Trauma and Relationship

Often, when I am consulting with advocates about working with a domestic violence or sexual assault survivor who has complex needs, an advocate will state that he/she is not trained or equipped to work with a survivor who has mental health issues. An advocate may feel that only a person who is trained in one of the alphabet interventions (EMDR, DBT, CBT, TF-CBT, etc.) has the skills necessary to provide what the survivor needs. Fortunately, the field of counseling/psychology is learning what grass roots advocates have known for years. It is the quality of the relationship between the survivor and the counselor/advocate that determines the person’s satisfaction with the intervention or contact.

Back in the 1950s and 60s Carl Rogers developed humanistic psychology and was considered to be at the forefront of understanding the need to develop therapeutic relationships. Here are the tenants of humanistic or client centered therapy as outlined in Rogers’ books Client Centered Therapy and On Becoming a Person:

The therapeutic relationship consists of a non-judgmental attitude, mutual respect, empathy, and unconditional positive regard.
The client has the answers.
The therapist’s job is to lead the client toward this self-knowledge.
The therapist’s opinion is unimportant.

Do these sound familiar? They should. They are the basics of empowerment based advocacy.

Carl Rogers’ work was well-respected until the mid 1990s when managed care companies began to require the use of evidence based interventions with measurable outcomes that could be a part of brief therapy (usually 6-8 sessions). Since it is difficult to measure attitudes and the value of a therapeutic relationship that develop over time, Rogers’ theories were set aside. Unfortunately, these new evidence based interventions did not necessarily meet the needs of clients and many dropped out of treatment.

Barry Duncan and Scott Miller, co-founders of the Institute for the Study of Therapeutic Change have authored and edited numerous professional articles and books. They have done research over 40 years to determine what really matters in the day to day work of a therapist and found the following:

The client's view of the relationship [with the therapist] is the 'trump card' in therapy outcome... Clients who rate the relationship highly are very likely to be successful in achieving their goals. Despite how chronic, intractable or 'impossible' a case may appear, if the client's view of the relationship is favorable, change is more likely to occur." From The Heart and Soul of Change: What Works in Therapy by Mark Hubble, Barry Duncan and Scott Miller.

In Judith Herman, M.D.’s book Trauma and Recovery, she outlines three stages of recovery from trauma – safety, remembrance and mourning, and reconnection. Advocates provide the safe place for all three stages. Advocates provide the means for a victim to obtain safety if she chooses and creates the safe relationship within the survivor can tell her story and reconnect and develop a trusting relationship. This does not need to be done through the use of evidence based interventions. It just takes being willing to connect and maintain a safe and trusting relationship.

What about someone with severe mental illness? In the community mental health system, the person who has the most contact with a person with a severe and persistent mental illness (the persons whom most advocates seem to feel unprepared to work with) is the client’s mental health case manager. In my experience as a case manager supervisor I found it was not what interventions that were used in working with a client, it was the relationship of trust and respect, non-judgment, and positive regard that predicted success for the person with the mental illness. Case managers are not necessarily trained therapists. Most have the same education and training as domestic violence advocates. They meet with persons with paranoid schizophrenia and psychosis in the clients’ homes and assist them in managing their daily lives. They may have some basic knowledge of an evidence based practice such as DBT (dialectical behavior therapy), but it is the quality of the relationship that is the basis for success as defined by the client.