627795

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QHRXXX10.1177/1049732315627795Qualitative Health ResearchWesterman et al.

Article
Qualitative Health Research

Trauma-Focused Cognitive Behavior

1­–10
© The Author(s) 2016
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DOI: 10.1177/1049732315627795

Adolescents qhr.sagepub.com

Nancy K. Westerman1,2, Vanessa E. Cobham3, and Brett McDermott3

Abstract
Repeated retelling of trauma narratives within Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) assists
participants to habituate to experiences that have precipitated symptoms of post-traumatic stress. In this study, the
narratives produced by children and adolescents, who developed post-traumatic stress disorder following a natural
disaster, and who were treated with a manualized TF-CBT intervention, were examined. The first author developed
a coding system utilizing three major concepts (coherence, elaboration, and evaluation) to identify changes in the
narratives as they were retold at each therapeutic session. Analysis using this coding system identified that the internal
logic of the stories was maintained as the detail diminished, and that the level of evaluation increased. Compression
emerged as a major pattern, alongside the reduction in participant distress over the course of the treatment. Although
requiring replication, these trial concepts, developed by the coding system, have potential analyzing trauma narratives
and enhancing clinician observations.

Keywords
adolescents; children; narrative inquiry; qualitative research; post-traumatic stress disorder (PTSD); trauma; therapeutic
change process; Australia

Treatment for post-traumatic stress disorder (PTSD) typi-
cally involves exposing the client to the experience that
has led to the post-traumatic symptomology via imaginal
and/or in vivo exposure (Cohen, Mannarino, & Deblinger,
2006; Ehlers & Clark, 2000). Within the trauma-focused
behavioral therapy (TF-CBT) intervention used within
the current study, the imaginal exposure element takes the
form of the client repeating a narrative version of their
traumatic experience at each therapy session. This pro-
cess encourages habituation to the frightening elements
of the trauma experience. Cognitive reprocessing within
the context of the imaginal exposure is an active feature
of TF-CBT (Cohen & Mannarino, 2008; Cohen et al.,
2006; FItzgerald & Cohen, 2012; Hamblen, Gibson,
Mueser, & Norris, 2006).
Clinical observation suggests that the trauma narratives
within TF-CBT provide unique clinical information. The
current study was designed as a trial to explore this possi-
bility more closely, incorporating a post-intervention nar-
rative analysis using a new coding system. Three concepts
within narrative analysis—coherence, elaboration, and
evaluation—were developed to describe in depth how the
narrative is transformed as therapeutic change occurs.
A diagnostic interview had established that the chil-
dren in the study who received the TF-CBT intervention
were all free from PTSD diagnosis post-intervention, a
result which was maintained at 6- and 12-month follow-
up (Cobham & McDermott, 2015). Based on this out-
come, the current exploration was based on the assumption
that there was relative hegemony among the participants
in their decrease in distress by the final telling of the
trauma narrative. It was hypothesized that the distress
experienced by the children and adolescents would ini-
tially increase during the retelling of the stories, and then
subsequently it would decrease in intensity. It was also
proposed that the stories generated by the children and
adolescents would significantly change during treatment.
This would be demonstrated by codification of the con-
cepts of coherence, elaboration, and evaluation. The spe-
cific hypotheses proposed that there would be an initial
1
Mater Child and Youth Mental Health Service, Brisbane, Queensland,
Australia
2
Queensland Health Child and Youth Mental Health Service, Brisbane,
Queensland, Australia
3
University of Queensland, Brisbane, Queensland, Australia
Corresponding Author:
Nancy K. Westerman, Queensland Health Child and Youth Mental
Health Service, Brisbane, P.O. Box 324, Annerley, Queensland 4103,
Australia.
Email: nancy.westerman@uqconnect.edu.au

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2 Qualitative Health Research 
increase in elaboration (the amount of detail) across the
repeated retelling of the stories, then a decrease in elabo-
ration making the final stories more succinct; the coher-
ence (establishing a logic within the stories) of the
narratives would become more consistent; and the level
of evaluation (making sense out of the experience) would
increase.
From December 2010 through to January 2011,
Queensland experienced a major flooding event. Seventy-
eight percent of Queensland (total area 1,852,642 km2)
was designated a disaster zone (Queensland Floods
Commission of Inquiry [QFCI], 2012). Property damage
was estimated at AUD6 billion, and displacement and
isolation from resources and services was common.
Throughout Queensland, the death toll was 38 (QFCI,
2012). From both an Australian and international per-
spective, natural disasters are common, with recent con-
cerns that global warming may increase the frequency
and severity of these events (Berry, Bowen, & Kjellstrom,
2010). A dedicated child and adolescent response to this
Queensland disaster was established based on published
research that has established the prevalence of post-disas-
ter mental health presentations (McLaughlin et al., 2009),
the likelihood of chronic conditions if symptoms remain
untreated (McDermott, Cobham, Berry, & Kim, 2014),
and evidence of associated psychosocial impairment
(Alisic, van der Shoot, van Ginkel, & Kleber, 2008).
The child and adolescent mental health response to the
disaster was led by the second and third authors, and
employed a stepped care approach inclusive of a com-
munication strategy; parent effectiveness and teacher
psychoeducation seminars; proactive school-based
screening; and TF-CBT for those children and adoles-
cents who were identified as meeting the criteria for an
anxiety or PTSD diagnosis (Cobham & McDermott,
2014; McDermott & Cobham, 2012). TF-CBT was the
treatment of choice due to its strong evidence base for
many types of trauma-induced symptomology (Cobham,
Fletcher, & Howard, 2013; Cohen et al., 2006; FItzgerald
& Cohen, 2012; Jaycox et al., 2010; Mannarino, Cohen,
Deblinger, Runyon, & Steer, 2012). In particular, TF-CBT
had already been used successfully in Australia for chil-
dren and adolescents affected by natural disasters such as
bushfires (McDermott & Cobham, 2012).
The children and adolescents participating in the cur-
rent study were identified via a screening process (as
detailed in the Method section below). The treatment
involved up to 10 sessions. The first two sessions were
with parents and featured psychoeducation about PTSD,
specifics of the therapy, acknowledgment that symptoms
may worsen in the initial weeks of therapy, and encour-
agement of parents to facilitate their child completing
homework tasks throughout the course of therapy. During
the child sessions (from Session 2 onwards), the children
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were asked to tell their particular story of the flood (ima-
ginal exposure) at each session. These are the trauma nar-
ratives that served as the data for analysis in this current
study.
Method
Participants
Primary and high school students from throughout
Queensland undertook a two-stage post-disaster school-
based screening. The first stage of screening consisted of
the administering of the classroom-based, age appropri-
ate, psychometrically robust measures of PTSD, anxiety,
and depression at 3 month post-disaster. Those who
scored high in the first stage of screening progressed to
the second stage. This included the administration of a
diagnostic interview to parents and children at around 5
to 6 months post-disaster (the Anxiety Disorders
Interview Schedule for Children [ADIS-IV-C/P];
Silverman & Albano, 1996).
With their parents’ consent, the young people who met
diagnostic criteria for PTSD based on the diagnostic
interview were offered TF-CBT (Cobham & McDermott,
2011a, 2011b). Parents also agreed to their children par-
ticipating in research exploring their treatment and out-
comes. The transcripts of 20 primary school students and
six high school students were selected for the present
study (87% of the children and adolescents within the
South East Queensland region) and exclusions were made
either because the treatment was incomplete or the chil-
dren were outside the rural region. This decision was
made to maintain a relatively hegemonic cultural group.
A total of 54% of the sample was female. The median
school level was Grade 5 (38.5%). The grade level range
was from Grades 3 to 12. In all, 61.5% of the participants
were between the ages of 6 and 11 years with a range of 8
to 17 years. Further demographic information that might
have described more specific variations in the narratives
(i.e., culturally specific details, age, reading level, and
pre-disaster developmental or psychological state) was
not available to the first author. The reason for this
was because the study was designed after the intervention
was completed, as a reflective exploration, rather being
integral to the outcome measures gathered initially.
Procedure
Each therapist followed the same protocol and received
the same training to administer the protocol. Clinicians
were supported by supervision, and fidelity review
occurred after each session. The manualized approach
meant that the same instructions were given to each par-
ticipant by the therapist with regard to telling their flood
Westerman et al.
story (Cobham & McDermott, 2011a, 2011b). The thera-
pists were encouraged to prompt the children in drawing
out the stories, and to relate other aspects of the treatment
to how the children updated their story each session. The
therapists’ protocol embedding the narratives within the
therapeutic process was integral to how the stories were
constructed (Cohen & Mannarino, 2008; Cohen et al.,
2006; FItzgerald & Cohen, 2012; McDermott & Cobham,
2012).
Details of the instructions explained that the story was
like a written piece on a computer that can be edited. The
therapists introduced the scientific approach as a meta-
phor to teach children the skill of seeking alternative
plausible appraisals for events, to reduce anxiety, and to
broaden the narrow parameters of explanations that often
occur in response to trauma (Cobham, 2006; Rapee,
Wignall, Spence, Lyneham, & Cobham, 2008). Simple 1
to 10 measures of distress were utilized throughout the
sessions to monitor the levels of stress and wellbeing of
the children and adolescents.
The Coding System
In exploring the patterns of change within the trauma nar-
ratives from a qualitative perspective, an original coding
system was developed and applied. An initial impression
of patterns was generated by listening to the stories, and
then concepts were refined via a reciprocal process of
matching concepts gathered from a literature search to
the categories observed in the narratives (Nagy Hesse-
Biber & Leavy, 2011).
Coding systems for different types of narratives have
been developed so as to maximize the information taken
from the data and create a “best fit” of categories to the
data (Angus, Levitt, & Hardtke, 1999; Braun & Clarke,
2006; Charmaz, 2006; McLeod & Angus, 2004; Nagy
Hesse-Biber & Leavy, 2011). In analyzing narratives,
coding systems range from simple to very complex.
Simple systems focus on a few elements only (Amir,
Stafford, Freshman, & Foa, 1998; Foa, Molnar, &
Cashman, 1995; O’Kearney & Perrott, 2006; Zoellner,
Alvarez-Conrad, & Foa, 2002). These simple systems
may include organization of narratives at each level of
construction; lexical dominance of sensory, perceptual, or
emotional information; temporal disruption; or internal-
izing versus externalizing lexical markers.
More complex systems construct matrices that com-
bine analyses of form with thematic means of organizing
content. Examples of complex coding systems include
the following: the Narrative Form Index and Matrix
(Albright, Duggan, & Epstein, 2008), the Narrative
Processes Coding System (Angus & Hardtke, 1994;
Angus et al., 1999), and the JAKOB system (Boothe,
Grimm, Hermann, & Luder, 2010; Boothe & Von Wyl,
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3
2004). Hence, coding systems may range from a focus on
form and syntactical detail to analyses of content and
semantic meaning (Albright et al., 2008; Angus et al.,
1999; Clandinin & Connelly, 2000; Elliott, 2005; McLeod
& Angus, 2004; Murray, 2003; Nagy Hesse-Biber &
Leavy, 2011; Pascale, 2011; Wertz et al., 2011).
The current study combines elements from the simple
and the complex coding systems into a matrix that links
concepts under the categories of coherence, elaboration,
and evaluation. The coding system was applied by exam-
ining the lexical information (word usage) as well as the
semantic information (content and context). This analysis
differs from studies that have used purely lexical infor-
mation (e.g. frequency of words used), or purely semantic
information (e.g. overall grids of thematic concepts), to
develop categories within coding systems. Lexical infor-
mation was situated within the discursive context of the
therapeutic process.
The resulting coding system was able to capture a
detailed picture of the changes in the narratives without
the surfeit of content information generated by the more
complex systems. The three concepts of coherence, elab-
oration, and evaluation formed a functional matrix with
which to describe the patterns within the stories.
Coherence was divided into structure (beginnings,
sequences, and endings), orientation (time, place, and
persons), and normative referents. Elaboration was
divided into description (sensory and kinesthetic infor-
mation), emotion, and sense of self. Evaluation was
divided into causality, insight, and integration. A detailed
summary of these concepts is presented in Table 1. (For
further elaboration of the construction of the coding sys-
tem, see Westerman, 2015)
Statistical Analysis
Audio recordings and written transcripts had been made
of the stories as part of the treatment protocol. The tran-
scripts were checked against the audio versions and cor-
rected where necessary, ensuring the quality of the
transcripts. Transcripts were inputted into the qualitative
computer software Atlas.ti (Gibbs, 2007; Hwang, 2008)
and subsequently coded using the aforementioned origi-
nal coding system. An iterative process was used to check
on the consistency of the coding.
Within qualitative research, the roles of the researcher
or the therapist are important elements in the performance
of the narrative (Elliott, 2005; Hyden, 2010; Peterson &
Langellier, 2006; Saldana, 2011). In this study, the first
author was blind to patterns observed by the principal
authors of the intervention and by the therapists. The first
author independently examined the literature, listened to
the stories and read the transcripts, constructed and applied
the coding system, and proceeded with the analysis. The
4 Qualitative Health Research 

Table 1. Details of the Coding System. information was included, sequence was clearer, more
Coherence: General
detail was remembered, and participants were usually
A coherent narrative is one that can be understood within more comfortable disclosing how they felt and thought.
an exchange The order was sometimes rearranged as details were
Coherence: Structure remembered toward the end of a narrative, and then rein-
How beginnings are constructed troduced in subsequent narratives. Specific patterns
The sequencing of information emerged from the coding of the flood stories. The details
How endings are constructed are summarized below and a reflection on these results
Coherence: Orientation
follows.
An awareness of time, setting, and persons
Coherence: Normative
The cultural context evident within the story
Coherence: Structure
Elaboration: General
The complexity of detail in the stories. (Stories may be The following excerpt is an example of the beginning of
sparse or complex) a trauma narrative in the final session of treatment.
The amount of detail may indicate accessibility, or
avoidance, of memories
Participant: I’m in my bed and mum’s calling me. Because
Elaboration: Description
it’s a bunk bed, I climb down my ladder and race to the front
Includes sensory details (sight, sound, touch, taste, smell,
and then mum tells us to wait and then a few, after a few
kinesthetic)
seconds, a big rush of water comes under our house.
Elaboration: Emotion
The level of articulation of emotional domains
Intensity of expressed emotion For this participant, the story begun the same way
Both internal feelings and awareness of the feelings of each time it was told, but by this final session, the story is
others less distressing and more compact. Details of who is pres-
Elaboration: Sense of self ent, where the story is taking place, and why events occur
The use of words that indicate thinking, knowing, have consistently been present in each telling of this
remembering, intentions, perspective taking or positioning,
story.
relatedness, and values
Evaluation: Causality
Explanations, links between information, and plausibility Beginnings. Possibly due to their placement within a man-
May relate to action, emotion, cognitions or social ualized intervention, most (92%) of the beginnings to the
relationships stories were, or soon became, structured and consistent. If
Evaluation: Insight the starting point was uncertain, it usually became consis-
Self-reflectivity and criticality tently defined by the final retelling. Often the beginnings
Flexibility and a tolerance of contradictions and became compressed by the later stories.
uncertainties
Immediate lessons or global understanding that are gained
from the traumatic experience Sequencing. Most (96%) of the narratives became more
Evaluation: Integration consistently sequential as therapy progressed. Informa-
Meaning making in sense of self and identity in relation to tion was sometimes combined, or detail added. Many
information; agency; and predictive ability (77%) of the narratives became more compressed by the
final stories.

role of the therapists and the protocol in structuring the
narratives distinguishes this data from free recall inter-
views and research into autobiographical narratives. The
site of performance is the interaction between the partici-
pants and therapist; the site of the analysis is between the
first author and the transcripts of the narratives. These
sites did not impact on each other.
Results
Many of the trauma stories were told hesitantly at first,
with a low amount of information and high distress. A
few first stories were told in a rushed and highly dis-
tressed manner. In the middle stories (mid-therapy), more
Endings. There was a great deal of variation in the end-
ings of the narratives, possibly due to the fact that the
stories were embedded in a greater therapeutic process as
integral to exposure and cognitive reappraisal. Most of
the endings (77%) became more defined and consistent
as therapy progressed. In some (12%) of the endings,
compression of detail was evident. Some (23%) endings
had no obvious pattern. Some (27%) endings flowed into
the questions that followed the story and were only given
structure by the encompassing session. The end of the
story was signaled either actively by the participants
(58%), or collaboratively negotiated (23%), or prompted
by the therapist (12%). Participants varied in their pat-
terns across sessions.

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Westerman et al.
Coherence: Orientation
Time and place. By the final stories, almost half (46%) of
the stories had increased in their orientation to time and
place. A third (35%) had a pattern where evidence of time
and place orientation peaked in the middle stories and
dropped off by the final stories, and some (19%) were
consistent throughout.
Person. About a third (38%) of the stories increased in
orientation to person by the final stories. About a third
(27%) of the stories consistently demonstrated orienta-
tion to persons, and about a third (38%) showed the cen-
tral peak shaped pattern. One set of stories decreased in
orientation to persons.
Coherence: Normative
Only a third (35%) of the stories had explicit normative
external referents. The floods were compared to recent
Tsunamis and the 1974 Queensland floods. Scientific
knowledge about weather events was cited. Death and
mourning generated many normative referents and an
example is presented below.
Participant: That’s how life is—happens for a reason
Participant: You can’t bring him back . . . Maybe God needed
him for something.
An intimate referent in one participant’s stories
described the influence of others on whether she had a
right to be upset by the traumatic events that she had
experienced.
Elaboration: Description
This is how one participant elaborated on the appearance
of the flood:
Participant: We saw cars in trees, we saw broken houses. We
saw furniture everywhere . . . that’s mainly all, just broken
objects, not people.
Details in the stories were added in, taken out, and rein-
cluded as therapy progressed. Core details often remained
consistent, and peripheral details were often dropped by
the final stories. Some extra details appeared for the first
time in the later stories. Half (58%) of the stories showed a
central peak pattern in the amount of detail included in the
stories and a few (15%) were consistent throughout. A few
(15%) increased in elaboration as therapy progressed.
A few of the sets of narratives of participants (12%)
had inconsistent levels of elaboration. This may have
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5
been due to one participant who was often tangential in
her descriptions, and to the way several of the partici-
pants reshuffled the core elements of their experiences.
A third (35%) of the stories became compressed by
their final retelling. Descriptions of positive events
appeared in only 12% of the later stories.
Elaboration: Emotion
In the first telling of the story, this participant demon-
strated her emotional state and a reason for why she felt
this way:
Participant: . . . I was cuddling my pillow and trying to take
my eyes off the window, because I was horrified.
In many stories, the affect changed from being ini-
tially flat or disengaged to becoming more varied in emo-
tional expression. Most (89%) of the participants reported
a decrease in distress by the final retelling. The patterns in
the level of articulation of emotional states were the cen-
tral peak pattern (38%), consistent (31%), an increase
(19%), and a decrease (8%). One participant’s narratives
were inconsistent, and this may have been related to an
overall difficulty engaging in the treatment process.
Elaboration: Sense of Self
An excerpt from a final telling of one story demonstrates
how the participant reflected on the experience of manag-
ing a food and clothing depot with his family.
Participant: I reckon it left everyone with good memories.
Anyone that came had good memories about it. I think
everyone who was there every day was always happy when
they came ‘cause we just tried to make everything fun I
guess, just mucking around. And then there was times we
were serious but we were still making it fun.
This coding category identified thoughts, memories,
wishes and desires, intentions, and perspective taking.
Over a third (42%) of the stories showed a central peak in
lexical detail demonstrating a sense of self and a third
(35%) were consistent throughout. Less than a third
(23%) of the stories showed an increase in sense of self
by the final stories.
Evaluation: Causality
There was a positive relationship in the narratives
between the use of causality statements and the level of
elaboration suggesting that causality may have been a
way to add detail both to description and in regard to a
sense of self.
6 Qualitative Health Research 
Participant: We were fine ‘cause our house was nice and
high and we didn’t get flooded. Lucky we weren’t in a one
story house that got ripped off its stumps.
Some (23%) of the stories were consistent in the
number of causality statements used throughout all
iterations, and a third (35%) demonstrated more cau-
sality by the final stories. A few (19%) had the central
peak, or a u-shaped pattern (8%), or decreased in the
amount of causality statements included (4%). These
variations were small and overall echoed the larger
patterns.
Evaluation: Insight
There is variation in how insight was presented in the nar-
ratives. One participant demonstrated insight in her story
as follows:
Participant: Ever since then I’ve noticed that . . . if I’d died
during the flood I wouldn’t have wanted very much in my
life, but I’m still alive, it’s probably my turn to make the best
of it . . . and so yeah, I think I’ve changed . . .
A third of the stories showed patterns of consistent
insight (31%), less than a third (23%) showed a central
peak in insight, less than a third were inconsistent (23%),
a few (15%) increased in insight, and a small number
(8%) had a u-shaped pattern of insight. This variation
may indicate a weakness in the refinement and definition
of this category (Charmaz, 2006).
Evaluation: Integration
The most common aspects of integration present were as
follows: meaning making, prediction, and tolerance of
uncertainty.
Participant: Stuff happens, when your times up your times
up, nothing you can really do about it, I mean it was gonna
be hard . . .
Participant: I was thinking that they were just there to help.
A third of the stories (31%) were consistent in demon-
strating integration throughout, about a third of the sto-
ries (23%) had a central peak pattern, and a few (15%)
of the stories increased in integration as the stories pro-
gressed, and 8% had a u-shaped pattern of integration.
About a third of the stories (23%) were inconsistent.
These inconsistencies were small and appear as varia-
tions on the other patterns (peak, increase, decrease, or
u-shaped). In a third (35%) of the stories, a positive
sense of self was related to evaluations by the final
stories.
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Compression
Compression is defined by the decrease of detail in the
narrative while maintaining its internal logic. This is a
pattern that has been noted within lexical analyses (Levy,
1999; Lillywhite et al., 2010; Saling, Laroo, & Saling,
2012). In this study, information was sometimes com-
bined, and at other times information was left out com-
pletely. Usually compression and positive statements
occurred by the final stories and less distress was associ-
ated with telling the story. The participants often com-
mented on how bored they were with telling the story.
This is understood to be a positive indication of the reduc-
tion of intensity associated with recall of the traumatic
experience (Foa et al., 1995).
Other Observations
The complexity or simplicity of the narratives varied
widely. Some participants had a broader range of vocabu-
lary than others. Most participants adhered to the specific
instructions from the therapist to tell the story in the pres-
ent tense (ensuring immediacy), but a few disregarded
these instructions and shifted between tenses.
Discussion
The coding system developed for this study elicited a
wealth of information about the changes that occurred
within the trauma narratives as therapy progressed. Our
results suggest that narratives within this clinical inter-
vention do have the potential to yield useful and specific
information about change processes for clinicians.
The clinicians’ observations were partially verified.
As stated, the received information was that the distress
experienced by the children and adolescents decreased
over the sessions. The coding system confirms this out-
come by observing the changes that occurred in the
trauma narratives. The elaboration did not increase
throughout; rather, it decreased by the final stories, form-
ing a pattern of compression. The global coherence of the
stories did become more consistent over time, and the
level of evaluation did increase overall. However, in both
of these areas, the elements of structure and orientation,
and causality and integration, demonstrated a more com-
plex picture than originally proposed.
In this study, there are the patterns where a small per-
centage of instances appeared as dissimilar to the greater
patterns observed. These instances may demonstrate a
weakness in the coding system in adequately capturing
the range of responses within some of the subcategories
of coherence, elaboration, and evaluation. Following a
grounded theory approach, the failure of the concepts to
adequately describe the data may indicate premature closure
Westerman et al.
in analytic categories (Charmaz, 2006; Wertz et al., 2011).
A return to the data, and possibly the use of additional
data, would enable the categories to become more defined
and a better fit (Charmaz, 2006).
The presence of normative referents validates the
choice of this concept as an aspect of coherence. However,
as there are few referents within these narratives, this cat-
egory would certainly be refined by additional studies.
The concept of insight was difficult to delineate as a cat-
egory and there was a lot of variation in the identified
patterns. Further refinement of the defining characteris-
tics of normative referents and insight might generate a
better understanding of how syntax and semantics dem-
onstrate these concepts.
Compression is the most consistent pattern in this
analysis of trauma narratives. Research shows that chil-
dren develop cohesive systems within the site of adult–
child interactions, both semantically and syntactically,
producing language for engagement (Levy, 1999, 2003;
Sawyer, 2003; Young, 2011). Repetition is integral to this
developmental process, and to the production of more
concise and compact narratives (Levy, 1999; Lillywhite
et al., 2010). Both the goals and situations of discourse,
and the allocation of attentional resources to the process,
affect the compression of discourse, in conversation and
in storytelling (Field, Saling, & Berkovic, 2000; Norrick,
1998; Saling et al., 2012).
The creation of a trauma narrative within TF-CBT
enables gradual reexposure to the experience, and ongo-
ing desensitization to the experience generally occurs as
the narrative is processed (Cohen et al., 2006). It is
intended that the traumatic experience become integrated
into the totality of the person’s life, part of a dynamic self-
concept and autobiographical life story, rather than
remaining dominating and troublesome (Cohen et al.,
2006). Neuropsychotherapy research also describes how
trauma experiences move from being “stuck” in the limbic
regions of the brain to becoming integrated into the spread
of neural activity as symptoms diminish (Grawe, 2007).
The interactive pragmatics and contextual information in
the narratives in this study revealed that the participants
behaved with boredom and impatience as their PTSD
symptoms diminished. The allocation of attention to the
telling of the stories, increasing familiarity with the task,
and the decrease in associated emotion through a process
of habituation and cognitive processing throughout the
treatment provide possible explanations for this behavior.
This is supported by Foa et al. (1995) who suggest that
compression is integral to desensitization.
Limitations
Isolating the stories as a discrete segment allows patterns
to be identified more easily, but also limits the greater
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7
picture of how therapeutic change occurs. A more com-
prehensive analysis might explore the site of the entire
therapeutic session to understand how the narratives
demonstrate exposure in relation to all elements of ther-
apy. One study examining the gains facilitated by the dif-
ferent elements of TF-CBT has compared narrative
processing with coping skills training, and has suggested
that although coping skills alone are useful for children
with a low level of traumatic stress, a combination of nar-
rative processing with coping skills training is more effec-
tive for children with a high level of distress (Salloum &
Overstreet, 2012). Differential effects need to be researched
further to strengthen these observations and create a clearer
picture of what behaviors are most assisted by narrative
processing as opposed to other treatments (Deblinger,
Mannarino, Cohen, Runyon, & Steer, 2011; Silverman
et al., 2008). The use of a coding system such as the one
designed for this study might be useful in isolating the spe-
cific changes that occur in the narratives, as opposed to the
entire sequence of therapeutic intervention.
There are several contextual factors that impacted how
the participants developed their trauma narratives. The
scaffolding of the storytelling within the therapeutic
intervention created the site of engagement within which
the narratives were transformed. Repetition is an integral
aspect of the treatment and cannot be separated from how
the therapist and the participant interacted with one another.
The stories are a negotiated communication, accruing clar-
ity due to both the progressive familiarity that the therapist
gains (by listening, questioning and seeking external infor-
mation), and that the participant gains (by prompts, repeti-
tion, therapeutic engagement and decrease in distress),
within the interaction. By exploring participant–therapist
interactions as the site of analysis, greater insight into how
the narratives evolve would be clarified.
Because of the reliance on the therapeutic protocol to
scaffold the stories, this research does not identify resolu-
tion patterns (the introduction of the event, a peak in the
experience, and the consequences of the event; Nelson &
Fivush, 2004; Thompson, Skowronski, Larsen, & Betz,
1996). Studies of autobiographical memory do examine
resolution patterns and hence are able to demonstrate the
development of memory systems, and the acquisition of
language, interactive communication, temporal under-
standing, representation of self, and theory of mind
(Nelson & Fivush, 2004). However, free recall of auto-
biographical memory is scaffolded by random and
unstructured contextual factors (such as repetition within
mother and child interaction dyads; Nelson & Fivush,
2004), making the processing of the trauma experience
unfold in an unpredictable context. By standardizing the
interactions through the imposition of a treatment proto-
col, patterns and outcomes are more readily identified
and can thus be correlated to change processes.
8 Qualitative Health Research 
Further Research
It has been demonstrated in this study that a close exami-
nation of the narrative element of TF-CBT yields a wealth
of information that might verify clinicians’ observation of
patterns of change. Apart from the possible extensions of
this study proposed as solutions to the challenges already
mentioned, adding to the contextual information (more
detail on participant variables) would enhance the gener-
alizability of this study. Refinement of categories would
be possible if further data were added to the original set
of participant narratives, allowing greater theoretical
delineation and linkage of categories in the coding
system.
Building in an exploration of the concepts of coher-
ence, elaboration, and evaluation from the beginning of
the intervention as qualitative outcome measures, or
developing screening measures based on these concepts
to establish baselines, would verify the efficacy of the
coding system. This would deepen clinician’s under-
standing of the integral nature of the trauma narrative
within TF-CBT. Contextual factors creating potential
individual differences (age, reading level, cognitive abil-
ity, comorbid emotional distress or psychopathology,
socioeconomic status, cultural differences, and other
environmental determinants of health) were not analyzed
in this study of the trauma narratives. Inclusion of these
details would elicit more information about the relation
of the patterns of change to developmental processes in
language and narrative, and observations in relation to
outcomes.
The information gathered via this original coding sys-
tem would be useful in forming further quantitative and
qualitative hypotheses that assist clinicians verify their
observations of change processes. Future research might
include a focus on specific lexical information (such as
word frequencies and usage) in relation to compression
and the reduction of PTSD symptomology. A focus on
syntax might clarify issues about how cognitive load
relates to elaboration of sensory detail or emotion. The
coding system could be used in qualitative research to
analyses changes that occur in free recall autobiographi-
cal narratives allowing comparisons to be made with
structured sites of analysis such as explored in this study.
Finally, it might also be useful to analyze the
therapist–participant interaction dyad to assess the adher-
ence of therapists to the manualized protocol, and how
this might affect the outcomes of the intervention.
Identical therapist training, regular supervision, and use
of manuals maintained consistency in this study. However,
analysis of the transactions between the therapists and the
participants might further enhance the quality of the
intervention, as well as describe more fully the interac-
tional space between therapist and participant.
Downloaded from qhr.sagepub.com at Gazi University on February 4, 2016
In summary, analyzing the trauma narratives produced
by the children and adolescents within the TF-CBT inter-
vention, in this first trial of the coding system post-inter-
vention, demonstrates that health and wellbeing are
related to coherence, elaboration, and evaluation in an
intricate and detailed way. Through the use of the qualita-
tive research methodology conducted in the current study,
it is possible to identify specific ways that change occurs
within the narrative element of TF-CBT. Replication of
this study, and further research in the directions suggested
above, would enhance this initial qualitative trial explora-
tion, and add to our understanding of the use of TF-CBT
treatment with disaster-affected children and adolescents.
Declaration of Interest
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The authors disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
There was internal funding from the Mater Hospital, Child
Youth Mental Health Service, Kids in Mind Research and the
Queensland Government, Child Health, Child Youth Mental
Health Service.
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Author Biographies
Nancy K. Westerman, BA Hons, BPsycScHons, MCouns, is a
provisional psychologist and researcher at the Lady Cilento
Children’s Hospital, Child and Youth Mental Health Service,
and at the Mater Young Adult Health Centre, in Brisbane,
Queensland, Australia.
Vanessa E. Cobham, PHD, is a psychologist, researcher, and
teacher in the School of Psychology, University of Queensland,
and at the Mater Research Institute, in Brisbane, Queensland,
Australia.
Brett McDermott, MD FRANZCP, is a consultant child and
adolescent psychiatrist and researcher at the Mater Research
Institute and the University of Queensland, Brisbane, Queensland,
Australia.