Mary Jo Barrett on the Collaborative Treatment of Incest and Complex Developmental Trauma

Mary Jo Barrett: That’s a good place to begin. When I first started, which was 45 years ago, I was a worker for the state, basically doing in-home counseling. I discovered that in all these child abuse and neglect cases, there was a significant number of cases involving incest and sexual abuse — whether immediate family members or close family members or clergy or whatever. I would go to my supervisors for guidance, but no one really knew how to treat it.

For example, Minuchin told me that I didn’t need to focus on the incest. I just needed to look at restructuring and building a hierarchy, and that the incest would then be alleviated. Carl Whitaker, who I was madly in love with, basically said, “You know what? I don't know what to tell you.” At least that was honest. He said, “I do schizophrenia. You better figure out how to do incest.” He was my teacher, so I decided I needed to figure it out.

And so, over the years, I started asking my clients more formally about incest and sexual abuse. I also had my supervisees ask their clients. And whether I was conducting training in Europe or here, I began to ask the clients what the most effective thing about their therapeutic experiences was, and what about the therapy they had received made it “good therapy.”

Basically, nobody said “techniques.” They said what we know they would say and did actually say. It was the relationship between the therapist and client. But they even said more specific things. And of the specific things they said, I narrowed the list down to what I call the five essential ingredients of trauma treatment. But what they said applies to all models of treatment. And as we know, none of these models are better than the other

I developed what I call a meta-model that applies to any trauma protocol that exists based on these five essential ingredients. And so, whether you do IFS or CBT or SC or any of the alphabet soup of techniques or protocols that are out there, they will be successful if they have the five essential ingredients.   

MB: People, especially those who have been abused, need to feel that they have value, power, control, and connection. So, these “ingredients” include the client:

• feeling valued
• learning specific skills in finding resources
• understanding contextual variables needed for an engaged mind state
• developing workable realities
• building a hopeful vision for the future

When a therapist, case manager, or foster care worker gets stuck with a client who has been abused or neglected, I suggest that they don’t go back to the protocol, but instead to the relationship.  

MB: The basic essence is that I go to the client to tell me what to do, versus going to a model or technique to tell me what to do.

MB: Larry, every day! That is my model. Every session. In every session when you’re talking about trauma, there will be an impasse. I call it differently. In any moment, there’s going to be what I call a traumatic stress, which means the client, because of their trauma, is going to experience therapy as dangerous.

As we always say, survivors often see danger where danger doesn’t exist. I mean, that’s a standard thing. But that happens in therapy all the time. That’s because the therapeutic relationship is based on hierarchy and attachment. There is a hierarchy, right? I mean the therapist has more power. And the therapist is often controlling the sessions or the direction or what’s going on. And there’s a necessary attachment. There’s going to be an attachment between therapist and client.

Abuse and neglect are embedded in hierarchical attachment relationships. Now, the thing is, every time I say abuse and neglect, people might go, “But we’re talking about trauma.” And I’m saying, again, almost all the trauma cases we talk about revolve around interrelationship violations.  

MB: I’d say that a majority of these clients anticipate and experience, from time to time, that violation in the therapeutic relationship. 

MB: Correct. And the collaborative change model is exactly that cycle. What you just described. And what’s interesting to me is that the collaborative change model is a natural model. And when I describe it, folks at the clinic say, “Oh, my god, yeah!” And the good clinician says, “That’s what I do in my sessions anyway.” And all I’m saying is, make it conscious. It’s a natural cycle of change.

The first phase is creating a context — which is creating refuge, making assessment, figuring out what’s going on — then making a direction, deciding what kind of intervention to use. And then when we start doing our interventions, which is natural, we’re challenging, right? And the relationship becomes embedded in this hierarchy because I’m sort of pushing and challenging by asking them to do something different. And in that moment, the client might experience a moment of fight-flight-freeze-submit. Or fix! And I have to, as a clinician, recognize that.

And in that moment, instead of pushing harder to make an assumption of, “Oh, they can’t tell,” or whatever it is, I need to stop and recreate a context of change. So, at that moment, I stop and say, “What do you need now? What’s going on? How do you feel? Should I slow down? What’s happening?”

I’ll give you an example. I had a client who often during the sessions would say, repetitively, “You don’t get it. You don’t get it. You don’t get it.” And I’d often get defensive. I’d sometimes want to say, “Well, help me understand,” or, “Explain it.” And then one day after the session, I was thinking, “I think that’s a trauma response. So, I said, “I’m wondering if when I’m doing something that triggers you, you experience me as threatening and go into ‘You don’t get it’ as a repetitive response.” And she really thought about it and looked at it and she said, “You know, I’ve often felt there’s things you do that remind me of my mother.”

This client’s mother was like Joan Crawford’s character in Mommie Dearest, and we’re not just talking severely abusive. I asked her what reminded me in those moments of her mother. In response, she said that I talked loudly, and it was the way I dressed in skirts. She experienced me as dressing in a way that was, for her, reminiscent of her mother, which she experienced as provocative. I don't know that it was, but she experienced it as such, so for her, it was.

So, when we then had that conversation, and from then on, I did consciously change how I dressed on the days I saw her. And I consciously changed my voice. And after that conversation, she never said, “You don’t get it,” again. 

MB: Violated. She was feeling violated.

MB: Yes.

MB: You did get it. I should bring up my PowerPoint. You’re doing a very good job. I have three slides that I use in trainings, which I introduce by saying, “These are the three watchwords or phrases of my faith.” The first one is by Mandela that says, “A good head and good heart are always a formidable combination.” The second one was by R.D. Laing who talked about the importance of awareness by saying something like, “If you aren’t aware that you’re not aware, there’s nothing you could do to make change.” And the third one is by Jay Woodman which says that “Life is a series of cycles of getting lost and finding yourself.” And that each time you’re lost, if you look at it as a possibility, then you will find yourself in a new place. And so, my thing is, therapy is a cycle of getting lost and finding yourself again. And once you’re aware of that, you integrate your mind and your brain, your heart, and you’re golden.   

MB: It’s an integration of the two. When we spoke with these clients, it was clear that they did need new skills. It was the third most important thing, not the first. But the first thing they said was connection. The second thing they said was they had to feel valued, and they had to value the clinician. Then they said they had to feel empowered. And then they said skills.

Everybody that’s developed a protocol model is going to argue with me and say the relationship is the basis of all those protocol models. I would say I got you; I believe you. But if you ask the people who are trained in those models, they will say the emphasis is on the protocol and the interventions.

And they would also say that the difference is that when they’re stuck or a client gets activated, that it’s “go back to the protocol,” versus going to the client to collaborate. 

MB: A hundred percent! This is actually the new thing that I’ve added to the “fight-flight-freeze” paradigm, which is “fix.” So, I think what happens when a clinician becomes overwhelmed — I call it a place of traumatic stress — fix becomes part of a trauma reaction. The traumatic stress reactions.

When a therapist falls into a “fix-it” state, that should be an indication that they are in the trauma field and are feeling dysregulated. They then have to get re-regulated in order to move to a different place. And it’s the same with the client, who at that moment needs skills to re-regulate themself. I don’t believe when a client or a therapist is dysregulating, that’s the time to automatically use a technique.

MB: I want to say one other thing which is not going to be popular. I believe that when therapists jump in with a technique, they’re hoping it’s a solution for the consumer of their services.

MB: Giving them something, which is capitalism. Everything is an agreement in the contract with my clients.

MB: Yes. Most of the clinical work I do is with couples and families. And this goes back to the research we did with these clients who said that rarely, if ever, did other clinicians include their family. So, what would happen is that after those sessions with the “other” therapists, these clients would go home and have abusive fights or get hit. Or a parent would continue the abuse or violate.

Here, I go back to what I said earlier. Abuse, neglect, and childhood developmental trauma are embedded in a relationship of hierarchy and attachment. So, I believe healing should happen in a relationship.

I want the therapy to recreate some of the crisis right in the room with me. So, if there’s a fight, and dissociation, we all can witness it together and address it in the moment — together. If there’s eyeball-rolling that then triggers the other person, I want it to happen in the room, because those are the cycles that cause the traumatic stress at home.

Everything I’m saying to you here and now is what I say in the first session. When I start a session, I want the safety in our relationship to spill over into their relationship. I want their relationship to be a source of regulation. Not me. I don’t want to be the primary person in their lives. 

MB: Let me delineate two things. One; when the incest is currently happening and its children, yes, I include everybody. But I have all sorts of rules and boundaries. If it’s currently happening, and in most states, if incest is currently happening, then usually the perpetrator, whether it’s a sibling or a parent or not, is kept away from the child, right?

So, I don’t bring the alleged offender, or the offender, into the room with the victim until they’ve acknowledged facts. So, if they’re denying facts and saying, “She made me do it,” or, “He made me do it,” or, “It never happened,” I don’t do family with them. But I would do family with other family members. But I don’t bring the alleged offender into the room until after they’re no longer denying facts. 

MB: They are in therapy. Yeah. I mean if it’s currently happening, then the offender is in individual and group therapy, according to how I think good incest therapy should happen. And the rest of the family are either in individual, group, or family treatment for whatever their issues are. And the kids could be in individual concurrently with the family therapy.

And then when the violator has met certain criteria, then they can start coming into the sessions. 

MB: The family. But/and my collaboration is with all. It’s a team. I mean it takes a village. Absolutely. When we’re talking incest, it can’t be done effectively by one therapist.

MB: I’ve developed what I call the “family dialogue program,” which is for adult survivors with their families. And so, I do bring them together but it’s different. I often do it in these intense weekend workshops because if people live all over the country, it depends on if we’re doing therapy about wanting to talk about the abuse and neglect or are we doing what I call the third reality, which is, let’s just focus on the future. Let’s not focus on, did it happen, didn’t it happen, what’s going on? Let’s just focus on, am I going to come to your funeral? Am I going to come to Passover? How can we be in the room together? Am I going to go to my niece’s wedding? Are you going to ever meet your grandchildren? That kind of thing.

MB: And that’s why I call it the third reality. Because we’re just focusing on, “it’s not about your reality,” it’s about if you want to see your grandchildren. If I want to come to your house, are you going to be able to tolerate me...you know, me believing this and being in the same room as you. 

MB: Oh, absolutely. And that’s what most survivors will say to me. I mean a lot of people have said, “I was in therapy for 10 years, and that weekend with my father was the most important thing in my healing.” 

MB: I don’t think people in private practice run from the adult survivors, but they run from when it’s currently happening. 

MB: Because I think it is one of the greatest taboos. And they never learned how to deal with it. And I think they never learned how to manage. And they often don’t understand how anybody can even want to see their father or their brother or their mother based on what they’ve done to me. Or done to them. Done to the victim. And so, I think a lot of them experience transference and/or feel inadequate.

And in terms of me, Larry, I supposed we could get me on a couch to figure out why. I do remember very distinctly one time bolting out of bed, like sitting up straight. I don't know if it was a particular case, and I said to my husband, “What kind of person likes working with sex offenders?”

But I would rather work with incest any day of the week over depression because people I work with change. And I see that change. I have seen plenty of sex offenders change. And I’ve had the fortunate experience of being able to follow up on some of my very first cases. I’ve seen one of my first cases 40 years after they stopped. It was an unbelievable experience.

Well, partly it was fun because I got to ask them all sorts of questions. I’ve always been a very creative therapist, where I just make shit up as I go along, that seems to fit. I remember one of my cases — it was incest and domestic violence. The father was in supervision and was told he couldn’t be within 365 yards of his family when he first got out of jail. He actually parked a mobile home 365 yards from the family home. And he was something else.

About a year into it, maybe less, I went back to court to get permission to have him come to family sessions. And he did. And one time, I was doing a good old family therapy looking for strengths, and I said to them, “You’re not always abusing each other. There are times when you’re not. Let’s talk about those times.” And the kids were younger, like 16, 11, and 10. I handed out these little recipe cards where I asked each family member to write down the recipe for nonviolence. Like a cup of this, and 3 tablespoons of that.

I gathered them all and laminated them, and then had them talk about it. The mother said, “It’s half a cup of going to church, and another quarter of a cup is no alcohol.” I mean that kind of stuff. And so literally 30 years later, I interviewed the same family. And the woman, the daughter who was the incest survivor was 40-something. I asked her a couple questions, one of which was whether she had gone to any trauma therapy. She said, “Why would I? I already had it.” So, I asked, “When you were getting married, or dating, what was that like? Were you always anxious? Were you afraid?” She opened her purse and pulled out the laminated card, and said, “I only dated people that had the ingredients.” 

MB: I burst into tears. I didn’t do the initial interview, one of my graduate students did. But I was behind a one-way mirror, because who wouldn’t want to see one of their first clients? I went in and I asked them questions. So, in fact, there’s an example of the use of a particular skill. I don’t know that- would it have been the same if it hadn’t really come from them? I don't know.

MB: Right, right.

MB: I have a case right now of sibling incest, and one of the kids is a young adult, but not even, I mean probably a teenager still, 18, 19, who is in individual therapy. I’m trying to do a family session because the parents have two children. So, the parents are involved, and the son who offended his sister. And I’m trying to coordinate. And the sister’s therapist didn’t call me.

MB: Well, the recourse I have is the parents. He is still a teenager. So, the parents can call this person up and say, “Our daughter signed a release, we signed a release. You need to call.” I’m not saying it in a nasty way. But I try to avoid doing that because I don’t need to start an adversarial relationship. But that’s the recourse I have. If the person was an adult, I mean I’d still have the parents to talk to their child and say, “Look, we want to heal this.” As it turned out, the son’s individual therapist calls me and cooperates. We have a great working relationship.

MB: Incest hasn’t decreased at all since I started in the field in ’78.

MB: : I think everybody’s neglecting it. I think that the problem is that we’ve lumped trauma into one thing — complex developmental trauma.

I think that there is something very important to calling violence or violations what they are. Incest is unique. It’s not just a sexual assault. It’s unique because this is often a relationship where the people also have a very positive connection. “This is my parent,” they might say. I had a client way back, I mean again, 30 or so years, who wrote a poem. The one line that sticks out into my head was — and I don’t think she was writing it just to me, it was in general — she said, “I asked you to put an end to the abuse, and you put an end to my family.”  

MB: I don’t think it was to me because I asked her. It was to the system. She’s another one that I still have contact with because periodically she’ll write me and say things like, “I just had a baby, just won a marathon.” I mean that kind of stuff. I think professionals feel anxious. I think they feel traumatized. I think it feels like you said. It’s such a moral violation that, as clinicians, we don’t know how to manage. How do I manage that I care about somebody? How do I manage that this woman stayed married to somebody who sexually abused her child?

I just think the taboo is so deeply entrenched that it causes such distress to those who work in this area. I just was working with a family where one of the children was sexually abused. And the other two weren’t. And when I talked to all of them, I said, “All of you were abused. But what happened to Susie is more of a moral violation.” And so that’s why people can’t tolerate it. I think there’s something about not being able to tolerate it. Like I said, I can find something positive. It makes sense to me that someone can be abused by a family member and still care. 

MB: All I know is that so many clients tell me that people either never asked them or understood it. So, it just gets lumped into a category of trauma. And all traumas are not created equal. I’m not saying incest is worse than being physically abused. I’m not saying it’s worse, I’m just saying it has its own unique connected relationship with somebody they cared about who I also had many positives. And it leaves me even in some ways more confused because it isn’t linear or simple. Even if the person was abused by somebody that came and left like a babysitter or Boy Scout leader, with whom they also had an intimate relationship, it’s very confusing. 

MB: Yes. I think sometimes clinicians can’t manage that level of complexity. Which goes back to your question; “Give me some techniques, it makes things less complex. I can feel better about myself if I know how to do this. Do that.” Larry, every single day, I go, “Wait, I don't know what I’m doing exactly. What do I do now? I just had this explosion.”

I was sitting in the room last week with somebody that got up, grabbed something off my table, threw it on the ground, and smashed it. “I got to go,” they said So, I said, “Wait a minute, okay, let me figure out.” What was I going to say in that moment? “Follow my finger?” 

MB: What I did in that moment was said, “I need a drink of water. You need to sit down. I am feeling afraid. And I want to talk about this. But right now, I need to calm down. And you need to. We both need to.” I had been seeing this guy for a while. It made sense to say, “We need to regulate.”

Well, the wife was there, and they have a child. But the child wasn’t there. I had a separate session with the child. And I had a separate session with the wife. I did break them all up. And then I had a session with him, and we just talked about it. And I talked to him. And of course, like every other, he said, “This is what happens when she does blah, blah, blah.” “This is what happens when my child…” And I explained to him that acts of violence are linear. I don’t think I said “linear,” but… “I get it. It is all these other things that activate you. However, you have to make a decision about how you’re going to react to these things.” 

MB: Acknowledgment is important, not apology. Because people say they’re sorry very easily.

MB: So, when somebody is going to make a formal acknowledgment, it’s a planned session where they write a narrative. They write it down, they talk about… Basically, I have them talk about facts, impact, responsibility. So, they’re giving it to me beforehand. And that’s part of the therapy process. They’re writing their acknowledgement as a therapeutic technique. So, they’re writing this, and that’s how I know it’s sincere.

MB: Well, on that level, they probably don’t look any different than any other form of abuse, neglect, or violation. They really don’t. Eating disorders, self-mutilating, suicide. Any of those things. Most of these are symptoms, I think are survival skills. I think they’re skills that people have used over time to survive their abuse and neglect. And now it’s become problematic. The skills themselves are problematic. The skills work. If I drank too much, if I cut, if I was sexually promiscuous, if I was suicidal, if I was dissociating. It might have worked to avoid memory and pain. That’s how I tell my clients; that most of their symptoms are utilized to avoid memory and pain until they don’t. 

And now the symptoms themselves are causing the pain. To me, incest doesn’t look any different. What happens is, as I start my sessions by asking people how they heard about me.

If they didn’t know my name, they might have typed in “trauma, abuse, childhood something.” And it’s not just “therapy.” Usually, they got to me, somehow, they typed something else in. Or they got to me through a therapist. And so, when they say trauma, which is usually what it is, I then say, “Look, if we’re going to talk about it, we’re not going to talk about it now. But I need you to know I feel really comfortable talking about incest. I feel really comfortable talking about sibling abuse. I feel comfortable talking if you beat each other up.” So, I’m just saying, down the road, if any of those things come up, I feel comfortable.  

MB: No. When I take a family history, when I do a genogram, and everything points to incest, I might just say, “You know what? I just need you to know from what you’re telling me; I’m not saying it was incest. But there might be, it could have been. It feels to me like emotional incest at least. Like you are hierarchically your father’s peer. Or it feels like you and your brother turned to each other in ways to get affection that you didn’t get from anyone else or your parent(s).”

So, it doesn’t have to be. And this isn’t your question. But it’s a question people often ask me. Do you need to know all the story to help? And the answer is no. 

MB: Well, I mean we have maybe a couple of million. But I think what I would say is, you know, we should talk again.