Introduction

Almost year on year, the number of specialist applications of the SF approach, expands. Since becoming an SF therapist in the early 1990s, I have sought to apply the principles, assumptions, tools and techniques of our wonderfully liberating approach to therapy, coaching and consultancy. Within the last 10 years, especially, I have concentrated on my two specialist mental health applications: Suicide Prevention and Severe Trauma Recovery. The second of these, developed out of my extensive training of military welfare workers, across the British armed forces, saw the publication of my first work: Beating Combat Stress: 101 techniques for recovery (Henden, 2011). This was both a reference book for welfare workers and a self-help book for military veterans and serving personnel, who may have experienced combat operational stress injury (COSI) or operational stress injury (OSI). (I avoid using the problem-focused term, PTSD, deliberately.)

Immediately after the book was published, there were requests from various quarters for a civilian version. This was published in Dec 2017 and is entitled, What it takes to Thrive: techniques for severe trauma recovery (Henden, 2017). Within this article, I will consider some aspects of my SF approach to severe trauma recovery, with a later focus on the recently designed above mentioned instruments.

In my psychotherapeutic work over some twenty plus years, with both adult survivors of childhood abuse and neglect; and, adult severe trauma experiences, I have found it helpful to provide clients with a degree of psychoeducation, to help them understand how what happened to them has caused their current symptoms and experiences; but more importantly, what they can do about them, to live full and satisfying lives. It is important for clients to be allowed to tell their story at the beginning of the therapy. “Being able to say to another human being…is a sign that healing can begin” (Van der Kolk, 2014).

Background

I owe a deep debt of gratitude to Yvonne Dolan (1998), who developed her notion of Victim-Survivor-living the authentic life (Thriver). By way of providing some background, after many years of working with victims of trauma, Dolan noticed that although such clients could acknowledge they were survivors, being able to function better than hitherto, they were still prone to spells of very low mood. Her belief was that there must be a third stage that clients could both aspire to – and reach. This she described as ‘The authentic self-identity’ or ‘Living the life you truly want and deserve’. (The term Thriver was suggested to me some fifteen years ago by Roger Meeson (2006), an SF colleague and private psychotherapist practicing in the South West of England.) In her book, Beyond Survival: Living well is the best revenge, Dolan outlined many novel and powerful tools and techniques for clients to try out, as and when appropriate.

Before looking at Dolan’s 3-stages of recovery, it may be helpful to say a little about the approaches of other SF practitioners in the severe trauma recovery field.

Contemporary SF Trauma Recovery Specialists

Jackie von Cziffra-Bergs

Being based and practicing mainly in Johannesburg, South Africa, von Cziffra-Bergs (Froerer et al., 2018) finds that much of her trauma recovery work comprises of car jackings and home invasions, often involving firearms. She makes the point, strongly, that she has made the shift from a ‘victimologist’ to a ‘resilientologist’, in that she asks survivors, questions of resilience: “How did you cope?” and “How did you respond at the time?” It is well known that people do incredible things in a traumatic situation, so it is most helpful to ask questions about it. In keeping with this SF emphasis on resilience, instead of debriefing such clients, she focuses on a re-briefing of client strengths. Presuppositional questions about client resilience and those leading to recovery are a cornerstone to von Cziffra-Bergs’ work.

Steve Flatt

Being one of the more experienced SF severe trauma recovery therapists I have met, Flatt (personal communication, 2020), having seen over 2,000 clients within the past twenty years, including survivors of the cruise ship Costa Concordia, which capsized in shallow waters off Italy, in 2012, uses a strength-based approach comprised, typically, of a 4 – 6 session episode over some 10 weeks. Being fully aware of the work of neuroscientist Joseph LeDoux (2011), he is a firm believer in the idea that therapists do not change clients’ brains for the better: clients change their brain for themselves. Flatt (personal communication 2020) believes that clients know within the first milliseconds of the first meeting whether or not they are going to get on with their potential therapist. Within this first meeting, he talks in a strengths-based way about what happened to them and about how they managed to cope at the time. Like so many of us, resilience is a key part of Flatt’s work. He has an elegant way of introducing the notion of clients’ best hopes for the work, at the beginning of the first session: “Supposing that you could work with me; and, supposing we did some work together that was useful to you, standing at the end of the line of this work, what would you notice about yourself that would tell you that this has been helpful?”

Frederike Bannink

A clinical psychologist based in Amsterdam, the Netherlands, Bannink (2014) wrote her first book on trauma, in which the theory and practice of positive psychology and solution-focused brief therapy are combined with traditional approaches. Her concept veers away from a focus on clients’ pathology and how to repair the worst to a focus on what is right with them and how to create the best. In her book, Posttraumatic Success (Bannink, 2014) she lists the 3 R’s of posttraumatic success as:

1. Recovery
2. Resilience
3. Enrichment (posttraumatic growth)

Bannink (2014) labors the point that it is time to turn the tide on treating trauma by shifting the focus from reducing distress and merely surviving, to building success and positively thriving.

Ben Furman

Being one of a growing number of psychiatrists who question the consequences of the biomedical approach, Furman (2020) both pioneered and promoted SF practice, in a variety of settings.

Regarding trauma recovery work, he invites the client to choose their own preferred term to refer to the adverse event, thus avoiding the medical term, ‘trauma’ (Furman, 2020). Also, he assumes a not-knowing position with clients, asking whether past traumatic events have a bearing on current problems. Other key aspects of Furman’s approach are to ensure the client defines the goal of therapy; to facilitate the client’s natural recovery process; to invite clients to appreciate possible positive consequences of the adverse life events; and, to regard these adverse life events as memories that can change. A light-hearted part of Furman’s work is to allow the client to share one or more amusing details related to the adverse event.

The 3 Stages of Recovery

Victim Stage

“Trauma make people feel either like somebody else or like nobody” (Van der Kolk, 2014. p247).

Acknowledgement of the Victim stage is the most important first step of healing: it is important for the person/ client/ survivor, to face the reality of the bad or unfortunate thing/s that happened to them; or that they experienced. Accurate naming is important, without minimizing or putting any sort of gloss on it. An example of a past client of my own, was their marked shift from, “My childhood was not particularly rosy” to “I was a victim of severe and enduring childhood emotional and physical abuse from care givers.”

Finding the courage to disclose to someone else what happened, breaks down the isolation and is crucial. Over the past twenty-five years, I have had numerous cases where, usually, the incident disclosed was between ten to fifty-one years previously. One memorable case, often which I cite on 2-day workshops, is of a 70-year old woman who had been imprisoned within a compound by soldiers in a war zone, when she was age 19. A young mother there, was worried about the distressed cries of her hungry baby. That night, under the cover of darkness, my client crept out, across the compound to a cattle shed where she milked one of the cows. The baby’s mother was very grateful for her act of kindness in supplying the urgently required milk. Unfortunately, in the morning, the guards found out what she had done and killed the baby, as punishment. She had told no-one about this incident after the war and carried the false guilt about the baby’s death throughout the intervening fifty-one years. Knowing what we know now about ‘depression’ resulting from either unexpressed negative emotion; and/or undisclosed or unresolved secrets from the past (Griffin & Terrell, 2000), this client fitted both of these categories; and consequently, had many occasions when, to the mystification and distress of her family, she was extremely low in mood.

A typical question at this stage, is as referred to above: “What happened to you?” (Langdon, 2013)

This is a vitally important question as it allows the client to name, in their own words, what they experienced. It replaces the medical model’s “What is wrong with you?” of yesteryear.

Naming the event/ abuse/ experience accurately, is an especially important part of the Victim stage; and, it is not necessary, unless the client wishes, for them to go into detail. Other useful questions to ask at this stage are:

For clients, feeling listened to and understood, changes their physiology. “Being able to articulate a complex feeling; and, having our feelings recognized, lights up our limbic brain and creates an ‘Aha’ moment.” (Van der Kolk, 2014) The simple SF techniques of acknowledgement and validation, facilitate this process.

Once full acknowledgement of victimhood has taken place, any negative emotions that might be around, can be expressed safely in several ways. These negative emotions most commonly are: grief, frustration, anger, guilt, shame, disappointment, hopelessness and helplessness. Expressing them safely, is a vital part of healing within the Victim stage.

Often, a challenge for the therapist is their helping the client to appreciate that what happened was not their fault. Survivors of child abuse often feel, that in some way, they were to blame for what happened to them. Many perpetrators are particularly skilled at imputing this belief into their victims. Any harm which comes to children is the responsibility of the responsible adults (parents or other care givers, teachers, etc.) around at the time, who were supposed to be ensuring they came to no harm. A helpful psychoeducational statement here, is: “From what we know from doing this work, it is never the child’s fault.”

Many survivors of traumatic events in adulthood feel, too, that they are either wholly or partly responsible for what happened, or, what they witnessed. For over twenty years, personally, I carried the guilt of a road traffic crash I witnessed at the age of 18, where a helmet-less motorcyclist crashed into the front of a lorry. The impact speed was approximately 50mph, the motorcyclist landing on the road head-first, after being propelled through the air for some distance, like a rocket. He bled out from a serious head wound within three minutes, creating a pool of blood two feet in diameter. I had been awarded a top-level first aid certificate only two weeks previously and did nothing to help, simply looking on, in shock. My therapist explained that, most probably, he was dead on impact with the oncoming lorry and was certainly dead on impact with the road. There was nothing I could have done; and, what I was experiencing was some sort of ‘survivor guilt’: quite a normal response. After that, I was able to let the guilt go.

There are some cases with adult traumatic experiences where some of the guilt may be owned, justifiably, by the survivor. However, it is rarely “100%”, as often expressed by survivors. Such clients, through a process of apportioning percentages to other factors, and individuals, can enable the correct proportion of blame to be carried. Appropriate SF techniques can then be used to deal with this remaining guilt, in constructive ways. Deep sorrow and repentance and forgiveness from either the victim in person, or via the healing letters exercise (Dolan, 1998), can lead to a freeing up.

Other valuable SF questions and statements for helping clients through this stage are:

Once the Victim stage has been understood and acknowledged, the client can then move on to the next stage – Survivor.

Survivor Stage

This begins when the traumatized person understands they have lived beyond the traumatic or highly stressful experience that occurred. The Survivor stage reinforces the fact that this/these experiences happened in the past. There is then a wonderful opportunity for the therapist to ask the following SF questions:

Acknowledgement of survivorhood also involves developing an inventory of internal strengths and positive personality characteristics. The list may include some of the following: creativity; curiosity; determination; honesty; having clear values; and, resourceful. This is important, because victims of whichever type of trauma can experience both low self-esteem and low self-confidence, as a result of what happened to them. Often, I have found severe trauma clients to be hard-pressed to list any positive characteristics. Using third parties, (e.g. best friend, mother, head teacher) can often build this much-needed list through the well-known Gestalt technique of the empty chair: “Just suppose, in that chair over there, is sitting your best friend. What would they say are your positive characteristics?”

Furthermore, clients can be asked to elaborate on other internal strengths and qualities such as hidden knowledge, courage, spirituality, personal beliefs and other positive aspects of self that have got them this far on their journey. There is a powerful process at work here, as through this line of SF questioning, clients realize that things are not all bad; and, that through answering, positive emotions can be elicited. This is an important aspect of solution-building. (Kim & Franklin, 2015).

It is worth enquiring about external resources that were available to the client, too, around the time or shortly after the abuse or trauma was experienced. These might comprise of a grandparent or neighbor (in the case of child abuse or neglect); mates; a minister or welfare worker.

Questions then may be asked such as:

At this stage, Survivors begin to regain better functioning in their everyday lives: both in terms of family and social life; and at work. Increased assertiveness and a determination not to be pushed around, bullied or abused, is often evident as clients embrace survivorhood, more fully. One client once remarked; “I’ve decided I’m not going to be taken advantage anymore, by some of my so-called friends!” There is a greater willingness to engage in household tasks, meet up with friends and be involved in community activities. Once survivorhood is fully acknowledged, with all skills, resources, strengths and qualities appreciated, they are ready then, to move on to Thriving. Psychoeducation in the form of a simple explanation about how what happened, has had an effect both on how the person feels about themselves now; and about how they have been living, can be both informative, liberating and empowering. Backing it up with written information can be helpful, too.

In addition to feeling better informed about the results of what happened to them, clients can learn some practical steps they can take to promote recovery in the form of useful tools and techniques, thus feeling more empowered and in control of their own recovery process. Victims of trauma have 6 fields of concern: Triggers; Flashbacks; Intrusive thoughts, ‘The Lows’; Sleep disturbance; and, Living life to the full (Henden, 2017). A simple, yet highly effective technique for dealing with triggers is: “Let it go…Let it go…Let it go…”

Clients are taught to repeat it in the session to ensure they are saying it slowly and deliberately for future occasions when they experience the trigger. It seems that no survivor is too old to change their brain’s response to take the sting out of a trigger, by this technique, so long as they are motivated to do so. There has been a great deal of research into this area of neuroscience, over the past two decades or so. “Investigators of neuroplasticity, demonstrated that the adult brain can continue to form novel neural connections in response to training…” (Garland & Howard, 2009)

During the early years, SF practitioners knew that something amazing was happening to clients’ brains, from what seemed on the face of it, carefully crafted SF questions and some simple techniques. The newer neuroscientific research can be declared the theory behind what is happening here with and explains how the SF approach sees clients recover from trauma over time. Another neuroscientist, Joseph LeDoux (2011), talks in terms of “traumatic learning” and “memory reconsolidation”, suggesting that the synapses in the brain get stuck around the traumatic memory, thus explaining the amygdala response to triggers (LeDoux, 2011).

By using an SF technique “Let it go…Let it go…Let it go…” what seems to happen here, is that these synapses are made fluid again through re-imaging the trauma as the trigger occurs and then via the application of the technique, reset in a healthier way, such that the client responds differently for future triggers. Clinical experience suggests that practicing it for some 30 – 40 occasions, achieves the desired result.

Now, to consider the all-important Thriver stage, within Dolan’s Victim-Survivor-Thriver continuum.

Thriver Stage

In my early years of working with both adult survivors of child abuse and neglect; and, with clients experiencing trauma in their adult lives, I produced a single-sided handout, summarizing Dolan’s key points at each stage, entitled ‘The three stages of survival’.

Helpful questions at this stage are:

Whilst being helpful to many, as far as it went, to explain the process, I observed some clients still struggled to grasp the importance of understanding and appreciating each step. Hence the need for something more detailed in the form of the three-pager: ‘What Thriving is Like’ (Figure 1), which was developed in the light of practical experience, with my clients over many years.

Within it, there is mention of acknowledgement of survival skills; rejecting the ‘damaged goods’ label; improved interpersonal relationships; personal skills, attributes, strengths and abilities; the many and varied techniques available for recovery; and, experience of real joy and fulfilment once the third stage, Thriving, is reached. Victimhood and survivorhood, it seems, are easier for clients to grasp, but it is this most important Thriver stage which needs that fuller appreciation and understanding. Interestingly, I have found for many clients, in the early stages of the work, neither do they believe it is possible, nor do they feel they deserve to thrive! Once clients have had explained this three-pager, re-read it as a between-session task, and inwardly digested it, the ‘Questionnaire for Measuring Thriver Progress (Figure 2) follows on naturally. This, also, was developed in the light of practical experience, with a wide range of clients. Within the ten-point Likert scale (below) for each of the questionnaire’s thirty-three questions, even the smallest steps of progress are measurable, as the client’s scoring range is between 33 – 330 points. To assist with understanding and appreciating the power of this measuring tool, I will examine a few of the questions.

Firstly, Question 2 deals with the issue of assertiveness which, invariably, is an issue for adult survivors of childhood abuse and neglect, who may have been blamed and shamed; and, also experienced assaults on their self-esteem. Passivity, (non-assertiveness), can result in their being taken for granted, bullied and/or abused by others. Once clients have a full understanding of the three main interpersonal communication styles (passivity – aggression – assertiveness) they can be encouraged to develop and practice their assertiveness skills with family, friends and in their interactions generally, with others. (Clients can choose to be self-rating and/or the therapist can complete the questionnaire, collaboratively, with the client in the session.) At an early stage in therapy, a score of 1 or 2 on this 1 – 10 scale, would be unsurprising; this increasing, typically, to 7 or 8, at the conclusion of the work. Question 13 measures willingness to take risks, to promote personal growth and life satisfaction. Clients in the Victim stage, generally, move within an exceedingly small world, often shunning change and valuing the security of the familiar. As these clients move into the Survivor stage, they are more likely to push the boundaries of their comfort zone, by taking risks. Thrivers want more fulfilment and therefore are more willing to challenge themselves. It is not uncommon for Thrivers to score 8 or 9 on this question by the end.

Improving sleep quantity and quality, is an important barometer of progress towards thriverhood. Question 17 addresses this. Once establishing client’s usual sleep patterns at the first session, I will ask again how it is, in the third or fourth session. Evidence of improved sleep is understandable in the sense that, through the SF severe trauma recovery process, the client starts to process and sorts things out in their conscious mind, obviating the need for dreamwork, during REM sleep, to attempt to resolve waking life conflicts. Some typical client responses during the third or fourth sessions are: “Since I saw you last; I have had three nights when I have slept for four and a half hours straight. That’s not happened for months!”; and, “I am waking up less often in a cold sweat, in the middle of the night, than before I started this work.”

The last question (No 33) is about one of the key aspects of thriverhood: that of moments of great joy and exhilaration. Victimhood is characterized by chronic low mood; survivorhood has great fluctuations in highs and lows; and thriverhood provides these benefits of a life lived to the full. These great joy and/or exhilaration moments may be fleeting and periodic, but they are very noticeable by clients in thriverhood and are indications that they are beginning to live life well.

Clients may be encouraged to complete the questionnaire between sessions and bring it to the next session. If photocopying facilities are unavailable, the scores for the 33 questions can be recorded within the worker’s case notes. A new blank copy can be provided to the client, as appropriate, at future sessions. Increasing total scores over time can be both affirming and a great encouragement to clients as they continue their journey towards thriverhood. Naturally, this questionnaire would be given to clients only as and when appropriate. Another important point to mention, from a research point of view, is that this questionnaire has not yet been standardized, in terms of reliability and validity. Each one simply tracks the progress of each client over time, during their episode of therapy. It may be that in future studies, this questionnaire could be subjected to statistical validation.

Returning to the concept of resilience, which is a strong feature of other specialists in the field, and mentioned in an earlier part of this paper, the Thriver Questionnaire highlights client strengths, qualities and abilities; and shows how even more resilient they are now despite their awful past experience/s.

By the very action of completing this instrument, clients are further transforming their feelings, thoughts, attitude and behaviors, thus accelerating and encouraging them along their Thriver journey. Just a few more points added to their total score, since the last time they completed one, is very reinforcing. Again, this can be corroborated by the research evidence referred to above.

Conclusions

In conclusion, this valuable severe trauma recovery work is both challenging and rewarding. Traumatized people who receive no help or ineffective help from some practitioners, are destined for a lowly existence which often involves poor physical and mental health and limiting life choices. Being in receipt of prescribed medication and/or self-medication to reduce their pain, they will live significantly shorter lives. Achieving thriverhood, despite whatever awful thing/s have happened, Thrivers are likelier to access healthcare systems less frequently; be in employment and consequently be net providers to the national exchequer through income taxes. Furthermore, they will enjoy better quality personal relationships; and, live more meaningful and purposeful lives. In the light of the practice-based evidence of more than twenty years of this particular specialist application of SF, the majority of the most severely harmed clients achieve thriverhood within approximately 7 to 9 sessions over 8 to 10 months.

Figure 1 — What Thriving is Like

Figure 2 — Questionnaire for Measuring ‘Thriver’ Progress