Trauma model therapy (TMT) is a treatment model that I developed over a period of years (Ross, 2007; Ross & Halpern, 2009). It is supported by a series of prospective outcome studies (Ellason and Ross, 1996, 1997, 2001; Ross, 2005; Ross & Burns, 2006; Ross & Haley, 2004) and is therefore evidence-based. TMT lacks the highest level of evidence, however, which is a randomized, prospective treatment outcome study with a waiting list, comparison or control group. Nevertheless, TMT has more of an evidence base than most of the work done with inpatients in psychiatric hospitals.
TMT is not designed solely for use in an inpatient setting, however. That is the environment in which it was developed, and in which I work, but TMT is a general model of addictions and mental disorders, and can be used in any setting by master’s, PhD or MD therapists. It was designed for clients with extensive childhood trauma and extensive comorbidity, but can readily be adapted for individuals without extreme trauma and with less complex mental health problems.
TMT involves a blend of cognitive, systems, and experiential therapies, with some psychodynamic elements. It is technically eclectic, but is carried out within a unified model. In the inpatient setting about half of the twenty-five to thirty hours a week of group therapy is based on psychoeducational and cognitive approaches, and about half consists of process and experiential groups. I will now describe the general principles of TMT to provide a flavor of how it works.
Overview of Trauma Model Therapy (TMT)
TMT is the psychotherapeutic component of the trauma model I developed (Ross, 2007). The trauma model is a comprehensive model of mental health and addictions. It includes many detailed, specific, and scientifically testable hypotheses and can potentially generate many research projects. The trauma model, then, is not just a personal opinion or philosophy—it is a wide-ranging, scientifically testable theory of the relationship between trauma, mental health disorders, self-defeating behaviors, and addictions.
The basic idea of the trauma model is that trauma is a major driver of mental health problems all across the DSM-5. The trauma includes but is not limited to childhood physical and sexual abuse, neglect, domestic violence, severe family dysfunction, loss of primary attachment figures, and severe medical and surgical disorders. In children, adolescents, and young adults it can include, among other things, military combat, sexual assault, natural and man-made disasters, accidents, and community violence. Social and cultural conditions such as extreme poverty, endemic disease, starvation, and political oppression contribute greatly to the overall burden of trauma on our planet.
According to the trauma model, most but not all mental health symptoms are understandable reactions to trauma. They occur in the context of people’s life story, and have a meaning and purpose—they are part of a survival strategy. This can include cognitive errors, emotions, and symptoms such as flashbacks, depression, auditory hallucinations, anxiety, substance abuse, self-harm, eating disorders, obsessions, and compulsions. The trauma model incorporates the role of temperament and genetic predisposition in its specific research predictions, but the main emphasis is on environmental causes of mental disorders. In adolescents, this means mostly family violence and dysfunction, abuse, neglect, and loss of primary attachment figures.
I believe that the emphasis in psychiatry on medication and psychosocial interventions has swung out of balance towards medications, and needs to be adjusted backwards in the direction of psychotherapy. This is a matter of restoring balance, not swinging from one extreme to another.
TMT is suitable for adolescents as it addresses the core developmental tasks of adolescence, including separation and individuation. Clients treated with TMT are usually working on stepping out of the shadow of the perpetrator and building a life free from disturbed family dynamics, relationship patterns, and beliefs about the self.
The two core ideas in TMT are the problem of attachment to the perpetrator and the locus of control shift. They are the focus of a great deal of the recovery work, and will be described in the following paragraphs.
The Problem of Attachment to the Perpetrator
Our clients are mammals. This means that at birth they could not survive without adult caretakers. Children are biologically programmed to bond, connect, attach to, love, and need to be loved by their adult caretakers. This is not about race, culture, IQ, gender or personal experience: it is about being a mammal. It happens automatically, and there is no possibility of not attempting to attach.
In a normal, healthy family this all works out relatively smoothly. The child feels safe, secure, loved, and special. A secure attachment pattern is formed. However, adolescents treated with TMT did not grow up in a healthy family at all. They grew up with variable combinations of physical, sexual, and verbal abuse; highly disturbed family dynamics; neglect; failure of bonding and nurturing by the parents; loss of primary caretakers through death, divorce, abandonment, and/or imprisonment; substance abuse or mental disorders; and a host of other difficulties.
For such children, two opposing forces come into play inside them. They must, and will, bond, connect, and attach, and then at other times they must fear, flee, avoid, and hate their caretakers, who are terrifying and abusing them. At times the parents are present and okay, then they are absent, then they are present, but abusive. This pattern continues in a chaotic, unpredictable, inescapable form for years and years.
The outcome of this process is “disorganized attachment.” The child is stuck in a love-hate, approach-avoid, “I hate you, but don’t leave me” pattern of relating to others. I call this “I’m okay, you’re okay mode” and “I’m not okay, you’re not okay mode.” The person bounces back from mode A to mode B endlessly, or temporarily escapes the whole mess through substance abuse, an eating disorder, depressive shutdown or some other set of survival strategies.
This is not just a theory about adolescents’ early childhood. It is an observable pattern of behavior dominating life in the present. As adolescents, the survivors of such a childhood may be in the foster system, living on the street, be living with dysfunctional relatives, or still be living in their traumatic family of origin. Adolescents are likely to be stuck in an attachment pattern I call “the borderline dance,” or the aforementioned “I hate you, don’t leave me” pattern. From the perspective of the trauma model, being borderline is the logical, predictable, unavoidable outcome of growing up with primary attachment figures who are also perpetrators. There is no other way to be or to survive. It is an endless cycle of not letting the perpetrator get too close and not letting the caretaker get too far away.
The work of therapy starts with seeing and understanding the problem of attachment to the perpetrator, then realizing the core fact of clients’ childhood, and often their current life: “I love the people who hurt me, and I am being hurt by the people I love. Both things are true, I feel both sets of feelings, and it is intolerable.”
In order to survive, children cannot afford to see the whole picture, cannot afford to have an integrated self. The picture has to be split into mode A and mode B. Why? At all costs, children must protect their attachment systems, because their attachment systems must be up and running in order to bond with a caretaker, and in order to survive, biologically, emotionally, and spiritually at all possible levels.
When this core realization begins to sink in, people are thrown back into the underlying, pervasive reality of their childhood: “I feel small, scared, sad, lost, and lonely.” The fundamental work, then, is mourning the loss of the childhood they never actually had, which is a good, normal childhood. There is a lot of grief work.
In adolescents, these feelings and conflicts exist in the past, the present, and the future. Being trapped in this reality, with no avenue of escape in sight, is deeply depressing and generates hopelessness, despair, and suicidal ideation. Suicide is the ultimate escape, but temporary escape can be found in drugs, alcohol, sexual promiscuity, self-mutilation, eating disorders or any of the many forms of acting out.
The Locus of Control Shift
The locus of control shift is like the problem of attachment to the perpetrator in that it is not about gender, race, culture, IQ or people’s particular temperament or personality. It is about how kids think. Here we are talking about Piaget and childhood cognitive development. We are talking about the sensorimotor stage and concrete operations. We are talking about the minds of magical children. This is how all kids think. These magical children are at the center of the universe, everything revolves around them, they cause everything that happens in their world, and they have a magical power to make things happen.
Imagine a four-year old girl. Everything is fine until suddenly, one day, daddy moves out. The little girl is powerless, trapped, and helpless. She cannot fix the situation and cannot escape it. Her future just crashed and she feels small, scared, sad, lost, and lonely. But, it turns out, she has already done seven PowerPoint presentations at her preschool. And she has signed up to complete a PhD in sociology at a remote learning institution.
This little, four-year old sociologist uses the vocabulary and thought processes of a normal four-year old. She emails her professor and says, “I’ve finished gathering my field data for my thesis. Can I have my degree now?”
The kindly professor emails back: “Great sampling technique, nice literature review too, but in order to complete your thesis, you need to have a theory to explain your data.”
“Oh,” the little girl thinks to herself, “I forgot about the theory part.”
The little girl goes away and thinks and thinks. Then she emails back to her professor: “I’ve got it! Daddy doesn’t live here anymore because I didn’t keep my bedroom tidy.”
This is a really dumb theory. It is completely out of touch with reality. So what do we have here? A psychotic girl? A borderline? Low IQ? No. What we have is a completely normal girl using completely normal childhood vocabulary and cognition to explain to herself what is going on in her world.
She has shifted the locus of control from inside the adults, where it really belongs, to inside herself. This happens automatically because of the way children process information. It is not an option or a defense in the usual sense. It’s just how kids think. But then a light bulb turns on: “Wait a minute, I’m not powerless, helpless or trapped. I know what the problem is. I’ll tidy up my bedroom, daddy will see I’m being a good girl, he’ll move back in, and everything will be okay.”
The locus of control shift creates a developmentally protective illusion of power, control, and mastery. The problem has been contained inside the self, a solution is at hand, and life is tolerable. The price tag attached to the locus of control shift is the “badness” of the self; in order to be in control and have a solution, the little girl must be bad. This cleans up and sanitizes the parents—they are now safe attachment figures because all the badness has been transfused to inside the self. They have been running a kind of tough love program, treating her the way she deserves to be treated. It’s better to be a bad girl with good parents than a good girl with bad parents.
In the severe, chronic trauma family, the child concludes that she is causing and deserves the abuse and neglect. This belief gets reinforced over and over by the perpetrators, then by an abusive boyfriend in high school, then again by an abusive parent, then by bullying at school, and on and on. It also gets reinforced by negative self-talk and unhealthy, destructive behavior towards the self.
By now an adolescent, the girl explains to her therapist that she is bad, doesn’t deserve to be happy, and has ruined her family and her life. There is no hope for her. This is the locus of control shift dominating her thinking, decisions, and behavior in the present. She is no longer a trapped, powerless victim—it was all her fault and she knows the solution.
The locus of control shift is the self-blame and self-hatred that drives self-punishment, self-neglect and self-harm, and contributes to people getting stuck in abusive relationships. Of course there are many other social, financial, and cultural forces at work as well, but this is a part of the problem that can be worked on in therapy.
The goal is to reverse the locus of control shift, to realize that all children are born special, and worthy of love and protection, and that the self is not the only exception to this rule in the history of the human race. The first step is to get this intellectually, and then with work it can sink into the heart. In cognitive therapy lingo, the core negative self-schema can begin to change.
What happens when you really, really get that it was not your fault, you never caused the abuse, and you deserved to be loved and protected? You don’t tiptoe off through the tulips. The realization throws you into the truth of your childhood: I feel small, scared, sad, lost, and lonely. The locus of control shift is a major grief avoidance strategy, and a core solution to the problem of attachment to the perpetrator.
The Problem is Not the Problem
The remaining principles of TMT are not quite as fundamental as the first two, but we use them all the time. “The problem is not the problem” is derived from family systems theory. For example, a family comes to treatment because their adolescent child has been stealing from stores. The family therapist realizes that this is just the presenting problem. The adolescent is the identified client, but the therapist knows that the child’s behavior is actually the family’s solution to some problem in the background. The challenge is to figure out what that problem is, and help the family find a more healthy solution.
In nonsystemic therapies, the adolescent will be given individual treatment in the form of psychotherapy and/or medications. But when the therapist takes a systemic perspective, the intervention is likely to be marital therapy for the parents, since the adolescent is the symptom-bearer for the family and the real problem is with the parents. They are drifting closer and closer to divorce. The only thing they share any joint passion about, and work together as a team on, is the bad behavior of their child, which is designed to keep the family from splitting up.
When treating the adolescent with individual therapy—which may be in conjunction with family therapy, or marital therapy with the parents—we take this principle and apply it to all symptoms, behaviors, addictions, diagnoses, and social roles. Sometimes we will be wrong and, like all approaches, the model does not apply. But most of the time, with most clients, “the problem is not the problem” is a guiding principle.
For example, a common reason for referring adolescents to partial hospitalization or inpatient treatment is self-mutilation. This is the presenting problem, and we want to solve it expeditiously so that adolescents are safe to step back down to a less restrictive level of care. In order to solve the problem of self-mutilation, we have to understand what problem in the background is being solved by the cutting. Most often, the cutting is a technique for mood state management; the bad feelings build up, build up, and build up and nothing seems to work to make them tolerable.
In chronic self-mutilators, most often the bad feelings go away instantly with the cutting. Now things are in control, now life is tolerable, and they don’t have to kill themselves to escape. Rather than being a suicidal “gesture”—a weak, pretend attempt at suicide—cutting is usually a suicide prevention strategy. It is a form of self-management, self-soothing, and self-care, just like shooting heroin. It works great for a while, until the problems return. The fact that the cutting works so well in the short term makes it highly self-reinforcing, just like any addiction. As it becomes harder and harder to deny the price being paid, one must go deeper and deeper into the addiction in order not to see it.
The cutting is also a form of self-punishment for being the bad girl who caused the abuse. Indeed, if the locus of control shift had been fully reversed, the adolescent girl would no longer give herself permission to cut, because she would know that she deserves to be treated with love, kindness, and respect.
That is why the addiction to the locus of control shift is often the core addiction underlying all the addictive behaviors. The behaviors are simultaneously self-punishment and a temporary escape from bad feelings, bad thoughts, bad situations, and bad beliefs about the self.
Just Say “No” To Drugs
“Just say ‘no’ to drugs” is the core addiction component of the model. Many adolescents report past or ongoing drug and/or alcohol abuse. Many have other addictions, whether it to sex, eating disorders, cutting, burning, abusive partners or any other unhealthy self-soothing behavior.
What is the purpose of any addiction? Addictions are transportation vehicles: they take you from here to there. Here is where you are now, which includes intolerable feelings, thoughts, memories or outside situations, or all of the above. Over there is anywhere but here, meaning stoned, wasted, thrilled, distracted or passed out.
I often say that the Twelve Steps are great, but there is actually a Step 0.5. Before clients can start working the Steps, they have to decide that they’re going to start working the Steps. This is the core commitment to abstinence and the work of recovery. If clients don’t get really, really serious about working on recovery—if they don’t say “no” to drugs—what do they expect us as counselors to do? If clients do make that commitment, then we can get to work, and we can suggest some things that may be helpful.
Adolescents may say that they don’t know how to make that commitment. I usually respond by saying that there is no “how” about it. There is no procedure or manual, nobody can show them how to do it, and nobody can do it for them. They just have to reach down inside and make that deep, core commitment to getting serious about sobriety, or not. It’s their choice.
Viewed from this perspective, all addictions are avoidance strategies. We classify all symptoms and behaviors as “addictions”—whether they are flashbacks, depression or something else. Clearly, if clients have been using crystal meth heavily for several years, they now have a brain disorder and a physical brain problem. But that’s not how the addiction got started, within the trauma model, in most cases. It started as a way of avoiding intolerable feelings and situations.
This approach, in my view and my experience, is empowering and instills hope. Adolescents are not powerless victims of what their brains are doing. They have been making understandable but unhealthy choices, and can learn a healthier way to cope. This is not a pipe dream. It is realistically possible, if they stick with it and work hard. But it is hard work, and it takes a while. There are no guarantees in the mental health field, but recovery is realistically possible. It starts with saying “no” to drugs.
Addiction is the Opposite of Desensitization
It took me a long time to figure out that addiction is the opposite of desensitization. Desensitization is when you say “no” to your drug or drugs, turn around, and start facing and dealing with what you have been avoiding, on the inside and the outside.
There are two subtypes of desensitization: flooding and systematic desensitization. In survivors of severe, chronic childhood trauma, flooding causes regression, melt-down, increased symptoms, increased acting out, reinforcement of the helpless victim role, and dependency on the therapist and mental health system. Systematic desensitization is the way to go. Step by step by step, with small steps.
We have a variety of experiential groups in which we get the affect up and running, whether it is fear, anxiety, sadness, anger or emptiness. We use a variety of different experiential techniques to achieve this. One of the most effective is throwing balls of clay at a board during anger management group. This particular technique is not feasible in an office or private practice setting, but there one can punch pillows or use other techniques.
In anger management, adolescent clients throw balls of clay at a board while shouting about whatever they are angry about. This is done in a contained, structured format for a limited period of time. Clients have to stay grounded, with their thinking caps on. Getting glassy eyed and sliding off into an uncontrolled abreaction is counter-therapeutic. If clients do start to lose their grounding, therapists intervene actively with grounding techniques and instructions.
The idea is to get angry without acting out. This serves two purposes: desensitization and affect management skill building. Adolescents feel the feelings while staying grounded; realize they are not as overwhelming, threatening, and intolerable as they were in early childhood; and realize they have better coping skills than they thought. Therefore they don’t have to avoid the feelings quite so desperately, and can conceive of dealing with them in a healthier fashion, without resorting to addictions. This is the desensitization component of the work.
The other aspect is that we get the feelings up and running—great, but now what? Now adolescents have to practice backing out, deescalating, and settling down, without acting out in any way. This is affect management skill building—adolescents are practicing new coping strategies in a real-life simulation, with the feelings up and running. All of the experiential components of TMT can be thought of as a combination of behavioral desensitization, decatastrophization, and cognitive restructuring.
The Victim-Rescuer-Perpetrator Triangle
The victim-rescuer-perpetrator triangle was originally called Karpman’s triangle, after the man who developed it in the 1950s. I like it because it is a systems model, because it is explicitly based on trauma, and because it is easy to understand. On the inpatient unit, we teach all these elements of TMT, including the triangle, in didactic groups, and we have a patient packet that explains them. We also talk about the triangle in other groups and in individual therapy.
I might say, “That is perpetrator behavior,” referring to some specific behavior someone has been doing on the unit. “What is the purpose of that behavior? What is it doing for you? What is it helping you avoid and not have to deal with?”
Similarly, I might point out that people are getting excessively involved with rescuing their peers on the unit, in order to avoid doing their own work. We take the same approach to anyone who gets stuck in the victim role: “What is the victim role helping you avoid, and how could you solve the problem in a healthier fashion?”
I like the motto: “You’re not responsible for being a victim, but you are responsible for remaining one.” This motto certainly applies to adults, but may not apply to younger adolescents who are still trapped in severely dysfunctional or traumatic families.
We track the different triangles that we encounter in therapy for two reasons: to help clients get out of their pattern of triangle reenactments and to make sure we don’t get stuck on one of the corners of the triangle. There can be many different triangles operating at the same time, and no triangle is necessarily stable. Adolescents can see you as the rescuer, but then when you are insufficiently care-taking, you suddenly become a perpetrator. This is the borderline dance that stems from the problem of attachment to the perpetrator. Clients can become “addicted” to the victim role, and in order to treat that we have to realize that the problem is not the problem. In therapy these different principles of TMT are as intertwined with each other as they are in clients’ defenses and lives.
TMT is suitable for adolescents with a wide range of mental disorders and addictions. It can be adapted for any setting, for many DSM-5 disorders, and for different ages. Of course, for young children, the vocabulary and interventions have to be scaled down to a child level, but the principles are the same. I can’t imagine how any children or adolescents in foster care could not have conflicted, ambivalent attachments to both their biological and their foster parents.
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Ross, C. A. (2007). The trauma model. A solution to the problem of comorbidity in psychiatry. Richardson, TX: Manitou Communications.
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Ross, C. A., & Halpern, N. (2009). Trauma model therapy. A treatment approach for trauma, dissociation, and complex comorbidity. Richardson, TX: Manitou Communications.