DM: That is really a big question and I think the answer to it depends on which specific population one is looking at. I don't think that there are robust questions that cut across all populations. In general, at the level of adult, we need to examine the interrelationship between various spheres of behavior. That is, neurobiological, psychosocial, cognitive, and cultural. My own area of interest, as we will get into in a moment, is trying to better understand the cognitive arena. Once we have developed a metric for each of these areas, then we can start to look at the interdependence of these factors across domains. A second major area that needs to be explored that has not been looked at adequately, involves the fact that three-quarters of the population in North America is going to experience a Criterion A event some time in their life (From the DSM-IV this relates to an event that a person experiences or witnesses that involves actual or threatened death or serious injury or threat to the physical integrity of self or others rendering the individual feeling helpless or fearful). Yet, on average, only about 25% of people develop posttraumatic stress disorder (PTSD). An interesting and challenging question is what distinguishes those individuals who go on to develop PTSD from those who do not. I think that explicating those differences can be valuable in guiding both assessment and treatment. The third and final area involves the role of cultural factors in influencing the nature of traumatic responses and the ways in which these are expressed. As an Editor of the Plenum series, we have recently published a series of books on the cross-cultural and intergenerational features of traumatic stress. I think this latter area has also been overlooked.
JSV:I know that you have been a major proponent of the constructive narrative approach for the treatment of trauma survivors. Can you please describe the constructive narrative perspective and how it is utilized with your patients?
DM:Therearenowanumberofinvestigatorsfromdifferentperspectiveswhohavebeenverysensitiveandinnovativeinexploringthenatureofthestoriesthatindividualstellabouttheirtrauma.Thosestorieschangeoverthecourseoftime.Themeaningthatatraumaticeventhasforindividualsiscritical.Thisisnotnovel.Anumberofpeoplehavehighlightedtheroleofappraisalprocessesandtheroleofthestoriesthatpeopletelloverthecourseoftime.Ihavebecomeparticularlyinterestedinhowthesestorieschangeinmypatients.Ispendagooddealoftimesupervisingclinicians-psychiatrists,psychologists,socialworkers-andwehaveaudiotapedandvideotapedtherapysessions.Wehavenotedthatbothsymptomreductionandbehavioralchangescovarywiththechangingnatureoftheaccountsthatclientsofferoverthecourseoftherapy.Asenseofpersonalagencyoftenemerges.Clients,overthecourseoftherapyastheyimprove,oftenshiftthefocusoftheiraccounts.Theynowmovefromviewingthemselvesasvictimstobecomingsurvivorsifnot-thrivers.Astheydosotheyofferinterestingaccountsofhowtheycannowoftenhavemanyofthesamekindofthoughts,feelings,intrusiveideation,etc.butthisdoesn'tseemtobotherthemasmuch.Theydonotfeel"stuck."Thereisacertainshiftinthenatureoftheirnarrative.Wehavebecomeveryinterestedintrackingthesechanges.Thechallengeforus,ataresearchlevel,iswhetherthesenarrativechangesareepiphenomenathatfollowbehavioralchangesandphysiologicalchangesorwhether
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