The development of training and practice in the UK: Reflections on the last 3 decades
Written by Sue Richardson, Attachment-based Psychoanalytical Psychotherapist, UK
Introduction: Background history
In 1989 I found myself professionally isolated twice over. First, as a result of being at the centre of the 1987 Cleveland child abuse crisis, in which the medical diagnosis of sexual abuse in 127 children led to a major public inquiry (Richardson and Bacon, 1991). Second, as a psychotherapist with adults disclosing extreme trauma. The way in which children and adults presented in both contexts introduced me to the world of dissociation. I read as much as I could on the subject and joined the ISSD (now ISSTD) but apart from the support of my psychotherapy training at what is now the John Bowlby Centre, I felt very alone. In a bid to overcome this, I contacted what at that time were the sole eight UK members of the ISSD. Remy Aquarone and Jeanie McIntee responded and in 1990 the UKSSD was launched with its own listserve. In 2007 the organisation merged with the ESTD. The UK membership has since remained one of the largest groups alongside Germany and the Netherlands.
In my experience, the development of training and practice in the UK has gone in stages. Each stage has been subject to four influences: the impact of high profile cases; the initiative of individual practitioners; the role of experts by experience; and the vicissitudes of the backlash, especially the memory wars.
Stage 1: The foundations
High profile cases of child sexual abuse throughout the UK in Nottingham, Cleveland, Orkney, Rochdale, and Ayrshire meant that, however much the facts were disputed, the issue of childhood trauma was firmly established on professional, societal, and political agendas. An insight into the long term impact of this era is provided by Nelson (2016). The study of complex trauma and dissociation resulted as the next developmental step, led by practitioners at the grassroots. Both the UKSSD and individual professionals like Norma Howes were instrumental in bringing colleagues together to learn from established clinicians such as Colin Ross, Bessel van der Kolk, and Marlene Steinberg. The shared hunger and thirst for knowledge at these events remains a vivid memory. Theory and practice were based on clinical experience in the US where the shift from abreactive to stage-orientated work took place.
With the exception of Cleveland, the high profile cases concerned allegations of ritual abuse. In 1989, Ritual Abuse Information Network and Support (R.A.I.N.S) was set up for professionals working with this issue (Buck, 2008). Awareness of extreme, organised, and ritual abuse developed sufficiently for R.A.I.N.S and other organisations such as Trauma and Abuse Group (TAG) to host trainings at both introductory and advanced levels led by colleagues from the US such as George Rhoades. We learned more about the impact of trauma on memory and consistently were given sound advice on avoiding leading questions and false positives. Even so, the training events were attacked by the proponents of false memory as responsible for causing moral panic and especially for allegedly creating a myth concerning the existence of ritual abuse. It seemed to me that the more the battle raged, the more survivors, often with pre-existing memories of trauma, came forward in the hope of finding a therapist who could help them. Learning from survivors has been an essential component of development at every stage.
Stage 2: Development of UK practice and training
UK training and practice moved to becoming more home grown. Two independent clinics were set up: the Pottergate Centre by Remy Aquarone and the Clinic for Dissociative Studies by Valerie Sinason. A small group of UK trainers were approved by ISSTD to deliver their standard and advanced courses. Responses to the material provided by the ISSTD were mixed. It reflected the work of the American pioneers and did not always resonate with a UK audience, not all of whom liked the seminar format. As a result, the ESTD UK went on to develop its own training modules. Uniquely, these were developed in an equal partnership with experts by experience from First Person Plural (FPP). All the UK trainers are both experienced as trainers and have many years working with DID clients. The days run by FPP also use experienced trainers who have a high level of personal insight, allowing them to bring clarity to some of the more complex issues, a key strength of us all working together. Alongside First Person Plural, ESTD UK has contributed to government consultations but as yet no clinical guidelines for treating complex trauma and dissociation have issued in the UK.
The original aims and principles established at this stage have remained unchanged. The overall aim is to encourage a co-ordinated approach to training in work with trauma and dissociation and avoid the fragmentation which can characterise this field of work. A core principle is the input, from design to delivery, of experts by experience. Other agreed principles are that all training should be as follows: targeted accurately at the participants' level of knowledge and experience; specific to the needs of the UK; provide for different learning styles; use a variety of training methods including experiential learning; draw on the relevant literature; incorporate an element of self-directed and reflective learning; relate to different practice contexts; allow for incremental learning; be aware of equal opportunities and provide for difference; be peer-evaluated using feedback from participants .
The core curriculum was established as: stage-orientated treatment, safety and affect regulation; methods of assessment; origins of dissociation of childhood and attachment issues; the structural model of dissociation; consideration of extreme/organised abuse; supervision and organisational issues; expert by experience perspective on all topics. The target audience was identified as, and in practice has largely been, caregivers in the professional and voluntary sectors such as social workers, mental health workers, therapists/counsellors, volunteer workers, and the health sector. Participant feedback has been overwhelmingly positive and enthusiastic. The engagement of staff in the national health service (NHS), especially psychiatry, has been slow.
The discussion of ritual abuse became muted during this stage. In response to the controversy it evoked, practitioners were either cautious or fearful. This did not stem the flow of survivors seeking help for whom R.A.I.N.S stood as a significant resource for them and their therapists.
Stage 3: To the present
The ESTD UK training has expanded from a 4-day foundation course to additional 4 days post-foundation training, providing 8 one-day modules in all. A master supervision class is run at intervals. The courses offer a progressive learning experience, which lay a solid foundation for understanding structural dissociation and working therapeutically. The post-foundation level reflects the growing number of practitioners with some training and experience.
Work to engage clinicians from the NHS is ongoing, where some breakthroughs are being made. There is more acceptance of dissociation, which is recognised more often even though the emphasis in the NHS on formulation and the predominance of other modalities such as CBT and EMDR does not necessarily lead to formal diagnosis. The hearing voices movement also promotes a dissociative framework within its own model of recovery. Individual ESTD members are bringing about change in their own health authorities. Mike Lloyd (2015) has demonstrated the cost-effectiveness of appropriate treatment. Angela Kennedy (2014) has demonstrated similar patient improvement and is advancing the provision of trauma-informed care. Remy Aquarone has helped to set up and consult to staff teams. He and Melanie Goodwin from FPP have taken forward regular training to NHS staff at a hospital in Norwich and are working alongside colleagues in the NHS to organise and promote a 2-day ESTD UK conference to be held in Norwich in March 2017.
The need for awareness-raising and foundation-level training is enormous. To assist in the size of this task, ESTD UK has produced as series of information sheets (available on the ESTD website) and collaborated with First Person Plural to produce an introductory training DVD, since joined by a second focussing on therapy (www.firstpersonplural.org.uk). An introductory online programme is to be launched in the future.
As far as I am aware, the John Bowlby Centre is the only school of psychotherapy in the UK, which gives dissociation a significant profile during training and which openly names ritual abuse and mind control. Evaluation at referral includes pointers to the diagnosis of dissociation. A Blues Project provides a low-cost service to increase access to therapy and there are a number of therapists at the Centre who work with severe complex trauma and organised abuse. Articles on dissociation, mind control, and ritual abuse have been regularly published in the Attachment Journal (e.g., Epstein, 2011; Richardson, 2010) and Centre members have addressed the manipulation of attachment needs inherent in organised abuse (Epstein et al., 2011).
Elsewhere, the fear of including extreme/organised abuse on the agenda has abated somewhat. The subject has re-emerged on the agenda of the ISSTD conferences in response to their special interest group on ritual abuse and mind control, which has as number of UK members. The ESTD UK training group is exploring the development of a module on this issue in collaboration with the Clinic for Dissociative Studies. In 2013, R.A.I.N.S hosted a 2-day training led by Alison Miller whose publications have done much to extend clinical knowledge (Miller, 2012, 2014). The spotlight of public concern has shifted to allegations of institutional abuse and its cover-up, currently the subject of another major public inquiry. Meanwhile, the demand from those with dissociative conditions for appropriate therapy continues to outstrip the supply of available therapists.
Conclusion: Challenges and future directions
While practitioners still often feel isolated, I hope that no one need feel as alone as I did in 1989. The mere existence of organisations like ESTD and its networks is validating and supportive. The challenge is to maintain them, to expand networking, co-ordination and collaboration, and to hand on to the next generation. It is still not entirely safe to go into the water. The backlash remains a factor. The early conferences described in Stage 1 above are still quoted as an alleged source of contamination, false memory, and moral panic, an opinion repeated in a BBC radio programme in May 2015. The challenge is to avoid being too fearful to integrate consideration of extreme, organised, and ritual abuse routinely into existing theory and practice (Richardson, 2013). The incorporation of the kind of modules developed by ESTD UK into other professional foundation training would be another major advance. The grassroots initiatives of pioneering professionals in partnership with experts by experience has achieved much. It is now time for top-down recognition of the prevalence of trauma and dissociation, the need to develop resources, and a training initiative, which claims ownership of complex trauma and dissociation as a public health issue. The ESTD UK conference ‘Facing the Challenge’ to be held in Norwich, March 30-31, 2017, will focus on improving services for people with trauma-related dissociation and provide a forum for these challenges to be explored.
Buck, S. (2008) The R.A.I.N.S Network in the UK. In: Noblitt & Perskin Noblitt (Eds.) Ritual Abuse in the 21st Century: Psychological, Forensic, Social and Political Considerations (pp., 307-326). Robert D. Reed Publishers: USA
Epstein, O. (2011) The leap from object use to intersubjective relatedness- a detailed clinical vignette. Attachment: New Directions in Psychotherapy and Relational Psychoanalysis, 5, 1, pp. 39–44.
Epstein, O., Schwartz, J & Wingfield Schwartz, R. (Eds.) (2011) Ritual Abuse and Mind Control: The Manipulation of Attachment Needs. Karnac: London.
Kennedy, A. (2014) Developing dissociation informed mental health services. Presentation at ESTD 2014 Conference, Copenhagen, 27-29 March, 2014.
Lloyd M. (2015) Reducing the Cost of Dissociative Identity Disorder: Measuring the Effectiveness of Specialised Treatment by Frequency of Contacts with Mental Health Services. J Trauma Dissociation. 2015 Nov 2.
Miller, A. (2012) Healing the Unimaginable: Treating Ritual Abuse and Mind Control. London: Karnac.
Miller, A. (2014) Becoming Yourself: Overcoming Mind Control and Ritual Abuse. London: Karnac.
Nelson, S. (2016) Tackling child sexual abuse - Radical approaches to prevention, protection and support. Bristol: Policy Press.
Richardson, S. & Bacon, H. (Eds.) (1991) Child Sexual Abuse: Whose Problem? - Reflections from Cleveland. Birmingham: Venture Press.
Richardson, S. (2010) Reaching for relationship: Exploring the use of an attachment paradigm in the assessment and repair of the dissociative internal world. Attachment: New Directions in Psychotherapy and Relational Psychoanalysis, 4,1: pp. 7–25.
Richardson, S. (2013) Installed structural dissociation: Cool thinking about a hot debate. ESTD Newsletter, Vol 3, No. 3, June 2013, 6-8.