paired t-tests. To investigate p = .001, and internal events, t(23) = 2.44, p
whether the two groups exhibited different changes = .023. Furthermore, there was a significant percen-
during therapy, change scores (post-treatment tage decrease in fragmentation during therapy, t
scores minus pre-treatment scores) for each of the (23) = 5.16, p = .001. No significant change in exter-
four narrative categories were calculated and sub- nal events was found, t(23) = 0.01, p = .991. To
mitted to an independent samples t-test. investigate changes in narratives for each group
8 M. Knutsen and T. K. Jensen
Table II. Symptom severity and percentages of utterances in first and last session narratives for non- and max-responders.

Non-responders (n = 12) Max-responders (n = 12)

First session Last session First session Last session

Symptom severity
PTSD symptoms 61.17 (25.58) 63.58 (27.21) 74.25 (13.92) 14.17 (14.56)
Narrative coding system
Organized thoughts 8.47 (12.73) 14.06 (8.77) 6.32 (4.67) 12.73 (4.79)
Internal events 29.81 (16.09) 39.50 (14.39) 26.64 (14.79) 31.02 (14.07)
External events 61.27 (19.34) 57.88 (16.71) 63.99 (16.60) 67.30 (14.05)
Fragmentation 19.17 (12.35) 6.21 (12.03) 23.83 (14.58) 3.14 (3.53)

Notes: Values given in the parentheses indicate SDs. P-values refer to differences in scores within groups from the first to the last session.

p < .05.

p < .01.

p < .001.

separately, we calculated the means and standard responders). When analyzing the groups together,
deviations for each group in the four combined narra- the results showed a significant increase in organized
tive category groups for the first and last narrative and thoughts and reports of internal events, reflecting
subjected them to paired sample t-tests, stratified by efforts at meaning making and greater processing of
groups. No significant changes in internal or external emotions during treatment. The results also showed
events were found for either of the groups. However, a decrease in narrative fragmentation from pre- to
a significant decrease in fragmentation was found for post-treatment further indicating the development
both non-responders, t(11) = 2.67, p = .022, and of more organized narratives during treatment.
max-responders, t(11) = 4.86, p < .001. Although These findings are in line with our hypothesis that
both groups showed an increase in organized the organization of the trauma narrative would
thoughts from the first to the last narrative, this increase during the course of therapy. Contrary to
increase was significant only for the max-responder our expectations and the findings of previous
group, t(11) = 3.63, p = .004. studies, we did not find a significant decrease in the
reporting of external events (i.e., references to
actions and dialogues in the narrative). Also, we did
Changes in Narratives and PTSD not find support for our last hypothesis that changes
To test whether changes in trauma narratives during in narratives during therapy were related to reduction
treatment were related to PTSS change post-treat- in PTSS.
This is the first study to examine changes in trauma
ment, independent t-tests were performed on change
scores for both groups in each of the four categories narratives in therapy for youth. The results corre-
(post-treatment minus pre-treatment scores). There spond with theoretical accounts (Foa & Riggs,
1993), and previous empirical findings in demon-
were no significant differences in any of the narrative
categories in the participants first narrative between strating that trauma narratives change during the
the two groups. The analyzes revealed no significant course of exposure treatment (Foa et al., 1995; van
Minnen et al., 2002). During therapy, the group as
differences in changes from pre- to post-treatment
scores between non-responders and max-responders a whole showed a significant increase in organized
for organized thoughts t(22) = 0.25, p = .81, internal thoughts and internal events. Increases in organized
thoughts can reflect the youths attempt to compre-
events t(22) = 0.92, p = .37, external events t(22) =
0.92, p= .37 or fragmentation, t(22) = 1.20, p = .25. hend the trauma and indicate efforts of meaning
making. Studies have outlined that it is important
for trauma victims to attempt to express, communi-
cate and make sense of traumatic experiences
(Fivush, 1998; Harber et al., 1992). In this way,
In this study, we examined changes in the trauma TF-CBT may have contributed to more coherent
narratives of youth receiving TF-CBT. We also and meaningful trauma narratives among the youth
explored whether changes in narratives were related in this study, making it easier for them to share
to changes in PTSS by comparing one group of their experiences with significant others. Internal
youth showing significant PTSS reduction (max- events consist of thoughts and feelings expressed in
responders) with a group of youth who did not the narratives that are thought to reflect cognitive
show reduction in PTSS during treatment (non- and emotional processing of the trauma. Researchers
Psychotherapy Research 9

argue that trauma-focused therapy leads to a more frameworks for fragmentation constructs and a het-
internal focus in the narratives because the impor- erogeneity regarding measurements and procedures
tance of external events decreases as memories prevent a clear understanding of the link between
become less frightening (Foa et al., 1995; van fragmentation in trauma narratives and PTSD
Minnen et al., 2002). A shift in focus can thus be (Crespo & Fernndez-Lansac, 2016; McKinnon
related to reduced anxiety and decreases in avoidance et al., 2017; OKearney & Perrott, 2006).
symptoms following therapy, making patients less TF-CBT has proven to be efficient in treating trau-
resistant to relate to their own thoughts and inner matized youth (de Arellano et al., 2014; Morina,
feelings (Mundorf & Paivio, 2011). An internal Koerssen, & Pollet, 2016), and the results of the
focus in the narratives may further have helped the present study confirm that the treatment seems to
youth in the process of exploring, identifying and help traumatized youth in the process of constructing
modifying unhelpful trauma-related thoughts and more organized narratives with a stronger internal
feelings and contributed to create meaning of the focus. However, the current studys findings indicate
traumatic experience. It is also suggested that more that there were no significant differences in changes
organized narratives with an increased internal from pre- to post-treatment scores in the narrative
focus reflects changes in how trauma memories are categories of organized thoughts, internal events,
formed. Exposure therapy can facilitate memory external events, or fragmentation between non-
organization through the elaboration and contextua- responders and max-responders. In light of previous
lization of traumatic memories. Repeatedly imagin- studies and theories of PTSD, it is puzzling that our
ing the trauma, which contributes to fear results showed that youth with very different PTSS
habituation, is expected to promote more adequate change scores demonstrated similar changes in the
processing of the traumatic event such that traumatic narratives. Foa et al. (1995) argue that exposure
memories become more integrated with other treatment facilitates more adequate processing of
memory structures (Foa et al., 1995; Foa & Kozak, the traumatic experience which promotes more orga-
1986). Following this assumption, it is possible that nized and less fragmented trauma memories evident
the youths trauma narratives became more coherent by changes in the narratives. However, van Minnen
and organized as the trauma memories became better et al. (2002) propose that the observable changes in
anchored and integrated into autobiographical trauma narratives may reflect a more general side
memory. Through gradual exposure to frightening effect of the treatment itself rather than changes in
memories and the development of more adaptive the trauma memories. Following Foa et al. (1995),
cognitive coping strategies, trauma narration may it is possible that the youth in the non-responder
have contributed to both meaning making and to group did not improve due to impaired processing
integrate the traumatic event as a memory of a past of the trauma memories. If this were the case, this
event and thus instilled a sense of current and should also been evidenced by less organized and
future strength and safety for the youth in this study. coherent narratives among the non-responders.
Both high responders and low responders showed a Another interpretation would be more in line with
significant decrease in narrative fragmentation during van Minnen et al. (2002). If the effect of repeatedly
treatment. Foa et al. (1995) propose that the absence telling the same story in therapy can explain the
of emotional processing characterizes fragmented changes in trauma narratives, this may be why the
trauma narratives. Based on our results that show two groups last narratives did not significantly differ
an increased reporting of internal events post-treat- since all participants worked on constructing a
ment and possibly reflecting greater emotional pro- trauma narrative in treatment. Based on this assump-
cessing, it makes sense that the trauma narratives tion, it is likely that repeatedly telling the traumatic
showed a decrease in fragmentation. On the other story in therapy may have helped both the max-
hand, other studies on adults have not found a responders and non-responders succeed in restruc-
decrease in fragmentation during the course of treat- turing their narratives. This is in line with other
ment (Foa et al., 1995; van Minnen et al., 2002). researchers suggesting that increased trauma narra-
Even though most scholars seem to agree that tive coherence post-treatment can be explained by a
trauma memories are somewhat different from combination of rehearsal, reduced avoidance and
other memories, the role of fragmentation in retrieval effort (Gray & Lombardo, 2001). In
trauma memory remains unclear, and developmental addition to disturbance in the memory processing
differences have not been examined. It may also be of the trauma, PTSD theories also emphasized the
that contradictions in results across studies are role maladaptive appraisals of the trauma and/or its
affected by the use of different index of fragmentation sequelae plays for symptom maintenance. Even
(Crespo & Fernndez-Lansac, 2016; OKearney & though both groups increased in narrative organiz-
Perrott, 2006). To date, different conceptual ation, differences regarding how therapy helped the
10 M. Knutsen and T. K. Jensen

youth in modifying maladaptive appraisals may be a Strengths and Limitations

possible explanation for different treatment response This study has several strengths worth noting. First,
between the two groups in this study. Future studies the youth participating in the study were recruited
should explore whether differences in cognitive from a clinical population and represent regular,
appraisals and degree of cognitive restructuring real-life cases that practitioners meet in their clinics.
together with characteristics of the trauma narrative Second, this is one of only a handful studies examin-
ing the relationship between narratives and PTSS in a
can predict outcomes. Furthermore, since we did
traumatized youth sample, and the first to study
not measure emotional change directly, we cannot changes in narratives during treatment, thus contri-
know whether non-responders did not habituate to buting to the scarce research on trauma narration
fear and other negative emotions even though their and PTSS in this population. Third, it is possible to
trauma narrative changed. It may be that the narrative compare our findings with similar studies in the
work did not activate the fear structure sufficiently for adult field because we applied and followed an exten-
sive coding manual used in previous studies. Finally,
the non-responders, thus preventing the emotional
the fact that the participants had experienced differ-
processing and habituation to negative emotions con- ent types of traumas, reflecting the reality of clinical
sidered necessary for symptom reduction to succeed cases, increases the external validity of the study.
(Foa & Kozak, 1986; Foa & McLean, 2016). We We acknowledge that this study also has some
can also not exclude the possibility that there is no important methodological limitations that must be
relationship between changes in narrative organiz- considered. Although the sample size was consider-
ably larger than that of previous comparable studies
ation and improvement in PTSS. There are studies
(Foa et al., 1995; van Minnen et al., 2002), we
that do not support an association between changes cannot exclude the possibility that the small sample
in narrative organization, degree of fragmentation size reduced the probability of finding a significant
and PTSS (Gray & Lombardo, 2001; Rmisch difference between changes in narratives and
et al., 2014; Rubin, 2011; Young, 2000). Further- changes in PTSS. We recognize that non-normality
more, some studies have found that disorganized and unequal variance across groups are factors that
could pose a threat to the validity of our results.
trauma memories can predict PTSS but not that suc-
However, results from non-parametric tests sup-
cessful recovery after therapy is related to the devel- ported all original conclusions. Because the narration
opment of more coherent and organized trauma took place in a treatment setting, in some cases, it was
memories (Halligan et al., 2003; Jones et al., 2007). difficult to determine when the first narrative started.
This study was not designed to examine the relative All narratives are co-constructed (Fivush, 1991), and
importance of trauma narration for treatment we have not analyzed how the relationship to the
outcome compared to the other components in TF- therapist or the therapeutic alliance may have influ-
CBT. Nevertheless, the results showing no signifi- enced the narrative process. In a previous study it
cant relationship between narrative changes and was found that a strong alliance along with trauma-
PTSS remission post-treatment is interesting and focused work predicted outcome (Ormhaug,
warrants further investigation. A dismantling study Jensen, Wentzel-Larsen, & Shirk, 2014), and it may
of TF-CBT showing that treatment conditions with be that a good therapeutic relationship facilitates the
or without the trauma narrative component was narrative work. Future studies should investigate
equally effective in reducing PTSS (Deblinger the role of the therapeutic alliance in narrative con-
et al., 2011), highlights the need to further clarify struction. Finally, it is worth mentioning limitations
the role of narration in trauma treatment. To date, regarding the narrative coding system used in this
it is not clear whether changes in narrative organiz- study. The coding manual developed by Foa et al.
ation are related to treatment response, and more (1995) is a complex and extensive manual that
knowledge on the mechanisms behind the construc- measures the degree of changes in narratives at a
tion of trauma narratives is needed. According to micro level by analyzing small units of text. A limit-
the developers of TF-CBT, all components are con- ation of this coding system is that it does not
sidered to be equally important and may contribute capture narrative organization at a more overarching
to treatment effects (Cohen et al., 2006). Future level. For example, it does not indicate the degree to
studies should investigate how other treatment com- which whole narratives are perceived as organized or
ponents of TF-CBT interact with the narrative com- comprehensible. Furthermore, because the coding
ponent in the recovery process and how they may protocol combines and measures several aspects
jointly contribute to outcome. and functions of narrative organization and
Psychotherapy Research 11

fragmentation, it is not clear whether different models such that treatment can be tailored and opti-
methods of operationalization or coding of narrative mized in the future.
organization and fragmentation can relate to PTSS
in somewhat different ways. This points to the need
for additional studies with a more coherent approach Disclosure Statement
to how trauma narratives can be conceptualized and
operationalized, and further underlines the need for No potential conflict of interest was reported by the
greater consistency regarding measurement authors.
methods in future narrative studies (for reviews see
Crespo & Fernndez-Lansac, 2016; OKearney &
Perrott, 2006). It should also be noted that the Funding
manual by Foa et al. (1995) was originally developed This work was supported by the Research Council of
for adults. Because the majority of our sample con- Norway, The Norwegian Directorate of Health.
sists of older children and youth, and a broad agree-
ment has been found on core processes and
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