Information for Professionals in CAMHS, social care, and EducationRBTT was developed within a multi-agency therapeutic team, in response to the complex needs of those families, who are of greatest concern to Social Services. These young people and their parents have experienced often extreme and enduring trauma, such as decades of sexual abuse, child physical abuse and domestic violence. We began by exploring and adapting different trauma-focussed therapeutic techniques, drawn mainly from systemic traditions and from CBT, in order to ascertain, which of them were most effective for our clients - within a brief period of time. The time factor was crucial to meet child protection concerns: rapid change meant that the family environment would become safer for children within a short space of time, providing them with the opportunity to develop secure attachment.
However, it was also necessary to have a psycho-social and community based perspective, as the social context to such cumulative trauma in families permeates every aspect of the work: socio-economic deprivation and social marginalisation, high crime rates, as well as high levels of aggression and violence in many of our clients’ neighbourhoods, form part of the backdrop to the families’ struggles to recover. Their difficulties become more understandable, when they are examined against their socio-economic background: clients’ key trauma-related experiences, such as fear and chronic anxiety – which can sometimes flip over into acute anger and aggression, when an individual attempts to gain control over their life - , a profound sense of helplessness, dissociation, fragmented interpersonal relationships and shame are often worsened by detrimental factors within the community, such as social isolation or high rates of crime and violence. These families have often been heavily involved with the statutory agencies over many years or even generations. Helplessness can further become exacerbated by the power differential between families and the educated, middle class professionals who act as agents of social control. It became necessary to use trauma-focussed techniques in such a way, that they could be used by our clients to develop a greater sense of personal agency or self-efficacy expectation – clients, who have felt helpless due to the often extreme trauma they have experienced, as well as the further disempowering socio-economic situation, and the re-traumatising effects of violence and abuse in the family, among friends, and in neighbourhoods, and in dealing with professional systems, need to feel in control of their lives, both within themselves and on all these different planes.
Combining elements from Solution Focussed Therapy, Solution Oriented Therapy, Narrative Therapy, CBT and Ericsonian Therapy, as well as NVR, enabled a multi-modal approach, to help our clients develop solutions to trauma and the fallout from trauma in various areas of individual and family life. Thus, RBTT directly addresses the anxiety-related post-traumatic difficulties individuals experience on the one hand, but also deals with the interpersonal, family and community levels on the other. Robert Schwarz’ concept of Trauma Cascade points to the many different kinds of effects trauma can have on families and other social networks – effects which may lead to fragmentation of survivors’ interpersonal relationships, to social isolation and to further trauma.
In our clinical experience, we have found that psychological therapy can inadvertently worsen such effects, thus slowing down recovery. E.g., the confidentiality of individual therapy with survivors of sexual abuse creates an impermeable boundary around therapist and client. To a non-offending parent, being excluded from information about the abuse of their child, and from information about how their child feels and thinks about her, can mirror the secrecy of the original abuse. Sexual abuse, as physical violence, requires the physical, social and emotional isolation of victims from potentially supportive others. A perpetrator of child sexual abuse needs to use divisive strategies to undermine the relationship between the child and their non-offending parent, in order to be able to abuse safely. Some of the many strategies are, for example, to undermine the non-abusive parent’s authority by encouraging the child to misbehave, telling the child the mother would not believe her, or that the child would be rejected by the mother if she learned about the abuse. A parent-child relationship that has already suffered from the offender’s divisive strategies in the past can thus be further weakened, if they again feel excluded from an important relationship, this time the therapeutic one. The therapist may even be idealised by a young person. RBTT has been designed to prevent therapy from exacerbating the fallout from the trauma and abuse within the family system. It does this by centring family members as the most significant supportive others, not the therapist.
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Case Vignette
15 year old Sophie has been sexually abused by an ex-partner of her mother Linda. He had also been physically violent against Linda. Linda eventually managed to escape the relationship with this violent man after several attempts in a women’s refuge, when he finally went to prison for the domestic violence. Sophie experiences intrusive memories of the sexual abuse, which cause her great anxiety. She also feels ashamed of these difficulties, believing that others would consider her ‘crazy’ and disturbed. She did not discuss these difficulties with her previous therapist, but instead focussed on the anger she felt at her mother. This anger pertained to not feeling protected by her mother, and the belief that her mother had been uncaring towards her. She felt particularly upset and angry, at times when her mother appeared more preoccupied than normal – which was when the ex-partner periodically re-appeared in the neighbourhood following his release from prison.
It became apparent, that Linda was experiencing similar post-traumatic difficulties to Sophie. However, working with Sophie alone on overcoming such difficulties could easily have had detrimental effects on their relationship, and on Sophie’s sense of safety. Sophie did not feel contained and protected, when her mother’s ex-partner came back to the neighbourhood, as Linda would become anxious and dissociative – appearing emotionally absent, which Sophie, as well as some professionals, would misinterpret as an uncaring attitude. However, Sophie also did not feel emotionally contained and protected by her mother, as long as she experienced intense anger. Positive regard for Sophie alone, from a caring therapist, would have contrasted with Linda’s apparent uncaring attitude, and further undermine the relationship between this young person and her non-offending mother. Joint conversations with mother and daughter helped Sophie understand, that her mother’s response pattern was similar to her own, and did not represent an uncaring attitude. An understanding emerged, that it would be helpful to both their recovery from past trauma, if they could resist the violence and abuse by working together to overcome its influence on their lives, e.g. by discovering instances, in which they had already been resisting the fragmentation of their relationship, and building on those experiences. Specific trauma-focussed techniques were introduced in joint mother and daughter sessions, which were aimed at overcoming intrusive difficulties, such as Sophie’s intrusive memories of sexual abuse, and her mother’s flashbacks relating to the violence. Mother and daughter then practiced these techniques together at home. They reported back how surprised they were at the effectiveness of some of these techniques, and how much they enjoyed the mutual support.
Linda also took up the offer to have sessions focussing on resistance against her son James’ aggressive behaviour. 16 year old James had begun to see himself as his mother’s protector, but was becoming increasingly threatening and controlling towards her and his sister. When James became angry, his mother would show the same dissociative responses, as when her ex-partner came to the neighbourhood. More and more, she felt controlled by James. Using Non Violent Resistance, Linda was able to build a support network with adults from the wider family and in her neighbourhood, which helped her overcome much of her social isolation and successfully resist James’ aggression towards her and Sophie. Particular trauma-focussed techniques, such as the use of the ‘safe situation’ (developed by Yvonne Dolan) were used to alleviate her post-traumatic anxiety, whilst she practiced carefully planned acts of resistance. Eventually, James benefited, by re-directing his attention away from controlling his mother and sister, to outside activities, such as taking up vocational training at a community college – a common positive development, when young people stop acting in violent ways. Sophie in turn experienced a calmer family environment, an improved relationship with her brother, who was no longer as aggressive and controlling towards her, and a sense of pride in her mother, whom she saw as standing up for herself and the family. This different family environment supported her own recovery from the effects of sexual abuse and the domestic violence she had witnessed, by providing a greater sense of safety.
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This case vignette exemplifies, how psychological therapy, which focuses on an individual’s response to trauma alone, can inadvertently deepen schisms between trauma survivors and significant others. Doing so would weaken the natural recovery environment, which we consider to be more important in overcoming the effects of violence and abuse that the therapeutic relationship alone.
For this reason, RBTT focuses on different levels, to maximise therapeutic outcomes:
- The individual or intra-psychic level – to bring about rapid reduction in post-traumatic difficulties. However, this is not ‘done to’ clients; instead, individuals develop a repertoire of trauma-reducing skills, drawn both from their own experience, and from trauma-focussed techniques.
- The dyadic level – by developing a shared understanding of post-traumatic difficulties, by exploring exceptions to abuse-related relationship problems and building on these exceptions, and by encouraging mutual support in the practice of trauma-reducing skills.
- The family and community levels – in this example, by developing a Non Violent Resistance network to help overcome another family member’s violence, reduce the risk of re-traumatisation, and re-integrate the nuclear family into the wider family and community.
- RBTT further addresses the family’s response to the wider system, which includes professionals from different agencies such as Social Services, CAMHS, Mental Health and Education.
Resource Based Trauma Therapy aims to facilitate the most productive and helpful recovery environment for an individual who is overcoming the after-effects of severe trauma, and their family. It operates in any modality or modalities that are necessary to achieve this aim. This may involve any combination of psychological interventions with the individual, with a significant other, within dyadic relationships, with the family, wider family, supportive others in the community, and with the professional system. In order to achieve this, RBTT draws elements from a variety of different evidence-based therapeutic approaches for working with both the individual and the social systems they are a part of. These therapeutic approaches have been adapted in such a way, that they complement each other in moving from one therapeutic modality to another. Information from one modality of therapeutic work is used in each other modality, in order to maximise the effectiveness of all interventions.
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Example of an RBTT intervention: linking internal and interpersonal resources to re-traumatising situations – 5 steps
Step # 1: Identify situations, which re-traumatise the client.
E.g., a mother may experience even a very young child’s anger as very similar to the violent behaviour his father showed towards her in the past, and react with similar post-traumatic difficulties. These difficulties may be seen as ‘depression’ or ‘attachment difficulties’ by professionals, and can cause feelings of guilt, shame and the fear her child may be taken into care. Explore the interactional pattern that takes place again and again, each time the client is re-traumatised in this manner.
Step # 2: Normalise the client’s reaction by re-framing it as an understandable response to earlier trauma.
E.g., the mother may be able to link her response to the violence his father perpetrated against her. On a cognitive level, she can recognise that she identifies the child with his father when the boy gets angry, and looks for traits which they appear to have in common. She may be able to recognise, that her responses during such angry moments – e.g. body posture, non-verbal and verbal communication, somatic sensations, proximity, movement, etc. – mirror those, that she showed during the original traumatising incidents. At this point, therapeutic communication can enable the mother to see her response to her son’s anger as understandable – ‘it makes sense’, rather than labelling herself as a poor mother, or being pre-occupied with resentfulness over being seen to have attachment difficulties. The therapeutic message is: “this is a limited difficulty, which many people in your situation experience, and which you will be able to deal with effectively”.
Step # 3: Identify internal and inter-personal resources that are now available to the client, and which would have been needed in the original trauma.
This mother may e.g. feel that she has developed a much greater awareness of her own abilities as an adult woman, since she has separated from her child’s abusive father; adult education has made her aware of her ability to learn, and since she has resumed social contact with other women, she has learned to feel appreciated as a friend. The therapeutic conversation raises her awareness of her competent self, and strengthens the confidence she draws from this awareness.
Step # 4: Explore how the internal and interpersonal resources could organise the client’s response to the re-traumatising situation.
Key questions could be e.g.: If you made yourself aware of your ability and strength as an adult woman next time Johnny ‘kicks off’, how would that affect the way you’ll feel about yourself in that situation? How will you stand, look, sound, act differently to the way you have up until now? What will Johnny notice, that’s different? Would you see Johnny in a different light? How would you see him differently? If you decided to ask your friend Jenny to join you in a situation in which Johnny is likely to ‘kick’ off, in what way would her presence support you? How would her presence remind you of the person you are, rather than the person (Johnny’s father) made you believe you were?
Step # 5: Link an associational cue for the internal resource, as well as the inter-personal resource, to the re-traumatising situation.
The client in this example may find that the phrase “I’m a woman and he’s only a child” reminds her of her own competence and makes her feel more confident, and dis-associates him in her mind from his father. Rather than shamefully hiding her child’s aggressiveness, she may ask her friend to be present in a situation, in which he is likely to become aggressive, and use both her friend’s support and the associational cue to help a different response pattern to emerge. The new and different response pattern can then be examined in the therapeutic conversation.
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