by Susan Rosenthal, MD, CGPP

Despite having spent two decades researching, studying, teaching, supervising, and practicing trauma psychotherapy, by the fall of 2009 I was feeling overwhelmed. One reason was that rostered general and family physicians had begun to refer more of their patients with chronic mental illness to GPPs like me.[1] A decade ago, a minority of my practice was composed of patients with histories of disabling trauma. By the end of last year, my practice was completely composed of these high-needs patients, my wait list had ballooned to six months, and new patients were being referred every day.

The heavy load was reason enough for my sense of overwhelm. But new discoveries in neuroscience (Solomon & Siegel, 2003) and my own preference for a systems approach left me questioning traditional trauma treatments. I had observed in sessions that the effects of trauma and therefore the potential for healing were not limited to the identified victim, but also involved significant others in the patient’s support system. As a result, I had developed a practice of insisting on the involvement of significant others in treatment. My biggest concern was the traumatized children who were either brought to me for treatment in isolation from their traumatized families, or who were not included in the treatment of traumatized parents and caregivers.

I was fortunate to meet Valerie Copping, whose experience working with children affected by chronic and complex trauma led her to develop the Inter-generational Trauma Treatment Model (ITTM) (Copping et al., 2001). Copping explained that the model had been implemented in a number of mental health clinics in Ontario and that she had partnered with Dr. Katreena Scott, Assistant Professor and Clinical Psychologist in the Department of Human Development and Applied Psychology at the University of Toronto, to conduct research on the efficacy of the approach. In 2009, Dr. Scott was assigned the Canada Research Chair in the prevention and treatment of family violence based on her extensive research and publications in the field.

Dr. Scott’s review of the literature (Scott, 2009) confirmed my own conclusions about research trends in trauma treatment, as well as my own experience as a practitioner:

• I had seen case after case of difficult behaviours and other symptoms of insecure attachment in children of traumatized parents. It is not surprising that parents pass their experiences on to their children, however inadvertently, and both trauma and attachment research has confirmed the increased probability of children of traumatized parents also experiencing trauma symptoms.
• In my experience, treating parents’ traumatic reactions made a difference in children’s well-being. In particular, when families faced subsequent traumatic events such as illness or job loss, parental resolution of previous trauma seemed to be associated with better outcomes for children. This, too, was borne out by Scott’s review of research.
• I had also observed that treating parents had positive effects on children, even when the children were not treated directly.  Dr. Scott cited studies confirming that, for some problems, treating parents alone had as favorable a result as treating children.
• Although I have long been an advocate of “co-therapy,” especially in a training setting, and although I believed that involving parents in treating children results in improved outcomes, I was uncertain how to incorporate these elements in trauma treatment. Dr. Scott claimed that inconsistent outcome in research on involving parents in trauma treatment had to do with whether parents’ trauma history was dealt with directly and separately from the children. The ITTM resolved this inconsistency by treating parents before involving them in the treatment of their children.

As a manualized treatment model, the ITTM lends itself to outcome research. Dr. Scott and Copping conducted pilot research on the efficacy of the ITTM at a children’s mental health center in Hamilton, Ontario (Scott & Copping, 2008). Twenty-seven families were recruited for the study. Over the course of the study, measures of parental depression showed significant reduction, and children’s behavior and social relations were significantly improved. A province-wide research study is currently under way in conjunction with the University of Toronto and the Children’s Hospital of Eastern Ontario (CHEO) Centre of Excellence for Child and Youth Mental Health.

I was convinced that the ITTM was a promising approach in agencies, but would it be effective in private practice? To observe the model firsthand, I selected three patients who agreed to work with Copping (as my co-therapist) for one session each. It became clear to me in those sessions that this model could lead to a more effective and more satisfying psychotherapy practice, and so I committed to the two-year training program.

Eight months later, I remain convinced of the effectiveness of the ITTM. I am seeing results that are far superior to those I was achieving previously. I no longer have a wait list and can see most new patients within a week or two of initial contact. And I no longer feel overwhelmed.

What is the ITTM? The short answer is that it is an attachment-based, cognitive-behavioural, manualized model for deconstructing the maladaptive behaviour patterns that arise in response to traumatic experience and that transmit that experience from adult to child.

The ITTM is designed to help:

• Adults who were neglected or traumatized as children and are concerned about transferring their hurtful experiences to their children.
• Parents/caregivers who want help for children who have experienced traumatic events.
• Adults who want to change maladaptive behaviour patterns.

Treatment is delivered in three Phases:

• Phase A consists of six (90 minute) psycho-educational classes for parents/caregivers and adults without children.
• Phase B consists of individual sessions in which the general information from Phase A is applied to each patient’s specific situation. Adults without children complete their treatment here.
• In Phase C, the therapist supports the parent/caregiver to treat trauma-related symptoms and behaviours in their child.

The ITTM has several unique features:

• The model is effective regardless of the type or source of the trauma.
• Parents/caregivers are the key agents of change for their children.
• The model can be learned and applied by psychotherapists from any educational or professional background.
• The model identifies patients who are ready to work, assists willing patents to become ready to work and selects out those who are not willing to work.
• The use of simple diagrams to convey complex ideas enables this method to be effective with patients who have little formal education – the population that is most traumatized and most poorly served by existing mental health services.

Benefits of the ITTM include:

• Interrupting the transmission of trauma from one generation to the next.
• Ending the lifelong use of mental health services by successive generations of traumatized families.
• Even though children are not seen until the parents/caregivers have competed their treatment, children’s symptoms and behaviours begin to improve from the first session of Phase A.
• Being able to provide effective treatment protects against therapist burnout.
• Treatment time is greatly reduced, and wait lists shrink dramatically.
• Therapists can take extended vacations without generating patient crises.

The ITTM is being applied in thirteen mental health clinics across Ontario. I will continue to investigate its value to practitioners in private practice.

References

Copping, V., Warling, D.L., Benner, D.G. & Woodside, D.W. (2001). A Child Trauma Treatment Pilot Study. Journal of Child and Family Studies, Vol. 10, No. 4, pp. 467–475.

Scott, K. L. (2009). Literature Review. http://www.theittm.com/traumaeducation-trainingcertification.shtml (accessed on 26 July 2010).

Scott, K.L. & Copping, V. (2008). Promising Directions For The Treatment of Complex Childhood Trauma: The Intergenerational Trauma Treatment Model. The Journal of Behaviour Analysis-Offender and Victim; Treatment and Prevention, Vol.1, No.3, pp. 273-283. http://www.theittm.com/files/KLscott273-v1i3.pdf

Solomon, M.F. & Siegel, D.J. (2003). Healing Trauma: Attachment, Mind, Body, and Brain. New York: W.W. Norton.

Declaration of Interests: Subsequent to Dr. Rosenthal’s involvement with the model, Adler Graduate Professional School has begun to offer certification in the ITTM. Dr. Rosenthal is on the faculty of Adler Graduate Professional School.

---

[1] The Ontario government has been recruiting general and family physicians (GPs) into rostered practices that pay GPs per patient, not per visit, creating a disincentive to see chronically ill patients. Because  rostered physicians are not penalized when their patients see GPPs, GPs are referring more patients with chronic mental illness to GPPs.  [Section 8.1 of the 2004 Physician Services Agreement  states that GP Psychotherapists’ billings will not impact Access Bonuses for Group Health Centres or Family Health Organizations. The Ontario Primary and Community Care Committee agrees that specialized services provided by GP Psychotherapists to enrolled patients of primary care physicians do not affect the Access Bonus.]