As noted earlier, a positive therapeutic relationship is of great importance in the treatment of multiply abused or traumatized individuals, including adolescents.
Because of its crucial nature, the relationship between client and therapist should be directly addressed in the same way as are other clinical phenomena. It may not be sufficient merely to wait for a positive relationship to build on its own accord. Traumatized youth may experience significant ambivalence – if not outright distrust – regarding any sort of enduring attachment to an older, more powerful figure. Others appear to attach very quickly, but their connection may remain insecure, based primarily on relational hunger or neediness associated with early attachment deprivation rather than a true belief in safety. In either instance, therapy may be slowed or compromised by insufficient trust and, as a result, reduced openness to the healing aspects of therapy. This chapter outlines ways in which the clinician can encourage, if not accelerate, a positive therapeutic relationship.
Because danger is such a part of many trauma survivors’ lives, the therapist’s ability to communicate and demonstrate safety is a central component to relationship building. The adolescent is more likely to “let down his/her guard” and open himself or herself to a relationship if, repeatedly over time, there is little evidence of danger in the therapy process. Conversely, if the client perceives or believes that some form of danger (whether it be physical, sexual, or associated with criticism or judgment) is potentially present, this experience may become a trigger for memories of prior instances of victimization, betrayal, exploitation, or abandonment, that – when reexperienced in the session – may reinforce the client’s mistrust and hypervigilance.
Therapist behaviors and responses that increase the client’s sense of safety are likely to include:
- Nonintrusiveness. The clinician is careful to time or avoid questions or behaviors that otherwise might push the client beyond where he or she is willing to go, activate feelings of shame, or violate the client’s personal/cultural boundaries.
- Visible positive regard. The therapist is able to access and communicate positive feelings about the client, and to respond to the client in ways that reinforce the client’s entitlements and intrinsic value.
- Reliability and stability. The clinician behaves in such a manner that he or she is perceived as someone the adolescent can count on – to be on time for sessions, to keep therapy safe, to be available at times of need, and to be an “anchor” in terms of consistent emotional caring.
- Psychological security. The clinician cultivates a “safe space” within the therapy sessions by remaining closely attuned to the sometimes quick and subtly changing needs of the adolescent, and by communicating psychological presence/attunement, empathic compassion, and acceptance. The therapist who practices this level of “mindful” awareness (see Chapter 8) may strengthen the client’s ability to tolerate intense trauma processing simply by bolstering his or her own ability to remain present and open to the adolescent’s experiences.
- Transparency. The therapist is as honest and open as possible, and does not appear to have a hidden agendas – including covert alliance with parents or social institutions over the youth’s own needs. Obviously, in some cases, the clinician must be responsive to systems beyond the adolescent, but when this must occur, the therapist discloses this to the client so that he or she does not appear to be operating from duplicity.
- Demarking the limits of confidentiality. In some ways similar to transparency, confidentiality issues are highly relevant to the client’s overall perception of the therapist as predictable and straightforward. This means that the clinician should always be clear with the adolescent regarding his or her responsibility to report child abuse, client danger to self or others, or otherwise to intervene without the client’s permission when certain events occur or seem likely to occur. Although such initial discussions are sometimes difficult, and the client may view them as evidence of clinician authoritarianism or dominance, in reality, the message is the reverse – that the client can count on the therapist to try to keep him or her safe, and to clearly demarcate the rules and boundaries of therapeutic interaction so that there are few surprises.
Visible Willingness to Understand and Accept
A major effect of traumatization is often the sense that one is alone, isolated from others, and, in some sense, unknowable. Having the opportunity to interact regularly with someone who listens, and who seems to understand, can be a powerfully positive experience – one that tends to strengthen the bond between client and therapist. Therapist behaviors that may increase this dynamic include:
- Attunement. The clinician is demonstrably aware of the client’s moment-to-moment emotional state during treatment, such that the adolescent feels that he or she is attended to and (by implication) worthy of such attention. In this way, the client feels “heard” by someone he or she views as important: a phenomenon that may be rare in the adolescent’s life.
- Empathy. The therapist feels for the client, in the sense that he or she has compassion for the client’s predicament or circumstance, without judging him or her. This is to be discriminated from pity, which implies client weakness or incapacity, and therapist superiority. It should be noted that even true therapist empathy can be problematic if it is expressed too intrusively or couched in a manner that appears artificial or as merely what would be expected of a therapist.
- Acceptance. The clinician is nonjudgmental of the client and accepts the client as he or she is. This does not always mean that the therapist supports the adolescent’s behavior, for example, when he or she is involved in self-destructive or hurtful behavior. Instead, the acceptance is of the client, him or herself – of his/her internal experience, inherent validity, and rights to happiness. When the client feels accepted, he or she has the opportunity to experience relational input that directly contradicts the rejection, criticism, and invalidation he or she may have experienced from harsh family members, peers, or society. This balance between acceptance of the client and, yet, nonsupport of his or her injurious behaviors is sometimes hard to accomplish – especially with acting-out adolescents. Examples would include:
- How do I accept and support a traumatized, hurt, and angry adolescent without endorsing or reinforcing his aggression towards others? and
- How do I support a multiply abused and exploited young woman without also supporting her negative views of herself or her suicidal behavior?
- Understanding. The therapist, partially because of his or her attunement and empathy toward the client, communicates that he or she “gets” the client – that the young person’s internal experience and behavior makes sense. Feeling understood by one’s therapist generally fosters a sense of shared experience and intensifies the importance and positive nature of the therapeutic relationship.
- Curiosity about the client’s perspective and internal experience ; The therapist communicates an active interest in the client (as opposed to solely support and caring), with respect to his or her perspective on life, the details of his or her interactions with the world, and, most importantly, the specifics of his or her thoughts, feelings, and other internal experiences. This curiosity should not be intrusive, nor should it reflect clinician voyeurism, but rather should communicate the notion that the client’s process and experience is interesting, worthy of attention, and reflective of his or her inherent worth and specialness.
Active Relatedness and Emotional Connection
ITCT-A encourages the therapist to be an active (as opposed to a passive or neutral) agent in therapy. The therapist makes direct statements about the wrongness of the adolescent’s victimization, and shows his or her emotional responses to the extent that they are helpful, i.e., neither extreme nor therapist-focused. The clinician does not give extensive unsolicited advice, but he or she actively assists the client in problem identification and problem-solving, supports and encourages him or her, emphasizes his or her strengths, and generally is psychologically available to the youth. This approach to therapy encourages connection, because the clinician emerges as an active, caring, and involved participant in the client-therapist relationship.
Psychotherapy for complex trauma effects rarely proceeds rapidly. Yet, the adolescent (and sometimes the therapist) understandably wants rapid improvement. The client may become frustrated that, for example, cognitive insights do not always result in immediate behavior change, or that an instance of talking about a trauma does not immediately desensitize emotional distress to it. Such experiences may lead to helpless and self-criticism, as the youth interprets a lack of relatively immediate distress reduction, or continued involvement in unhelpful behaviors, as evidence of personal failings. He or she may also feel that he or she is letting the therapist down, or in some way being a “bad” or unintelligent client. As the therapist counsels patience and a longer-term perspective, and remains constant and invested in the therapeutic process, he or she communicates acceptance of the client and trust in the value of the therapeutic relationship.
This process requires, of course, therapist patience as well. Despite the prevalence of short-term interventions for traumatized youth in the treatment literature, effective interventions with multiply and chronically traumatized adolescents often takes time (e.g., Lanktree & Briere, 1995). The development of a trusting relationship with a repeatedly sexually and physically abused 14 year old, for example, may require a relatively long therapeutic “track record” of safety and support, especially if he or she is also dealing with ongoing community violence, poverty, and social marginalization. There may be distrust of the therapist based on the latter’s race, ethnicity, or social status. The client’s attention to the therapeutic process may be adversely affected by hunger, lack of sleep (a common issue for youth raised in the context of repeated drive-by shootings, chronic maltreatment by caretakers, or the need to work long hours to support the family) or worry about other compelling, real-life issues, such as impending homelessness or the traumatic loss of a friend or family member. In addition, multiply traumatized adolescents, as noted earlier, frequently suffer from a range of different psychological symptoms or disorders, and may be involved in maladaptive substance use – a significant impediment to psychological processing of traumatic stress. As a result, the clinician must be patient in the face of what may appear to be minimal clinical progress within the first months of treatment, and should be careful to note and comment upon any signs of progress or emerging psychological strengths. Although the client’s problems may be chronic and complex, and his or her current circumstances less than optimal, in many cases socially marginalized and traumatized youth can show real improvement and significant symptom remission in the context of therapies such as ITCT (Lanktree, 2008).