Building a safe therapeutic relationship for TF-CBTp: Insights from STAR study
Threats and vulnerability lie at the heart of traumatic experiences and psychosis.
So how do you build a safe therapeutic relationship with individuals who have understandable difficulties with trust?
Traumatic experiences – particularly interpersonal abuse or violence from others - make it hard to feel safe and connected to others. Similarly, hearing threatening voices or feeling persecuted understandably triggers feeling vulnerable or wary about people’s intentions.
Many people who have experienced trauma and psychosis report challenging, disempowering experiences within mental health services (such as being restrained, forcibly medicated, discriminated, and involuntarily detained). This can also be more subtle in clinical practice, such as assuming survivors lack capacity, using stigmatising language, or deciding treatment routes without shared agreement. Such encounters reinforce fears about trusting others, particularly professionals working in mental health services or people in positions of power.
However, trauma-focused therapy requires survivors to build enough trust in a therapist to open-up about their lives. To take a risk of trusting someone enough, to share what can feel unspeakable and to face things that have been avoided.
Developing a safe therapeutic relationship - where the survivor feels validated, empowered and trusting – is vital for this therapeutic work. The STAR therapy protocol highlights that attention to engagement should run through every phase of therapy.
Quote from STAR research participant
Top Tips for building enough trust to start TF-CBTp
Here are some tips for therapists on managing potential obstacles to engagement.
This guidance is grounded in trauma-informed approaches to understanding and overcoming relationship challenges.
Keep in mind that many people who have experienced trauma and psychosis have experienced feeling disempowered; of ‘things being done to them’ with little choice or control.
Develop a shared (where possible) understanding of links between traumatic experiences and the origins of relational challenges, such as feeling safe enough to trust others.
This can be an opportunity to normalise their concerns, and a vital starting point for engagement.
Bear in mind explicit discussion of trust may be too threatening for some survivors. If so, just acknowledge trust issues and move forward.
Explore the best way to build trust for them. Invite conversations about how their trust can be earned. Stress the collaborative nature of this approach, whilst being clear about remits and limits of this therapy.
Agree clear boundaries of your therapeutic relationship and confidentiality.
To build a sense of safety, re-visit informed consent and the rationale of what you are covering in therapy throughout, particularly for memory work.
Invite the survivor to share their hopes and fears about therapy from the start. A commonly held fear is that trauma-focused therapy will make things worse or will cause them to lose control or destabilise. (See Clinicians fears blog for more tips).
Find out if the survivor has any fears, doubts or questions about their relationship with you as their therapist. Ask about previous therapy experiences, exploring what worked more or less well.
Validate and problem solve worries about getting ‘too attached’ or fears about ending leading to feeling ‘rejected’ or ‘abandoned’, as well as worries about ‘being let down’ or ‘taken advantage of’. Plan ahead for ending. The therapist can normalise the range of emotions this brings up, and model how to tolerate and contain them.
Be curious about any aspects of identity that may resonate with their experiences of harm or abuse. Consider similarities or differences that you and your client bring to the relationship (e.g. gender, ethnicity, faith). Sometimes a level of self-disclosure can be helpful, especially for people who have experienced harm from a certain group.
Some survivors may experience critical or threatening voices or other unusual experiences which reflect interpersonal fears. For instance, voices might warn them not to trust you. Gently explore these to develop a shared understanding of where they may come from and how they will be managed as a team.
Explicitly hand over choice and control to the client. For instance, invite them to decide the pace of therapy; collaboratively negotiate session agendas and re-check this during sessions. Consider using a symbolic panic button to give the option to pause at any point. Set ‘between session’ tasks for both the client and therapist. Encourage the client to take notes if helpful.
Regularly get feedback to understand ways to help the client feel safe and supported. Check if anything during a session concerned the client or impacted voices, visions, felt presences or other psychosis experiences.
Think together about how you manage ruptures. Schedule regular review points. Normalise obstacles to therapy (such as critical voices causing fear and avoidance). Anticipate and plan how to manage exacerbations of risk, collaboratively agreeing safety plans around concerns about the person’s safety (such as what to do if they do not show up for an appointment, particularly if working remotely).
Use supervision to help with engagement-related issues, and explore themes of identity, intersectionality and self-disclosure in therapy.
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