social innovations

Treating Adult Survivors of Childhood Emotional Abuse and : A New Framework

Frances K. Grossman Joseph Spinazzola and Marla Zucker The Trauma Center at Justice Resource Institute, The Trauma Center at Justice Resource Institute, Brookline, Massachusetts Brookline, Massachusetts, and Suffolk University

Elizabeth Hopper The Trauma Center at Justice Resource Institute, Brookline, Massachusetts

ver the past four decades, we of study participants with less complicated American Academy of Pediatrics produced have seen major advances in co-occurring clinical disorders, behavioral a policy report naming psychological mal- O mental health intervention for issues, and functional impairments than treatment as “the most challenging and prev- adults and more recently children affected those typically encountered in real-life clin- alent form of and neglect.” by exposure to traumatic events and experi- ical community practice settings. At our outpatient trauma-specialty clinic in ences. An impressive body of clinical re- This historic partial reliance upon un- Brookline, MA, we have grappled for decades search now supports the empirical evidence representative samples to validate tradi- with how to best serve adult (and child) sur- base for a number of psychotherapeutic tional treatment models raises important vivors of complex trauma, namely, prolonged treatment models for use with victims of questions about the generalizability of and recurrent exposure to maltreatment, ne- traumatic stress. However, despite the great these findings toward meeting the needs of glect, violence, and exploitation and the ensu- proliferation of approaches to the treatment adult trauma survivors from ing complex effects these experiences have on of , the majority of more complex adaptation to trauma. This mental health and physical wellbeing, mal- these models and the research that supports concern has led prominent scholars and adaptive coping, engagement in risk behav- their effectiveness have been principally de- clinical researchers such as Marylene iors, and the derailment of normative life tra- signed to address symptoms of one specific Cloitre to challenge the adequacy of one- jectories leading to long-term health and psychiatric diagnosis, posttraumatic stress size-fits-all approaches to trauma treat- educational, relational, and occupational suc- disorder (PTSD). Although undoubtedly a ment, particularly when attempting to aid cess. At the forefront of this struggle has been pernicious and pervasive condition, epide- the recovery of adult clients with chronic, the challenge of adequately treating the clients miological research in adult and child pop- multilayered, and treatment-resistant psy- most often “in the shadows:” adult survivors ulations has clearly established that PTSD is chological and psychiatric conditions. of severe childhood emotional abuse and ne- neither the sole nor even most common con- Perhaps least represented in existing treat- glect. Despite nearly a half-century of atten- dition experienced by survivors in the after- ment outcome research are the needs of tion directed in psychiatry, psychology, social math of trauma. In fact, our own research adult survivors of childhood maltreatment work, and allied professions to the develop- has demonstrated that much of the extant experienced primarily in the form of severe ment of treatment models for victims of psy- clinical research supporting the evidence emotional abuse and neglect during child- chological trauma, resulting in the establish- base of traditional models for hood. Frequently overlooked, minimized, or ment of nearly 100 distinct evidence-based or promising practices, to date not a single one of treatment of PTSD and related disorders in misunderstood is psychological maltreat-

This document is copyrighted by the American Psychological Association or one of its allied publishers. these models has been specifically designed to adults has been predicated upon recruitment ment, defined as children’s exposure to re- This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. current and severe forms of emotional abuse target the effects of childhood emotional abuse and emotional neglect including , and neglect in adult or (for that matter) child shaming, degradation, threats, shunning of survivors. Moreover, the vast majority of these Frances K. Grossman, The Trauma Center at , forced , exploitation and models neglect to include even a single page Justice Resource Institute, Brookline, Massachu- imposition of excessive and unrealistic de- of specific guidelines or considerations for setts; Joseph Spinazzola and Marla Zucker, The mands. Psychological maltreatment has long working with this population. Trauma Center at Justice Resource Institute and been identified in large-scale research—in- In our research and that of our colleagues, Department of Psychology, Suffolk University; cluding the Centers for Disease Control’s we have amassed considerable evidence ver- Elizabeth Hopper, The Trauma Center at Justice ifying that victims of childhood emotional Resource Institute. seminal Adverse Childhood Experiences Correspondence concerning this article should be studies—as a major public health problem. abuse and neglect exhibit equal or worse addressed to Frances K. Grossman, Trauma Center Only recently, however, has it been recog- immediate and long-term effects than survi- at Justice Resource Institute, 1269 Beacon Street, nized as a major target of health disparities vors of other forms of maltreatment and Brookline, MA, 02446. E-mail: [email protected] research and policy. In fact, in 2012 the violence that have been much more the fo-

American Journal of Orthopsychiatry © 2017 American Orthopsychiatric Association 2017, Vol. 87, No. 1, 86–93 http://dx.doi.org/10.1037/ort0000225 social innovations

cus of clinical and research attention over central mission. In this spirit, we endeavored of multidisciplinary psychotherapists and al- the past four decades (e.g., physical abuse, to articulate a clinical framework for complex lied professionals locally and nationally. sexual abuse, community and domestic vio- trauma treatment intentionally designed to ad- CBP is an evidence-informed model that lence). Moreover, through this research we dress longstanding disparities in the mental bridges, synthesizes, and expands upon sev- have been able to demonstrate empirically health field by emphasizing the needs of this eral existing schools, or theories, of treat- ment for adult survivors of traumatic stress. These include approaches to therapy that stem from more classic traditions in psy- To date, no treatment model has been specifically chology, such as psychoanalysis, to more designed to target the effects of childhood emotional modern approaches including those in- formed by feminist thought. Moreover, CBP abuse and neglect places particular emphasis on integration of key concepts from evidence-based treatment models developed in the past few decades what we had long observed anecdotally in our chronically marginalized and misunderstood predicated upon thinking and research on clinic work, namely that these survivors ex- subpopulation of trauma survivors. the effects of traumatic stress and processes hibit overlapping but distinct outcomes, or We regard this emphasis upon social jus- of recovery for survivors. clinical profiles, compared with other survi- tice to be of particular importance for two vors of childhood trauma. For example, we reasons. First, we have come to view the found that victims of emotional abuse and heretofore often overlooked or minimized The Empirical Base for CBP neglect tend to have more widespread or backdrop of pronounced childhood emo- The overall structure and four compo- global effects across domains of self and iden- tional abuse and emotional neglect as an nents of CBP intentionally build directly tity, behavior and functioning, and clinical invisible web that binds and drives many of upon four empirical bases of evidence: (a) psychopathology. Specifically, these trauma our clients toward lifelong trajectories of the extensive clinical and research evidence survivors tend to show greater impairment in failure, revictimization, and self-loathing. base on the importance of processing trau- Second, we believe that authentic engage- the capacity to establish and maintain safe, matic memories and constructing a trauma ment in trauma-informed services necessi- healthy, and loving relationships; to possess narrative as an essential component of treat- tates that therapists educate and collaborate more negative self-image, worth, or esteem; to ment of traumatic stress; (b) the evolving with multidisciplinary professionals not be more likely to internalize their distress, awareness across disciplines of psychology only to recognize and appreciate the perva- leading to more frequent difficulties with de- and psychiatry that the quality of engage- sive reality and deleterious effects of child- pression, , social withdrawal, and iso- ment, empathic rapport, and authenticity in hood emotional abuse and neglect, but also lation; and to engage in more maladaptive the client–therapeutic relationship is integral to identify and challenge mental health prac- forms of coping, including greater prevalence to the treatment process; (c) the expert tices and societal structures that obfuscate or of self-injury, alcohol and substance abuse, guidelines of the International Society of impede recognition of and adequate re- and other risk-taking behaviors including sex- Traumatic Stress Studies highlighting the sponse to these issues. Such intersectionality ual acting out. importance of phase-based approaches to is essential to challenge and overcome Accordingly, whereas the new framework trauma treatment that foster regula- chronic stigma and injustice surrounding for adult psychotherapy we describe in this tion prior to traumatic memory processing these survivors. Specifically, in the absence article has been designed for use with all through specific efforts to increase the cli- of more overt or “tangible” traumatic events adult survivors of complex childhood inter- ent’s capacity to identify, tolerate, safely or adverse experiences, their difficulties personal trauma, we pay particular attention manage or “modulate,” and appropriately have historically often been objectified, dis- to adults with histories that include pro- express as an essential component missed, or responded to with aversion by nounced childhood emotional abuse and ne- of complex trauma intervention; and (d) the coworkers, family members, significant oth- glect. Much of the therapy with such clients forthcoming expert consensus guidelines ers, and providers alike as indications of This document is copyrighted by the American Psychological Association or one of itsat allied publishers. our trauma center revolves around build- from the International Society for the Study innate defects in personality or character, This article is intended solely for the personal useing of the individual user and their is not to be disseminated broadly. capacities for , attachment and of Trauma and Dissociation that maintain and not as the inevitable consequences of (at relationships, sense of self, and tolerance of that the treatment of clinical dissociation is a worse) malicious wrongdoing or (at best) intense emotions. These capacities were ei- core element of intervention with virtually chronically impaired caregiving. ther not acquired in early childhood or were all adult survivors of childhood complex built in distorted ways because of the lack of trauma. adequately responsive and consistent emo- CBP intentionally attends to and builds tional support in childhood. This attention to Component-Based upon these four paradigms in the traumatic the kinds of traumatic wounds that often Psychotherapy (CBP) stress field. It represents an evolution of remain unseen is directly informed not only CBP is an outgrowth of several decades earlier paradigms of phase-oriented, com- by our clinical experience, but also by the of work as clinicians and supervisors at The plex trauma intervention through reliance guiding tenets of our nonprofit organization, Trauma Center at Justice Resource Institute upon a more comprehensive, intensively re- which upholds the promotion of social jus- in Brookline and our clinical practices and lational, and concurrent component-based tice in mental health service delivery as its extensive consultation supporting the work approach. In our articulation of the CBP

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framework, we have sought to distill and niques for ongoing self-examination, self- sion, sexual urges, childlike yearnings to be disseminate our center’s innovation in the management, and self-care of the therapist loved and protected) associated with mem- arena of complex trauma treatment through have been incorporated into the CBP model. ories of enduring or escaping overwhelming our careful integration and advancement of Third, in CBP we realize that in real-life traumatic experiences to parts of self. These each of these four prevailing and emerging clinical practice, gains around emotion reg- strong emotional states are often tied to spe- cific visual, olfactory, auditory, or somatic fragments of traumatic memory. Although typically suppressed or existing partially or We are ultimately more interested in enhancing the fully outside of conscious awareness, these personhood of the trauma survivor than merely components of self have the propensity to emerge suddenly in the form of high-risk reducing their psychopathology and acting-out behaviors, particularly when the adult complex trauma survivor becomes triggered by reminders of their past, feels paradigms. ulation are best achieved via more compre- threatened by present circumstances, or be- First, in CBP we recognize that particu- hensive attention to and focus on all the comes overwhelmed by the activation of larly for adult complex trauma survivors intertwined systems of self-regulation (be- intense emotional states including empti- whose childhood was characterized by havioral, physiological, cognitive) that fuel, ness, , hopelessness, and . identity-defining emotional deprivation, de- drive, suppress, and mediate processes of CBP is the first treatment model to attempt basement, and neglect, the entire story of emotion regulation. Moreover, CBP empha- to integrate highly specialized approaches to their lives has been impacted. Therefore, sizes the heightened challenge in working the treatment of clinical dissociation into a the trauma treatment component tradition- with adult complex trauma survivors in gen- general model of trauma-focused therapy in- ally focused upon construction of a life eral, and those with histories of profound tended to be widely disseminated and effec- narrative must be expanded to address the rejection, shaming, and by tively and safely delivered by new, in-training, effects of trauma on our clients’ entire life formative attachment figures in particular, and experienced general psychotherapists narratives, including their development of around the delivery of emotion regulation alike and not just psychoanalysts or highly a sense of self and social identity. This skills and techniques in the context of the specialized experts in the small subfield of stance is inherently and explicitly therapeutic relationship. Namely, for many clinical dissociation. strength-based, with irrefutable social jus- of our clients, the therapeutic relationship, In sum, CBP integrates several prevail- tice implications. Namely, we are ulti- or the personhood of the therapist, often ing theories and models of trauma treat- mately more interested in enhancing the precisely because of their efforts to exude ment into a comprehensive, relational, personhood of the trauma survivor than warmth and , is frequently expe- strength-based, and social justice- informed approach to working with adult merely reducing their psychopathology rienced as a primary source of emotional survivors of complex trauma, with partic- and symptoms of posttraumatic stress. It is dysregulation that undermines the effective- ular emphasis on the legacy of chronic not just about helping our clients to stop ness of whatever specific coping technique childhood emotional abuse and neglect. In “living in the past,” “haunted by their the therapist may be attempting to deliver. a full description of this model, described trauma” but to cultivate and embrace a Accordingly, in contrast with most other in the forthcoming book Treating Adult past, present, and future narrative of self trauma treatment models that focus on the Survivors of Childhood Emotional Abuse that is greater than the sum of their trau- content of the many emotion regulation and and Neglect: Reaching Across the Abyss, matic experiences. coping skills being taught to clients, the we present ways to conceptualize and Second, in CBP we acknowledge that the CBP model places just as much emphasis on carry out this work in its real-life messi- personhood of the therapist, or their profes- the relational context and process of skills ness and complexity. In this article, we sional and personal identity, inevitably has a administration. briefly describe the four components of profound influence (for better or worse) Fourth and finally, CBP devotes particu- the CBP model and highlight some key

This document is copyrighted by the American Psychological Association or one of itsupon allied publishers. the treatment process. Therefore, we lar attention to integration of treatment strat- elements of this approach.

This article is intended solely for the personal usebelieve of the individual user and is not to be disseminated broadly. that incorporation of a more rela- egies that address the pervasive presence of tional approach to treatment, such as has clinical dissociation in adult survivors of been increasingly recommended for psycho- complex trauma. These include manifold The Four Components of CBP therapy in general and complex trauma in- expressions of dissociative coping, includ- tervention in particular, will likely be best ing spacing out, mentally shutting down, CBP integrates four components: rela- served by taking this a step further. We and retreating to internal fantasy worlds to tionship, regulation, working with dissoci- recommend adoption of a social justice- escape emotional , relational conflict, or ated aspects of the self, and narrative. In this informed focus (primarily achieved through perceived threat. Far more complex is the approach, we pay particular attention to the intensive ongoing supervision) on the per- not infrequent dissociative fragmentation of internal experience of the therapist and that sonhood of the therapist and its influence identity or consciousness encountered in of the client and view the therapeutic rela- upon, responsibility to, and vulnerability/ working with these clients. These involve tionship as a primary medium for healing. In fallibility in the treatment process. Accord- the off of strong emotions or per- our descriptions, we try to illustrate the real- ingly, numerous specific strategies and tech- sonality attributes (e.g., intense , aggres- life complexity of the sequencing and lay-

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ering of intervention components. This when their attachment styles or other issues and nurturing to them and activities and model also focuses on addressing dissocia- interfere with the therapies they do, and all interests that are energy-giving. tive processes and integrating approaches to of us continue to need trauma-informed the treatment of dissociation. supervision. Regulation component. Many cli- ents with histories of childhood emotional ne- glect and abuse come to therapy deeply dys- The relationships we work to build with clients need regulated, in part as a result of dissociation. They can be volatile and reactive and can to be much more responsive to contextual factors manifest an extreme range and intensity of emotions in their lives and in their therapies. than therapists are usually trained to be or do It is often the intensity of their reactions that frightens nontrauma-trained therapists. As Judith Herman described in her ground- Relationship component. We, as The relationships we work to build with breaking book, Trauma and Recovery, help- others, have learned much from several pi- clients need to be much more responsive to ing clients regulate their emotional states is oneers in the field of trauma therapy, includ- contextual factors than therapists are usually a key aspect of therapy for clients with his- ing Psychological Trauma and the Adult trained to be or do. These include all the tories of sexual abuse (whom we now know Survivor by Lisa McCann and Laurie Anne subtle nuances of therapists’ and clients’ mostly also have histories of emotional Pearlman, Trauma and the Therapist by upbringings and locations in the social abuse and neglect). Inadequate brain devel- psychologists Laurie Anne Pearlman and world, including but not limited to social opment from faulty attachment relation- Karen Saakvitne, and psychiatrist Philip class, sexual orientation, ethnicity, and reli- ships—and insufficient early support for and Bromberg’s book, Standing in the Spaces: gion, some of which may be similar and modeling of regulation—can lead these Essays on Clinical Process, Trauma, and many of which are often different. In her adult clients to come into therapy with lim- Dissociation. Beyond that, research on psy- 2012 article in the National Register of ited capacities to identify, accept, modulate, chotherapy has shown repeatedly that it is Health Psychologists, psychologist Dorothy and appropriately regulate their emotions, the client’s about the quality of their E. Holmes articulated that in order to deal physiological states, behavior, thoughts, and relationship with their therapist that deter- meaningfully with differences between attention. In CBP, eating disorders, addic- mines how much they benefit from the themselves and their clients, therapists need tions, problems with sexuality, self-harming therapy. to learn not the details about the particular behaviors, avoiding closeness, , and In CBP, as in some other approaches, the cultures of the clients, but rather how to find anxiety are all seen as ways of attempting to most important early tasks in therapy are and explore in themselves all of the biases manage dysregulation. seen as building a relationship and establish- about others that they learned growing up, Furthermore, in our attempts to help our ing safety. Here is a brief sampling of what including such difficult issues as racism, clients regulate, therapists at The Trauma we have learned about building and main- sexism, homophobia, and class biases. Center at Justice Resource Institute often taining good relationships with these clients. CBP also supports therapists being as experience the profound sense of emptiness Clients who have experienced complex fully as possible in the present moment and that preoccupies many of these clients, trauma often develop problematic attach- noticing the relational ebbs and flows re- along with their deep yearnings, extreme ment models because of their early histories flected in clients’ body language, tone, eye sensitivity, and difficulties allowing connec- tion and nurturance. These clients often of emotional neglect and abuse. Thus, they contact, and so forth, while also being aware come to us not knowing who they are, what may come to therapy mistrustful or overly of the often subtle shifts in themselves. Our they need, or what they feel. How therapists trustful, often angry and frightened or des- model encourages therapists to maintain this make use of themselves in the midst of their perately needy, and lacking the skills to en- present-moment awareness while also bear- clients’ intense affective and physiological gage comfortably with a therapist or anyone ing in mind the broader framework of the states is at the core of CBP. else. Some are clingy, some avoidant, and therapy and the treatment. Although no ther- This document is copyrighted by the American Psychological Association or one of its allied publishers. In CBP the relationship is seen as a way some both. Some present with a disorga- apists can be totally mindful of all of these This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. of holding, or containing, these clients’ ex- nized attachment style and are very unpre- aspects of the encounter all of the time, the periences so that they can begin to develop dictable or variable in their approaches to more we can do it, the more able we are to the capacity for self-regulation. Because of their therapists. These often problematic hold the client, the relationship, and the ther- the extreme sensitivities and vulnerabilities styles then interact with the therapist’s at- apeutic frame. clients may bring to therapy, nuanced as- tachment style, making it harder for the ther- In CBP, we encourage therapists to work pects of the therapeutic relationship are re- apist to maintain a steady, empathic, accept- together with clients to figure out what they quired, such as the development of gently ing, warm, appropriately boundaried, and want and/or need from us, and our capacities and empathically humorous rituals, careful authentic approach. In our view, therapists to meet their needs. We often help them find use of confrontation, response to shifts in of these clients need to be open to intimacy additional supports (e.g., a trauma therapy state, and thoughtful use of self-disclosure. but not needy of closeness with their clients. group, class) and work with them from How therapists are in the room is more Almost all therapists have to do their own the beginning to develop relationships out- important than what regulation techniques therapeutic work, particularly but not only side of the therapy that can be supportive they use. These clients need their therapists’

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patient, even presence over long periods of sodically present in treatment at much ing totally dissociated from other compo- time to begin to feel safe, and ultimately, to younger levels of development and func- nents of the psychological system. In our heal. Therapists need to be able to under- tioning. In these instances we often find that view, the key element in creating extreme stand themselves well, to know how their clients experience our use of regulation tools dissociation is inadequate bonding, particu- vulnerabilities and strengths are engaged in and techniques initially developed for chil- larly in early infancy and the ensuing first 3 years of life, leaving the infant and young child at the mercy of intense and intolerable physiologi- cal and . (Cults who How therapists make use of themselves in the midst practice mind control have found deliberate of their clients’ intense affective and physiological ways to fracture infants’ systems.) In CBP, dissociated parts or states are states is at the core of CBP often built on aspects of early attachments, and sometimes on specific aspects of abuse, terror, and neglect. We, like Richard Chefetz any given therapy, and to believe in the dren or adolescents as more safe, resonant, and Phillip Bromberg and others, emphasize power of sitting together mindfully for cli- or effective than those designed for adults. the interpersonal aspect of dissociation. That ents to heal. Moreover, many of our clients encounter is, when a dissociative part of a client reacts Window of engagement is a new clinical profound challenges in their efforts to at- to something that part sees in the therapist, construct we introduce in CBP to character- tain, tolerate, and sustain meaningful at- often, if not usually, that part is seeing ize and guide the complex trauma therapists’ tachments and intimate connections given something real—and dissociated—in the role as a coregulator for adult complex their often treacherous early histories of therapist. For example, a client became en- trauma survivors contending with over- relational betrayal, victimization, belittle- raged because she thought her therapist was whelming and often oscillating states of ex- ment, or abandonment. Consequently, we putting her down for a comment she made, treme dysregulation. Here we challenge recognize in CBP that the empathic pres- and only after the session was the therapist therapists not only to increase their aware- ence of the therapist itself often inadver- able to see that in fact some part of her did ness or attunement to their clients’ momen- tently functions as a primary and direct indeed feel critical of the client for a com- tary level of hypo- or hyperarousal, but also (i.e., nontransferential) source of dysregu- ment that seemed hurtful to a part of the to endeavor to stretch the limits of their own lation to these clients that can undermine therapist. comfort to inhabit extremes of dysregulation or derail the effectiveness of whatever Further, we, like others in the field, see a in order to meet their clients where the work specific regulation technique or tool the similar organization of parts in all dissocia- needs to be engaged. clinician is endeavoring to deliver. For tive clients, with most having very young A number of regulation techniques have some such clients, the internalized pres- parts that carry intense unmet needs (e.g., been developed, including grounding tech- sure to please or comply with their well- for nurturance), that were unaccept- niques and relaxation and breath control. intentioned therapist conflicts with their able to the family (e.g., rage), or memories CBP emphasizes skill-building in many ar- hyperattuned detection of even subtle non- of traumatic experiences (e.g., being re- eas, including developing an increased tol- verbal expressions of uncertainty or frus- jected by Mom when she was in an alcoholic erance for and a growing ability to identify tration by the clinician. It collides against stupor). When therapists engage with them, emotional states, learning to communicate their own recurrent feelings of hopelessness these parts seem to be developmentally the to safe others about these internal states, and or nagging about the futility of any age they were when they first came into making links between aspects of internal coping skill to ever be sufficient to fill the being, with the cognitive, language, and states and past and present experiences. seemingly immense emotional void in their emotional abilities they likely had then. CBP uses imagery, sensory and emotion- lives. Accordingly, a critical aspect of our Many parts pretend to be older, as they also focused techniques, movement, various approach to regulation in CBP is our embed- had to pretend in the original circumstance breathing techniques, biofeedback, progres- ding of this work within the relational con- in an effort to survive overwhelming expe-

This document is copyrighted by the American Psychological Association or one of itssive allied publishers. muscle relaxation, and other body- text and tailoring strategies to address frag- riences and navigate treacherous relation-

This article is intended solely for the personal usefocused of the individual user and is not to be disseminated broadly. techniques. Learning these skills mented, dissociative, and developmental ships with dangerous and unpredictable can ultimately transform these internal states younger aspects of self. adult caregivers, authority figures, older sib- and our clients’ capacities to live their lives lings, and other youth. fully and richly. Dissociative parts component. Built upon this young layer of parts, re- Finally, CBP emphasizes that in treatment We view working with dissociative parts as ferred to in CBP as child parts, another layer with adult survivors of complex trauma and central to treatment of survivors of emo- develops to silence, destroy, or otherwise especially chronic childhood emotional tional abuse and neglect. In CBP, we under- manage the young parts who carry the abuse and neglect, the processes of engaging stand dissociation as a process that keeps trauma. A troubled mom gets enraged by her and cultivating a client’s regulatory capacity different mental states and body experiences toddler leaving a mess, so when that child is are often of equal or greater importance to disconnected from one another. Parts are a little older, he in turn may develop a part successful skill acquisition than the particu- viewed as an aspect of normal development, who makes very sure he never leaves a mess lar regulation techniques utilized. For exam- existing on a continuum from normal to and who becomes angry, either at himself ple, many of these clients routinely or epi- pathological, with the most problematic be- when he makes a mess accidentally or at

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others who make a mess. Many of these with some level of problematic dissociation, her up to be so triggered by her daughter’s parts develop in adolescence and present in is to describe and illustrate our model of behavior. It is important to note that this is therapy as adolescents. Over time, these pro- dissociative parts. We often begin this all cognitive; at this point we are not explor- tector or defensive parts become part of the psycho-educational approach in the first ses- ing feelings, although we are talking about a personality, and that individual may become sion. A few clients initially do not accept it feeling of . The final step, which allows CBP to go deeper into the work with dissociative parts than many models do, is to invite the client In CBP, we view many individuals as having an to bring herself and sometimes her concep- adult self which may or may not have developed tion of the therapist into imagery of the part and begin to reeducate and heal that part. outside of trauma This method, described in detail in our book, very much involves feelings and can only be done with clients who have sufficient re- activated or dysregulated when his spouse or because it makes them feel they are very sources and therapists who have the super- child leaves a mess. There can be many disturbed, like having or dis- visory resources and foundational knowl- protectors or few, depending on how many sociative identity disorder. Normalizing the edge to ensure that this advanced feature of child parts there are and how fragmented the idea of parts as something inherent in every- the model is implemented cautiously and individual has had to become. one, to greater or lesser degrees of dissoci- judiciously. It is a technique that is meant to Finally in CBP, we view many individu- ation, often helps. In fact, most clients are connect the affective, cognitive, physiolog- als as having an adult self—or at least an receptive to it and may be greatly relieved ical, sensory, and behavioral aspects of the underdeveloped or fragmented adult compo- that they are not “crazy” or schizophrenic client’s fragmented experience, and thus can nent of self—which may or may not have because they have parts. It is important to generate a strong emotional response. developed outside of trauma. The particular note that the existence of dissociated parts Even with the most centered, relational, capabilities of this adult self that are critical does not imply a psychiatric diagnosis of and skilled therapists, interpersonal difficul- to healing are the capacity to learn compas- dissociative identity disorder; it can also in- ties occur with regularity in this work. What sion for the whole self, including young clude complex or classic PTSD. Often the used to be called transference and counter- parts, to be curious, and to have a bigger language matters to clients: parts may reso- transference we have come to think of as picture of the world. One easy test of nate with some, but others prefer the thera- enactments. Enactments occur when some- whether a client has some adult self func- pist to use feeling language or some other thing in some part of either the client or the tions is, when they are struggling with a unique way of describing the idea of parts. therapist gets activated, or triggered, by question like “What should I do about my For example, one client referred to her var- something in the relational environment. neglectful and sometimes abusive boy- ious “planets” and another to his “brothers.” This process often occurs outside of either friend,” to ask them how they would advise It is never useful to force a perspective on participant’s conscious awareness. The indi- a friend who came to them with that same clients if it does not resonate, but therapists vidual having the reaction in some way signals question about herself. The clients who can often reraise the idea of parts as the therapy the other, often nonverbally but sometimes by say “I would tell her she should think about continues. tone or language, and a usually nonconscious whether this relationship makes sense for The second level of parts work involves part of the other reacts. These predictable dis- her and consider breaking up with him,” are focusing on parts cognitively but not affec- turbances between therapist and client are de- speaking from a coherent adult self. For tively. When a client comes in ashamed and scribed in a 2001 article by psychiatrists Rich- clients who do not appear to have a func- regretful because she yelled at her adoles- ard Chefetz and Phillip Bromberg in Trauma, tioning adult self but may have some frag- cent daughter, the therapist might say some- Dissociation and Multiplicity: Working on mented capacities of this self, they might be thing like, “Some part of you gets triggered Identify and Selves. Enactments exist between able occasionally to take a larger perspective by your daughter.” This kind of comment the therapist and client rather than residing

This document is copyrighted by the American Psychological Association or one of itson allied publishers. their children’s difficulties or why they helps the client develop a frame for under- separately in the therapist and/or in the client,

This article is intended solely for the personal usethemselves of the individual user and is not to be disseminated broadly. are struggling so much in their standing her mystifying behavior. It indi- as is often understood to be the case with lives, but that clarity is only accessible oc- cates that the therapist does not think she, as transference and countertransference. In CBP, casionally or about a few topics. How to a total person, gets that angry with her we see the successful recognition and repair of continue to develop, integrate, and daughter, but rather that this is a part of her. these events as key moments of healing in strengthen the adult self is crucial in CBP, It continues to educate the client about parts therapy with clients with histories of emo- because the adult self needs to help heal and what therapists mean by parts. It paves tional neglect and abuse. dissociated parts. When clients do not ap- the way for the next step in the intervention, The conscious experience of therapist pear to have anything approximating an which may be to say, “Do you know what and/or client might be that they suddenly do adult self, it makes the work slower and the things your daughter does that particularly not know what is happening between them, ultimate prognosis less positive. get to that part of you?” This question may or that they feel frozen, that something is In CBP, we have developed a model for then lead to further discussion of the daugh- wrong. Less experienced trauma therapists working with parts that has three levels. The ter’s specific behavior and eventually to the are likely to leap into action, for example first, which is useful for virtually all clients events in the client’s family of origin that set suggesting a topic or a regulation technique,

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or becoming overtly reactive to the client. CBP advocates for therapists to first learn Suggestions for Further Reading the signals that an enactment is occurring. Chefetz, R., & Bromberg, P. (2001). “Talking with ‘me’ and ‘not me:’” A dialogue. In V. Sinason When noticing these signals, therapists need (Ed.), Trauma, dissociation and multiplicity: Working on identify and selves (pp. 155–203). New to stop doing and start thinking and feeling about what is occurring. It is then appropri- York, NY: Routledge. ate to say to most clients—the ones who can Cloitre, M. (2015). The “one size fits all” approach to trauma treatment: Should we be satisfied? tolerate a process comment, which is most European Journal of Psychotraumatology, 6, 27344. clients at some point in the therapy—that Cloitre, M., Stovall-McClough, K. C., Nooner, K., Zorbas, P., Cherry, S., Jackson, C. L.,... something seems to have happened between Petkova, E. (2010). Treatment for PTSD related to childhood abuse: A randomized controlled them, or that they noticed a different feel- trial. American Journal of Psychiatry, 167, 915–924. ings in themselves, and ask if the client Grossman, F. K., Sorsoli, L., & Kia-Keating, M. (2006). Gale force wind: Resilient male survivors noticed anything. Often they have. It might of childhood sexual abuse. American Journal of Orthopsychiatry, 76, 434–443. then be appropriate to say to the client, if it Hibbard, R., Barlow, J., MacMillan, H., & the Committee on Child Abuse and Neglect and is the first time this process has occurred in American Academy of Child and Adolescent Psychiatry. (2012). Psychological maltreatment. the therapy, “I could tell you what I experi- Pediatrics, 130, 372–378. enced or you could go first; which do you Howell, E. F. (2005). The dissociative mind. New York, NY: Routledge. prefer?” The therapist and client each take a Hopper, E., Grossman, F., Spinazzola, J., & Zucker, M. (in press). Treating adult survivors of few moments together to try to discern what childhood emotional abuse and neglect: Reaching across the abyss. New York, NY: Guilford was going on between them when the enact- Press. ment began, and then each describe as hon- Spinazzola, J., Blaustein, M., & van der Kolk, B. (2005). PTSD treatment outcome research: The estly as possible their internal experiences study of unrepresentative samples? Journal of Traumatic Stress, 18, 425–436. during the period of the disturbance. A client Spinazzola, J., Hodgdon, H., Liang, L., Ford, J., Layne, C., Pynoos, R.,...Kisiel, C. (2014). Unseen who is experienced at these processing mo- wounds: The contribution of psychological maltreatment to child and adolescent mental health ments might say, “It felt to me from your and risk outcomes in a national sample. Psychological Trauma: Theory, Research, Practice and tone that you disapproved of what I said to Policy, 6, S18–S28. my partner, and then part of me got mad at Teicher, M., & Sampson, J. (2016). Annual research review: Enduring neurobiological effects of you.” The therapist might then say: childhood abuse and neglect. Journal of Child Psychology & Psychiatry, 57, 241–266. A part of me appreciated that you were standing up for yourself in that interaction Suggested Websites and another kid part of me, the part that likes everyone to be “nice,” was a little distressed The Trauma Center at Justice Resource Institute, www.traumacenter.org by it. I am sorry that the disapproving part of Centers for Disease Control, Adverse Childhood Experiences Study, www.cdc.gov/ me came out in my tone. I think you have violenceprevention/acestudy done a good job describing it. In further discussion, it may become clear that some young part of the client also dis- found that the therapist has to hold the client struggle to understand. This process approved of what the client had said because awareness of what is occurring until the helps to clarify the story and build both of it was not “nice,” and the therapist was client can tolerate these discussions. their attachments to the characters in the either carrying that emotion for the client or story, which are the client at different joining with it because of their own young Narrative component. These cli- stages of life. As this work progresses, part. ents, as described by several contempo- clients begin to explore what happened These process discussions of enactments rary trauma theorists and in our book in a inside themselves to cope with their expe- are reparative and sometimes the first time special contribution by psychologist Jodie riences and to learn more about their inner

This document is copyrighted by the American Psychological Association or one of itsin allied publishers. the client’s life that such direct and ex- Wigren, struggle with meaning making. space and how it has been shaped by their

This article is intended solely for the personal useplicit of the individual user and is not to be disseminatedemotional broadly. repairs have occurred. This process requires knowing their larger early trauma. The therapist also assists in When the therapist routinely and comfort- stories, which is often challenging both helping connect different parts of the story, for ably takes responsibility for his own mis- because their stories are so difficult and example how being subjected to endless angry steps and misattunements, it models a kind because of dissociation and fragmentation tirades by his father in childhood has led the of relationship the client has likely never among the parts of the self who hold as- client now to shut down and withdraw when- experienced. When it is not recognized and pects of the story. Helping these clients ever he perceives even a small conflict or acknowledged by the therapist, either be- build a coherent narrative about large and tension in a current personal or professional cause of the therapist’s lack of self- small aspects of themselves is key to re- interaction. knowledge or comfort with acknowledging covery and occurs in almost all aspects of In CBP, therapists are taught to notice their mistakes, therapies can and do become the work. Typically, as they struggle to the gaps in the stories they begin to hear stuck. There are also clients who are not able share pieces of their narrative—in dreams, and to attend to the various cultural con- to do this kind of work, sometimes for many enactments, body language, and recollec- texts within which the narrative is con- years of therapy, and in those cases we have tions—the therapist and adult self of the structed, which provides a wider perspec-

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tive and helps to make the stories more the clients’ understanding of “I may never proaches to psychotherapy to advance four complete. The development of clients’ know.” In two studies of resilient male and intertwined components within both the narratives occurs in every aspect of the female survivors of childhood trauma by client and therapist: relationship (working work, from the way clients approach ther- psychologists Frances Grossman, Lynn Sor- within a relational frame), regulation (in- apy, to the side comments they make and soli, and Maryam Kia-Keating, survivors creasing self-regulatory capacity), parts the enactments in which they participate. found a commitment to helping others, (working with dissociative parts), and nar- All are ways of “telling” their narrative sometimes using what they had learned in rative (identity development, integration, and the ways we encourage therapists to healing from their traumas, to be greatly and meaning-making of traumatic and listen. Some stories have not been shared satisfying. Furthermore, engaging in helping other life experiences through narrative because they are too horrible and because others seemed equally helpful whether or work as both therapist and client come to telling them and insisting on their truth not survivors associated it with their trau- construct a shared understanding of the may lead the client to be cut off by or to matic histories. client’s story). have to cut off from their family. CBP Finally, we have observed that clients The CBP model awaits empirical vali- emphasizes the importance of making impacted by complex childhood trauma dation through carefully controlled out- these possible outcomes clear, and thera- seem to evolve in a five-stage process of come research, but to date we have pists help to create a safe space for the identity development. The first is no self, amassed considerable practice-based evi- client to weigh the possibilities for and emphasizing the emptiness and disconnec- dence of its utility. At our trauma- against telling. Often clients cannot tell be- tion. The second is damaged self, during specialty clinic and private practices in cause they have forgotten, or more likely, which shame about being so damaged is a Greater Boston, we have a long history of dissociated parts hold the information that key emotion, as well as a sense of being implementation of this model with a mix the adult self cannot yet access. Marked bad or evil, and/or being irrevocably dam- of urban adults of color living in poverty emotional dysregulation often accompanies aged. The third stage is victim, in which amid high crime neighborhoods in Boston the beginning of telling these dark stories, the client focuses on the harm done to and upper-middle class to economically and the therapist must both continue to help them. The fourth is survivor, which has privileged adults living, working and qui- clients build stronger and less problematic historically often been regarded as the ap- etly suffering lives of self-degradation, methods of self-regulation and also guide propriate end of trauma therapy, in which emotional constriction and isolation the pacing of the telling. the client’s identity is still focused around across Metropolitan Boston. In addition, With this particular group of clients, the abusive history but the individual has over the past several years we have con- grown significantly and is living life much ducted extensive training and ongoing much of their stories are about what didn’t more fully. Some individuals arrive at a clinical supervision in CBP for therapists happen—the lack of adequate emotional fifth stage: that of person, in which their working with diverse clinical populations support, of mirroring, of being taught traumatic history becomes one aspect of of complex trauma survivors in a rich va- about emotions and regulation—and these the many life experiences and influences riety of settings. These include Caucasian and are typically the parts of the story they that have brought them to become the per- Black adults receiving Christian and pastoral cannot tell. Instead they show their thera- son they are. counseling at a community-based general out- pists in what they expect and do not expect In CBP, movement across these stages patient clinic in Tennessee and an exclusively from them and from others in their lives, and is seen as fluid. This therapeutic work Medicaid-insured, adult population of Cauca- in the enactments therapists experience with often involves helping clients envision, sian, Black, and Alaskan Native adults with them. In this way, therapists come to under- glimpse, or come to believe in the possi- extensive trauma histories and comorbid sub- stand how what didn’t happen, and the cli- bility of higher stages of identity, and stance abuse/dependence and/or severe and ents’ resulting relational styles, have shaped when possible, to hold onto and sustain persistent mental illness receiving outpatient their identities over time. experiences of self at higher levels of services at a large community-based mental Therapists, of course, also have their identity in the present moment. Notably, health system in Anchorage, Alaska. Ulti- narratives, professional and personal, and different parts of self often carry different mately, the value of CBP, as should be the these also change over the course of their stages of identity development, and not all case for any model of psychotherapy, will This document is copyrighted by the American Psychological Association or one of itswork, allied publishers. although generally less dramatically clients go through all stages. CBP also hopefully rest at least as much upon its This article is intended solely for the personal usethan of the individual user and is not tothose be disseminated broadly. of clients. Therapists’ narra- proposes various facets and stages of the demonstrated capacity in replicable, real- tives what they can see and what trauma therapist’s professional identity life practice to help many adult survivors they fail to see, what they can respond to that variously inform, limit, enhance, be- of childhood trauma transcend suffering and what they avoid, and what needs of come challenged by, and have opportunity and live meaningful lives, as on the vali- their own they bring to their work. to evolve in the context of this work. dation that comes from the test of its ef- Developing a narrative is a way of mak- ficacy in a carefully designed, randomized ing meaning, which is central to the task of controlled trial (see Appendix for sugges- healing for these clients. Coming to terms Conclusion tions of further reading and web sites). with questions like “Why did this happen to me?” or “Why did they abandon me?” are In this brief introduction to CBP, we Keywords: emotional abuse; emotional important aspects of these therapies, even if describe how the model integrates recent neglect; complex trauma; Component- sometimes they are ultimately answered by work in the trauma field with classic ap- Based Psychotherapy

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