The perspective offered in this treatment guide is that many of the relationship problems experienced by traumatized adolescents arise from early learning about – and adapting to – childhood maltreatment.
Interpersonal issues are often especially challenging for youths, since, even for those who have not been abused or neglected, adolescence is a developmental period when relationships with peers become more important, and sexual, romantic, or pair-bonding dynamics typically emerge for the first time. Because child abuse and neglect usually involves maltreatment in the context of what should have been nurturing relationships, these relational issues and yearnings can become powerful triggers for subsequent interpersonal difficulties in youth.
One of the earliest impacts of abuse and neglect is thought to be on the child’s internal representations of self and others (Allen, 2001), inferred from how he or she is treated by his or her caretakers. In the case of abuse or neglect, these inferences are likely to be especially negative. For example, the child who is being maltreated may conclude that he or she must be inherently unacceptable or malignant to deserve such punishment or disregard, or may come to see him or herself as helpless, inadequate, or weak. As well, this negative context may mean that he or she comes to view others as inherently dangerous, rejecting, or unavailable.
These early inferences about self and others often form a generalized set of expectations, beliefs, and assumptions, sometimes described as internal working models (Bowlby, 1988) or relational schemas (Baldwin, Fehr, Keedian, Seidel, & Thompson, 1993). Such core understandings are often relatively nonresponsive to verbal information or the expressed views of others later in life, since they are encoded in the first years of life and thus are generally pre-verbal in nature. For example, the young man who believes, based on early learning, that he is unlikable or unattractive to others, or that others are not to be trusted, will not easily change such views based on others’ statements that he is valued by them or that they can be relied upon.
Because they become the default assumptions the adolescent carries in his or her interactions with others, these negative schema are easily activated and acted upon in current relationships, ultimately making it hard for the youth to maintain meaningful connections and attachments with other people. As a result, formerly abused or neglected youth may find themselves in conflicted and chaotic relationships, may have problems with forming intimate peer attachments, and may engage in behaviors that are likely to threaten or disrupt close relationships.
Because relational schemas are often encoded at the implicit, nonverbal level, and are primarily based in safety and attachment needs, they may not be evident except in situations where the survivor perceives abuse-similar interpersonal threats, such as rejection, abandonment, criticism, or physical danger. When this occurs, these underlying cognitions and emotions may be triggered with resultant interpersonal difficulties. For example, a young woman who experienced early separation or abandonment may function relatively well in a given occupational or intimate context until she encounters relational stimuli that suggest (or are in some way reminiscent of) rejection, empathic disattunement, or abandonment. These perceived experiences, because of their similarity to early neglect, may then trigger memories, emotions, and cognitions that – although excessive or out of proportion in the immediate context – are appropriate to the feelings and thoughts of an abused or neglected child. This activation may then motivate behavior that, although perhaps intended to ensure proximity and to maintain the relationship, is so characterized by “primitive” (i.e., child-level) responses and demands, and so laden with upsetting emotions that it challenges or even destroys that relationship.
The most dramatic example of chronic relational trauma activations may be what, in adults, is referred to as borderline personality disorder. Those identified as having borderline personality features are often prone to sudden emotional outbursts in response to small or imagined interpersonal provocation, self-defeating cognitions, feelings of emptiness and intense dysphoria, and impulsive, tension-reducing behavior that are triggered by perceptions of having been abandoned, rejected, or maltreated by another person. Although many maltreated adolescents are too young to be diagnosed with this disorder (American Psychiatric Association, 2000, 2013), in extreme cases, their symptomatic presentation may be very similar, and some may receive this diagnosis as they grow into adulthood.
A fair portion of “borderline” behavior and symptomatology can be seen as arising from triggered relational memories and emotions associated with early abuse, abandonment, invalidation, or lack of parental responsiveness, generally in the context of reduced affect regulation capacities (Allen, 2001; Herman, Perry, & van der Kolk, 1989; Linehan, 1993). Upon having abuse memories triggered by stimuli in his or her current context, the adolescent may then attempt to avoid the associated distress by engaging in activities such as substance abuse, inappropriate proximity-seeking (e.g., neediness or attempts to forestall abandonment), or involvement in distracting, tension-reducing behaviors, as described in Chapter 2.
The ITCT-A approach to relational disturbance parallels, to some extent, those outlined in Chapters 9 and 10 for cognitive and exposure-based interventions. In the relational context, however, the components of trauma processing occur more directly within the therapeutic relationship. Because most disturbed relatedness appears to arise from maltreatment early in life, and is often triggered by later interpersonal stimuli, it is not surprising that the most effective interventions for relational problems seem to be, in fact, relational (Pearlman & Courtois, 2005).
Among other things, the therapeutic relationship is a powerful source of interpersonal triggers. As the connection between adolescent and clinician grows, the client’s increasing attachment to the therapist can increasingly trigger implicit (nonverbal, sensory/experiential) memories of attachment experiences in childhood. For many clients, these early attachment memories include considerable abuse or neglect, which may be reexperienced in the form of maltreatment-related thoughts and feelings during therapy. Because these “relational flashbacks” are largely implicit, they do not contain autobiographical information in that they represent the past, and thus are often misperceived by the adolescent as being feelings related to the current therapist-client relationship (see Briere, 2002 for more on these “source attribution errors”). Once activated and expressed, such cognitions and emotions can be discussed and processed in the context of the safety, soothing, and support associated with a positive therapeutic relationship. It is always incumbent on the therapist, of course, to make sure that such activation responses are normative aspects of relational therapy, and not triggered by negative or inappropriate therapist behaviors.
Components of Relational Processing
As in work with more simple traumatic memories, the therapeutic processing of relational memories and their associations (e.g., attachment-level cognitions and conditioned emotional responses) can be seen as involving the exposure, activation, disparity, and counterconditioning described in Chapter 10.
- Exposure : during psychotherapy, the adolescent encounters stimuli that trigger implicit memories of early interpersonal abuse or neglect.
Therapy stimuli can trigger exposure to relational memories by virtue of their similarity to the original trauma; including the clinician’s physical appearance, his or her age, sex, or race, and the power differential between client and therapist. Even positive feelings associated with the therapeutic relationship can trigger distress – the adolescent’s caring feelings towards the therapist (or perception of similar feelings from the clinician) can activate sexual feelings or fears, and perceptions of therapist support and acceptance can trigger fears of losing such experiences (i.e., of abandonment by an attachment figure). As well, therapists, like other people, may evidence momentary lapses in empathic attunement, distraction by personal problems, fatigue, or the triggering of their own issues by some aspect of the client’s presentation – any of which may inadvertently expose the client to intrusive memories of earlier maltreatment or neglect. Finally, a caring and supportive therapeutic relationship may trigger anger in the client as he or she comes to understand more fully the neglect he or she experienced as a child – anger that, in some cases, paradoxically may be focused back on the therapist as a representative parental figure.
Beyond these discrete triggers, the therapeutic relationship itself – by virtue of its ongoing nature and importance to the youth – may produce stimulus conditions similar to those of early important relationships, including the client’s childhood need for attachment. To the extent that the earlier relationship was characterized by trauma, the current therapeutic relationship is therefore likely to trigger negative relational memories.
Importantly, just as noted in previous chapters for simpler trauma processing, exposure must occur within the context of the therapeutic window. The clinician may have to work actively, and pay very careful attention, to ensure that his or her stimulus value or the characteristics of the therapeutic relationship do not produce so much exposure to negative relational memories that the adolescent becomes overwhelmed. Just as the therapist treating PTSD may titrate the amount of exposure the client undergoes regarding a traumatic memory, the clinician treating relational traumas tries to ensure that reminiscent aspects of the therapeutic environment are not overwhelming.
For example, adolescents with schemas arising from punitive parenting may require treatment that especially avoids any sense of therapist judgment. Similarly, the youth who has been physically or sexually assaulted may require (a) special, visible attention to safety issues, (b) therapist responses that stress boundary awareness and respect, or even (c) a greater-than-normal physical distance between the client’s chair and the therapist’s. A client with abandonment issues arising from early psychological neglect, on the other hand, may be less triggered when the clinician is especially attuned and psychologically available. On a more general level, therapists of chronically traumatized adolescents may need to devote greater attention than usual to avoiding behaviors that in some way appear to involve intrusion, control, or narcissism.
Unfortunately, some characteristics of the therapist may be such powerful triggers that the therapeutic process is especially challenged. For example, the female adolescent who has been recently sexually assaulted by a man or men may have considerable difficulty working in therapy with a male clinician: regardless of the therapist’s personal qualities and best intentions, his masculine stimulus value may trigger trauma memories of assault by a male. Similar scenarios may occur when the therapist’s ethnic or racial identity is the same as those who have maltreated or discriminated against the client. More subtly, the (usually middle-class) social status of the therapist may trigger negative feelings in the socially marginalized adolescent, based on a long history of not being understood, or of being judged as somehow less important, by people of the therapist’s social position.
Even in these cases, however, exposure to memories involving social deprivation or discrimination often can be titrated. The male clinician treating an abused young woman can be careful to avoid interactions that could be perceived in any way as sexually or physically threatening. The Caucasian therapist working with a young African-American man can work hard to nondefensively communicate a nonracist perspective, and to support the client’s expression of thoughts or feelings related to seeing a therapist whose racial identity is similar to those who have harmed him in the past. The economically advantaged counselor can consciously strive to avoid making assumptions or judgments based on his or her background when interacting with economically marginalized clients. When social differences almost inevitably emerge during treatment, the clinician can work hard to foster discussion of these issues in the context of acceptance, support, and a willingness to challenge his or her own biases, should they appear.
Whether involving exposure to memories of childhood maltreatment by a parent or social injury by a devaluing culture, relational exposure thus refers to any aspect of the therapeutic relationship that causes the client to reexperience relational trauma memories. It is titrated exposure to the extent that the clinician modifies the degree to which that the memory is triggered, generally by avoiding activities that increase the extent to which the current therapy stimuli are reminiscent of the original trauma. In most cases, this means that although the therapeutic relationship is intrinsically similar to the survivor’s early relationships by virtue of its dyadic nature, encouragement of intimacy, and relationship to early attachment dynamics, it is not similar in that the therapist is careful to avoid any behaviors or verbalizations that might imply rejection, abandonment, revictimization, exploitation, etc.
- Activation : as a result of therapeutic exposure, the client experiences emotions and thoughts that occurred at the time of the relational trauma.
Activated emotional responses to early relational memories during treatment are often notable for the suddenness of their emergence, their intensity, and their seeming contextual inappropriateness. Intrusive negative cognitions about self or the therapist may be activated, or attachment-related schema involving submission or dependency may suddenly appear. In some cases, such activation may also trigger sensory flashbacks and dissociative responses.
Cognitive-emotional activation can be easily understood by both client and therapist when it occurs in the context of discrete trauma memories, such as those of an assault or disaster. When activation occurs in the context of triggered relational stimuli, however, the actual “reason” behind the client’s thoughts and feelings may be far less clear. Because the original trauma memory (a) may have been formed in the first years of life, and therefore is not available to conscious (explicit) awareness, or (b) may be so associated with emotional pain that it is immediately avoided, neither client not therapist may know why the client is feeling especially anxious or angry, or why he or she is suddenly so distrustful of the clinician. In fact, in instances where such activations are dramatic, they may appear so irrational and contextually inappropriate that they are seen to some as evidence of significant psychopathology. Ultimately, however, these activations are logical, in the sense that they represent conditioned cognitive-emotional responses to triggered relational memories, albeit ones that may not be traceable to specific childhood events. More generally, these activations are necessary to effective treatment. Trauma memories, relational or otherwise, can be processed only when exposure activates cognitions and emotions that are then addressed through disparity, as described below.
- Disparity : although the adolescent trauma survivor thinks and feels as if maltreatment or abandonment is either happening or is about to happen, in reality the session is safe, and the therapist is not abusive, rejecting, or otherwise dangerous.
Although this component is often critical to trauma processing, youth who have been victimized interpersonally – especially if that victimization was chronic – may find disparity difficult to apprehend fully at first, let alone trust. There are a number of reasons for this. First, those exposed to chronic danger often come to assume that such danger is inevitable. The “street kid” or victim of chronic abuse may find it very difficult to accept that the rules have suddenly changed and that he or she is safe – especially in situations that bear some similarity to the original dangerous context, such as in a relationship with a powerful other. Second, in many cases, the original perpetrator(s) of violence promised safety, caring, or support as a way to gain access to the victim. As a result, reassurance or declarations of safety may seem like just “more of the same,” if not a warning of impending danger. Finally, therapy implicitly requires some level of intimacy, or at least vulnerability from the client. This requirement – from the survivor’s perspective – can be a recapitulation of past experiences of intimate demands and subsequent injuries.
For these and related reasons, not only must disparity/safety be present, but the adolescent must be able to perceive it. Although occasionally frustrating for the therapist, this sometimes means that considerable time in therapy is necessary before sufficient trust is present to allow true relational processing. For example, the survivor of extended maltreatment may require months of weekly therapy before letting down her guard sufficiently to participate in trauma therapy. The therapist should be prepared in such cases for client disbelief or immediate rejection of statements like “you are safe here” or “I won’t go away.” This does not mean that the clinician shouldn’t make such statements (when they are accurate, and expressed in a nonintrusive, non-demanding way), but the therapist should understand that such declarations rarely alter cognitions that have been repeatedly reinforced by prior adversity.
In fact, for those hypervigilant to danger in interpersonal situations, disparity cannot be communicated; it must be demonstrated. Therapist statements that he or she should be trusted can even have the opposite effect on traumatized clients – because they have heard similar promises or protestations from ill-meaning people in the past, such statements may make them feel less safe, not more. Instead, when working with young survivors of chronic relational trauma, the therapist must behave in a reliably safe and non-exploitive way, over time, until the youth can experience an enduring sense of safety. Behaving in a way that actually communicates disparity means that the therapeutic environment must be the antithesis of how injurious others have been in the adolescent’s past – involving reliability and connection rather than abandonment; relational safety rather than maltreatment or exploitation; a pro-diversity, culturally competent perspective rather than one that supports discrimination or social marginalization; and so on.
The exposure-activation-disparity process may proceed in a step-wise fashion for the relational trauma survivor. Early in therapy, he or she may occasionally (and often inadvertently) reveal some small degree of vulnerability or suffering to the therapist, and then reflexively expect a negative consequence. When this vulnerability is not, in fact, punished by the therapist, but is met with support and some carefully titrated level of visible caring, the adolescent may slowly lower his or her psychological barriers and express more thoughts or feelings. As these responses are likewise supported, and not exploited or punished, the client’s willingness to process pain in “real time” (i.e., directly, in the presence of the therapist) generally increases. It should be stressed that this may take time, and therapist expressions of impatience ironically may subvert the process by communicating criticism or implied rejection.
In other cases, disparity may be considerably easier to establish and trauma processing may be possible sooner. For example, when the client has experienced less extreme or less chronic relational trauma, when the conditions surrounding the victimization are clearly quite different (and perceivable as such by the client) than in therapy, or when there were supportive people in the client’s environment in addition to the perpetrator(s). However, this is an assessment issue, rather than something that can be automatically assumed.
- Counterconditioning : relational triggering of negative emotional states occurs at the same time as the adolescent experiences positive emotional states associated with growing attachment to the therapist.
When counterconditioning was described in Chapter 10, the healing aspect of this phenomenon was described as the simultaneous presence of both (1) the activated distress associated with traumatic memory exposure and (2) the positive feelings engendered by a positive therapy environment. When relational trauma is being processed, counterconditioning is potentially even more important. In this regard, activated negative relational cognitions (i.e., “he or she doesn’t like me,” “he or she will hurt or abandon me,” or “I’ll be taken advantage of if I become vulnerable”) and feelings (e.g., associated fear of authority figures or intimacy) are directly – and, therefore, potentially more efficiently – contradicted by positive relational experiences. In other words, there may be something especially helpful about having fears and expectations of maltreatment in the specific context of nurturance and acceptance. In the language of earlier psychodynamic theory, such real-time contradiction of activated schema and feelings may provide a “corrective emotional experience.”
There is also a potential downside to the juxtaposition of negative expectations and positive experiences in therapy, however. Just as positive experiences in therapy may contradict earlier held beliefs about close relationships, it is also true that activated, negative relational cognitions can at least temporarily prevent the client from identifying and accessing the positive relational phenomena that occur in therapy. Fortunately, this is rarely an all-or-none experience; in most cases, even the distrustful or hypervigilant youth will slowly come to reevaluate negative relational cognitions when therapist support and validation are visibly and reliably present. As is the case for client difficulties in perceiving therapeutic safety, the incremental process of “letting in” therapeutic caring and positive regard (and, thereby, positive attachment experiences) may require considerable time in treatment.
In some cases, activation of early thoughts and feelings may cause the client to “regress” to a more basic level of relational functioning with the therapist. However, it is important that the therapist understand this as attachment-level reliving, in the same way as a flashback to an assault is reliving. As described earlier, the goal is to work within the therapeutic window – providing sufficient relational contact, support, and positive regard that the client has the opportunity to reexperience implicit childhood memories in the context of a distress-diminishing state. At the same time, however, the clinician must not provide so much quasi-parental support that early trauma-related distress is too strongly activated, or the youth’s dependency needs are reinforced in a way that is detrimental to growth. The latter is probably best prevented by the therapist’s continuous examination of his or her own needs to protect and/or rescue the client. In addition, obviously, the possible emergence of attachment-level feelings in the therapist requires special vigilance to the possibility of inappropriately sexualizing or romanticizing the client, or exploiting the client to meet the therapist’s unmet attachment (including parenting) needs. Any such “countertransference” (referred to as counteractivation in the Self-Trauma model; Briere, 2002), if acted upon, both destroys disparity (i.e., eliminates safety) and reinforces trauma-related emotions and cognitions.
- Desensitization : the adolescent survivor’s repeated exposure to relational trauma memories, triggered by his or her connection with the therapist, in combination with the reliable non-reinforcement and counter-conditioning of his or her negative expectation and feelings by the therapeutic relationship, leads to a disruption of the learned connection between relatedness and danger.
As described in Chapter 10, the process of relational exposure, activation, disparity, and counterconditioning, when repeated sufficiently in the context of the therapeutic window, often leads to the desensitization of trauma memories. This probably involves a series of processes, including (a) extinction of non-reinforced emotional responses, via disparity, (b) counter-conditioning effects, involving some form of “overwriting” the association between memory and emotional pain with new connections between memory and more positive feelings, and (c) an alteration in the capacity of relational stimuli to trigger trauma memories (i.e., insight or new information that changes the client’s interpretation of interpersonal events). Regarding the last point, positive therapeutic experiences may change the ability of relationships or interpersonal intimacy to automatically trigger early abuse memories, since relationships, per se, are no longer perceived as necessarily dangerous and are therefore, less reminiscent of childhood abuse or neglect.
However this occurs, the overall effect of the progressive activation and processing of implicit relational memories and their cognitive and emotional associations during ITCT-A is to change the youth’s reaction to his or her interpersonal world. Successful therapy, in this regard, means that the client is more able to enter into and sustain positive interpersonal relationships, because connection with others no longer triggers the same levels of fear, anger, distrust, and negative or avoidant behaviors. As a result, the client’s interpersonal life can become more fulfilling and less chaotic – a source of support rather than of continuing stress or pain.