Traumatology, Vol. 12, No.

1 (March, 2006)

The Counting Method: Applying the Rule of Parsimony to the Treatment of Posttraumatic
Stress Disorder

David Read Johnson and Hadar Lubin1

______________________________________________________________________________

The authors contend that the primary therapeutic element in psychological treatments for
posttraumatic stress disorder is imaginal exposure, and that differences among major
approaches are determined more by secondary techniques designed to circumvent the client’s
avoidant defenses against exposure. A study is described comparing Prolonged Exposure, Eye
Movement Desensitization and Reprocessing, and the Counting Method with 51 multiply-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

traumatized women. Measures of PTSD were significantly reduced by all three methods, but
This document is copyrighted by the American Psychological Association or one of its allied publishers.

differences among the methods were negligible. Because the Counting Method utilizes only
imaginal exposure as a therapeutic element, support is given to the more parsimonious
conclusion that imaginal exposure may be both the necessary and sufficient factor in therapeutic
effect, countering a trend in the field toward more complex, multi-faceted treatment packages.

____________________________________________________________________________

Key words: Brief treatment; PTSD; women; imaginal exposure; counting method

The lively debate occurring within the trauma field has led to an increasing array of
psychological treatments, which involve increasingly complex arrangements of therapeutic
elements, and accompanying theoretical justifications. In this article, we wish to apply the rule
of parsimony in an attempt to persuade the reader that the state of affairs in the psychological
treatment of trauma may be simpler than currently appears.

Our contention is this: the primary therapeutic element in effective treatments for PTSD
symptoms is imaginal exposure. Differences among techniques can be largely explained by the
different methods through which the client’s avoidant responses to imaginal exposure are
circumvented or inhibited. The need to differentiate methods from each other has therefore
preferentially focused on these secondary aspects, upon which theoretical justifications then are
built. The result has been an obfuscation of the role of the central therapeutic factor underlying
most approaches.

There is a consensus among major psychological approaches to PTSD treatment, including

exposure therapy, cognitive-behavioral therapy, and Eye Movement Desensitization and
Reprocessing (EMDR), that imaginal exposure to the traumatic memory will lead to the

1
Post Traumatic Stress Center, 19 Edwards Street, New Haven, Connecticut 06511 and Department of Psychiatry,
Yale University School of Medicine, New Haven, Connecticut, 203-624-2146, 203-624-2791 (fax),
[email protected]

Acknowledgments: The authors wish to thank Edna Foa, Frank Ochberg, and Francine Shapiro for their support, as
well as Julie Jarvis, Steven Lazrove, Barbara Corn, Theresa Bergherr, and Michelle Loris. This study was partially
funded with a grant from the Dart Foundation.

83
 84 The Counting Method and Posttraumatic Stress Disorder

habituation and diminuition of the fear response, based on well-established principles of learning
theory (Foa, Keane, & Friedman, 2000). All major approaches include some form of imaginal
exposure as a central element. The challenge in treatment is how to deliver this imaginal
exposure when the clients’ avoidant defenses become activated in order to protect themselves
from the anticipated distress. We propose that the major differences among PTSD methods are
due to differences in approach to handling the client’s avoidant responses. It therefore may not
matter which method of circumventing avoidance is used, as long as a dosing of imaginal
exposure is delivered. This may explain why in general significant differences in treatment
outcomes among different methods have not been found.

To explore our proposal, we will report on a study that directly compares two well-established
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

PTSD approaches: Prolonged Exposure (PE) (Foa, Rothbaum, Riggs, & Murdock, 1990), and
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Eye Movement Densitization and Reprocessing (EMDR) (Shapiro, 1997), with the Counting
Method (CM) (Ochberg, Johnson, & Lubin, 1996), a more recently developed method that is a
highly streamlined application of imaginal exposure. Our contention will be supported if all
three treatments have comparable therapeutic effects.

Prolonged Exposure Treatment (PE). Prolonged Exposure Treatment (PE) was

developed by Edna Foa and her colleagues, is a leading approach to PTSD treatment, and has
achieved a high level of empirical support (summarized by Rothbaum, Meadows, Resick, & Foy,
2000). Prolonged exposure treatment is based on a learning model of anxiety in which continued
avoidance of the feared situation prevents habituation and/or extinction of the fear response (Foa,
Steketee, & Rothbaum, 1989; Foa & Rothbaum, 1998). The goal of treatment is to activate the
trauma-related material and expose the client (through imaginal and in vivo stimuli) over a
prolonged period of time until the anxiety diminishes. A variant of this theory, called emotional
processing theory, emphasizes that corrective information is incorporated by the client that
decreases the unrealistic thoughts associated with the fear structures (Foa & Kozak, 1986).
Exposure-based treatments have been named implosive therapy, flooding, and prolonged
exposure, in order to distinguish them from systematic desensitization, a method that relies on
relaxation methods to reduce anxiety and fear (Wolpe, 1958). Prolonged exposure treatments
induce a high state of arousal in the client, which has been shown to be essential to the
therapeutic effect (Foa, Riggs, Massie,& Yarczower, 1995). Exposure treatments have been
shown to be an effective treatment for a wide range of trauma victims (Boudewyns, Hyer,
Woods, Harrison, & McCranie, 1990; Cooper & Clum, 1989; Foa, Rothbaum, Riggs, &
Murdock, 1991; Foa et al., 1999; Keane, Fairbank, Caddell, & Zimering, 1989; Keane &
Kaloupek, 1982; Tarrier et al., 1999).

Prolonged Exposure’s protocol consists of a series of nine sessions which include elements of
psychoeducation, breathing/relaxation practice, written homework, in vivo exposure homework
between sessions, verbal discussion, and a central element of imaginal exposure both in session
and between sessions. In-session exposure requires the client to describe the scene to the
therapist repeatedly between 45-60 minutes (Foa & Rothbaum, 1998; Foa, Rothbaum, Riggs, &
Murdock, 1990).

PE addresses the client’s avoidant responses through presentation of the rationale of the method,
direct encouragement, reassurance, and availability by phone between sessions (Foa &
Rothbaum, 1998).
 Johnson & Lubin 85

Though PE clearly attributes the therapeutic effect to imaginal exposure in the habituation of the
fear schemas and responses, the method incorporates a large number of other elements that may
or may not be required for any additional benefit. It is possible that the resulting complexity and
intensity of this approach has interfered with its dissemination among mental health
professionals, despite established empirical support.

Eye Movement Desensitization Reprocessing (EMDR). The EMDR procedure described

by Shapiro (Shapiro, 1989; Shapiro, 1995; Shapiro & Forrest, 1997) was developed specifically
for the treatment of traumatic memories and stress-related symptoms. The technique has been
widely disseminated among mental health professionals and is currently a major form of PTSD
treatment (Chemtob, Tolin, van der Kolk, & Pitman, 2000). In the EMDR procedure, after a
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

preparation phase, clients are requested to follow with their eyes the therapist’s fingers, which
This document is copyrighted by the American Psychological Association or one of its allied publishers.

are moved rapidly from side to side in order to generate rhythmic, multi-saccadic eye movement.
During that time, the client is asked to visualize the traumatic event. Irrational cognitions are
also addressed in this procedure. EMDR is based on a combination of learning theory and
information processing models (Shapiro, 1995). This form of treatment does not rely on
relaxation techniques, detailed verbal reporting, or evocation of high levels of arousal. A
growing number of studies have found significant improvement among veterans (Boudewyns,
Stwertak, Hyer, Albrecht, & Sperr, 1993; Carlson, Chemtob, Rusnak, Hedlund, & Muraoka,
1998; Pitman et al., 1996), sexual assault victims (Edmond, Rubin, & Wambach, 1999;
Rothbaum, 1997), and mixed trauma samples (Marcus, Marquis, & Sakai, 1997; Vaughn, Wiese,
Gold, & Tarrier, 1994; Wilson, Becker, & Tinker, 1995).

Though Shapiro accepts that imaginal exposure is a “necessary element” in EMDR (Shapiro,
1995, p. 311), she and her colleagues maintain that the eye movements make an independent
contribution to the primary therapeutic effect, including both psychological and neurological
processes. However, a developing consensus based on dismantling studies indicates that EMDR
without eye movements provides equivalent significant therapeutic effect (Chemtob et al., 2000;
Hembree & Foa, 2003).

A possible explanation for these contradictory proposals is that the eye movements, while not
directly contributing to the therapeutic effect, are indeed a means by which the client’s
avoidance is circumvented, as we propose. By providing the external focus and the repeated
dosing of exposure, the eye movements interfere with the client’s avoidant response.
Dismantling studies which eliminate the eye movements are likely to have instituted other means
of addressing the avoidance.

The Counting Method (CM). The counting Method (CM) was recently developed by
Ochberg (1996) is perhaps the most pared down version of an imaginal exposure technique,
which includes a minimum of other therapeutic elements. The central action involves the
therapist counting out loud from 1 to 100 as the client brings the traumatic memory into
awareness and remembers it chronologically from just before its initiation to just after its end.
The procedure includes a preparation phase, in which the rationale is presented and a specific
memory is identified; the counting phase in which the client remembers the event as the therapist
counts; a review phase in which the therapist discusses the recollection process with the client
(Johnson & Lubin, 2005). The method does not rely on cognitive restructuring (as in EMDR),
homework or in vivo exposure (as in PE). Similar to EMDR, the Counting Method allows the
 86 The Counting Method and Posttraumatic Stress Disorder

client to remember the traumatic event privately, that is, without detailed verbal communication
to the therapist (as is required in PE).

In this method, the role of the counting is viewed as a structuring technique to aid the client in
maintaining focus on the traumatic memory and thereby inhibit avoidance. The knowledge that
the exposure will come to an end at 100 presumably offers a measure of control and
predictability to the client. The therapeutic effect is assumed to be the habituation of the fear
response as a result of the imaginal exposure to the memory.

The method has been manualized (Ochberg, Johnson, & Lubin, 1996) and has been utilized in
clinical settings by trained therapists. To date, there have been no empirical studies of this
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

method.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Current Study. The current study compared Prolonged Exposure, Eye Movement
Desensitization and Reprocessing, and the Counting Method in a community sample of multiply-
traumatized women with PTSD. Each of these three treatments utilizes imaginal exposure as a
central element in the desensitization process in addition to unique elements particular to its
approach. All three methods have been manualized. The study design utilized a waitlist
(standard treatment) control group, randomization to treatment condition, blind evaluations using
standardized measures, assessment of therapist adherence, and competence, and a three-month
follow-up evaluation.

If a method such as the Counting Method, which includes only imaginal exposure, was to be as
effective as more developed methods such as EMDR and Prolonged Exposure, which include
imaginal exposure as well as other elements, then, by the rule of parsimony, there would be
strong support for our contention that imaginal exposure is the primary therapeutic element in
successful psychological treatments for PTSD.

Method

Participants

Fifty-one female victims of psychological trauma were recruited through local referring agencies
and clinicians to take part in a brief treatment study. Participants satisfied diagnostic criteria for
PTSD as measured by the Mississippi PTSD Scale (MISS) (Keane, Caddell, & Taylor, 1988),
and the presence of at least one traumatic memory that upon imaginal re-exposure resulted in a
Subjective Units of Distress (SUDS) of at least 6 (scale from 1 to 10). Exclusion criteria were
presence of psychosis, or hospitalization within the past year. All of the participants had been in
ongoing supportive individual psychotherapy from four months to ten years prior to this study,
and all participants continued with their standard treatment during the study. None of the
participants had had, or was receiving, any form of exposure therapy. The waitlist control group
was therefore actually a standard-treatment condition. Fourteen participants were entered into
the waitlist control condition, given the initial evaluation, and then evaluated again three months
later. Three persons dropped out of this condition prior to the final evaluation, leaving 11
participants. These participants were then offered treatment independent of the current study.

Thirty-seven participants were recruited directly into the active conditions. Ten participants
dropped out (nine after the initial evaluation but before attending the first session with a
 Johnson & Lubin 87

therapist, and one after the first meeting prior to being assigned to a specific treatment). No
participant dropped out once she had initiated treatment. This dropout rate is consistent with
similar studies (e.g., Foa et al., 1991). At the conclusion of the study, there were 11 waitlist
controls, and 27 active treatment participants, nine in each of three treatments, for a total of 38
separate participants. Power analyses of previous studies showing effect sizes between 1.50 and
2.00 for PE and EMDR indicated that this study design had sufficient power to test the main
effects for each treatment. Participants provided written informed consent after the study was
completely described, and were paid $40 for each of the three evaluation sessions.

Traumatic Memory
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

The most significant traumatic experience that was currently distressing the participant was
This document is copyrighted by the American Psychological Association or one of its allied publishers.

identified as the Index Trauma. The index trauma was required to have a SUDS value of over
six to be included in the study. The mean initial SUDS for the entire sample was 8.70
(SD=1.34). The treatment conditions aimed to reduce the PTSD symptoms accompanying this
memory. On average, participants reported suffering 4.21 (SD= 3.46) traumatic events during
their lifetime.

Evaluation

Evaluations were conducted at Pre-treatment, Post-treatment, and at Follow-up by a research

assistant blind to the treatment condition of the participant. The Post-treatment evaluation
occurred approximately three months after the Pre-treatment evaluation, and the Follow-up
evaluation three months later. At the pre-treatment timepoint, background demographic and
trauma-related measures (i.e., age at traumatization, type of trauma, identity of perpetrator,
dissociation during trauma) were collected, based on the measures used by Foa et al., 1991.
Each evaluation consisted of the Mississippi Civilian PTSD scale (MISS)(Keane, Caddell, &
Taylor, 1988), Clinician Administered PTSD Scale (CAPS)(Blake et al., 1990), Beck Anxiety
Scale (BECK-A)(Beck, 1987), Beck Depression Scale (BECK-D)(Beck, 1987), and the SCL-90
(Derogatis, 1977). In addition, the participant was asked to narrate in detail her index traumatic
memory, which was audiotaped. A SUDS rating was taken immediately after this narration
(SUDS-REEXPOSURE).

Assignment to Condition

After screening and acceptance into the study, active treatment participants were randomly
assigned to one of the three therapists, each of whom had been trained in each of the three study
treatments. After meeting with the therapist in Session 1, the specific treatment condition was
then randomly selected by the study authors, and the therapist and participant were informed.
This design feature was implemented in order to measure the initial treatment alliance,
independent of treatment condition. The study continued until the three therapists had completed
three participants in each of the three treatment conditions.

Procedure

Session 1 consisted of a structured introductory session in which the therapists introduced

themselves, reviewed the study procedures, inquired about the participant’s life and background,
identified her Index Trauma and accompanying symptoms, taught her the SUDS measure, and
 88 The Counting Method and Posttraumatic Stress Disorder

conducted a breathing relaxation exercise. In Session 2, the specific treatment was described and
begun. Each session was 75-90 minutes long and was scheduled weekly. The total number of
sessions was guided entirely by the specific treatment manual – consistent with the study’s intent
to compare treatment approaches – and therefore the “dosing” of sessions was not equivalent.
Mean number of treatment sessions for each approach were: PE: 9.66 (SD=.51), EMDR: 6.33
(SD=.93), CM: 5.89 (SD=1.10).

Process Measures

After the first session, the therapists filled out a questionnaire regarding their assessment of their
alliance with the client (ALLIANCE: three questions, range 3 - 27). At the same time, the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

participants filled out a questionnaire rating their confidence in the therapist’s competence
This document is copyrighted by the American Psychological Association or one of its allied publishers.

(COMPETENCE: three questions, range 3 -27). After session 2, the participants filled out a
questionnaire regarding their confidence in the efficacy of the treatment as it was explained to
them (CONFIDENCE: three questions, range 3 -27). At the end of each session, the participants
rated themselves on the SUDS regarding the level of arousal (END OF SESSION SUDS, range 0
- 10). Participants and therapists also filled out a brief questionnaire after each session about
their assessment of the efficacy of the session (SUBJ AND TH OUTCOME: three questions,
range 3 - 27).

Therapist Training

Three female therapists (two Ph.D. psychologists and one M.D. psychiatrist), who had completed
their training specializing in posttraumatic stress disorder, were trained in each of the three
procedures over the course of one year prior to participant enrollment. Dr. Edna Foa conducted
a 15-hour training on Prolonged Exposure. The therapists attended and completed Level One
and Level Two training in EMDR (30 hours). Dr. Frank Ochberg conducted a 15 hour training
in the Counting Method. Each therapist then practiced these methods on participants not
included in this study, under supervision by senior practitioners and in compliance with the
respective treatment manuals (Foa, Rothbaum, Riggs, & Murdock, 1990; Ochberg, Johnson, &
Lubin, 1996; Shapiro, 1997).

Therapist Adherence and Competence

Each therapist attempted to follow each procedure strictly according to the respective treatment
manual. All EMDR sessions were videotaped, and all Counting and PE sessions were
audiotaped. Adherence ratings were made by supervisors on randomly selected audiotapes or
videotapes of actual sessions. Each therapist was continuously supervised on each case by
senior supervisors familiar with the particular method. Participants also filled out evaluation
questionnaires at every session rating the therapist’s competence. Every attempt was made to
minimize therapist bias throughout the study, by monitoring therapists’ attitudes towards each
method, and underscoring the need for the therapists to self-monitor their own potential biases
and deliver the treatment as best they could according to the treatment manuals.
 Johnson & Lubin 89

Data Analysis

Differences in outcome between Pre- and Post-Treatment timepoints were first analyzed by
repeated measures ANOVAs contrasting the waitlist group to the experimental groups combined.
Those measures with a significant interaction effect (indicating a difference between active and
waitlist groups) were then subjected to a second repeated measures ANOVA (3 Treatments x 2
Timepoints) comparing the three active conditions to determine both the main effect for Time
(treatment outcome), and interaction effects (indicating differences among the three treatments).
It was expected that there would be a strong main effect for Time and nonsignficant interaction
effects.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Similarly, differences among the three active treatment conditions across Pre- to Post - to
Follow-up timepoints were analyzed by repeated measures ANOVAs (3 Treatments x 3
Timepoints). Significant interaction effects would indicate differences among the treatments.
Differences in outcome among the three therapists were also analyzed by repeated measures
ANOVAs (3 Therapists x 3 Timepoints).

Results

Dropouts

Pre-treatment measures on the 13 dropouts were compared with completers, and significant
differences were found on two variables: BECK-A (Dropouts: 42.00 (13.21) vs. Completers:
26.54(16.36), t = 7.53, p<.01), and participants’ initial SUDS- REEXPOSURE rating (Dropouts:
9.70(.82) vs. Completers: 7.77(2.18), t=4.54, p<.05). However, there were no differences on the
PTSD measures (MISS and CAPS), Beck Depression, or SCL-90. Dropouts appear to have been
more anxious about being re-exposed to their memories

Demographic Factors

Participants were of heterogeneous backgrounds in terms of social status, education,

employment, and income. Their mean age was 38.90 (SD = 10.10). Two-thirds were employed;
83% were Caucasian; 60% were currently single; 62% had children; and 31% had completed
college. There were no significant differences among groups on these variables.

Trauma Factors

Table 1 lists the trauma-related variables for the participants’ Index Traumas. Approximately
half of the sample had been traumatized as children, either with sexual or physical abuse and
usually by a family member. One-third had been traumatized as adults by rape (usually by a
stranger), and 4% had been traumatized by motor vehicle accident. The active conditions were
largely evenly divided across these categories, and chi square analyses of these differences were
not significant
(p> .30).
 90 The Counting Method and Posttraumatic Stress Disorder

Table 1
Trauma-related Factors in Treatment Sample (N=27)
Measure N Percent
Age at Traumatic Event
Child 13 48%
Adult 14 52%
Type of Trauma
Rape 10 37%
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Physical abuse 9 33%

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Sexual abuse 7 26%

Motor Vehicle 1 4%
Perpetrator Type
Family member 14 52%
Stranger 11 41%
Acquaintance 2 7%
Dissociation at Time of Trauma
Minimal 5 19%
Moderate 16 59%
Severe 6 22%

None of the trauma-related factors were significantly correlated with any outcome measures,
indicating that all three treatments were equally effective across these categories.

Process Variables

There were no significant differences among the process variables across the four study
conditions. Therapists’ ratings of ALLIANCE, as well as participants’ ratings of
COMPETENCE and CONFIDENCE in treatment were moderately strong (means ranging from
20 - 24 out of a possible score of 27). Participants’ ratings of therapist’s COMPETENCE and
therapists’ ratings of ALLIANCE were moderately correlated (r=.48, p<.05), but participants’
ratings of therapist COMPETENCE and CONFIDENCE in treatment were uncorrelated. At the
end of treatment, there were no differences among treatments in the therapists’ or participants'
ratings of OUTCOME, which were moderately high (means ranging from 19 to 23 out of 27).
None of these self-reported ratings of ALLIANCE, COMPETENCE, or CONFIDENCE, taken
during the beginning of treatment, were significantly correlated with any of the standardized
outcome measures, suggesting that treatment effects were not influenced by relationship factors.
There were no significant differences in outcome in relation to the number of treatment sessions
delivered.

Therapist Effects

Repeated measures ANOVAs comparing outcome measures across each of the three therapists
showed no significant differences on any measure, indicating that the therapists were equally
effective.
 Johnson & Lubin 91

Pre-Post Comparisons by Treatment Condition

Omnibus ANOVAs contrasting waitlist with treatment groups resulted in significant interaction
effects for CAPS-Total (F(1,36)=13.12, p<.001), CAPS-Reexperiencing (F(1,36)=11.15,
p<.002), CAPS-Avoidance (F(1,36)=9.68, p<.003), CAPS-Hyperarousal (F(1,36)= 4.80, p<.04),
Mississippi (F(1,36)=8.58, p<.006), and SUDS (F(1,36)=17.45, p<.001). Nonsignficant
interaction effects occurred for SCL-90 (F(1,36)=3.16, p<.10), BECK-A (F(1,36)=.96, p>.10),
and BECK-D (F(1,36)=2.85, p<.10) measures. These results indicate that the active treatments
primarily targeted PTSD symptoms rather than more general psychiatric symptoms. The
treatment effect for the Hyperarousal cluster was less robust, consistent with recent reports
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

(Zayfert & DeViva, 2004).

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Table 2 lists the results of the secondary ANOVAs which examined the main effect for Time and
interaction effects among the three conditions. Data for the waitlist groups are included only for
reference.

As indicated in Table 2, these measures show very strong effects for Time, indicating that the
active treatments reduced these symptoms by Post-Treatment, and very weak interaction effects,
indicating that there were no perceptible differences among the treatments.

Pre-Treatment to Follow-up Comparisons

Also indicated in Table 2 are the ANOVAs across all three time periods, which indicate very
strong effects for Time, indicating that gains made by Post-Treatment were maintained at
Follow-up. Again the interaction effects were negligible, indicating no perceptible difference
among the treatments. Effect sizes of the active treatments among the PTSD-related measures
from Pre-treatment to Follow-up [CAPS = 1.66; MISS= 1.20; SUDS= 1.69] were greater than
those of the general psychiatric or physiological measures (SCL-90= .77, BECK-A= .58; BECK-
D= .63), suggesting that these treatments did preferentially target PTSD symptoms.

Clinical Significance

Overall, 44% of the participants in the active conditions reduced their CAPS scores more than
two standard deviations. The overall CAPS score for the entire sample was reduced to a sub-
clinical level (equivalent to a score of 1.26 on the basic CAPS scale of 0 - 4). MISS was reduced
from a mean of 122 to 105, just under the criterion score for PTSD. General psychiatric
measures showed reduced but still clinical levels of distress (e.g., Beck Depression: sample mean
= 16.37)
 92 The Counting Method and Posttraumatic Stress Disorder

Table 2
Repeated Measures ANOVAs for Pre-Treatment, Post-Treatment, and Follow-up Timepoints on
Selected Measures

ANOVAs

Pre-Post Pre-Post-FU

Measure Time Interaction Time Interaction

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Pre-Tx Post-Tx FU F(1,24) F(2,24) F(2,48) F(4,48)

CAPS - Total

Counting 82.00 54.00 53.89 38.09*** .13 35.30*** .85

SD 13.77 25.29 26.69

EMDR 61.78 35.33 24.56

SD 16.04 17.05 18.36

PE 72.00 49.11 50.22

SD 19.79 26.19 25.40

----------------------------------------------------------------

Waitlist1 64.27 64.00

SD 24.82 25.42

CAPS- Re-experiencing

Counting 23.11 12.78 10.67 74.25*** .29 65.28*** .89

SD 7.02 11.21 8.46

EMDR 19.78 7.67 4.78

SD 5.91 6.82 4.79

PE 19.67 9.78 10.00

SD 8.59 9.55 9.10

--------------------------------------------------------------------

Waitlist1 16.36 13.09

 Johnson & Lubin 93

SD 7.67 9.98

ANOVAs

Pre-Post Pre-Post-FU

Measure Time Interaction Time- Interaction

Pre-Tx Post-Tx FU F(1,24) F(2,24) F(2,48) F(4,48)

CAPS - Avoidance
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Counting 33.22 22.78 24.89 21.81*** .05 19.76*** .61

SD 5.85 9.39 12.25

EMDR 23.66 13.11 9.67

SD 7.21 9.52 7.84

PE 30.56 21.44 22.00

SD 10.90 11.59 9.62

-------------------------------------------------------------------

Waitlist1 27.54 28.64

SD 13.02 13.65

CAPS - Hyperarousal

Counting 25.67 18.44 18.33 12.61** .65 12.26*** 1.03

SD 4.58 7.02 8.47

EMDR 18.33 14.55 10.11

SD 5.92 7.18 8.05

PE 21.78 17.89 18.22

SD 3.60 7.29 8.18

----------------------------------------------------------------------

Waitlist1 22.18 22.27

SD 7.88 5.83
 94 The Counting Method and Posttraumatic Stress Disorder

ANOVAs

Pre-Post Pre-Post-FU

Measure Time Interaction Time Interaction

Pre-Tx Post-Tx FU F(1,24) F(2,24) F(2,48) F(4,48)

MISS
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Counting 134.22 123.67 115.56 20.66*** 1.61 30.00*** .79

SD 7.86 12.58 12.75

EMDR 104.78 98.78 85.67

SD 25.05 23.87 28.24

PE 127.56 110.89 105.44

SD 23.05 21.28 19.74

------------------------------------------------------------------

Waitlist1 114.82 117.27

SD 24.29 28.04

SUDS

Counting 9.00 4.67 4.56 56.68*** 3.03 43.96*** 1.89

SD .87 2.59 3.05

EMDR 7.11 4.88 4.33

SD 2.31 1.62 1.66

PE 8.89 3.56 3.56

SD .78 2.69 3.28

-------------------------------------------------------------------

Waitlist1 8.00 7.82

SD 2.05 2.14
 Johnson & Lubin 95

** p < .01 *** p < .001

1
Included only for reference; not part of analyses.

Discussion

This study suggests that three forms of brief treatment for PTSD - Prolonged Exposure, Eye
Movement Desensitization and Reprocessing, and the Counting Method - are effective in
reducing PTSD symptomatology among traumatized women. These treatments were less
effective in reducing general psychiatric distress. The data also indicate that these treatments
have a low risk: no participant showed any significant worsening, and only three participants
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

showed no improvement (one from each condition). No similarities could be identified among
This document is copyrighted by the American Psychological Association or one of its allied publishers.

these three persons. In most cases, participants experienced improvement in symptoms that had
been unchanged despite months or years of standard psychotherapeutic treatment. These
outcome data are consistent with a large number of previous studies.

Of more importance for the hypotheses of this study, differences in outcome among the three
approaches were negligible, no matter how the data was analysed. The three approaches were
indistinguishable on overall outcome at each timepoint, for each therapist, for type of trauma,
and by demographics of the participants. Thus, the data of this study strongly support the
contention that the primary therapeutic factor in the treatment of PTSD symptoms is imaginal
exposure, for it is the only element shared by all three approaches, and it is the only element in
the Counting Method.

Given the effect sizes reported by previous studies, the sample was of sufficient size to test the
main effect of time (that is, outcome). Given the extremely small effect size of the interaction
terms in this study, a sample of several hundred participants would be required to detect
differences among the treatment conditions, differences that one could argue would have little
clinical significance.

Limitations

The study had a number of limitations, including a restricted sample, including the fact that the
participants and therapists were female. Another limitation of this study was that the therapists
conducted all three types of treatments, creating the possibility for bias. However, all three
therapists were equally effective across all three treatments, and no relationship variables
showed any impact on outcome or preference for treatment condition. Another limitation was
that all participants were seen in their ongoing standard individual therapy throughout the study.
However, this reduces the possibility that the effect of the active conditions was due simply to
attention from a therapist, which would be a problem in a no-treatment comparison group design.

Dropout rates for the waitlist group (23%) and the active conditions (27%) were nearly
equivalent to those reported in a meta-analysis of exposure studies conducted recently by
Hembree et al. (2003). Importantly, no participant dropped out once treatment had commenced.
Instead, dropouts appeared to have high levels of anticipatory anxiety regarding revisiting their
traumatic memories
 96 The Counting Method and Posttraumatic Stress Disorder

This study attempted to reduce potential sources of error through the use of manual-based
treatments, therapist adherence and competence measures, waitlist (standard treatment) control
group, random assignment to condition and therapist, and use of well-known and standardized
PTSD and psychopathology measures. These components have been recommended by experts
in the field (Foa, Keane, & Friedman, 2000).

Conclusion

As many previous studies have shown, treatments such as the ones utilized in this study are
effective in reducing PTSD symptoms in a relatively short period of time. The data from this
study indicate that clinicians could choose any of these approaches, based on their experience,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

training, or preference. The critical question now, however, is what are the necessary and
This document is copyrighted by the American Psychological Association or one of its allied publishers.

sufficient therapeutic elements in such treatments? We believe that imaginal exposure may be
both necessary and sufficient, and that other therapeutic elements may offer limited
contributions. The only other elements needed in a therapeutic procedure are those that allow
the dosing of imaginal exposure to be delivered by circumventing or inhibiting the client’s
avoidant responses. Such techniques as direct encouragement, psychoeducation, counting, eye
movements, finger tapping, or suggestion are examples. If further studies show that streamlined
methods such as the Counting Method are as effective as more complex and articulated
approaches, then our hypothesis will gain support. Applying the rule of parsimony to trauma
treatment, designers of treatment interventions would then be encouraged to simplify rather than
complicate their methodologies and theoretical propositions.

References

Beck, A. T. (1987). Beck depression inventory manual. The Psychological Corporation: San
Antonio, TX.

Blake, D.D., Weathers, F.W., Nagy, L.M., Kaloupek, D., Klauminzer, G., Charney, D., & Keane,
T. (1990). A clinician rating scale for assessing current and lifetime PTSD: The CAPS-1.
Behavior Therapist, 13, 187-188.

Boudewyns, P., Hyer, L., Woods, M., Harrison, M., & McCranie, E. (1990). PTSD among
Vietnam veterans: An early look at treatment outcome using direct therapeutic exposure.
Journal of Traumatic Stress, 3, 359-368.

Boudewyns, P., Stwertak, S., Hyer, L., Albrecht, J., & Sperr, E. (1993). Eye movement
desensitization and reprocessing: A pilot study. Behavior Therapy, 16, 30-33.

Carlson, J.G., Chemtob, C.M., Rusnak, K., Hedlund, N.L., & Muraoka, M.Y. (1998). Eye
movement desensitization and reprocessing for combat-related posttraumatic stress
disorder. Journal of Traumatic Stress, 11, 3-24.

Chemtob, C., Tolin, D., van der Kolk, B., & Pitman, R. (2000). Eye movement desensitization
and reprocessing. In E. Foa, T. Keane, & M. Friedman (Eds.), Effective treatments for
PTSD (pp. 139-154). New York: Guilford.
 Johnson & Lubin 97

Cooper, N.A., & Clum, G.A. (1989). Imaginal flooding as a supplementary treatment for PTSD
in combat veterans: A controlled study. Behavior Therapy, 20, 381-391.

Derogatis, L. (1977). SCL-90: Administration, scoring, and procedures manual. Towson, MD:
Clinical Psychometrics Research.

Edmond, T., Rubin, A., & Wambach, K.G. (1999). The effectiveness of EMDR with adult
female survivors of childhood sexual abuse. Social Work Research, 23, 103-116.

Foa, E., Dancu, C., Hembree, E., Jaycox, L., Meadows, E., & Street, G. (1999). The efficacy of
exposure therapy, stress inoculation training and their combination in ameliorating PTSD
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

for female victims of assault. Journal of Consulting and Clinical Psychology, 67, 194-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

200.

Foa, E., Keane, T., & Friedman, M. (2000). Effective treatments for PTSD. New York:
Guilford.

Foa, E., & Kozak, M. (1986). Emotional processing of fear: Exposure to corrective information.
Psychological Bulletin, 99, 20-35.

Foa, E., Riggs, D., Massie, E., & Yarczower, M. (1995). The impact of fear activation and anger
on the efficacy of exposure treatment for PTSD. Behavior Therapy, 26, 487-499.

Foa, E., & Rothbaum, B. (1998). Treating the trauma of rape: Cognitive-behavioral therapy for
PTSD. New York: Guilford.

Foa, E., Rothbaum, B., Riggs, D., & Murdock, T. (1990). Treatment of post-traumatic stress
disorder in rape victims. (Unpublished manual).

Foa, E.B., Rothbaum, B.O., Riggs, D.S., & Murdock, T.B. (1991). Treatment of posttraumatic
stress disorder in rape victims: A comparison between cognitive-behavioral procedures
and counseling. Journal of Consulting and Clinical Psychology, 59, 715-723.

Foa, E.B., Steketee, G., & Rothbaum, B.O. (1989). Behavioral/cognitive conceptualization of
post-traumatic stress disorder. Behavior Therapy, 20, 155-176.

Hembree, E., & Foa, E. (2003). Interventions for trauma-related emotional disturbances in adult
victims of crime. Journal of Traumatic Stress, 16, 187-200.

Hembree, E., Foa, E., Dorfan, N., Street, G., Kowalski, J., & Tu, X. (2003). Do patients drop out
prematurely from exposure therapy for PTSD? Journal of Traumatic Stress, 16, 555-
562.

Johnson, D., & Lubin, H. (2005). The counting method. Traumatology, 11, 189-198.

Keane, T.M., Caddell, J.M., Taylor, K.L. (1988). The Mississippi scale for combat related
PTSD: Studies in reliability and validity. Journal of Consulting and Clinical Psychology,
56, 85-90.
 98 The Counting Method and Posttraumatic Stress Disorder

Keane, T., Fairbank, J, Caddell, J., & Zimering, R. (1989). Implosive (flooding) therapy reduces
symptoms of PTSD in Vietnam combat veterans. Behavior Therapy, 20, 245-260.

Keane, T., & Kaloupek, D. (1982). Imaginal flooding in the treatment of post-traumatic stress
disorder. Journal of Consulting and Clinical Psychology, 50, 138-140.

Marcus, S., Marquis, P., & Sakai, C. (1997). Controlled study of treatment of PTSD using
EMDR in an HMO setting. Psychotherapy, 34, 307-315.

Ochberg, F., Johnson, D., & Lubin, H. (1996). The Counting Method treatment manual. New
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Haven, CT: Post Traumatic Stress Center.

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Ochberg, F. (1996). The Counting Method for ameliorating traumatic memories. Journal of
Traumatic Stress, 9, 873-880.

Pitman, R.K., Orr, S.P., Altman, B., Longpre, R.E., Poire, R.E., & Macklin, M.L. (1996).
Emotional processing during eye movement desensitization and reprocessing therapy of
Vietnam veterans with chronic posttraumatic stress disorder. Comprehensive Psychiatry,
37, 419-429.

Rothbaum, B.O. (1997). A controlled study of eye movement desensitization and reprocessing
for posttraumatic stress disordered sexual assault victims. Bulletin of the Menninger
Clinic, 61, 317-334.

Rothbaum, B., Meadows, E., Resick, P., & Foy, D. (2000). Cognitive-behavioral therapy. In E.
Foa, T. Keane, & M. Friedman (Eds.), Effective treatments for PTSD (pp. 60-83). New
York: Guilford.

Shapiro, F. (1989). Efficacy of the eye movement desensitization procedure in the treatment of
traumatic memories. Journal of Traumatic Stress, 2, 199-233.

Shapiro, F. (1995). Eye movement desensitization and reprocessing. New York: Guilford.

Shapiro, F. (1997). EMDR Treatment Manual. Palo Alto: EMDRIA Institute.

Shapiro, F. & Forrest, M. (1997). EMDR. New York: Basic Books.

Tarrier, N., Pilgrim, H., Sommerfield, C., Faragher, B., Reynolds, M., Graham, E., &
Barrowclough, E. (1999). A randomized trial of cognitive therapy and imaginal exposure
in the treatment of chronic post traumatic stress disorder. Journal of Consulting and
Clinical Psychology, 67, 13-18.

Vaughn, K., Wiese, M., Gold, R., & Tarrier, N. (1994). Eye movement desensitization:
Symptom change in posttraumatic stress disorder. British Journal of Psychiatry, 164,
533-541.
 Johnson & Lubin 99

Wilson, S.A., Becker, L.A., & Tinker, R.H. (1995). Eye movement desensitization and
reprocessing treatment for psychologically traumatized individuals. Journal of
Consulting and Clinical Psychology, 63, 928-937.

Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Palo Alto: Stanford University Press.

Zayfert, C., & DeViva, J. (2004). Residual insomnia following cognitive behavioral therapy for
PTSD. Journal of Traumatic Stress, 17, 69-74.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.