Beyond Words

BEYOND WORDS

Teaching Providers to Use Role-Play When Treating PTSD

Eric Rutberg, DHEd

January 10, 2010

Abstract

A comprehensive literature review reveals the use of role-play as safe and effective for facilitating exposure therapy when treating the psychobiological aspects of PTSD. Yet, these very techniques, touted in scholarly literature as being most effective, that are seen as dubious to many clinicians. With the intent of bridging the divide between theory and common practice, a continuing education course was developed, delivered, assessed and evaluated. Central to this applied dissertation was the implementation of three best practices.

1.	A curriculum was developed that teaches counselors the theories supporting the use of role-play as a form of exposure therapy, as well as the practical integration of those theories into their current practices. 2.	Assessment tools, such as pre- and post-course surveys and targeted observation forms, were developed for collecting quantitative and qualitative data. 3.	Standard operating procedures were established to allow for the reliable and consistent implementation and evaluation of the curriculum.

This one-day training resulted in an average increase of 16% in participant understanding of the biology of PTSD, an average increase of 7% in understanding the psychology of PTSD and an increase of 33% in participant understanding of safety precautions required when using role-play to treat PTSD. The mean of the difference between the post-test and pre-test responses also indicates an average increase of 10% in confidence among participants in using role-play, after taking the course. The data gathered during the research lead to course refinements that are expected to improve course delivery and so lead to improved learning outcomes. CONTENTS
 * Overview of the Research Environment
 * Evidence of Impact and Need
 * Course Design and Educational Theory
 * Exposure Therapy
 * Using Role-Play as a Form of Exposure Therapy
 * The Psychobiology of Exposure Therapy
 * The Psychology of PTSD
 * The Biology of PTSD
 * Using Archetypes Rather then Personal Narratives in Role-Play
 * Integrating Role-Play into Current Tratment Paradigms
 * Research Design, Implementation and Analysis
 * Methodology
 * Data Collection
 * Data Analysis
 * Future Directions in Research and Course Development
 * References

Beyond Words: Treating PTSD

This article outlines the general criteria of post-traumatic disorder (PTSD), the wide-ranging impact of this disorder and evidences that employing role-play as a form of exposure therapy, can effectively assist counselors in treating the psychobiological aspects of PTSD. Research shows cognitive-behavioral therapy (CBT), especially exposure therapy, is effective in treating PTSD on a psychobiological level by reconditioning the body’s fight, flight or freeze mechanism. Yet according to studies by Becker, Zayfert., and Anderson (2003) and Cahill, Foa, Hembree, Marshall, and Nacash (2006) many psychologists and master’s level clinicians, respectively, do not include an exposure therapy component in their treatment of PTSD. In response to this disparity, a day-long training entitled “Beyond Words” was developed, delivered and assessed to raise counselor awareness of treatment options. Overview of the Research Environment

Since its establishment by this researcher/clinician in 2000, the counseling center has offered individual and group therapy for children and adults suffering from a multitude of mental health disorders including trauma. An eclectic approach to applying Gestalt Therapy, Analytical Therapy, Expressive Arts Therapy and Cognitive-Behavioral is most commonly applied in treatment. The common thread tying these therapies together is a mind-body approach to healing. Located in a rural town in Western Maine, continuing education training often requires traveling more than an hour to the nearest cosmopolitan area. This continuing education training was offered at four different locations around the State of Maine. The sample was comprised of 36 (n = 36). mental health counselors licensed in Maine or nationally certified.

Evidence of Impact and Need

PTSD may result from exposure to a traumatic event or experience involving intense fear and helplessness. The DSM-IV-TR (1998) lists symptoms of PTSD including flashbacks or nightmares related to the traumatic event, somatic sensations such as hyper arousal, dissociation and anxiety, as well as physical and psychic numbing. When current events, vaguely reminiscent of the original trauma, cause patients to “feel or act as if they were traumatized all over again” (van der Kolk, 1994, para. 27) it is appropriate to render a diagnosis of PTSD.

While PTSD is often associated with victims of natural calamities or military personnel, the diagnosis emerges with great frequency among the general population. In a report entitled The Numbers Count (2008), the National Institute of Mental Health states, in any given year approximately 7.7 million American adults age 18 and older are diagnosed with PTSD. According to the Veterans for America (2007), 30% of soldiers and Marines and 49% of national guardsmen in high combat situations develop a mental health problem, such as depression or post-traumatic stress disorder. As for civilians, the National Center for PTSD, cites the National Co-morbidity Survey Report, reporting “60.7% of men and 51.2% of women reported at least one traumatic event” (Department of Veterans’ Affairs (2007, para. 3).

Along with the evidence of rising rates of PTSD diagnosed in America, there is also evidence of a shortage of trained clinicians. “Despite all the evidence for the efficacy of exposure therapy and other CBT programs, few therapists are trained in these treatments and few patients receive them” (Cahill et al., (2006), p. 597). According to Cahill et al., (2006), there is an underutilization of exposure therapy due to beliefs by clinicians that there is; a) an increased drop-out rate among patients, b) exposure therapy poses a risk for re-traumatizing patients and c) exposure therapy is perceived as a rigid treatment model, with a prescribed outline that tends to diminish the current orientation of a clinicians’ practice and fails to recognize the individual needs of patients.

These concerns likely emerge from the counter-intuitive nature of exposure therapy, as it requires counselors and patients elicit the very symptoms that patients seek to avoid. However, counselors would be “prudent to avoid viewing increases in PTSD symptoms related to the introduction of exposure therapy as an adverse occurrence that should be avoided and instead these reactions should be seen as part of the path towards recovery” (Wells, 2004, p. 5). Suggesting “all cognitive behavioral therapies are equally tolerable” (Hembree, Dorfan, Kowalski, & Xin, 2003. p.6). Indeed, Hembree et al., (2003) suggest drop out rates may be the result of fast and effective outcomes instead of the presumed incapacity of the patient to tolerate the treatment.

With the hope of bridging the divide between research findings and common practice, this researcher hypothesized a continuing education course that endeavored to assist participants in learning ways to safely integrate exposure therapy into their current practice. The course is specifically aimed at increasing confidence in using role-play, as a form of exposure therapy. While assessing post-training application of this technique is beyond the scope of this research, it is still hopeful that by increasing confidence among counselors in employing this type of exposure therapy, increased accessibility to effective treatment for clients with PTSD may result.

Course Design and Educational Theory

Development and delivery of this training was built upon the theories of constructivism, learner-centered teaching and experiential learning. According to constructivist theory, “the role of the teacher is raised from someone who simply dispenses information to someone who structures activities that improve communication, that challenge students’ pre-conceived notions, and that help students revise their world-views” (Constructivism, 2008, para. 12). As such, the instructor must endeavor to deliver the course material so it may be transformed in a way that has personal meaning and relevant application in each participants work setting. To that end, constructivists provide student’s with opportunities for scaffolding knowledge. Scaffolding knowledge means building upon "what students already know and believe, based on the sense they have made of their previous concrete experiences” (Kolb & Kolb, 2005, p. 1).

Additionally, in his book, Client-Centered Therapy, Carl Rogers examined the concept of learner-centered teaching. “Rogers saw himself as a facilitator, one who created the environment for engagement” (Carl Rogers, Core, 2004. para. 9). Liu & Liu (2006) note learner-centered teaching is called for by researchers yet teacher-centered teaching is still predominant. In the case of facilitating this continuing education training, the participants have a wealth of information to share. Thus, adopting the role of facilitator of a learner-centered environment was intended. The third educative component in the Beyond Words training is experiential learning. Experiential learning involves a “direct encounter with the phenomena being studied rather than merely thinking about the encounter” (Smith, 2001. para. 1). This training provided experiential activities including opportunities for large and small group discussions, writing and kinesthetic learning through the use of role-play. Offering opportunities to scaffold knowledge experientially assists participants in transforming information into practical knowledge. It also familiarizes participants with the methods they may employ when presenting treatment ideas and practices to their clients. For example, consider Rogers’ client/student-centered principles. Counselors must experience the empowerment inherent in facilitated learning and they must feel the benefits of being validated for their unique intelligences if they are to employ these principles in clinical practice. The same is true for experiential learning. For counselors to learn to use role-play safely, they were challenged to experience the safe use of role-play. The upcoming sections introduce the cognitive-behavioral technique of employing role-play as a form of exposure therapy as an effective tool for treating the psychobiological underpinnings of PTSD. Facts about the ways the mind and body are connected and examples of ways to apply the above mentioned educational methods are presented.

Exposure Therapy

Human beings call upon historical, factual, and emotionally valenced data to draw conclusions about present day events. This function is critical to survival. For instance, when an individual experiences emotional or physical pain associated with an activity, the emotionally charged memory of the event or even the slightest sign of impending pain, is likely to cause them to respond quickly or even dissuade them from repeating the activity. This emergency response system often referred to as the fight, flight or freeze mechanism, releases neurohormones just as they were issued during the original event. This results in the symptoms described by those with PTSD. If clinicians are to employ effective interventions, they must consider the research that shows memories are stored both in mind and body. Exposure therapy is well established as being effective in treating the fight, flight, freeze response associated with PTSD. During an initial traumatic event or when memories are triggered, neurohormones condition the body’s fight, flight and freeze response. The original trauma conditions the client both psychologically and biologically. According to Ochberg, (2006), exposure therapy engages the client in a way that reconditions the client’s stress response on a psychobiological level. Exposure therapy requires one directly confront situations which trigger extreme anxiety. Commonly, exposure therapy is employed either in vivo or through re-imagining past events. In either case, the challenge is to recall a memory with “optimal emotional intensity” (Ochberg, 2006, para. 62) strong enough to elicit the body‘s emergency response system but not so strong as to overwhelm the ability to manage the ensuing symptoms.

Using Role-Play as a Form of Exposure Therapy

Role-play is an effective supplement or alternative to in vivo and imaginal approaches to treatment. It can be employed safely while eliciting a response that can recondition the client’s stress-response and it is a malleable technique that can be integrated with many different theoretical orientations. Psychological risk, when employing role-play as a form of exposure, can be mitigated by teaching specific treatment precautions. For instance, it is important to examine “previous experiences of safety and competency (as a way to) recall memories of what it feels like to experience pleasure, enjoyment, focus, power, and effectiveness before activating trauma-related sensations and emotions” (van der Kolk, 2006, pt. 4). Hudgins (2002) emphasizes informed consent, effective assessment and evaluation, accepting client limits, as well as a strong therapeutic alliance between client and counselor as key protocols for safely employing role-play when treating PTSD.

The Psychobiology of Exposure Therapy

Informed by a wealth of knowledge about the psychobiology of PTSD, the implications for role-play as a form of exposure therapy become better defined. van der Kolk, van der Hart, and Burbridge (1995) posit two conditions relevant to treatment of PTSD. First, clinicians and patients must engage in directly activating memories to modify the psychobiological conditioning. Secondly, the patient must successfully cope with the trauma memory and experience mastery over symptoms. As to the former, the counselor and patient are charged with the challenge of recalling a memory with “an optimal emotional intensity” (Ochberg, 2006, para. 62), strong enough to elicit the body’s emergency response system but not so strong as to overwhelm the ability to manage the ensuing symptoms.

Role-play engages the many senses involved in the original traumatic event, which leads to emotional and cognitive processing. Role-play engages motor skills, as well as sight, smell, touch and other senses which are important gateways to the original trauma memory. Furthermore, it allows for the repeated and powerful pairing of a fear-producing situation with a positive experience of improved management of somatic sensations, validation and support. It may even result in the creation of an alternate memory that brings open-ended tensions to a close. Role-play brings problems and fears to a conscious level in order to affect a psychic purge” (Dayton, 1994, p. 14) This catharsis occurs “on a physical level, cleansing the body, causing a cellular release of the held memory within the brain and body” (Dayton, 1994, p. 16). Thus, according to van der Kolk (2006), one may unlearn previous psychological and physiological conditioning.

The mechanical retelling of events, in counseling, is insufficient for the effective treatment of PTSD. Counseling must offer an experience that engages the many senses, so one can recall memories at the somatic level, as well as the opportunity to process the scene on a cognitive level, guided by a clinician. Indeed, Hudgins (2002) proposes role-play to address the very symptoms of PTSD, facilitate developmental repair, provide structures for safe re-enactment of core trauma scenes, and promote control, containment, and stability in the therapeutic setting. The Psychology of PTSD

In 1889, Pierre Janet described dissociation as “the most direct psychological defense against overwhelming traumatic experiences” (van der Hart & Horst, 1989, p. 1). This precept, according to van der Hart (2005) is widely accepted to this day. For more than a century, researchers and clinicians have sought a theoretical framework from which to understand and develop effective treatments of dissociated psychic content. Dissociation represents a process whereby certain mental functions which are ordinarily integrated with other functions presumably operate in a more compartmentalized or automatic way usually outside the sphere of conscious awareness or memory recall" (Ludwig, 1983, p. 93). Thus, when dissociating many sensory experiences bypass consciousness and become lodged in the subconscious. van der Kolk, van der Hart., and Burbridge (1995) propose dissociating at the moment of the trauma (peridisociation) is the ultimate predictor for the development of PTSD. This repressed, residue of the original trauma surreptitiously drives attitudes and actions.

Psychological treatment of PTSD focuses on reintegrating dissociated, cognitive, and somatic experiences. Thus, employing treatment modalities which addresses dissociation is indicated. “Neurobiological research into post-traumatic stress disorder (PTSD) has shown that trauma responses are rooted in the unconscious mind and stored in the right-brain, which cannot be easily accessed through traditional talk therapy” (Hudgins, 2002, para. 5). Moreover, Rubenfeld (2000) reports it is evident that emotions and memories are stored both in our minds and bodies. Role-Play directly engages the body, which in turn facilitates emotional and cognitive processing. Guided by a clinician, role-play offers an experience that engages the many senses, so one can recall memories at the somatic level, as well as the opportunity to process the scene on a cognitive level. In their article, Nijenhuis, van der Hart and Steele (2004) report patients with PTSD often present with cognitive distortions resulting from an inability to integrate the facts and implications of a traumatic event. Role-play “gives us the opportunity to suspend (trauma) in time, allowing one to study a memory in its concrete form” (Dayton, 1994, p. 3).

The Biology of PTSD

Understanding the biological workings of exposure therapy offers another perspective on treatment. PTSD is the result of repeated, autonomic misinterpretations of current events with disturbing psychological and somatic symptoms ensuing. Specific symptoms can be correlated to the release of certain neurohormones. For instance, norepinephrine is an activating agent, responsible for initiating fight, flight or freeze behaviors while “cortisol, allows a person to think clearly in the midst of a triggered fight, flight or freeze response” (Sturgeon, 1999, pt. 2). Sturgeon (1999) cites studies that show the hypothalamic-pituitary-adrenal (HPA) axis may be conditioned to release lower levels of cortisol in those who experience a traumatic event. While more research is needed, the result of reduced cortisol production and the conditioning of the HPA axis, in cases of repeated trauma, is a likely explanation for the increased feelings of anxiety in patients with PTSD.

Post-traumatic symptoms such as physical and psychic numbing, fragmented memories and dissociation may well be correlated to the conditioned release of endogenous opioids dispatched to defend against perceived or real emotional or physical pain. This powerful biological reaction occurs at the time of the original traumatic event, as well as each time the feared memories are triggered. Each time these responses misfire, the conditioned response becomes ever more engrained. In addition to the mechanical release of neuro-hormones and beyond reconditioning an individual's response to anxiety provoking stimuli, role-play may directly impact the way one remembers the past trauma. “Alterations in memory form an important part of the clinical presentation of patients with PTSD” (Bremner, 1999/2002,para. 5). Various aspects of memory are processed by different brain structures. “Factual memory mainly involves the hippocampal formation whereas the emotional component of learning involves the amygdaloid complex” (Desmedt, Garcia, & Jaffard, 1998, p. 1). “The architecture of the brain gives the amygdala the priviledged position as an emotional sentinel” (Goleman, 1995, p. 17), allowing quick response in an emergency. “For individuals diagnosed with PTSD the hippocampus and amygdala malfunctions which result in the distortion and fragmentation of memories, dissociation and even amnesia” (Bremner, 2002, p. 1). Using role-play, clinicians address trauma at a biological level by “eliciting the release of endogenous, stress-responsive neurohormones, such as cortisol, epinephrine and norepinephrine (NE), oxytocin and endogenous opioids” (van der Kolk, 1994, p. 3). The counselor then “assists clients in focusing on the regulation of affective states and the experience of intense emotion” (Fosha, 2003, p. 9). Role-play also effectively facilitates the recall of memories, emotions or thoughts and integrates them into ones personal, current-day narrative. As such, memory becomes as much an act of creation as a vestibule for trauma.

Using Archetypes Rather then Personal Narratives in Role-Play

Jung proposed archetypes are primordial images “inherited from ones ancestral past including all human ancestors as well as is pre-human and animal ancestors” (Hall & Nordby, 1973/1999, p. 39). Not fully developed at birth; “they are more like a negative that has to be developed by experience” (Hall & Nordby, 1973/1999, p. 39-43). The “Personal Unconscious contains all the psychic material that is incongruous with ones consciousness” (Hall & Nordby, 1999, p. 34). Thus, traumatic experiences such as rape or natural calamity are repressed and delegated to the Personal Unconscious. Memories relegated to the Personal Unconscious must be retrieved and proactively re-integrated into consciousness, as part of treatment.

Recalling the details of trauma memories is common practice amongst cognitive-behavioral therapists using exposure therapy. Yet, recalling trauma memories is a burdensome challenge for many clients, as they elicit uncomfortable, sometimes disabling symptoms. Using Archetypes rather then personal narratives in role-play offers clients the opportunity to practice accessing their personal unconscious, as well as develop skills for symptom management. Using archetypes in role-play still has the potential to illicit the necessary, psychobiological responses required for the effective treatment of PTSD without requiring the client to draw from autobiographical narratives from their conscious past. To that end, participants were taught a method of role-playing using archetypes.

Designed by Myss (2010), archetype cards illustrating light and shadow attributes of over 80 different Archetypes were employed. Each participant, with an archetype card of their choosing, was paired with a partner. Each took turns suggesting a role-play. To best prevent the unconscious unveiling of any past trauma or internal conflicts, while practicing the method, training participants were instructed to recall an innocuous event in their lives and role-play a correlated archetypal concept. For instance, one participant chose to address the feeling of being unappreciated at work. She had chosen the “vampire” archetype card. She and her partner experimented with a role-play that explored the light and dark attributes of vampirism as it relates to their workplace. Using a role-play technique called role-reversal; the actual employee took on the employer role. She adopted the dark attribute of the vampire. This role depicts one who metaphorically sucks the employee dry. The partner played the employee role. S/he adopted the light attribute of vampirism. This role depicts one who gives of him or herself, entirely, to the employer.

The goal of this exercise was not to resolve the employee/employer conflict. Rather, the role-play raised the participant’s awareness of gestures, expressions, postures and incongruities between verbal and nonverbal communications, as well as to practice the essential action-therapy skills of creativity and spontaneity. Froggatt (2005) proposes several other experiential exercises familiarizing participants with the safe use of specific role-play techniques. These include;

•	The Double-standard dispute: If the client is holding a ‘should’ or is self-doubting about his/her behavior, use role-play to explore how the patient might respond to another person for doing the same thing (Froggatt, 2005, p. 15). •	Catastrophe scale: Role-playing a worst scenario can demystify the unknown factors or release tensions that have been building in ones mind, but that hold little power in the light of the day (Froggatt, 2005, p. 15) •	Devil’s advocate: this useful and effective technique (also known as reverse role-playing) is designed to get the client arguing against his/her own dysfunctional belief. The therapist role-plays adopting the client’s belief and vigorously argues for it; while the client tries to ‘convince’ the therapist that the belief is dysfunctional. Through role reversal, the protagonist discovers many viewpoints that expand his own insight and help him to choose more adaptive responses. Not only are the new ideas talked about, but by using psychodramatic methods, they are tried out in a simulated situation (Froggatt, 2005, p. 15). •	Successful and spontaneous behaviors are reinforced, while ineffective adaptations become immediately apparent and are gradually extinguished. This calls for the counselor to elicit these sensations and teach the patient ways to cope with those very somatic sensations elicited by the recalling of a traumatic experience through role-play (Froggatt, 2005, p. 15). •	Reframing: another strategy for getting bad events into perspective is to re-evaluate them as ‘disappointing’, ‘concerning’, or ‘uncomfortable’ rather than as ‘awful’ or ‘unbearable’. Through role-play, a variation of reframing is to help the client see that even negative events almost always have a positive side to them (Froggatt, 2005, p. 15). •	Time projection: this technique is designed to show that one’s life and the world in general, continue after a feared or unwanted event has come and gone. Ask the client to role-play the unwanted event occurring, then role-play going forward in time a week, then a month, then six months, then a year, two years, and so on, considering how they will be feeling at each of these points in time. They will thus be able to see that life will go on, even though they may need to make some adjustments (Froggatt, 2005, p. 15). •	The ‘blow-up’ technique: this is a variation of ‘worst-case’ imagery, coupled with the use of humor to provide a vivid and memorable experience for the client. It involves asking the client to role-play whatever it is he/she fears happening, then blow it up out of all proportion until he/she cannot help but be amused by it (Froggatt, 2005, p. 15).

PTSD is a psychobiological response to a traumatizing event. “If past experience is embodied in current physiological states and action tendencies and trauma is reenacted in breath, gestures, sensory perceptions, movement, emotion and thought, therapy may be most effective if it facilitates self-awareness and self-regulation through these same processes (van der Kolk, 2006, p. 13).

Participants of the training learned that by employing role-play, they may assist clients in a way that words alone may not.

Research Design, Implementation and Analysis

Every counselor developes a personal style or theoretical orientation that is useful and relevent to their work. This treatise, by no means, is intended to invalidate any treatments being practiced by counselors. In fact, “for most mental disorders, there is generally not just one but a range of treatments of proven efficacy” (Introduction, 2010. p. 1). Employing role-play, as a form of exposure therapy is flexible enough to be assimilated into most counseling practices and allows for individualized treatment planning. In this section the research design, implementation and analysis of this training is described.

Participants of this continuing education training were taught the theoretical underpinnings and methods for the safe use of role-play within their current practice, when treating PTSD. Participants volunteered based on a brief description of the course goals and objectives, posted through a local mental health agency. The full-day training was delivered four times, in different locations around the State of Maine. This researcher evaluated each workshop to improve its design and delivery in subsequent workshops. The sample population included 36 State-licensed mental health practitioners (n = 36).

Methodology The researcher designed best practices and protocols which were followed for the delivery of this training and for the collection, assessment and evaluation of data in a reliable and valid manner. A mixed design of qualitative and quantitative methodologies was employed to this end. Both quantitative and qualitative research has limits and benefits. A mixed-methodology allows the researcher to counterbalance the shortcomings of each approach without compromising the benefits each offers.

The training was delivered in two parts, the first part dealt with the psychological and biological theories for using role-play as a form of exposure therapy. The second part of the day was devoted to practicing safe techniques for using role-play. The results of the surveys and targeted observations were utilized to evaluate the effectiveness of instructional strategies for course refinement.

Data Collection

Four evaluation tools were primarily used to collect qualitative and quantitative data. A pre-course survey and a post-course survey supplied quantitative data. Targeted observation forms and a group generated treatment plan provided qualitative data. From a quantitative perspective a pre-course survey was used to collect demographic data, as well as information to establish a baseline of participant knowledge and understanding of the subject matter. The post-course survey re-assessed knowledge and understanding of the subject matter, as well as participant impressions of course delivery.

From a qualitative perspective, formative feedback between the facilitator and peers, class discussions, and practicum efforts were documented using targeted observation forms completed by two research assistants. Drawing from “Experiential Learning Theory” (Kolb & Kolb, 2005, para. 4), the targeted observation forms categorized observations into four categories); (1) Concrete experiences, such as participant responses to lecture, class activities, and other course experiences, (2) Abstract conceptualization including participant capacity to reflect on lecture, activities, the course agenda, and research goals, (3) reflective Observation, offering participants the opportunity to observe and reflect on activities and (4) Active experimentation in the form of participant contribution in actively experimenting with ideas exchanged in the training. These categories organize the data for content analysis.

In addition to data collected using the targeted observation forms, qualitative data was also gathered through the development of a group-generated treatment plan, during an in-class activity. This activity afforded feedback regarding current practices, as well as theories and techniques learned in the training that participants report may be integrated into their current practice. Data Analysis

Pre- and post-survey results were entered into and organized using Microsoft Excel. Microsoft Excel was also utilized for data analysis of the dependent variable (participant knowledge) and the independent variable (training curriculum). Data were collected on the sample population before and after the educational intervention. A paired t-test was used to determine to what degree the mean averages from the pre- and post-surveys differed from each other. The t-test allowed for the mean of the difference between the pre-test and related post-test responses to be calculated. Ascertaining the mean on a normal distribution, with an estimated standard deviation, this researcher calculated percentages of similarities and dissimilarities within the sample population with a confidence interval of moderate width. This allowed the researcher to make inferences as to how the data from the sample population may be generalized to a broader population.

Using a correlation coefficient formula, the researcher endeavored to determine the relationship between an increase in confidence in using role-play and ...

a)	An increase in understanding of the psychology of PTSD.

b)	An increase in the understanding of the biology of PTSD, or

c)	An increase in the understanding of safety precautions for using role-play. 

To determine the relationship between an increased confidence in using role-play to treat PTSD and an understanding of the psychology and biology of PTSD, a correlation coefficient was calculated. When using a correlation coefficient “an r-value of ‘-1’ indicates that the two data sets are almost certainly related. The correlation coefficient of the variables (understanding vs. confidence) for the study was (r =) - 0.18894. This indicates a very weak correlation coefficient (relationship between the two data sets).

Most interesting, though, was the data collected from pre- and post-course surveys indicating participants were, on average, 10% more confident in using role-play to treat PTSD after learning about safety precautions. To determine the relationship between increased understanding of safety precautions and increased confidence levels in using role-play, a correlation coefficient was, again, calculated. In this analysis, the correlation coefficient of the variables (safety precautions vs. confidence) was (r =) .43945. Thus, there was a stronger association found between learning about safety precautions when employing role-play than there was learning about the psychological and biological theories behind using role-play in treatment.

Interpreting the Data

As mentioned in a previous section, the training was delivered in two parts. The first part was delivered through lecture, accompanied by a PowerPoint presentation. A question and answer period followed. The lecture reviewed the psychological and biological theories for using role-play as a form of exposure therapy. The second part of the day was experiential, devoting time to practicing safe techniques for using role-play. Looking at the quantitative and qualitative data collected from the pre- & post- course surveys and the TOF’s, one gains insight into why learning about safety precautions when using role-play was more significant in raising confidence levels than was understanding the psychological and biological theories underlying the importance of using role-play in treatment. On a 1 to 4 scale, the quantitative results from survey’s indicate an average increase of 7% in understanding the psychology of PTSD, an average increase of a 16% in understanding the biology of PTSD, and an increase of 33% in understanding the safety precaution required when using role-play to treat PTSD.

These data can be interpreted to mean several things. Perhaps participants arrived to the course with a great deal of theoretical understanding already. Yet, scholarly literature reveals that many counselors are not sufficiently knowledgeable in the psychobiological underpinnings of PTSD. Furthermore, CACREP, the primary accrediting agency for graduate programs in counseling does not require course work in the biology of mental illness. Therefore, the data may also be interpreted to mean that the delivery of the theoretical components of the training was inadequate in increasing the understanding of the psychological and biological underpinnings of PTSD. Interestingly, qualitative data collected using the Targeted Observation Forms (TOF’s) indicated participants did gain confidence in the use of role-play during the experiential component of the course. This could be interpreted to mean participants arrived without a great deal of knowledge or experience in the safe use of role-play. If participants arrived with less knowledge of the material, then any additional information would naturally result in an increase in confidence. However, the qualitative data does reveal participants preferred the experiential learning components of the course.

Summary

This treatise examines the use of role-play as a form of exposure therapy when treating the psychobiological aspects of PTSD. Cognitive-behavioral therapy, including exposure therapy, is touted in scholarly literature as being most effective for treating PTSD. Yet, exposure therapy is seen as dubious to many clinicians. In order to bridge the divide between research findings and common practice, this continuing education course was created. The principles for course development were drawn from the constructivist theory of education. The training was learner-centered including traditional pedagogical approaches and experiential learning opportunities that accommodated participants’ multiple intelligences. Evidence of the impact PTSD has on individuals and society as a whole was presented, as was the growing need for more counselors trained in the efficacious treatment of PTSD.

Examples of research design, implementation and analysis revealed important data regarding current treatment practices and future direction for research and course refinement. Most signifiant was data that suggested material presented in combination with experiential activities was most effectively transferred. This recognition has been interpreted to mean that experiential activities need to be included throughout the training. To that end, additional experiential activities and tools must be developed. Moreover, the trainng itself must be extended from one day to a miniumum of two days in length.

Over the past ten years, the definition of scholarship has expanded to validate academic professionals dedicated to the resolve of complex ideas. According to Boyer (1999), the practices of discovery, integration, application and teaching proposes these activities are vital, core values, critical to the advancement of education in America. In this study of what Boyer (1999) might refer to as the scholarship of discovery and application, the complimentary aspects of psychology and education were synergized in order to develop, deliver and evaluate this continuing education course. Ideally, when met with curious experimentation and infused with disciplined assessment and evaluation, these efforts may result in scholarly acclaim, and in fact do more than teach concepts. Such efforts might indeed inspire. References

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