Psychotherapy Research

ISSN: 1050-3307 (Print) 1468-4381 (Online) Journal homepage: http://www.tandfonline.com/loi/tpsr20

Changes in the trauma narratives of youth

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

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

To link to this article: http://dx.doi.org/10.1080/10503307.2017.1303208

Published online: 04 Apr 2017.

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Psychotherapy Research, 2017
http://dx.doi.org/10.1080/10503307.2017.1303208

EMPIRICAL PAPER

Changes in the trauma narratives of youth receiving trauma-focused

cognitive behavioral therapy in relation to posttraumatic stress
symptoms

MARIE KNUTSEN1 & TINE K. JENSEN1,2

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)

Abstract
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
PTSS.

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.

Introduction
It is assumed that the ability to construct a coherent
narrative is important for coping after trauma
(Fivush, 1998; Mundorf & Paivio, 2011; Pennebaker
& Seagal, 1999; Salmond et al., 2011; Tuval-
Mashiach et al., 2004). Therefore most rec-
ommended trauma treatment models for both chil-
dren and adults focus on the construction of a
trauma narrative (Cohen, Mannarino, & Deblinger,
2006; Foa, Hembree, & Rothbaum, 2007; Neuner
et al., 2008; Schauer, 2011; Smith, Perrin, Yule, &
Clark, 2010).
Constructing a trauma narrative may serve several
important functions. First, the ability to construct a
coherent narrative is important for being able to com-
municate ones experiences to others and create
meaning to the event(s) (Deblinger et al., 2011;
Fivush, 1998; Harber, Pennebaker, & Christianson,
1992; Mundorf & Paivio, 2011; Nelson, 2003).
Second, traumanarrative work can contribute to the
processing of the trauma and to integrate the
trauma memory with other autobiographical mem-
ories (Ehlers & Clark, 2000; Foa & Riggs, 1993;
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: marie.knutsen@psykologi.uio.no

2017 Society for Psychotherapy Research

2 M. Knutsen and T. K. Jensen
experience in the context of therapy is a form of
exposure that can aid in reducing trauma-related
negative emotions in response to trauma reminders
through the integration of corrective and new infor-
mation into the fear structure in memory (Cohen &
Mannarino, 2008; Foa & Kozak, 1986; Foa &
McLean, 2016; Foa, Molnar, & Cashman, 1995).
And lastly, trauma narration can help identify and
challenge unhelpful cognitions (Ehlers & Clark,
2000; Smith et al., 2010). In these ways constructing
coherent trauma narrative involves exposure to, and
emotional processing of, the traumatic event which
can contribute to meaning making and to reduce
trauma-related symptoms such as posttraumatic
stress. However, our understanding of how trauma
narratives change during therapy and whether these
changes are related to symptom reduction is not
clear and research is scarce (Deblinger et al., 2011;
Dorsey et al., 2016; Salloum & Overstreet, 2012).
Therefore the aim of this study was to examine
changes in the trauma narratives for youth receiving
TF-CBT, and further to investigate whether there
was a relationship between narrative changes and
posttraumatic stress symptoms (PTSS) by comparing
one group of youth that reported having a significant
reduction in PTSS with a group of youth who did not
report reductions in PTSS during treatment.
Although there is a need to pay attention to the
developmental phases children undergo and how
traumatic stress can disturb development, several
scholars have argued that cognitive models of post-
traumatic stress disorder (PTSD) for adults can be
adopted as a framework to explain and understand
the development of PTSD in children and youth
(Ehlers, Mayou, & Bryant, 2003; Meiser-Stedman,
2002; Meiser-Stedman, Dalgleish, Smith, Yule, &
Glucksman, 2007: Salmond et al., 2011). According
to cognitive models of PTSD, negative appraisals of
the trauma and/or its sequelae together with a dis-
turbance of autobiographical memory play an impor-
tant role in the development and maintenance of
PTSS (Brewin, Dalgleish, & Joseph, 1996; Ehlers &
Clark, 2000; Foa & Rothbaum, 2001). In Ehlers
and Clarks model (2000), traumatic memories are
thought to be poorly elaborated and contextualized
and are not adequately integrated with other autobio-
graphical memories. Disturbance in the memory pro-
cessing of the trauma can explain the intrusive and
involuntary characteristic of trauma memories
where vivid sensory, emotional, and perceptual
impressions dominate the memories. This is in line
with several reviews showing that trauma narratives
are characterized by sensory, emotional, and percep-
tual details (Crespo & Fernndez-Lansac, 2016;
OKearney & Perrott, 2006). The other central
aspect of Ehlers and Clarks model is the role
appraisals of the trauma and/or its sequelae play in
generating various feelings such as a persistent
sense of threat, guilt, and shame, as well as feeling
weak, crazy, or damaged. These feelings often lead
to a range of coping strategies that may be maladap-
tive and unhelpful (Bryant, Salmon, Sinclair, &
Davidson, 2007; Ehlers et al., 2003; Meiser-
Stedman et al., 2007; Stallard & Smith, 2007).
Together these mechanisms can explain why
trauma narratives often are disorganized and frag-
mented among those with PTSD (Brewin et al.,
1996; Ehlers & Clark, 2000). According to cognitive
theories of PTSD, the trauma narrative work can set
the scene for improving narrative organization and
cohesion, identifying and modifying misappraisals
and maladaptive cognitions, and cause habituation
to negative emotions through the construction of
new meaning (Brewin et al., 1996; Clark & Ehlers,
2004; Ehlers & Clark, 2000; Foa & Kozak, 1986).
Several studies have found that type and quality of
cognitive processing after a traumatic event may have
significant effects on narration, which, in turn, is
related to mental health and PTSS (Alvarez-Conrad,
Zoellner, & Foa, 2001; Foa et al., 1995; Harvey &
Bryant, 1999). For instance, studies of traumatized
adults show that individuals with PTSD have more
fragmented and disorganized narratives than those
without PTSD (Halligan, Michael, Clark, & Ehlers,
2003; Harvey & Bryant, 1999; Jones, Harvey, &
Brewin, 2007). However, other scholars have criti-
cized this assumption and claim that the relationship
between narratives of traumatic memories and
PTSD lacks empirical support (Gray & Lombardo,
2001; Rmisch, Leban, Habermas, & Dll-Hentsch-
ker, 2014; Rubin, 2011; Young, 2000).
Only a few studies have investigated the relationship
between characteristics of the trauma narratives and
posttraumatic stress reactions in youth (Filkukova,
Jensen, Hafstad, Minde, & Dyb, 2016; Kenardy
et al., 2007; McKinnon, Brewer, Meiser-Stedman, &
Nixon, 2017; OKearney, Speyer, & Kenardy, 2007;
Salmond et al., 2011). Kenardy et al. (2007) con-
ducted a study where they examined the trauma narra-
tives of physically injured children. The findings
showed that temporal disorganization was related to
PTSS (Kenardy et al., 2007). Another study by
OKearney et al. (2007) explored the association
between children`s memory of a traumatic event
(i.e., an accident requiring hospitalization) and sever-
ity of different sub-clusters of PTSD. A coding
scheme was developed to assess childrens trauma
memory report through measures of narrative struc-
ture and organization. The results identified a signifi-
cant relationship between level of lexical structure
and cohesion, and their self-report of intrusive symp-
toms 47 weeks after the traumatic event. The

authors argue that the findings demonstrate the impor-
tance of developing a cohesive and conceptual
memory of the traumatic event in order to reduce
trauma-related distress. A recent prospective study
by McKinnon et al. (2017) examined whether percep-
tions of trauma memory quality would predict PTSS
over and above trauma narrative characteristics. The
study used the same coding scheme developed by
OKearney et al. (2007) to analyze the trauma narra-
tives in a sample of injured children, acutely and at 3
months after experiencing a potentially traumatic
event. To measure the perception of trauma memory
quality, McKinnon et al. (2017) used a self-report
questionnaire which is thought to measure the
sensory, fragmented, and disorganized aspects of a
memory of a traumatic event (Trauma Memory
Quality Questionnaire (TMQQ): Meiser-Stedman
et al., 2007). The findings indicate that self-reported
trauma memory characteristics could better explain
the variance in PTSS than trauma narrative character-
istics. This finding is inconsistent with the results from
a previous child study also measuring both narrative
features (coded according to the Foa et al., 1995
manual) and perception of trauma memory quality
(measured by TMQQ) in order to examine the
relationship between trauma memory and PTSS
(Salmond et al., 2011). Salmond et al. (2011) found
that children and youth with acute stress disorder pro-
duced trauma narratives with greater disorganization
compared to narratives of non-traumatic unpleasant
events and compared to the narratives of non-
trauma-exposed controls. The results also showed
that narrative disorganization, together with the
childs cognitive appraisals of the trauma, predicted
post-trauma symptom severity. Contrary to the
finding of McKinnon et al. (2017), self-reported
trauma memory characteristic did not explain
symptom severity over and above narrative features.
According to the authors, their findings provide evi-
dence that narrative disorganization is specifically
related to trauma memory in youth (Salmond et al.,
2011). Lastly, one study examined the relationship
between narrative structure and PTSS in a group of
youth who survived a terror attack using the coding
manual developed by Foa et al. (1995). In this study
the authors found that survivors with high levels of
PTSS described more external events and fewer
internal events in their narratives compared with survi-
vors with low levels of symptoms, and that narratives
containing more descriptions of dialogue and fewer
organized thoughts were related to higher levels of
PTSS. The groups did however not differ in levels of
narrative fragmentation or in length of the narratives
(Filkukova et al., 2016). Conclusions based on these
existing studies are limited due to the lack of within-
subjects control narratives (with the exception of
Psychotherapy Research 3
Salmond et al., 2011 study), variations in research
designs and the use of different coding schemes.
These concerns are not limited to the child trauma
field, but are also main concerns in the adult trauma
literature (OKearney & Perrott, 2006).
To the best of our knowledge, no youth studies and
only three adult studies have examined how trauma
narratives change during therapy and how these
changes could be related to changes in PTSS. Foa
et al. (1995) examined the cohesiveness of adult
patients trauma narratives and the process of narra-
tive organization by analyzing transcriptions of the
narratives of 14 female sexual assault victims. Their
findings supported their predictions that exposure
treatment, which focuses on reducing trauma-
related anxiety through the trauma narrative work,
can enhance narrative organization. Further, they
found that narrative length and reports of internal
events in the narratives, such as descriptions of
thoughts and feelings the patients experienced
during the traumatizing event, increased during
therapy. Organized thoughts, that is, thoughts that
reflect reasoning, planning and attempts to organize
the trauma memory, also significantly increased
from the first session to the last session. External
events, which are defined as utterances about
actions that occurred during the event or verbaliza-
tion or dialogues in the narrative, decreased during
treatment, although this decrease was not significant.
The authors did not find significant decreases in
utterances indicating fragmentation during therapy,
although symptom improvement was related to
reduced fragmentation. Based on the results, the
authors suggest that treatment recovery is related to
increased narrative coherence (Foa et al., 1995). A
study by van Minnen, Wessel, Dijkstra, and Roelofs
(2002) replicated and extended Foa et al.s study by
examining two groups of patients with different treat-
ment outcomes. The study revealed that all partici-
pants (n = 20) showed increased reporting of
internal events, and decreased reporting of external
events and disorganized thoughts independent of
improvement. Neither of the groups exhibited a
decrease in fragmentation. These results are in line
with the findings of Foa et al. (1995). The only sig-
nificant differences between the groups involved dis-
organized thoughts. The improvers (n = 8) exhibited
a significantly greater reduction in disorganized
thoughts in their narratives from pre- to post-treat-
ment than non-improvers. The results raise uncer-
tainty regarding the assumption that changes in
trauma narratives are related to more adequate pro-
cessing of the traumatic event, and the authors ques-
tion whether these observable changes in narratives
may be due to the beneficial treatment effect of
repeatedly telling the same story rather than a
4 M. Knutsen and T. K. Jensen
reflection of changes in memory representation (van
Minnen et al., 2002). A third study, by Mundorf
and Paivio (2011), examined the trauma narratives
before and after emotion-focused therapy for PTSD
in patients exposed to childhood abuse. The results
showed that during therapy there were significant
increases in positive words, temporal orientation,
and exploration of subjective internal experiences.
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-
cantly from pre- to post-treatment. There was a sig-
nificant association between increased temporal
orientation and post-treatment outcome. Based on
the results, the authors argue that processing the trau-
matic experience contributes to improvement in nar-
rative quality which in turn is associated with better
outcomes. It should be noted, that Mundorf and
Paivio (2011) did not use the coding manual devel-
oped by Foa et al. (1995) which may challenge the
comparison of results across the three studies.
As shown, the existing studies on changes in narra-
tives and their association to PTSS in adults is limited
and to some degree inconclusive. Studies examining
narrative changes in youth therapy are non-existent.
More knowledge about changes in youths trauma
narratives are needed to increase our understanding
about how therapy can contribute to the processing
of a traumatic event and how these processes are
related to PTSS.
Aims of the Study
In this paper we analyze changes in narration for
youth with good and poor treatment response after
receiving trauma-focused behavioral therapy (TF-
CBT). The overall aim is to examine changes in the
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
organization of trauma narratives will increase from
pre- to post-treatment and will be evidenced by
more organized thoughts. Moreover, we predict
that we will find more reports of internal events and
fewer reports of external events in post-treatment
trauma narratives than in pre-treatment narratives.
Given the inconclusive empirical findings regarding
changes in narrative fragmentation during therapy,
we do not propose a hypothesis in any particular
direction. In order to explore whether changes in
the fragmentation and organization of trauma narra-
tives during treatment are correlated with changes
in PTSS, we compare one group of youth that
reported having a significant reduction in PTSS
(max-responders) with a group of youth who did
not report reductions in PTSS during treatment
(non-responders). Although there are mixed findings
in the literature, our hypothesis is that more orga-
nized and coherent narratives will be related to
reductions in PTSS given the centrality of trauma
narrative work in TF-CBT.
Method
Procedures
This study uses data from a randomized effectiveness
study that compared TF-CBT with therapy as usual
(TAU) for traumatized youth in child and adolescent
community mental health clinics (Jensen et al.,
2014). The study is approved by the Regional Com-
mittee for Medical and Health Research Ethics. The
sample included youth ranging in age from 10 to 18
years. The youth were referred to treatment by
Child Welfare Services or by their primary physician:
hence, standard referral procedures were followed.
The inclusion criteria were as follows: the youth
had experienced at least one traumatic event
meeting the A criterion of a PTSD diagnosis
defined in the Diagnostic and statistical manual of
mental disorders (4th ed.; DSM-IV; American Psy-
chiatric Association, 1994), and suffered from clini-
cally significant PTSS. Acute psychosis, suicidal
behavior, mental retardation, and the need of an
interpreter were the exclusion criteria. Participants
were assessed with the Clinical-Administered
PTSD-Scale for Children and Adolescents (CAPS-
CA: Griffin, Uhlmansiek, Resick, & Mechanic,
2004) before and after treatment by two clinical psy-
chologists who were nave to treatment allocation
(Jensen et al., 2014).
Participants
In the present study only youth who received TF-
CBT were included, as none of the youth in the
TAU group created trauma narratives. Because we
were interested in examining the relationship
between changes in narratives and changes in
PTSS, we selected groups of participants with differ-
ent outcomes. Outcome was measured by changes in
PTSS from pre- to post-treatment. Non-response
was defined as a reduction of PTSS symptoms <1/2
SD from the pre-treatment mean. This is considered
as an acceptable criterion for non-response (Wise,
2004). Based on this definition, 12 participants
were classified as non-responders. These participants
were compared with the 12 participants who showed

the most improvement during therapy, labeled max-
responders. The final sample consisted of 24 youth
(12 non-responders and 12 max-responders)
between the ages of 10 and 17 years (M = 14.3, SD
= 2.35; 75% girls). Participants had experienced mul-
tiple traumatic events, and the traumatic event that
they reported to be the worst event is presented in
Table I.
Treatment
All the youth received TF-CBT, a treatment model
developed by Cohen et al. (2006). TF-CBT is a
short-term, trauma-specific treatment consisting of
the following core components: psychoeducation,
relaxation skills, affect regulation, cognitive coping,
working through the trauma narrative, cognitive pro-
cessing, in vivo mastery of trauma reminders, enhan-
cing safety and future development. The intervention
typically consists of 1215 sessions. Parental involve-
ment is viewed as important and the youths non-
offending parent or caregiver is offered interventions
focusing on improving parenting skills in both paral-
lel and conjoint sessions. Elements from cognitive,
behavioral, interpersonal, and family therapy prin-
ciples and trauma interventions are integrated into
the model. Working through the trauma narrative is
emphasized as an important element of TF-CBT.
The youth are gradually exposed to the traumatic
event(s) throughout the different phases and com-
ponents of the treatment leading up to the trauma
narrative component, when the therapist encourages
the youth to elaborate on and describe the traumatic
event(s) in detail. Typically, three to five sessions are
devoted to working directly with the trauma narra-
tive, although the number of sessions deemed necess-
ary is tailored to each individual`s needs. Although
the creation of a trauma narrative is viewed as a
central part of the treatment to help the youth
Table I. Distribution of worst trauma reported.
Non-respondersa Max-respondersa
Traumatic experience n (%) n (%)
Extra-familial sexual 4 (33.3) 2 (16.7)
abuse
Intra-familial sexual 2 (16.7) 1 (8.3)
abuse
Peer violence/bullying 3 (25) 3 (25)
Exposure to intra- 1 (8.3) 2 (16.7)
familial violence
Sudden death/injury of 5 (16.7) 2 (16.7)
close person
Other traumatic 0 (0.0) 2 (16.7)
experiences
a
N = 12.
Psychotherapy Research 5
create a more coherent, organized and meaningful
narrative of the traumatic experience, all components
are considered to be important in contributing to
treatment effects (see also Cohen, Deblinger, & Man-
narino, 2016).
Therapists
The TF-CBT therapists (n = 16) were psychologists,
psychiatrists, educational therapists, and social
workers. The therapists were trained in TF-CBT
and were supervised weekly or biweekly by trained
TF-CBT consultants to ensure treatment adherence.
Furthermore, all sessions were audio-recorded and
coded for treatment fidelity by trained TF-CBT
therapists using the treatment adherence checklist
for TF-CBT (Deblinger, Cohen, Mannarino,
Murray, & Epstein, 2008).
Measurement
Posttraumatic stress symptoms. The CAPS-
CA was used to measure the youths PTSS. The
CAPS-CA is a semi-structured clinical interview suit-
able for use with children and adolescents and is
regarded as the gold standard for assessing PTSD
symptoms among children aged 8 years and older
(Griffin et al., 2004; Nader et al., 1996, 2004).
Assessments are based on the youths scores on a 5-
point frequency scale and a 5-point intensity rating
scale for the past month. The youths answers,
together with clinical judgment during the interview,
serve as the basis for scoring of the items. The CAPS-
CA has demonstrated good psychometric properties
in several studies (Ohan, Myers, & Collett, 2002).
In the present study, the total scale showed satisfac-
tory internal consistency ( = .90). The DSM-IV-
defined tripartite model also showed satisfactory
internal consistency (re-experience: = .87, avoid-
ance: = .77, hyperarousal: = .79).
Narrative coding system. To analyze the narra-
tives we used the coding manual developed by Foa
et al. (1995) since this manual is widely accepted in
the literature. The coding aims to explore changes
in narratives from the first to the last session of
therapy. First, the narratives were divided into dis-
crete units of text according to the manuals chunking
rules. These units of text are referred to as chunks
and constitute meaningful parts of the text that
include only one thought, action or speech utterance.
The next step was to code each unit for content by
assigning each chunk to one utterance category. Fol-
lowing the manuals instructions, each utterance
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
category, the most appropriate code was identified by
referencing a predetermined coding priority list. Fol-
lowing Foa et al. (1995) and van Minnen et al.
(2002), these 22 categories were then reorganized
into groups that were considered to belong to the
same construct. Descriptions of the combined
groups that we analyzed are presented below.
(1) Organized thoughts are utterances reflecting
efforts to comprehend the trauma and
attempts to understand what is happening
through, for example, reasoning, planning,
rationalizing, questioning, or decision
making. An example of an organized
thought is as follows: then, I realize that he
is up to something, () and Im thinking
that I have to be quiet.
(2) Internal events, reflect thoughts and feelings,
and refer to descriptions of internal states.
This category is proposed to reflect the
degree of internal focus in the participants
narratives. Thoughts refer to attempts of
cognitive processing and are subdivided
into four classes: (a) organized thoughts;
(b) disorganized thoughts, reflecting con-
fusion and/or disjointed thinking; (c) despe-
rate thoughts, involving utterances
reflecting that all coping strategies are una-
vailable; and (d) unfinished thoughts, reflect-
ing sentences that are incomplete or single
words relating to ideas. An example of an
unfinished thought is as follows: and then
I started to . Feelings capture utter-
ances involving participants expression of
emotion and are subdivided into three
classes: (a) positive feelings; (b) negative feel-
ings; and (c) angry adaptive feelings, concep-
tualized as coping emotions such as anger,
disgust and outrage.
(3) External events are viewed as an index of the
degree of external focus in the narratives and
refer to overt, observable events. This cat-
egory captures all utterances referring to
different types of actions and dialogues in
the narratives. Actions are further divided
into the following categories: (a) action-self,
reflecting the narrators own behavior or
actions that the narrator and another person
other than the perpetrator jointly take; (b)
action-perpetrator-threat, involving the per-
petrators actions that frighten or intimidate
the victim; (c) action-perpetrator-non-threat;
(d) action-joint, referring to actions that the
perpetrator and subject take at the same
time; and (e) action-other, involving
descriptions of action that an individual
other than the perpetrator or the narrator
takes. Dialogues are chunks reflecting
direct or indirect verbalization uttered with
the intent to be heard by another person.
This category consists of five classes, which
are classified according to the speaker: (a)
dialogue-perpetrator-threat; (b) dialogue-
perpetrator-non-threat, referring to the per-
petrators verbalizations directed to the
victim that are not experienced as threaten-
ing; (c) dialogue-self-perpetrator; (d) dialo-
gue-self-other, involving the narrators
verbalizations to a person other than the per-
petrator; and (e) dialogue-other.
(4) Fragmentation is proposed to measure the
degree of flow in the narrative and consists
of non-functional utterances, referring to
chunks that do not add any new information.
The fragmentation category consists of the
following utterances: (a) repetitions; (b)
speech fillers, reflecting words or phrases
that do not carry any meaning in and of
themselves, such as kind of and you
know; and (c) unfinished thoughts.
Two of the codes fall into more than one category.
Organized thoughts can be coded both a separate
category and an internal events category. This
choice was based on both theory and empirical find-
ings indicating the important role that organization is
thought to play in treatment and recovery from
trauma. Additionally, in line with Foa et al. (1995)
and van Minnen et al. (2002), unfinished thoughts
can be coded both as an internal events category, and
as fragmentation.
All therapy sessions were audio-taped. The first
narrative was defined as the youths first free story-
telling of the traumatic event to the therapist
during the trauma narrative component. The story
was a free recall elicited by the following open-
ended question posed by the therapist: Today we
are going to work on your trauma narrative. Start
by telling me what happened. This first free recall
of the narrative laid the foundation for further
working with the trauma narrative in subsequent
session. During the narrative work the therapist
wrote down the narrative during the session and
encouraged the child to include thoughts, feelings,
body sensations, and the worst moment of the trau-
matic experience into the narrative (Cohen & Man-
narino, 2008). After several sessions working with
the trauma narrative, the last narrative was defined
as the final narrative that was shared with the thera-
pist. The majority of the youth also shared these final
narratives with their parents in conjoint sessions.

The first and last narratives were transcribed verba-
tim resulting in 48 narratives. These 48 narratives
were first coded by hand according to the standar-
dized coding manual developed by Foa et al.
(1995). A psychologist with experience in applying
the coding system coded the 48 narratives. The
rater was blind to participants outcome scores and
which group the narratives belonged to. To ensure
raters reliability, the first author coded a random
sample of 10 narratives (20.8% of the total
sample). Prior to the coding, the two coders met fre-
quently to discuss and study the manual, and they
practiced together using narratives that were not
included in the study to achieve agreement on how
to divide the narratives into chunks and code the
chunks. Dilemmas arising from different interpret-
ations of the manual instructions and a few disagree-
ments between the two independent raters were
discussed and resolved in group meetings to
ensure reliability. Inter-rater agreements for separ-
ate categories ranged from 89.6% to 100%. The nar-
ratives were then uploaded in the program NVivo,
where raters labeled the text by the categories
described above. The strength of this program is
its ability to organize thousands of coding units
and to provide information regarding the percentage
that each category constitutes of the total text. Fol-
lowing Foa et al. (1995), the percentage of utter-
ances in each category was used in the analyzes
due to the significant variation in the length of the
narratives between and within participants.
Data Analyzes
To evaluate whether the difference in PTSS
reduction across the non-responder and max-respon-
der groups was statistically significant, an indepen-
dent samples t-test on the change scores was
performed. Due to differences in narrative length
within and across participants, percentages of utter-
ances in the categories of organized thoughts, internal
events, external events, and fragmentation were sep-
arately computed for each participant and session.
The means and standard deviations of each of the
four combined narrative categories for non-respon-
ders and max-responders, both pre- and post-treat-
ment, were calculated. To examine changes in
narratives during therapy, the pre- and post-treat-
ment means of each of the combined categories
were subjected to paired t-tests. To investigate
whether the two groups exhibited different changes
during therapy, change scores (post-treatment
scores minus pre-treatment scores) for each of the
four narrative categories were calculated and sub-
mitted to an independent samples t-test.
Psychotherapy Research 7
Results
Initial Analyzes
There was no significant difference in pre-treatment
PTSS scores between the non-responder and max-
responder group. Furthermore, in line with our
classification of the two groups, there were significant
differences in PTSD change scores from pre- to post-
treatment between the groups, t(22) = 5.55, p = .029.
More specifically, participants in the max-responder
group showed a significant decrease in PTSS
during therapy, t(11) = 21.5, p < .001, whereas par-
ticipants in the non-responder group did not, t(11)
= 0.76, p = .465. The majority of the sample was
female (75%). The non-responders group had fewer
boys (8%) than the max-responder group (42%),
and the participants in the non-responder group
were slightly older (M = 15, SD = 1.81) than those
in the max-responder group (M = 13.7, SD = 2.71).
Due to differences in the number of participants
who had experienced sexual abuse between the two
groups, we used a multinomial logistic regression
analysis to examine whether exposure to sexual
abuse increased the probability of being a non-
responder. The result showed that there was not a
significant relationship between sexual abuse
trauma and outcome group (non-responder versus
max-responder), p = .203. Furthermore, we tested
whether sexual abuse was related to PTSS level
post-treatment (using CAPS difference scores from
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.
Changes Between First and Last Narratives
The results of the analyzes of the narrative organiz-
ation and PTSS scores for the two groups pre- and
post-treatment are summarized in Table II.
To test our first hypothesis that the narratives
would change during treatment, pre- and post-treat-
ment means and standard deviations for the total
sample in each of the combined categories, organized
thoughts, internal events, external events, and frag-
mentation, were subjected to paired t-tests. As
expected, the results showed that for all participants,
their post-treatment trauma narratives had a signifi-
cant increase in organized thoughts, t(23) = 3.66,
p = .001, and internal events, t(23) = 2.44, p
= .023. Furthermore, there was a significant percen-
tage decrease in fragmentation during therapy, t
(23) = 5.16, p = .001. No significant change in exter-
nal events was found, t(23) = 0.01, p = .991. To
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)
First session
Symptom severity
PTSD symptoms 61.17 (25.58)
Narrative coding system
Organized thoughts 8.47 (12.73)
Internal events 29.81 (16.09)
External events 61.27 (19.34)
Fragmentation 19.17 (12.35)
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
deviations for each group in the four combined narra-
tive category groups for the first and last narrative and
subjected them to paired sample t-tests, stratified by
groups. No significant changes in internal or external
events were found for either of the groups. However,
a significant decrease in fragmentation was found for
both non-responders, t(11) = 2.67, p = .022, and
max-responders, t(11) = 4.86, p < .001. Although
both groups showed an increase in organized
thoughts from the first to the last narrative, this
increase was significant only for the max-responder
group, t(11) = 3.63, p = .004.
Changes in Narratives and PTSD
To test whether changes in trauma narratives during
treatment were related to PTSS change post-treat-
ment, independent t-tests were performed on change
scores for both groups in each of the four categories
(post-treatment minus pre-treatment scores). There
were no significant differences in any of the narrative
categories in the participants first narrative between
the two groups. The analyzes revealed no significant
differences in changes from pre- to post-treatment
scores between non-responders and max-responders
for organized thoughts t(22) = 0.25, p = .81, internal
events t(22) = 0.92, p = .37, external events t(22) =
0.92, p= .37 or fragmentation, t(22) = 1.20, p = .25.
Discussion
In this study, we examined changes in the trauma
narratives of youth receiving TF-CBT. We also
explored whether changes in narratives were related
to changes in PTSS by comparing one group of
youth showing significant PTSS reduction (max-
responders) with a group of youth who did not
show reduction in PTSS during treatment (non-
Max-responders (n = 12)
Last session First session Last session
63.58 (27.21) 74.25 (13.92) 14.17 (14.56)
14.06 (8.77) 6.32 (4.67) 12.73 (4.79)
39.50 (14.39) 26.64 (14.79) 31.02 (14.07)
57.88 (16.71) 63.99 (16.60) 67.30 (14.05)
6.21 (12.03) 23.83 (14.58) 3.14 (3.53)
responders). When analyzing the groups together,
the results showed a significant increase in organized
thoughts and reports of internal events, reflecting
efforts at meaning making and greater processing of
emotions during treatment. The results also showed
a decrease in narrative fragmentation from pre- to
post-treatment further indicating the development
of more organized narratives during treatment.
These findings are in line with our hypothesis that
the organization of the trauma narrative would
increase during the course of therapy. Contrary to
our expectations and the findings of previous
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
not find support for our last hypothesis that changes
in narratives during therapy were related to reduction
in PTSS.
This is the first study to examine changes in trauma
narratives in therapy for youth. The results corre-
spond with theoretical accounts (Foa & Riggs,
1993), and previous empirical findings in demon-
strating that trauma narratives change during the
course of exposure treatment (Foa et al., 1995; van
Minnen et al., 2002). During therapy, the group as
a whole showed a significant increase in organized
thoughts and internal events. Increases in organized
thoughts can reflect the youths attempt to compre-
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,
TF-CBT may have contributed to more coherent
and meaningful trauma narratives among the youth
in this study, making it easier for them to share
their experiences with significant others. Internal
events consist of thoughts and feelings expressed in
the narratives that are thought to reflect cognitive
and emotional processing of the trauma. Researchers

argue that trauma-focused therapy leads to a more
internal focus in the narratives because the impor-
tance of external events decreases as memories
become less frightening (Foa et al., 1995; van
Minnen et al., 2002). A shift in focus can thus be
related to reduced anxiety and decreases in avoidance
symptoms following therapy, making patients less
resistant to relate to their own thoughts and inner
feelings (Mundorf & Paivio, 2011). An internal
focus in the narratives may further have helped the
youth in the process of exploring, identifying and
modifying unhelpful trauma-related thoughts and
feelings and contributed to create meaning of the
traumatic experience. It is also suggested that more
organized narratives with an increased internal
focus reflects changes in how trauma memories are
formed. Exposure therapy can facilitate memory
organization through the elaboration and contextua-
lization of traumatic memories. Repeatedly imagin-
ing the trauma, which contributes to fear
habituation, is expected to promote more adequate
processing of the traumatic event such that traumatic
memories become more integrated with other
memory structures (Foa et al., 1995; Foa & Kozak,
1986). Following this assumption, it is possible that
the youths trauma narratives became more coherent
and organized as the trauma memories became better
anchored and integrated into autobiographical
memory. Through gradual exposure to frightening
memories and the development of more adaptive
cognitive coping strategies, trauma narration may
have contributed to both meaning making and to
integrate the traumatic event as a memory of a past
event and thus instilled a sense of current and
future strength and safety for the youth in this study.
Both high responders and low responders showed a
significant decrease in narrative fragmentation during
treatment. Foa et al. (1995) propose that the absence
of emotional processing characterizes fragmented
trauma narratives. Based on our results that show
an increased reporting of internal events post-treat-
ment and possibly reflecting greater emotional pro-
cessing, it makes sense that the trauma narratives
showed a decrease in fragmentation. On the other
hand, other studies on adults have not found a
decrease in fragmentation during the course of treat-
ment (Foa et al., 1995; van Minnen et al., 2002).
Even though most scholars seem to agree that
trauma memories are somewhat different from
other memories, the role of fragmentation in
trauma memory remains unclear, and developmental
differences have not been examined. It may also be
that contradictions in results across studies are
affected by the use of different index of fragmentation
(Crespo & Fernndez-Lansac, 2016; OKearney &
Perrott, 2006). To date, different conceptual
Psychotherapy Research 9
frameworks for fragmentation constructs and a het-
erogeneity regarding measurements and procedures
prevent a clear understanding of the link between
fragmentation in trauma narratives and PTSD
(Crespo & Fernndez-Lansac, 2016; McKinnon
et al., 2017; OKearney & Perrott, 2006).
TF-CBT has proven to be efficient in treating trau-
matized youth (de Arellano et al., 2014; Morina,
Koerssen, & Pollet, 2016), and the results of the
present study confirm that the treatment seems to
help traumatized youth in the process of constructing
more organized narratives with a stronger internal
focus. However, the current studys findings indicate
that there were no significant differences in changes
from pre- to post-treatment scores in the narrative
categories of organized thoughts, internal events,
external events, or fragmentation between non-
responders and max-responders. In light of previous
studies and theories of PTSD, it is puzzling that our
results showed that youth with very different PTSS
change scores demonstrated similar changes in the
narratives. Foa et al. (1995) argue that exposure
treatment facilitates more adequate processing of
the traumatic experience which promotes more orga-
nized and less fragmented trauma memories evident
by changes in the narratives. However, van Minnen
et al. (2002) propose that the observable changes in
trauma narratives may reflect a more general side
effect of the treatment itself rather than changes in
the trauma memories. Following Foa et al. (1995),
it is possible that the youth in the non-responder
group did not improve due to impaired processing
of the trauma memories. If this were the case, this
should also been evidenced by less organized and
coherent narratives among the non-responders.
Another interpretation would be more in line with
van Minnen et al. (2002). If the effect of repeatedly
telling the same story in therapy can explain the
changes in trauma narratives, this may be why the
two groups last narratives did not significantly differ
since all participants worked on constructing a
trauma narrative in treatment. Based on this assump-
tion, it is likely that repeatedly telling the traumatic
story in therapy may have helped both the max-
responders and non-responders succeed in restruc-
turing their narratives. This is in line with other
researchers suggesting that increased trauma narra-
tive coherence post-treatment can be explained by a
combination of rehearsal, reduced avoidance and
retrieval effort (Gray & Lombardo, 2001). In
addition to disturbance in the memory processing
of the trauma, PTSD theories also emphasized the
role maladaptive appraisals of the trauma and/or its
sequelae plays for symptom maintenance. Even
though both groups increased in narrative organiz-
ation, differences regarding how therapy helped the
10 M. Knutsen and T. K. Jensen
youth in modifying maladaptive appraisals may be a
possible explanation for different treatment response
between the two groups in this study. Future studies
should explore whether differences in cognitive
appraisals and degree of cognitive restructuring
together with characteristics of the trauma narrative
can predict outcomes. Furthermore, since we did
not measure emotional change directly, we cannot
know whether non-responders did not habituate to
fear and other negative emotions even though their
trauma narrative changed. It may be that the narrative
work did not activate the fear structure sufficiently for
the non-responders, thus preventing the emotional
processing and habituation to negative emotions con-
sidered necessary for symptom reduction to succeed
(Foa & Kozak, 1986; Foa & McLean, 2016). We
can also not exclude the possibility that there is no
relationship between changes in narrative organiz-
ation and improvement in PTSS. There are studies
that do not support an association between changes
in narrative organization, degree of fragmentation
and PTSS (Gray & Lombardo, 2001; Rmisch
et al., 2014; Rubin, 2011; Young, 2000). Further-
more, some studies have found that disorganized
trauma memories can predict PTSS but not that suc-
cessful recovery after therapy is related to the devel-
opment of more coherent and organized trauma
memories (Halligan et al., 2003; Jones et al., 2007).
This study was not designed to examine the relative
importance of trauma narration for treatment
outcome compared to the other components in TF-
CBT. Nevertheless, the results showing no signifi-
cant relationship between narrative changes and
PTSS remission post-treatment is interesting and
warrants further investigation. A dismantling study
of TF-CBT showing that treatment conditions with
or without the trauma narrative component was
equally effective in reducing PTSS (Deblinger
et al., 2011), highlights the need to further clarify
the role of narration in trauma treatment. To date,
it is not clear whether changes in narrative organiz-
ation are related to treatment response, and more
knowledge on the mechanisms behind the construc-
tion of trauma narratives is needed. According to
the developers of TF-CBT, all components are con-
sidered to be equally important and may contribute
to treatment effects (Cohen et al., 2006). Future
studies should investigate how other treatment com-
ponents of TF-CBT interact with the narrative com-
ponent in the recovery process and how they may
jointly contribute to outcome.
Strengths and Limitations
This study has several strengths worth noting. First,
the youth participating in the study were recruited
from a clinical population and represent regular,
real-life cases that practitioners meet in their clinics.
Second, this is one of only a handful studies examin-
ing the relationship between narratives and PTSS in a
traumatized youth sample, and the first to study
changes in narratives during treatment, thus contri-
buting to the scarce research on trauma narration
and PTSS in this population. Third, it is possible to
compare our findings with similar studies in the
adult field because we applied and followed an exten-
sive coding manual used in previous studies. Finally,
the fact that the participants had experienced differ-
ent types of traumas, reflecting the reality of clinical
cases, increases the external validity of the study.
We acknowledge that this study also has some
important methodological limitations that must be
considered. Although the sample size was consider-
ably larger than that of previous comparable studies
(Foa et al., 1995; van Minnen et al., 2002), we
cannot exclude the possibility that the small sample
size reduced the probability of finding a significant
difference between changes in narratives and
changes in PTSS. We recognize that non-normality
and unequal variance across groups are factors that
could pose a threat to the validity of our results.
However, results from non-parametric tests sup-
ported all original conclusions. Because the narration
took place in a treatment setting, in some cases, it was
difficult to determine when the first narrative started.
All narratives are co-constructed (Fivush, 1991), and
we have not analyzed how the relationship to the
therapist or the therapeutic alliance may have influ-
enced the narrative process. In a previous study it
was found that a strong alliance along with trauma-
focused work predicted outcome (Ormhaug,
Jensen, Wentzel-Larsen, & Shirk, 2014), and it may
be that a good therapeutic relationship facilitates the
narrative work. Future studies should investigate
the role of the therapeutic alliance in narrative con-
struction. Finally, it is worth mentioning limitations
regarding the narrative coding system used in this
study. The coding manual developed by Foa et al.
(1995) is a complex and extensive manual that
measures the degree of changes in narratives at a
micro level by analyzing small units of text. A limit-
ation of this coding system is that it does not
capture narrative organization at a more overarching
level. For example, it does not indicate the degree to
which whole narratives are perceived as organized or
comprehensible. Furthermore, because the coding
protocol combines and measures several aspects
and functions of narrative organization and

fragmentation, it is not clear whether different
methods of operationalization or coding of narrative
organization and fragmentation can relate to PTSS
in somewhat different ways. This points to the need
for additional studies with a more coherent approach
to how trauma narratives can be conceptualized and
operationalized, and further underlines the need for
greater consistency regarding measurement
methods in future narrative studies (for reviews see
Crespo & Fernndez-Lansac, 2016; OKearney &
Perrott, 2006). It should also be noted that the
manual by Foa et al. (1995) was originally developed
for adults. Because the majority of our sample con-
sists of older children and youth, and a broad agree-
ment has been found on core processes and
symptoms between adults and adolescents popu-
lations (Meiser-Stedman, 2002; Salmond et al.,
2011), developmental adaptions of the coding
manual was not considered necessary. We can none-
theless not rule out that the lack of developmental
adaptation may have influenced our results.
Conclusions and Implications
Studying changes in trauma narratives during therapy
has the potential to increase our knowlegde about the
way children experience and process traumas. The
results of this study correspond with previous empiri-
cal findings showing that trauma exposure therapy
contributes to more organized and coherent trauma
narratives. However, the research field continues to
debate how changes in narratives should be under-
stood and explained, and especially how different
narrative characteristics are related to PTSS
(Crespo & Fernndez-Lansac, 2016; OKearney &
Perrott, 2006). Although changes in narratives were
not significantly related to changes in PTSS during
treatment, it is reasonable to assume that a more
organized and coherent trauma narrative in itself is
beneficial as it enables the youth to express and com-
municate their traumatic experiences with significant
others. Furthermore, the creation of a more coherent
narrative with more organized thoughts and internal
events may have contributed to meaning making for
the youth, which is considered of outmost impor-
tance for future development and coping. Neverthe-
less, the findings of the study indicate that the
construction of a coherent narrative in itself may
not be sufficient to reduce PTSS. This study high-
lights the need for additional studies to offer a more
comprehensive understanding of the trauma narra-
tive processes and its relationship to PTSS, particu-
larly in youth. A greater understanding of important
change mechanisms in the treatment of traumatized
children and adolescents may inform treatment
Psychotherapy Research 11
models such that treatment can be tailored and opti-
mized in the future.
Disclosure Statement
No potential conflict of interest was reported by the
authors.
Funding
This work was supported by the Research Council of
Norway, The Norwegian Directorate of Health.
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